Person-centred care and whistleblowing: can you have one without the other?

Sue Sherratt

Communication Research Australia

Newcastle NSW 2287

Australia

Email: Communication.Research.Oz@gmail.com

Tel: +61 2 4953-9727

Keywords: ethical dilemmas, person-centredness, ethics, whistleblowing, breaches of care.

Running head: Person-centred care and whistleblowing

© Sue Sherratt
 Person-centred care and whistleblowing: can you have one without the other?

Abstract

Purpose: This article proposes that providing solutions to ethical dilemmas and, if necessary,

disclosing breaches of care are critical to speech-language pathologists’ ethical behaviour and

professional responsibilities. They are also pivotal to incorporating person-centred-care into

our clinical practice.

Method: Evidence is reviewed regarding the nature of breaches of care in speech-language

pathology, disclosure of these breaches and the training and resources that are currently

available. The significance of either disclosing or not disclosing breaches of care is also

discussed.

Results: Although the profession already has an armory of resources for tackling ethical

dilemmas, innovative and ongoing ethical education is needed to deal with the increasingly

complex situations that arise in the current healthcare climate. Within the workplace,

appropriate arenas for discussion and avenues for disclosure would minimize the need for

disclosure of breaches of care.

Conclusions: In some circumstances, disclosing breaches of care may be necessary if the

safety or care of our clients is being negatively affected and person-centred care is being

jeopardised. Such disclosures can be used as a feedback mechanism to improve our

effectiveness as clinicians, enable us to enhance the quality of care for our clients and ensure

the future health of our profession.

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Background

The underlying principle of centredness is currently of intense interest and is increasingly

endorsed within healthcare (Jesus, Bright, Kayes, & Cott, 2016; Macleod & McPherson,

2007; McCormack, Karlsson, Dewing, & Lerdal, 2010). This principle refers to a

“philosophy intended to underpin care and service delivery” (p. 1) aimed at meeting the

client’s needs and values and completely involving the clients’ perspectives into the care they

receive (Jesus et al., 2016). Person-centred care is compassionate, empathic, authentic and

collaborative (Macleod & McPherson, 2007). This philosophy has engendered substantial

debate within rehabilitation; it requires the active participation of the client (DiLollo &

Favreau, 2010; Jesus et al., 2016; McPherson & Siegert, 2007) and the client and family are

placed at the centre of healthcare decisions (Bright, Kayes, Worrall, & McPherson, 2015;

Macleod & McPherson, 2007; Ward, 2012).

Furthermore, for healthcare to be deemed to be of good quality, it is generally considered

necessary for it to be person centred; indeed, person-centredness is considered as the

cornerstone of high-quality care (Hewitt-Taylor, 2015). Clients receiving person-centred care

reported increased satisfaction with, and perception of the quality of, the care they received

(compared to control clients) (D. M. Wolf, Lehman, Quinlin, Zullo, & Hoffman, 2008).

Aspects of health care that negatively affect the safety of, or the care provided to, clients (here

referred to as “breaches of care”) have been reported in most health professions. Usually,

dilemmas in healthcare can be solved before they reach the stage of having any effect on

clients and being a breach of healthcare. Disclosing such breaches within or external to an

organization has engendered considerable debate in allied health professions like nursing and

social work. However, this topic has rarely been mentioned in speech-language pathology

since the publication, almost two decades ago, of Pannbacker’s (1998) journal paper on

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whistleblowing. Within the health professions including speech-language pathology,

whistleblowing is considered to be a difficult ethical dilemma (Pannbacker, 1998) and one

that has moral, practical, ethical and professional implications (Wilmot, 2000).

Whistleblowing outside an organization about a breach of healthcare would be an infrequent

event. However, dealing with ethical dilemmas is an intrinsic part of working as a speech-

language pathologist. Professional training and development incorporates learning codes of

ethics, how to apply them and how to make ethically-based decisions. Most professional

associations provide members with a confidential forum in which to informally discuss ethical

dilemmas. In addition, speech-language pathologists have recourse to a variety of resources,

including the codes of ethics of their own associations and the profession’s ethics literature.

The codes of ethics provide a unique context for decision-making (Chabon & Ulrich, 2006).

Furthermore, a number of ethical decision-making models have been developed in speech-

language pathology (for example, see Irwin, Pannbacker, Powell, & Vekovius, 2007; Kenny,

Lincoln, & Balandin, 2007; McAllister & Lincoln, 2004). However, in a cautionary note,

Body and McAllister (2009) state that ‘protocols arising from speech and language therapy

may offer a form of scaffolding to support consideration of ethical decisions but still leave the

user with much to do in complex situations’ (p 32).

Despite this armory of knowledge and resources, there are still some decisions or actions

which violate our responsibility “to hold paramount the welfare” (American Speech-

Language-Hearing Association, 2016) of our clients. Ethical dilemmas are difficult to handle

because “right versus wrong can be separated by many areas of gray” (Waguespack, 2016, p.

44) and decisions regarding “the small stuff that happens every day” are less clear cut

(Fairbrother, 2012, p. 13). This paper focuses solely on the issue of disclosing breaches of

care as a last resort, when all other means of addressing the issue have been exhausted.

