International Journal of Speech-Language Pathology

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Ethical dilemmas experienced by speech-language pathologists working in private practice Danielle R. Flatley, Belinda J. Kenny & Michelle A. Lincoln To cite this article: Danielle R. Flatley, Belinda J. Kenny & Michelle A. Lincoln (2014) Ethical dilemmas experienced by speech-language pathologists working in private practice, International Journal of Speech-Language Pathology, 16:3, 290-303 To link to this article: http://dx.doi.org/10.3109/17549507.2014.898094

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Date: 10 November 2015, At: 08:28

International Journal of Speech-Language Pathology, 2014; 16(3): 290–303

Ethical dilemmas experienced by speech-language pathologists working in private practice

DANIELLE R. FLATLEY, BELINDA J. KENNY & MICHELLE A. LINCOLN

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Faculty of Health Sciences, The University of Sydney, Sydney, Australia

Abstract Speech-language pathologists experience ethical dilemmas as they fulfil their professional roles and responsibilities. Previous research findings indicated that speech-language pathologists working in publicly funded settings identified ethical dilemmas when they managed complex clients, negotiated professional relationships, and addressed service delivery issues. However, little is known about ethical dilemmas experienced by speech-language pathologists working in private practice settings. The aim of this qualitative study was to describe the nature of ethical dilemmas experienced by speech-language pathologists working in private practice. Data were collected through semi-structured interviews with 10 speech-language pathologists employed in diverse private practice settings. Participants explained the nature of ethical dilemmas they experienced at work and identified their most challenging and frequently occurring ethical conflicts. Qualitative content analysis was used to analyse transcribed data and generate themes. Four themes reflected the nature of speech-language pathologists’ ethical dilemmas; balancing benefit and harm, fidelity of business practices, distributing funds, and personal and professional integrity. Findings support the need for professional development activities that are specifically targeted towards facilitating ethical practice for speech-language pathologists in the private sector.

Keywords: Ethics, ethical dilemmas, private practice, speech-language pathology.

Introduction Speech-language pathology is a dynamic profession continually undergoing change (Speech Pathology Australia, 2003). Speech-language pathologists must adapt to changing healthcare demands and constraints whilst maintaining effective and ethical practice. Typically they are employed within contexts of limited budgets, increasing costs to deliver healthcare (Kenny, Lincoln, Blyth, & Balandin, 2009), and service rationalization (Cross, Leitão & McAllister, 2008; Kenny et al., 2009). Private practice has been identified as an area of growth for the profession, which may be attributable to demand for services unmet by the public sector (Speech Pathology Australia, 2005). Healthcare policy and practice in Australia has been widely influenced by bioethical principles of beneficence/non-maleficence, justice, and respect for autonomy (Beauchamp & Childress, 2012). The underlying duties and values incorporated in doing good, preventing harm, and advocating for justice and respect for persons serve as a framework to guide healthcare decision-making processes (Freegard, 2007). These ethical principles are

perceived as equally important. However, healthcare practice may require prioritization of one or more principles (Freegard, 2007). For example, decisions regarding the distribution of healthcare resources within the community involve consideration of justice, benefits to identified priority client groups, and potential harms to clients who may need to wait longer or receive less occasions of service. Healthcare professionals must attempt to balance competing ethical principles when such dilemmas occur. Beauchamp and Childress (2012) conceptualize ethical dilemmas into a paradigm of two types of ethical conflict. An ethical dilemma may exist where one option exists and can be considered both right and wrong, with reasonable evidence to support both sides, or, alternatively, where two or more options exist, each with reasons either supporting or opposing that option (Beauchamp & Childress, 2012). This tension between what one ought to do and not do differentiates ethical dilemmas from wider professional issues where ethical principles may not be at stake. Nonetheless, professional issues that impact upon client care, service delivery, professional standing, and the wellbeing of the community