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Furthermore, the disclosure, if taken outside the organization, should occur only when internal

disclosure has been ineffective and only with regard to disclosing “a significant deficiency in

the quality or safety of health care” (Bolsin, Faunce, & Oakley, 2005, p. 612) or one that

happens with significant frequency. Whilst Pannbacker focussed on whistleblowing, this

paper will discuss disclosing breaches of care at any level – from discussing the issue with

those involved, to extreme cases of disclosure to the media/law. In this paper, it is taken as

read that disclosing such breaches of care is aimed solely at stopping the deleterious

behaviour and to prevent similar conduct in future (Ray, 2006). It would not be “for personal

reprisal, as a means of addressing personal animosity, or as a vehicle for retaliation”

(American Speech-Language-Hearing Association, 2016).

Breaches of care

Most dilemmas in allied healthcare are primarily about day-to-day decisions (e.g. selection or

availability of appropriate assessment tool) rather than the dramatic life or death situations

occurring in medicine (Barnitt, 1998). Over a decade ago, Buie (1997) reported the most

common ethical challenges in speech-language pathology to be clinical practice dilemmas.

More recently, almost half (47%) of the ethical dilemmas which caused speech-language

pathologists conflict about the right thing to do were concerned with colleagues, and with

evaluation and treatment issues (Lass, Pannbacker, Armstrong, Murdock, & Casto, 2007).

Clinicians in private practice also raised concerns about the quality of services provided by

colleagues (both within and external to their own practice) and about the resulting harm to

clients (Flatley, Kenny, & Lincoln, 2014). Breaches of care will vary widely in severity,

context, duration, parties involved, financial constraints, etc. For example, ethical decision-

making in acute care involves clients who are particularly vulnerable (Goldsmith, 1999) and

may focus on physical needs (e.g. regarding swallowing). In rehabilitation, the dilemmas are

5
considered to be highly complex and difficult to define (Barnitt, 1998; Kirschner, Stocking,

Wagner, Foye, & Siegler, 2001). Breaches of care in speech-language pathology may occur

across the spectrum of our scope of practice. Table 1 provides examples of breaches of care

relating to a range of speech-language pathology issues.

Table 1: Examples of breaches of care

Examples* of breaches of care

Evaluation An SLP consistently uses impairment-only or out-

of-date assessments on clients.

An SLP conducting videofluoroscopic assessments

of dysphagia without an attending radiologist.

Treatment An SLP refused to allow a palliative care client

with dysphagia cups of tea as a comfort measure

because of safety concerns.

A woman with aphasia was force-fed through her

nose without her consent.

Staff shortages A woman, who had suffered a stroke, was left for

five days without food or drink because no SLP

was available to test her swallowing.

Client abandonment An SLP gave the employer two days’ notice of her

resignation, resulting in clients being left without

appropriate care.

Funding To obtain reimbursement, a school district wants

an SLP to sign off on Medicaid reimbursement

requests for clinicians in other local schools who

are not certified and not supervised by the SLP.

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Technical equipment Audiometers not calibrated as directed by

manufacturer on an annual basis due to cost.

Employer demands Employer sets productivity expectations that the

SLP feels are too high to achieve or will

compromise the quality of patient care

Supervision of students/junior staff A clinical supervisor attends a meeting, leaving a

student to conduct the supervisor’s treatment

sessions unsupervised.

A clinical supervisor instructed three students to

each elicit the gag response three times (9 times in

total) on the same client. The client became upset

and refused to return to therapy.

Cultural issues A monolingual English-speaking SLP regularly

assesses children who are monolingual Spanish

speakers without any assistance or support.

Lack of respect SLPs told by their manager to prevent clients for

voice assessments from talking and to interrupt

them if they do speak.

Discharge An SLP had to discharge a client whose funding

was no longer available even though she believed

that additional services were necessary.

*(American Speech-Language-Hearing Association, 2010; Chabon, Brown, & Gildersleeve-

Neumann, 2010; Davidson & Denton, 2010; Denton, 2009b, 2010; Huffman, 2003;

King, 2003; Mandelstam, 2011; Pannbacker, Irwin, Lass, Miller, & Waguespack,

2006; Ulrich, 2004)

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The sequelae of these breaches to clients may be physical harm (e.g. in dysphagia,

tracheotomy and laryngectomy) or psychosocial errors (e.g. unfair allocation of resources,

inappropriateness of treatment, lack of respect for clients, and incompetent or unprofessional

colleague behaviour) (Barnitt, 1998; Flatley et al., 2014; Kirschner et al., 2001; Mu, Lohman,

& Scheirton, 2006; Scheirton, Mu, & Lohman, 2003). In our profession, there are only a

limited number of evidence-based assessment and treatment programs available (Dodd, 2007;

Ratner, 2006). Therefore, at times, it may be difficult to determine the difference between

incompetence and a professional difference of opinion (e.g. the precise consistency of fluids

for clients with dysphagia).

Eby (2000) distinguishes between two forms of ethical problems. Firstly, barriers within the

workplace may prevent a course of action which the clinician considers to be the right choice,

resulting in ethical distress. This may relate to systemic issues (inadequacies in resources,

service delivery or policies) or to clinician’s behaviour or actions (e.g. manager’s directive to

prevent clients from speaking to shorten appointment times). The most troubling of all ethical

dilemmas for speech-language pathologists, as reported by Buie (1997), was to discover

unethical behaviour by another therapist. Unethical and incompetent professional behaviour

is of deep concern to these clinicians (Kenny, Lincoln, Blyth, & Balandin, 2009). Secondly,

ethical dilemmas occur “between competing personal and professional values as well as

between personal and organizational values” (Eby, 2000, p. 122). The concern in this case is

the clash of values between being loyal to one’s clients or one’s own values, and being loyal

to or showing respect for the employer, profession and friends (Ray, 2006; Stewart, 2008).

Therefore, by fulfilling one professional ethic (e.g. disclosing the breach, as directed by many

ethical codes), we may potentially reject or violate another (e.g. loyalty to employer or

8
colleagues) (Jackson, 2008; Pannbacker, 1998; Sawyer, 2005). In fact, Kenny et al (2009)

found that new and experienced speech-language pathologists reported conflicting

responsibilities to their clients, employers, profession and colleagues. In a recent survey, 31%

of speech-language pathologists had felt pressured to engage in unethical activities (e.g.

pressured to provide inappropriate intensity of services or services not clinically appropriate,

clinicians reporting productivity pressures affecting patient-care decisions)(American Speech-

Language-Hearing Association, 2017; J. Brown & Hemm, 2015). Also, the most frequent and

recurring concern to ASHA’s Board of Ethics were the demands and requests made by

employers or supervisors which would potentially violate the code of ethics (Denton, 2009b).

Organizations can exert a number of influences on individuals which may make them

reluctant to act as reporters; these include the significance of group belonging, fear of being a

“turncoat” or “tattle-tale”, negative publicity for the organization, lengthy procedures to

investigate activities, etc)(Clarke, 2016; Rhodes & Strain, 2004). Those features of an

organisation’s culture which act as a barrier to whistleblowing are the same as those hindering

client-centred care (Bright, Boland, Rutherford, Kayes, & McPherson, 2012). Claiming that

“loyalty to a colleague… exceeds a fiduciary duty to a patient is difficult to defend” (Fost,

2001, p. 1079). This dilemma may be intensified by cultural expectations (e.g. mateship and

loyalty are highly valued in Australia) (Sawyer, 2004; Thompson, 2008). Such ambivalence

in loyalty flies in the face of a client-centred approach and, as Kline and Khan (2013) state, if

you are concerned about the practice or behaviour of a colleague, “your first loyalty is to the

service user” (p. 21).

Another factor to consider is the relatively small size of the speech-language pathology

profession (e.g. the ratio of speech-language pathologists to physical therapists is 111,640 to

174,490 (US) and 11, 566 to 43,017 (UK)(Bureau of Labor Statistics, 2009; Workforce

Review Team NHS, 2007). Therefore, practitioners may know or be known by colleagues

9
within their geographic location or professional specialty (e.g. autism, dysphagia). The fact

that women derive social and emotional support from workplace friendships may be an

additional moral burden in such a female-dominated profession (2.5 – 6% of clinicians are

male)(American Speech-Language-Hearing Association, 2017; Health Workforce Australia,

2014).

Does the disclosure of breaches of care occur in speech-language pathology?

It is difficult to determine the extent of disclosure of such breaches in speech-language

pathology due to the sensitivity of the topic and a lack of research. A small number of journal

papers mention breaches such as unethical or incompetent medical practices or behaviour by

speech-language pathology colleagues, limited or inappropriate resources and provision of

treatment, etc (Buie, 1997; Helm-Estabrooks, 2003; Irwin et al., 2007; Kenny et al., 2007).

A source of more objective evidence is adverse incident reporting (used to estimate the extent

of medical injuries and patient safety health services). The under-reporting of adverse clinical

incidents is usually the norm and often less than 1% of incidents are reported (Vincent (2006)

quoted in Wakefield & Morin, 2009). The precise rates may be difficult to access due to

confidentiality and may vary by country, terminology/definition, profession, work experience,

type of incident or nature of reporting (Braithwaite, Westbrook, & Travaglia, 2008; Evans et

al., 2006; Lawton & Parker, 2002; C. Shaw & Coles, 2001) and existing research is

sometimes contradictory. Therefore, incident reporting systems are unable to provide a true

estimate of the possible rates of adverse events (Okuyama, Sasaki, & Kanda, 2010),

particularly as thus far, speech-language pathology has been unexplored. Serious, life-

threatening incidents or those which are immediate and often witnessed (e.g. falls) may be

more likely or more often reported than incidents which occur gradually (e.g. patient’s

therapy continuing without a review of effectiveness or progress)(Evans et al., 2006;

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Wakefield & Morin, 2009). Errors relating to the lack of necessary treatment are less likely to

be reported and yet twice as likely to be implicated in adverse events, compared to errors

relating to the wrong treatment (Evans et al., 2006). Similarly, breaches relating to quality of

life or participation limitation may not be disclosed. Financial and/or service delivery

restrictions may frequently prevent us from providing the treatment we judge to be

appropriate for our clients.

Complaints reported to professional associations and health councils may provide some

information on breaches of care. However these are usually confidential, often provided

without regard to the source (e.g. by the public, speech-language pathologists themselves,

other staff) or the nature of the complaint (e.g. medical fund fraud, misrepresentation of

qualifications/experience, service delivery cuts, workplace regulations, etc). The number of

complaints within healthcare professions in general (Health Professions Council, 2017; K.