Correspondence: Belinda Kenny, Discipline of Speech Pathology, Faculty of Health Sciences, The University of Sydney, 75 East Street, PO Box 170, Lidcombe, NSW, 1825, Australia. Email: [email protected] ISSN 1754-9507 print/ISSN 1754-9515 online © 2014 The Speech Pathology Association of Australia Limited Published by Informa UK, Ltd. DOI: 10.3109/17549507.2014.898094

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Ethical dilemmas in private practice

clearly incorporate ethical decision-making (Leitão, Bradd, McAllister, Russell, Kenny, Scarinci, et al., 2012). The values, principles, and standards that comprise Speech Pathology Australia’s Code of Ethics support speech-language pathologists to demonstrate professionally acceptable behaviour and take a leadership role in managing ethical issues in the practice of speech pathology (Speech Pathology Australia, 2010, Code of Ethics, p. 1). Health professionals, including speech-language pathologists, have experienced caseload changes in response to an ageing population, advances in surgical and medical technology, and improved trauma survival rates (Atherton & McAllister, 2009; Bureau of Labor Statistics, 2014; McAllister, 2006). These changes may pose ethical dilemmas when decisions need to be made regarding prioritization of clients or maintaining quality-of-life whilst working within limited budgets (Atherton & McAllister, 2009). In order to maintain ethical practice, speech-language pathologists must also consider their own competence in working with new and increasingly complex caseloads (Atherton & McAllister, 2009). Business and ethical practice In response to needs for guidance in ethical practice, professional associations have developed Codes of Ethics (American Speech-Language-Hearing Association, 2010; Canadian Association of SpeechLanguage Pathologists and Audiologists, 2005; Speech Pathology Australia, 2010). The codes define ethical principles and professional values that underpin ethical decision-making. Speech Pathology Australia’s Code of Ethics is based upon five bioethical principles; beneficence (and non-maleficence), truth, fairness (justice), autonomy and professional integrity (Speech Pathology Australia, 2002, 2010). See Supplementary Appendix A available online at http://informahealthcare.com/doi/abs/10.3109/1754 9507.2014.898094 for definitions of these principles. These principles are aspirational rather than regulatory and were developed for broad application in professional work places (Kenny, 2008). Speech Pathology Australia revised the association’s Code of Ethics to address contemporary ethical concerns raised by the profession and the community (Speech Pathology Australia, 2010). Speech-language pathologists work in diverse settings, including: hospitals, private practice, community health, education, aged care, mental health, non-government organizations, correctional institutions, and within clients’ homes (Speech Pathology Australia, 2002), and may identify different pressures and ethical dilemmas according to their work environment. When speech-language pathologists consult their Code of Ethics, they are required to interpret and apply the principles, duties, and values within their healthcare context (Kenny,

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2008). MacKenzie (1992) proposed that clinicians working in private practice perceive principles within Codes of Ethics differently to their public sector colleagues. Private practitioners must address professional and business concerns and are directly responsible and accountable for decisions made in their day-to-day work. While the need to uphold ethical standards is strongly upheld by members of the business community (Issa & Pick, 2010; Pimentel, Kuntz, & Elenkov, 2010), potential conflict between healthcare and business outcomes requires further consideration. Ethical dilemmas in speech-language pathology Few studies have examined ethical dilemmas experienced by speech-language pathologists. However, previous surveys of health professionals from other disciplines, including physiotherapists and occupational therapists (Barnitt & Partridge, 1997), general practitioners (Braunack-Mayer, 2001), and pharmacists (Chaar, Brien, & Krass, 2005) demonstrated that health professionals frequently experience ethical dilemmas that involve issues of benefit, harm, and autonomy in client care. For example, studies of medical professionals showed that issues of overtreatment and end-of-life care result in ethical conflict particularly when concerns exist regarding clients’ decision-making capacity (Hurst, Perrier, Pegoraro, Reiter-Theil, Forde, Slowther, et al., 2007; Sørlie, Förde, Lindseth, & Norberg, 2001; Sørlie, Lindseth, Udén, & Norberg, 2000). Furthermore, healthcare economic constraints and team or family conflict around goal-setting were shared interdisciplinary concerns (Kirschner, Stocking, Wagner, Foye, & Siegler, 2001). Previous studies indicated that health professionals experience shared and profession-specific dilemmas related to their professional roles and responsibilities. Barnitt (1998) surveyed a large group of 182 occupational therapists and 179 physical therapists from England and Wales. More than 70% of respondents from each professional group reported that they experienced ethical dilemmas in the workplace. However, there were differences in perceptions of the nature of ethical conflicts. Occupational therapists described difficult patient behaviour, working with unprofessional and incompetent colleagues, perceived lack of respect from therapists towards vulnerable patients and from patients towards clinicians, complex discharge decisions, confidentiality issues, and resource limitations as ethically troubling. Physical therapists shared concerns regarding the management of “difficult” patients, unprofessional colleague behaviours, and perceived disrespect for healthcare recommendations. However, physical therapists reported that unfair resource allocation, external factors impacting upon quality of intervention, and truth-telling during healthcare interactions underpinned many ethical dilemmas in their professional practice.

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Braunack-Mayer’s (2001) interviews with South Australian general practitioners identified professional relationships with colleagues as a major source of ethical conflict. Findings suggested that medical practitioners have other discipline-specific ethical concerns that may incorporate attitudes towards abortion, provision of sickness certificates, treating patients with histories of substance abuse, euthanasia, and decisions regarding concealment of information from patients and their families. Two studies have identified ethical dilemmas in the speech-language pathology profession. Buie (1997) reported findings of a survey conducted by the American-Speech-Language-Hearing Association (ASHA). A total of 815 ASHA members completed the survey; 84% were speech-language pathologists, 11% were audiologists, and 5% were certified as speech-language pathologists and audiologists. Buie found that participants experienced ethical dilemmas relating to client management, prioritizing clients, external limits upon treatment, inadequate training or supervision, and unethical behaviour of colleagues. Survey responses did not provide a description of these dilemmas. The number of privately employed speech-language pathology participants was not reported; however, 46% of respondents were employed within public schools (46%). Many participating audiologists were employed privately (42%). Survey responses were presented for the cohort as a whole; therefore, it is not possible to determine which ethical dilemmas were identified by speech-language pathologists working in public or private settings. Healthcare contexts have continued to evolve since 1997, and changing workplace demands may have altered the nature of ethical dilemmas experienced by contemporary speech-language pathologists. Kenny et al. (2009) qualitatively investigated the nature of ethical dilemmas experienced by new graduate and experienced speech-language pathologists within public settings. Twenty speech-language pathologists participated in the research. Data was collected through in-depth interviews. The participants of this study were employed in public hospitals, community health centres, or disability services. The authors found that speech-language pathologists experienced different types of ethical dilemmas depending upon professional experience. New graduate speech-language pathologists experienced ethical dilemmas when they were required to make complex intervention choices, avoid conflict with clients and colleagues, follow strict workplace policies whilst providing quality services, and assert their professional identity. Experienced speech-language pathologists experienced ethical dilemmas regarding clients and decision-making, adapting workplace policies, and professional status as role models and advisors to less experienced clinicians. Kenny et al.’s (2009) findings showed that a serious medical diagnosis, poor prognosis, psychosocial, and