Shaw, Cassel, Black, & Levinson, 2009), and speech-language pathologists in particular

(Speech Pathology Association of Australia, 2008), is rising. These trends may be due to the

implementation of new techniques (e.g. diagnostic instrumentation), the broader scope of

practice, new modes of service-delivery (e.g. person-centred care), greater consumer

awareness and litigation, the expectations of healthcare partnerships, increasing

caseload/workload/productivity, and burgeoning rates of chronic disease (American Speech-

Language-Hearing Association, 2017; Speech Pathology Association of Australia, 2008).

However, although the ASHA Board of Ethics receives approximately 3,000 ethics inquiries

per year (Denton, 2007), the number of complaints is considered to be relatively small

(Huffman, 2003). .

Patient satisfaction surveys may also be problematic in terms of identifying breaches of care.

These surveys, usually in the form of questionnaires, tend to simplify the complex issue of

11
patient satisfaction and are considered to be flawed (Draper, Cohen, & Buchan, 2001). A

major issue with such surveys is that clients may not report unethical behaviour in either

surveys or complaints; almost two-thirds of clients had experienced an ethical transgression

but of those clients, over 70 per cent had remained silent (Brüggemann, Wijma, &

Swahnberg, 2012). Furthermore, the number of patients who are unable to complete

satisfaction measures is a particular concern in rehabilitation (Keith, 1998). The survey format

of complaint form may exclude those health service users who are marginalized in the health

service (Draper & Hill, 1996) e.g. those with communication problems, poor health literacy or

mental health issues, or are older, too ill or of non-dominant language or cultural

backgrounds. They may also be dependent on services and therefore unwilling to challenge

the system openly in case they lose their existing care (H. Brown, 2000). Communicatively-

impaired populations may be particularly at risk of not being able to make a complaint or

complete a patient survey.

Whilst these more formal channels provide little conclusive proof for the existence of

breaches of care, in-depth qualitative research, although sparse, has indicated that clients and

their families have concerns regarding client care and speech-language pathologists’ actions.

For example, people with aphasia have described their dissatisfaction with the services

available to them (Parr, 2007; Parr, Byng, Gilpin, & Ireland, 1997; Worrall, Rose, Howe,

McKenna, & Hickson, 2007) and educators and parents have expressed concern regarding

certain aspects of speech-language pathology services in schools (Bellon, Vereen, & Ogletree,

2001; Sanger, Hux, & Griess, 1995) and in paediatric services (Carroll, 2010; Pappas,

McLeod, McAllister, & McKinnon, 2008). ASHA also publishes details of those members

who violate the Code of Ethics, although the incidence of less serious misconduct dealt with

in private is unknown (Denton, 2008).

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Disclosing breaches of care – what guidance do we have?

In the event of a violation of care, the actions expected are clearly and unequivocally spelled

out in the codes of speech-language pathology associations i.e. the concerns must be made

known to the association (American Speech-Language-Hearing Association, 2016; Canadian

Association of Speech-Language Pathologists and Audiologists, 2005; Royal College of

Speech and Language Therapists, 2006; Speech Pathology Australia, 2010). The resources

available for dealing with ethical dilemmas have been outlined above. ASHA’s Board of

Ethics “encourages individuals to work with colleagues to solve ethical dilemmas before they

mature to a point of a violation mandating the filing of a complaint” (Denton, 2009a). In

addition, speech-language pathologists are instructed to encourage their colleagues to file a

complaint against professionals who engage in intentional (rather than negligent) misconduct

(Denton, 2008). Health services or providers may place a stronger onus on employees; for

example, employees in the National Health Service in England “have a contractual right and a

duty to raise genuine concerns they have with their employer” (National Health Service,

2012, Section 21.1). In contrast, it is troubling that private practitioners perceived limited

options for managing the unethical behaviour of colleagues (Flatley et al., 2014).

The principle of nonmaleficence (not harming clients or even subjecting them to the risk of

harm through our negligence) is critical to disclosure. In some circumstances, the only way to

prevent harm happening may be to disclose the action or situation. According to Body and

McAllister (2009), nonmaleficence places us under “greater moral expectation not to harm

people than we are to actively help them” (p, 17). Even if clinicians are “merely passively

involved or just regular observers at their place of work, they must still speak up”

(Mandelstam, 2011, p. 366). We are accountable and responsible for our acts but also for our

omissions when we fail to act (e.g. using the same therapy programme for all clients with

13
aphasia, failing to take action on incompetent colleagues). As stated above, errors of

omission play a significant role in adverse events.

Disclosure can be considered as a form of advocacy, as it is in social work and nursing (Erlen,

1999; Greene & Latting, 2004). Advocacy is incorporated into many of the ethics codes

(Canadian Association of Speech-Language Pathologists and Audiologists, 2005; Speech

Pathology Australia, 2010) and is included as one of the four pillars in ASHA’s Strategic

Pathway to Excellence (Gottfred, 2008). As advocates for our clients and the profession, we

may be required to speak out about aspects of clinical practice in the interests of our clients

obtaining the most effective services possible e.g. therapists “have a responsibility to

challenge policies where they feel these are not in the best interests of individuals” (Royal

College of Speech and Language Therapists, 2006, p. 37)

A limitation of many codes of ethics is that they are aspirational, rather than prescriptive, in

nature and are profession-centred whereas clinical ethics are person-centred (Eadie &

Charland, 2005). In addition, these codes cannot accommodate all situations and dilemmas

and we may still be faced with uncertainty and conflicts. Large health organizations or

systems (like Medicare in the US) are concerned with communities and societies and

therefore focus on services which provide the greatest good for the largest number of clients

(Eby, 2000). This focus may clash with our duty to individual care and treatment.