cultural issues increased the complexity of client management and the vulnerability of some healthcare consumers to potential harm. Furthermore, participants reported that existing healthcare policies did not ensure equal quality of intervention or health benefits across speech-language pathology caseloads. For example, participants employed in hospital settings were concerned when clients who were frail and/ or aged received limited access to rehabilitation. Conflict between upholding standards of professional competence and a need to distribute existing resources across large caseloads was consistently raised by participants who perceived a widening gap between evidence-based practice and day-to-day clinical reality. The authors also found that speech–language pathologists experienced conflict between duties towards their employers and clients and during negotiating professional relationships with clients, carers, and colleagues. Participants debated the benefits of filtering information to meet the perceived skills and resilience of clients and their carers. New graduate speechlanguage pathologists were confronted by diverse community attitudes towards parenting and health issues. Participants also considered responsibilities and boundaries when advocating for people with communication and swallowing problems. Concerns with duties to employing organizations were evident in speech-language pathologists’ attempts to avoid negative media attention or consumer complaints, even when they were troubled by service delivery policies. Another finding from this study demonstrated that speech-language pathologists are deeply concerned by unethical and incompetent professional behaviour but may be somewhat reluctant to report colleagues who engage in such behaviours. Some of the ethical dilemmas experienced by new graduate and experienced speech-language pathologists in Kenny et al.’s (2009) study involved aspects of professional practice which are not restricted to the public sector. For example, conflict with professional colleagues or concerns about professional reputation may not be context-specific issues. Nonetheless, many of the dilemmas identified by Kenny et al.’s (2009) participants were based upon their struggles with long waiting lists, under-staffing and health service policies. Such dilemmas may not resonate within the private sector. To date there has been no investigation into the nature of ethical dilemmas experienced by speechlanguage pathologists working in private practice. MacKenzie (1992) suggested that ethical dilemmas may arise in private practice as a result of combining business with service delivery. However, Edwards (1992) refuted Mackenzie’s claims and postulated that speech-language pathologists shared ethical dilemmas, irrespective of work settings. Concerns arising in private practice may be interpreted and managed differently to those working in public settings due to different personal and professional pressures (e.g., maintaining a financially viable practice

Ethical dilemmas in private practice

and an adequate source of income). Private practitioners may experience additional ethical conflict with issues of marketing and competition, fees charged for services, and motivation for profit (MacKenzie, 1992). Additional concerns included clients’ desire for service due to public waiting lists, efficacy of services provided, and access to supervision. Limited knowledge about ethical dilemmas in private practice is a barrier to developing adequate resources, educational materials, and mentoring for managers and new graduates who join a private practice.

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Ethical dilemmas in private practice The private sector has been identified as an important growth area in the speech-language pathology profession (Speech Pathology Australia, 2005). Hence, it is important to describe the nature of ethical dilemmas experienced by speech-language pathologists working in this sector and to support these professionals to achieve and maintain ethical professional and business practices. This exploratory investigation was the first to specifically address ethical dilemmas in privately-funded speech-language pathology workplaces. The aim of this study was to identify and describe the nature of the ethical dilemmas experienced by speech-language pathologists working in private practice.

Method Approach A qualitative approach to research design and data collection was adopted to provide the researchers with insight into how issues were experienced by participants (Higgs & Cant, 1998). A constructivist philosophical stance allowed the researchers to interpret and describe the experiences from participants’ perceptions (Higgs, 1998). Important features of the constructivist world view are the concepts of multiple realities and that people from a similar background may share perceptions of experiences. Here, speechlanguage pathologists shared roles and responsibilities associated with managing a privately-funded practice. However, they may assign different meanings to ethical concerns according to the nature and location of their practices. A qualitative descriptive research design was used as it provided “a comprehensive summary of an event in the everyday terms of those events” (Sandelowski, 2000, p. 336). A qualitative descriptive approach focuses upon the “who”, “what”, and “where” of phenomena with outcomes of a rich, descriptive summary of participants’ experiences. Recruitment Purposive sampling involves the selection of cases with knowledge and experiences relevant to specific