The Boards of Ethics of the speech-language pathology associations are often limited in their

jurisdiction. They are thus unable to adjudicate on certain complaints, e.g. in the US, the

person complained about must be a member of ASHA (Denton, 2009a), and in Australia, the

association has no power to enforce standards. In the event of a serious issue (e.g. a child

reporting being physically abused by an SLP - Speech Pathology Association of Australia,

2008), the association would be obligated to report this to the appropriate authority.

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Unethical practice such as revealing information becomes ethical when it will prevent

someone from being hurt or mistreated (Guy, 1990).

The limited clinical ethics literature in our profession predominantly describes disclosure as a

complicated ethical conflict (Irwin et al., 2007) but exhorts speech-language pathologists to

report ethical breaches (Kenny et al., 2009) “despite personal and professional costs”

(McAllister, 2006, p. 79). The argument is clear; they should be disclosed for the sake of the

welfare and competent management of clients. In some situations, it would be unethical or

problematic for someone not to report an event because of fear of reprisal or a lack of interest

(Chabon & Ulrich, 2006).

It is apparent that within the speech-language pathology profession we do not have evidence

of either breaches of care or of the decision to report them. However, it would be naïve to

consider that our profession, amongst all other health care professions, could be devoid of

breaches or the need to report them. Given the complexity involved, the speech-language

pathology-related discussion in the literature is sparse and limited guidance is available.

Indeed, “experienced speech pathologists did not indicate that ethics literature, codes of

ethics, published case studies or hypothetico-deductive problem solving models facilitated

their ethical reasoning” (Kenny, Lincoln, & Balandin, 2010, p. 129). Furthermore, they had

difficulty in accessing adequate support from fellow professionals and, even then, did not

avail themselves of advice from the ethics committees of either their own employer or that of

their professional association.

The majority of health care professionals agree that breaches of care should be reported, even

if the effects of these breaches are transient and without long-term effects (Evans, Berry,

Smith, & Esterman, 2004; Scheirton et al., 2003). However, health care professionals may

not be willing to admit mistakes or breaches (Scheirton, Mu, Lohman, & Cochran, 2007)

15
This has been well-documented amongst doctors (Z. R. Wolf, Serembus, Smetzer, Cohen, &

Cohen, 2000) and occupational and physical therapists are equally hesitant to disclose errors

(Scheirton et al., 2007). Although clinicians value honesty, they may be fearful of admitting

errors because they fear being blamed and sanctioned within their profession, particularly as,

compared to doctors, allied health professionals were the most likely to say that they had a

punitive work culture (Braithwaite et al., 2008).

What are the costs of disclosing a breach of care?

The fallout from disclosing a breach of care to a supervisor, a professional association or

within an organization remains unreported in speech-language pathology. However,

generally within the health professions, the person who discloses a breach of care relating to

their practice is considered to be the problem, rather than the issue they raise (Faunce and

Bolsin 2003). Sources in speech-language pathology and other health professions are

unanimous in their views specifically of whistleblowing, describing it as a “morally

courageous action” (Fletcher, Sorrell, & Silva, 1998, p. 3), not to be taken lightly (Freegard,

2007), “not the easiest road” (Body & McAllister, 2009, p. 132), “extremely dangerous”

(Kerridge, Lowe, & McPhee, 2005, p. 109), “fraught with serious consequences for all

parties” (Pannbacker, 1998, p. 19), with many whistleblowers who “do not survive unscathed

or intact” (Bolsin, 2003, p. 294).

Those who disclose breaches of care may get fired, discredited, harassed, intimidated and

silenced, often resulting in high financial, health and emotional costs (Martin, 2005). In

medicine, disclosure is considered “a professional dilemma and a personal disaster” (p. 1262),

with doctors who report poor patient care being punished with career damage and

professional isolation (Cassidy, 2009). Speech-language pathology students disclosing

breaches may risk lower grades or failure (Body & McAllister, 2009). Nurses who acted as

16
whistleblowers reported high levels of stress-induced physical effects (sleep disturbances,

immune system disturbances, digestive system problems and respiratory/cardiac problems)

and emotional problems (anger, sadness, anxiety, fear, unworthiness)(McDonald, 2002).

They may also “experience significant hardship and are often alienated by their organisation,

managers and colleagues” (Jackson et al., 2014, p. 248). The fact that disclosing a breach of

care is considered to be so detrimental to the individual may convince many speech-language

pathologists and other health professionals to remain silent.

Are there any costs to not speaking out about a known breach of care?