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research aims and may be used to target representative and contrast cases (Teddlie & Yu, 2007). Purposive sampling was used to recruit speech-language pathologists who were engaged in private practice for one or more days per week, with a minimum 12 months experience working in private practice, and who were eligible for full practising membership of Speech Pathology Australia. The investigators clearly indicated that the study was exploring ethical dilemmas in private practice. Participants were recruited by contacting the NSW representative for the Private Practice Network, Speech Pathology Australia, who forwarded study information to private practitioners on this mailing list. The first author also emailed speech-language pathologists whose public listing on the Speech Pathology Australia website indicated they were currently employed privately within metropolitan Sydney. One hundred speech-language pathologists were contacted regarding the study. The first author aimed to maximize variation by targeting potential participants from a range of practice locations and searching for diverse caseloads in practice descriptions. A reminder email was sent 1 week after the initial contact. Speech-language pathologists who expressed an interest in the study were emailed a Participant Information Statement. Following a limited response, the first author emailed a further 104 speech-language pathologists using the aforementioned process. A total of 14 speech-language pathologists expressed an interest in participation. However, one respondent did not meet the inclusion criteria, one responded after data collection was completed, and two respondents were unable to commit time to participate. The remaining 10 respondents were included in the study. Participants Table I describes the 10 participants who were included in the study. All participants were women and reported that they were managers and owners of their practices. General demographic information was recorded, including age and experience range, to protect the identity of the SLP and their practice. One participant declined to provide an age range, but indicated that she was aged over 60 years. Most participants (n ⫽ 7) were aged between 30–40 years, with two above and one below this age range. One participant did not supply information regarding her private practice experience. Of the remaining participants, four reported 5 or less years of private practice experience, five participants had accrued more than 5 years of experience, and two very experienced participants reported more than 25 years employment within the private sector. Participants’ practices were diverse in settings and caseloads. Eight participants reported full-time workloads and two were employed part-time. Four participants reported managing a mixed caseload, whereas two participants specialized in adult disorders, and four

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Table I. Participants.

Age

Years of experience working in private practice

Caseload

Workload

40–50 35–45 30–40 20–30 30–40 30–40 30–40 60⫹ 30–40 30–40

25⫹ 5–10 1–5 1–5 5–10 5–10 # 25⫹ 1–5 1–5

General paediatric, nursing homes Developmental delay/disability, general Paediatric, adolescent Paediatric, disability Paediatric General, nursing homes, Adult acute, rehabilitation Paediatric, adults Paediatric Adult voice, speech, swallowing

Full-time Full-time Full-time Full-time Full-time Full-time Full-time Part-time Full-time Part-time

Participants* Anne Ellie Aimee Kate Emma Clare Rebecca Therese Debbie Renee

Size of practice 4 7 1 6 8 1 3 1 4 1

SLPs, 2 locations SLPs SLP, 1 Psychologist SLPs SLPs, 2 locations SLP SLPs SLP SLPs, 1 Occupational Therapist SLP, 2 locations

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* Pseudonyms have been used to protect identity of participants. #Participant did not disclose years of experience in private practice. SLP, Speech-language pathologist.

participants managed paediatric clients. Two participants reported that they were bilingual and provided services to clients from diverse cultural and linguistic backgrounds. Practices were located in different socioeconomic areas from southern, eastern, and western Sydney, NSW. The practice settings ranged from single clinician home-based practices to specialist office-based practices and multidisciplinary centres. Participants reported individual, group, and consultative service delivery models. Data collection Interview questions were developed by the authors and piloted with two experienced speech-language pathologists, with private practice experience, prior to the study. The semi-structured interview protocol was based upon three levels of questions (Rubin & Rubin, 2012). Broad (main) questions were prepared to address the research aims. These questions were open-ended to provide participants with an opportunity to describe experiences in narratives. Probes were developed to facilitate participants’ providing evidence or examples of ethical concerns. Potential follow-up questions were prepared, but this question type was adapted on line in response to specific comments made by participants. Follow-up questions were designed to elicit additional depth or detail in participants’ responses. The research interview protocol is presented in Supplementary Appendix B available online at http://informahealthcare.com/doi/ abs/10.3109/17549507.2014.898094. The first and second authors conducted and audio-recorded individual interviews with the participants in their workplace following responsive interviewing techniques. Responsive interviewing is drawn from interpretive constructivist philosophy and is based upon the premise that the relationship between an interviewee and interviewer is significant, depth of understanding is paramount in research findings, and flexibility underpins effective data collection (Rubin & Rubin, 2012). A semi-