If disclosing breaches is so problematic, what are the implications of not doing so? Firstly, by

not disclosing, the people we care for may be at risk of failing “to deliver our professional

obligation to patients” (Stevens, 2009, p. 486); that is to prevent abuse or harm. Kenny et al

(2009) stress that “our failure to accept professional responsibility for reporting ethical

concerns may perpetuate incompetent practice” (p. 430). Catt (2000) states that being a

member of a profession means being both loyal and a steward; professionals are loyal to their

clients and hold their interests paramount over their employer’s interests. Loyalty is usually

considered a virtue; however, at times loyalty to colleagues and the organization/profession

can be blind or misplaced and no longer considered a virtue because harm is the result (Ray,

2006). This conflict between the need to prevent abuses and preserve trust is a major point of

ambivalence for potential reporters. Preventing abuse is of particular significance within

speech-language pathology because the desire to help others was found to be the main reason

for choosing and remaining in speech-language pathology as a career (Russo & Flahive, 2005;

Whitehouse, Hird, & Cocks, 2007).

Person-centred care includes fostering good communication between clients and their care

team, providing appropriate information for clients and caregivers and practising shared

17
decision-making (Levit, Balogh, Nass, & Ganz, 2013). Keeping clients informed on all

aspects of their treatment also extends to those aspects that may have not been beneficial.

Non-disclosure can easily destroy the fragile relationship of trust and truthfulness between

practitioner and client (Scheirton, 2008) and damage the very means by which we deliver

treatment i.e. the relationship between client and therapist (Worrall et al., 2010). Trust is

considered essential in healthcare “where patients are vulnerable and must put themselves in

the hands of health care professionals” (Beauchamp & Childress, 2009, p. 41). For effective

person-centred decision-making to take place, all the facts, even the breaches, need to be

known to the client. Concern for harming the client, damaging client trust and staff

opposition are not regarded as valid reasons to justify secrecy regarding breaches of care

(Beauchamp & Childress, 2009).

Secondly, if we do not appropriately disclose a breach of care, we are not aspiring to the code

of ethics of our professional organization or responsibility to our profession; this is considered

the ultimate outcome of not disclosing an alleged ethical violation (Irwin et al., 2007). The

lack of disclosure has been described as a “stain on the medical profession” (Cassidy, 2009, p.

264) and a contradiction of the “very essence of professionalism” (Stevens, 2009, p. 483).

Speech-language pathologists’ failure to accept professional responsibility for disclosing

breaches of care may perpetuate incompetent or improper practices (Pannbacker 1998) and is

a significant issue which affects workplace culture (Kenny et al., 2009).

Thirdly, our own personal values may be compromised. Those who speak out usually do so

“out of a sense of public duty arising from high personal ethical standards” (Kerridge et al.,

2005, p. 171). If we do not speak out we compromise our own integrity; the cost of

remaining silent is to “lose a little of our soul” (Body & McAllister, 2009, p. 143) or suffer

from moral distress i.e. “when one knows the right thing to do, but institutional or other

18
constraints make it difficult to pursue the desired course of action” (Raines, 2000, p. 30). As

Freegard (2007) states, “(k)nowing that real harm is continuing to be perpetrated against

innocent people subverts personal conscience and self-respect. Health professions and health

professionals face loss of integrity and, ultimately, harm if the unacceptable behaviours

continue” (p, 88). In a surprising finding, “non-whistleblowers” (nurses who

identified/witnessed unethical situations in the workplace but who did not report it openly)

experienced stress-induced physical (64%) and emotional (92%) symptoms, similar to those

of the whistleblowers themselves (McDonald, 2002). Therefore, either speaking out or

remaining silent may result in similarly distressing physical and emotional effects. If we do

not attempt to deliver person-centred care, we may manage rehabilitation in a personally

distanced way; this may protect us from moral distress but the treatment offered will be very

restricted (Macleod & McPherson, 2007).

Working continually under conditions of moral compromise may be emotionally damaging

and exhausting. As professionals, we are expected to have “a heightened sensitivity to the

presence of a moral issue, ... enhanced skills in implementing moral decisions and acting in

morally demanding situations” (Hussey, 1996, p. 251). Furthermore, the speech and language

therapy profession commends itself to people with an attitude of caring (College of Speech

and Language Therapists, 1992). Health professionals have higher levels of stress of

conscience and reported emotional exhaustion and depersonalization (from lack of time to

provide adequate care, having to deaden one’s conscience, not living up to others’

expectations and lowering aspirations)(Glasberg, Eriksson, & Norberg, 2007, 2008). This

moral distress is exacerbated by, and more frequently-occurring in, a more negative ethical

healthcare climate (e.g. working with incompetent staff, compelled to act in ways not in the

client’s best interests, etc)(Oh & Gastmans, 2015). Not speaking out may lead to feelings of

helplessness (Ash, 2016). Burnout amongst personnel is becoming increasingly common,

19
particularly amongst health professionals including speech-language pathologists (Felton,

1998; Glasberg et al., 2007; Kälvemark, Höglund, Hansson, Westerholm, & Arnetz, 2004; Oh

& Gastmans, 2015; Rittenmeyer & Huffman, 2009; Whitehouse et al., 2007). It also

contributes to attrition e.g. it was a factor for 25.5% in leaving a speech-language pathology

position (American Speech-Language-Hearing Association, 2007) and for 13% of current

members of Speech Pathology Australia intending to leave the profession in the next 12

months (McLaughlin, Lincoln, & Adamson, 2008). Speech-language pathologists report

stress, tension and negative attitudes arising from excessive workload/pressure/stress (22.5%)

and the inability to give good patient care or have enough patient contact time (18%) (Loan-

Clarke, Arnold, Coombs, Bosley, & Martin, 2009). Systemic factors (overwhelming

paperwork, overwork, lack of time, and large caseload sizes) were stressors amongst school

clinicians (Blood, Thomas, Ridenour, Qualls, & Hammer, 2002).