structured interview protocol provided the interviewer with the opportunity to guide content through pre-determined questions and to respond to content by generating questions as the interview was in progress (DiCicco-Bloom & Crabtree, 2006). Features of responsive interviewing included acknowledging participants’ emotional responses to ethical conflict, providing opportunities for participants to focus upon aspects of dilemmas that they perceived as important or concerning and accepting participants’ accounts of experiences as true and meaningful reflections. The first author collected demographic information, provided a definition of an ethical dilemma, and asked pre-determined broad interview questions. The second author supported the interview process by asking probe or follow-up questions to facilitate rich description or clarify key features and perceptions of participants’ experiences. At the beginning of an interview, participants were provided with the following definition of an ethical dilemma: “An ethical dilemma may exist where one option may be considered both right and wrong, or where two options exist and both would be equally reasonable choices to make”. This definition was consistent with an interpretation of ethical dilemmas as conflict regarding “what ought to be done” and tensions between satisfactory and unsatisfactory solutions (Aroskar, 1980; Beauchamp & Childress, 2012). The next section of the interview addressed participants’ experiences of ethical dilemmas. The interviewers requested participants only discuss ethical dilemmas experienced in private practice during the previous 2 years to focus upon relevant and contemporary ethical dilemmas. Following is an overview of topics covered during this section: (1) General question exploring experiences of ethical dilemmas; (2) Most challenging ethical dilemma; (3) Most frequent ethical dilemma;

Ethical dilemmas in private practice

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(4) Any other ethical dilemmas that have not been mentioned; and (5) Ethical dilemmas which may arise in the future. In keeping with a responsive interviewing approach, the investigators sought to minimize any bias, or leading participants into describing particular ethical dilemmas, by providing general prompts (e.g., “We are interested in the ethical dilemmas you experience at work”). Prompts were used to elicit a thorough description of each ethical dilemma (e.g., “Please tell me more about what happened”). When appropriate, probe and follow-up questions were used to gain further details about the ethical dilemmas, such as the nature of the participant’s major concerns, what she considered to be at stake, or what principles from the Speech Pathology Australia Code of Ethics were considered at risk. Recording commenced following collection of demographic data and interview instructions and concluded when participants indicated that they had no further information to contribute. Ten interviews were completed. Duration of recordings was 15.83–59.45 minutes (x¯⫽ 39.26, s ⫽ 15.83). Seven participants’ recordings exceeded 30 minutes and the remaining three participants’ recordings were 15–30 minutes duration.

Data analysis The first and second author conducted preliminary analysis immediately following each interview. This analysis involved identifying key issues raised by the participant and determining whether interview content was consistent with previous interviews or the participant had raised new ethical dilemmas. This preliminary analysis provided opportunity for the authors to adapt follow- up and probe questions to determine similarities and differences between participants’ experiences and interpretations. The authors noted that, by completion of the tenth interview, participants were raising recurring ethical concerns with different examples of the same type of dilemma. Hence, there was evidence of data saturation (DiCicco-Bloom & Crabtree, 2006), and the authors did not pursue further recruitment or include the late responder in the study. Previous studies of a similar nature also reported saturation of themes with 10 participants (Kenny, Lincoln, & Balandin, 2007, 2010; Kenny et al., 2009). Each interview was transcribed verbatim, with the exclusion of identifying information. To facilitate accuracy of transcriptions the first author reviewed each completed transcript while listening to the corresponding audiotape. When irregularities were noted, the author reviewed the recording again to ensure transcription was accurate.

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Interview transcripts were analysed using the Qualitative Content Analysis protocol described by Graneheim and Lundman (2004). This analysis complemented the qualitative descriptive approach because it is a data-derived process that stays close to participants’ words and description of events whilst summarizing and organizing the data and underlying meaning (Sandelowski, 2000). Qualitative content analysis incorporates five stages of analysis: identifying meaning units; condensing meaning units; interpreting meaning units; developing subthemes; and themes. (1) Identified meaning units. The first stage involved identifying all text relevant to the research questions. The meaning unit represented words or statements that were about ethical dilemmas. Meaning units contained detailed and relevant description of ethical dilemmas. Social behaviour including conversation fillers (e.g., “I’m just thinking”) or humour (e.g., “I’m sounding very old”) were excluded from meaning units. An example of a meaning unit identified from an interview transcript is provided below. Every child 0–6 as long as they have a diagnosis of Autism is entitled to apply for $12,000 over 2 financial years.

(2) Condensed meaning units. Following identification of meaning units, the meaning units were condensed using words close to participants’ words. Following is an example of a condensed meaning unit using the identified meaning unit presented in step 1. Children aged 0–6 with diagnosis of Autism entitled to funding.

(3) Interpreted meaning units. At this stage, the researchers interpreted the experience described by a participant. For example, the condensed meaning unit presented in step 2 was interpreted as: Diagnosis impacts access to funding.

(4) Developed sub-themes. Each ethical dilemma described by participants was then interpreted with reference to the Code of Ethics (Speech Pathology Australia, 2010). Comparative analysis was used in the development of sub-themes and themes, where ethical dilemmas which were associated with similar ethical principles and areas of professional practice were grouped together. An example of sub-theme development is provided below. Sub-theme: Funding to purchase resources. Included: Meaning units that related to access, distribution and accountability for funding. Ethical principles: Beneficence and non-maleficence, fairness (justice).

(5) Generated themes. The final stage of data analysis resulted in development of themes. At this

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stage, data was organized into major content areas (Graneheim & Lundman, 2004). Themes were identified when ethical dilemmas which were similar in nature were identified on multiple occasions across interviews. Although participants may have provided different examples of ethical dilemmas, where the meaning and implication of the sub-themes were the same, they were collated into themes that reflected the ethical challenges of private practice. Final themes were confirmed by consensus between the researchers. An example of the final theme associated with the example above is: Accessing and distributing funds fairly and honestly.

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Research credibility Several measures were taken to address credibility of the research findings. Following the participant’s description of each ethical dilemma during an interview, the researchers verbally summarized key information. This process provided an opportunity for participants to explain or elaborate upon ethical dilemmas and facilitated interpretation of meaning during data analysis. Field notes were completed following each interview and included information on the context of the private practice and the interviewers’ impressions of the interviewing process. The first and second author shared these reflections after each interview to maintain the quality of responsive interviewing. The entire data set was transcribed and only identifying information or irrelevant content was excluded from analysis. Comprehensive data analysis focused upon a search for shared meaning rather than individual anecdotal cases (Silverman, 2005). Credibility of qualitative descriptive research is increased when the most appropriate meaning units are selected from the interview text (Graneheim & Lundman, 2004). The criteria for inclusion of interview text as meaning units were agreed upon by the authors. The first author kept an audit of decisionmaking to support consistent approaches to identifying, condensing, and interpreting text. Member checking was completed after interviews were transcribed and coded (Creswell, 2013). Participants reviewed the analysis of their interview, which confirmed interpretation of meaning units. No changes were made as a result of member checking; however, one participant requested omission of information about a nearby landmark from the transcript. Although data was analysed in sequential steps, the process was iterative. Sub-themes and themes were confirmed by returning to individual transcripts to ensure that meaning and context were not lost. By developing themes through author consensus and completing member checking with participants, the credibility of the themes derived from the data was maximized.