In addition and more importantly, those speech-language pathologists who have high ethical

values may not be able to continue in a profession where they have to contravene their own

ethical values; for example, 15% stated that “ethical conflict with policies” was a factor in

leaving a speech-language pathology position (American Speech-Language-Hearing

Association, 2007). These are the clinicians whom McAllister (2006) suggests can act as

moral agents in the workplace and raise awareness in others about ethical issues by example

and through education. Disclosing wrongdoing was highly valued both by those who reported

it and by those who observed, but did not report, the event (A. J. Brown, 2008) and is more

likely to lead to more constructive coping mechanisms and resultant practice changes (Mu et

al., 2006).

What can we as individuals and as a profession do?

20
Looking to the future of the profession, enhancing the ethical education of speech-language

pathologists should be a priority. New graduates need to be adequately prepared for ethical

practice and for their involvement in discussions about ethics, especially as healthcare

practices change (Kenny et al., 2009). Of concern is the fact that about one third of ASHA

respondents reported that they had no training as undergraduate students and more than a

quarter said they had no training in ethics as graduate students (Buie, 1997), although recent

emphasis on ethical training may have altered these statistics. Similarly, 71% of Australian

respondents indicated that they had received no training related to their Code of Ethics and

“as many as sixty percent of new graduate speech pathologists may be unable to demonstrate

entry level competency in ethical practice” (Smith, 2007, p. 232). Based on this, current

education does not appear adequate to equip us to deal proactively with the constant ethical

issues confronting us.

The focus on competency-based education and assessment has the advantage of greater

transparency and public accountability but, it tends to “limit the reflection, intuition,

experience and higher order competence necessary for expert, holistic or well-developed

practice” (Talbot, 2004, p. 587). Therefore those complex skills which we need for

professional practice, including ethical behaviour, may be ignored; the danger is that more

technical competencies which are more easily measured are assessed whilst those higher-

order competencies may be side-lined (DiLollo & Favreau, 2010; Kälvemark et al., 2004).

Increasing the opportunities for students to discuss and reflect on ethical situations in a non-

threatening environment may benefit our practice. Ethics is considered to be fundamentally a

matter of questions and these questions require openness, deliberation, self-questioning, and

reflection (Austin, 2007). Therefore, by discussing ethical situations with others one may

reach appropriate ethical solutions (Austin, 2007). Working with students to apply ethical-

decision-making models to case scenarios has been found to be beneficial (McAllister &

21
Lincoln, 2004) and may facilitate the development of ethical reasoning (Kenny et al., 2007).

Giving students the opportunities to reflect on their moral distress or troubled consciences and

express their moral concerns, their conscience and moral sensitivity may become an asset

rather than a burden (Glasberg et al., 2007, 2008).

Similarly, the focus on the medical model of treatment and evidence-based practice in speech-

language pathology may be at odds with person-centredness (DiLollo & Favreau, 2010).

Person-centred care needs to be integrated into therapeutic processes and reflected in

education/professional development (DiLollo & Favreau, 2010; McCormack et al., 2010). A

shift in training and in practice is required, away from concrete, discipline-specific knowledge

and skills towards the incorporation of knowledge such as psychodynamic, intrapersonal,

subjective and affective constructs (Geller & Foley, 2009a, 2009b).

The recently extended scope of speech-language pathology practice, including advocacy,

disclosure, and changing organizational culture, need to be emphasized in training and

professional development. As stated above, advocating for our clients is part of our

professional behaviour and therefore students need to learn how to manage situations in

which there is a breach of care and need to be prepared to be a client advocate which may, at

times, mean being a reporter of these breaches (Erlen, 1999; Kenny et al., 2009). If new

graduates can move into the workplace armed with opportunities and strategies to advocate

effectively for clients, they may achieve outcomes that are consistent with ethical practice

(Kenny et al., 2007). Ongoing education, professional development and guidance from

professional associations in ethics should be paramount to provide clinicians with access to

discussions on complex ethical decision-making (Kenny et al., 2010). It is of concern that

undergraduate students were more likely to blow the whistle than qualified practitioners, in

social work, physiotherapy, nursing and in medicine (Mansbach & Bachner, 2008; Mansbach,

22
Kushnir, Ziedenberg, & Bachner, 2014; Mansbach, Melzer, & Bachner, 2012; Rennie &

Crosby, 2002). There are increasing opportunities to attend workshops or presentations (e.g.

at the ASHA Annual Conventions), or to learn from journal papers on various aspects of

ethics.

No matter how extensive or comprehensive ethics education is, it does not make a person

more ethical (Begley, 2006). Behaving ethically does not depend on acquiring a static body

of knowledge or specific guidelines to manage ethical dilemmas. As Brecher (2010) states,

professionals must act “not in their capacity as such-and-such a professional, but in virtue

simply of their being a person, and as such being a moral agent” (p. 355). McAllister (2006)

has highlighted the need for research into how to develop ethical awareness and reasoning in

professional development. Therefore, what is needed is teaching that facilitates “moral

development, practical wisdom, and excellence of character (moral virtue) so that the

professional can make sound ethical judgements in practice” (Begley, 2006, p. 258). The role

of the educator must include increasing the student’s sensitivity to ethics so that this is always

at the forefront of their mind (Denton, 2008). Therefore clinical educators should take a more

direct approach to teaching ethics (Smith, 2007) and they should also be valued for their role

as ethical mentors.

As an employee, the most appropriate place for dealing with most alleged violations is within

rather than outside the organization (American Speech-Language-Hearing Association, 2016).

Although clinicians perceived that sharing ethical dilemmas could facilitate ethical outcomes,

they often hid such issues from colleagues (Kenny et al., 2010). The healthcare team can be

an exceptional source of support for its individual members, as well as a useful arena in which

to discuss values (Byng, Cairns, & Duchan, 2002). Most clinicians (86%) discussed their

ethical dilemmas with their colleagues whilst 47% spoke to a third party (which would have

23
confidentiality issues)(Buie, 1997). More experienced clinicians (61%) discussed the issues

directly with the person with whom they disagreed. If necessary, disclosure should follow the

chain of command (Pannbacker, 1998), by discussion face-to-face with a colleague or

supervisor, before resorting to discussions with the ethics committee of the organization, and

then finally to local, state or national adjudication processes (Greene & Latting, 2004; Irwin et

al., 2007). These steps maintain the confidentially of all involved and are the most cost-

effective. Experienced clinicians reportedly did not seek advice from their professional

associations, even though they provide a confidential environment in which to discuss ethical

dilemmas (Kenny et al., 2010)

Finally, to be truly accountable to our clients, our profession, our employer and ourselves, we

should focus on changing healthcare employers’ organization and management. Calls have

highlighted the urgent need for change in healthcare quality and safety (Faunce & Bolsin,

2004), as well as a culture change to encourage appropriate disclosure (Connor, Ponte, &

Conway, 2002; Gooderham, 2009; Johnstone, 2004; McAllister, 2006). Also, the

organisational context is important in encouraging and facilitating professionalism (Health

and Care Professions Council, 2014); the extent to which rehabilitation is person-centred is a

function of the organisation’s culture and operation (Cott, 2004; McCormack et al., 2010).

Ray (2006) argues forcefully that “an organization that does not support those that

whistleblow because of the violation of professional standards is indicative of a failure of

organizational ethics” (p, 438). This institutional failure demonstrates a lack of accountability

on the part of the organization and the health care worker (Fletcher et al., 1998) which may

endanger the safety and welfare of the clients (Lachman, 2008). Disclosing breaches can thus

be considered as an important integrity system for keeping organizations accountable (A. J.

Brown, 2008). Such disclosures can provide an organization with the impetus to develop a

wide range of options to resolve conflicts and prevent them from reoccurring (Irwin et al.,

24
2007). These strategies may include developing new mission and value statements, or their

own code of conduct, providing ongoing educational forums and training programs,

establishing appropriate internal disclosure/complaints procedures which ensure those who

report violations are not subject to retribution, etc (American Speech-Language & Hearing

Association, 2016; Greene & Latting, 2004; Lachman, 2008; Ray, 2006). Those clinicians in

managerial and supervisory roles are ideally placed to reinforce their ethical and accountable

stance within their department (Blanchard & Peale, 1988).

Conclusions

Our profession is continually evolving and developing due to a broader scope of practice,

greater consumer expectations and knowledge, increased person-centred care and expanded

use of technology, constrained by an increasingly ageing population, escalating financial

limitations and a litigious healthcare climate. This recent and ongoing transformation of the

speech-language pathology profession demands renewed vigilance as we deal with unfamiliar

and complex ethical dilemmas. This paper has focussed on the resources, training and

frameworks required to deal with these dilemmas as well as strategies to tackle and minimize

the need for disclosures of breaches of care.

Disclosing breaches of care within or outside of an organization is not an easy step to take.

However, if the care or safety of our clients is in jeopardy, then this is a step we may have to

take. Such disclosures can be considered to serve the same function as an alarm (a warning to

arouse or attract attention to a problem) or a safety valve (a means of saving a system from

danger). These disclosures can thus be used as a feedback mechanism to improve our

effectiveness and enable us to practice our profession with increasing proficiency and

enhancing the care to our clients. Healthcare services can benefit by learning from complaints

and by examining adverse incidents (Kline & Khan, 2013). It is imperative that both

25
individuals and organisations recognise that those speaking out about harm are alerting the

organisation about failure (Ash, 2016).

Of any profession within health, speech-language pathologists are acutely aware of the

importance of communication; most of our work is aimed at helping others find their voice so

that they are able to communicate their thoughts, feelings, concerns and needs. We are in a

unique position; we are bound not only to care for our clients but also to act as advocates,

either in partnership with them or on their behalf, if there is a breach of care. It is imperative

that health care professionals recognise the importance of “moving away from what could be

regarded as a cowardly stance,; that is, passing by in silence the suffering of those they are

meant to be caring for” (Mandelstam, 2011, p. 366). It is vitally important for our clients, the

speech-language pathology profession and for ourselves that we actively and continuously

prepare ourselves for the demands of solving ethical dilemmas and dealing with possible

disclosures so that our clients receive person-centred, timely and effective care.

Declaration of interest: The author reports no declarations of interest. The author alone is

responsible for the content and writing of the paper.

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