Ethical considerations Approval was gained from the Human Research Ethics Committee of the University of Sydney to conduct the research.

Researchers At the time of the study, the first author was an undergraduate speech-language pathology student. The second author was a post-doctoral researcher and lecturer and an active member of the Ethics Board of the relevant professional association, providing assessment and education when ethical concerns arise. The third author was a senior university academic, administrator, and researcher, with research interests in professional and workplace issues. These backgrounds may have influenced interactions with research participants and interpretations of their stories.

Results When asked to identify challenging and frequently occurring workplace ethical dilemmas, participants reflected upon their clinical, professional, and business roles. Four themes reflected the nature of these dilemmas; balancing benefit and harm, fidelity of business practices, personal and professional integrity, and accessing and distributing funds fairly and honestly. Findings indicated ethical dilemmas reoccurred as “most challenging” and “most frequent”, and the themes reflect both elements. Themes reflected the nature of the ethical dilemmas discussed by participants; however, a wide range of ethical dilemmas were raised by participants and specific cases reflected individual practice contexts. Table II presents the four themes, with underlying features expressed as sub-themes.

Theme 1: Balancing benefit and harm Seven participants discussed ethical dilemmas that involved balancing benefit and harm to clients. Five sub-themes were included within this theme, presented in Table II. Expectations of outcomes. Participants discussed concerns regarding the need for outcomes and ethical dilemmas which arose when outcomes were not achieved. Two ethical dilemmas were raised where outcomes were not achieved due to family circumstances and therapy was discontinued as a result. Aimee perceived parental expectations for immediate and measurable change. In response to parental expectations, Aimee reported pushing her clients to practice intensively, and this level of practice sometimes resulted in children becoming frustrated or distressed during treatment sessions. She discussed

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Ethical dilemmas in private practice Table II. Themes.

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Theme

Subthemes

Number of participants

1. Balancing benefit and harm

Expectations of outcomes Consequences of diagnostic labels Quality of speech-language pathology services provided by others Breaches in confidentiality Reporting to FACS

7

2. Fidelity of business practices

Supervision of staff members Managing less experienced staff Policies to protect business income Discharging clients Recovering unpaid fess

7

3. Personal and professional integrity

Leaving a practice Sharing clients Behaviour of other speech-language pathologists

4

4. Distributing funds fairly and honestly

Speech-language pathologists presenting as specialists Eligibility for funding Funding to support therapy and purchase resources

4

tensions between therapeutic outcomes and emotional cost. Aimee reported that she set challenging but achievable goals for her school-aged clients and that sometimes she considered it necessary to withhold rewards or continue practice until these goals were achieved. There are certain things that they are going to have to achieve before I give them some level of support. And I do upset them. (Aimee)

Consequences of diagnostic labels. Participants raised concerns when they disagreed with diagnoses made by other speech-language pathologists, especially when diagnoses were perceived to distress families. Therese cautioned that diagnoses must be based upon sound clinical evidence and speech-language pathologists must be sensitive to the consequences of providing labels that may be associated with significant and long-term challenges for children. If you go onto apraxia or childhood apraxia of speech or verbal dyspraxia or any of those and you just Google it, it comes up with such a serious, serious lifelong issue and the child has all these other things as well and it creates enormous anxiety in the parents. (Therese)

Therese recommended that diagnostic labels are provided with caution, because the benefits associated with a clear diagnosis may be outweighed by potential psychosocial harms for a client and family. Speech-language pathologists must be mindful of such harms, particularly now that many healthcare consumers source internet health information. However, it was equally important to ensure accurate and early diagnosis so that clients received appropriate intervention. Quality of speech-language pathology services provided by others. Participants raised concerns about quality

of speech-language pathology services provided by colleagues within and external to their own practice. Clare discussed concerns regarding another speechlanguage pathologist’s intervention. When you see a therapist working in a particular way that you don’t agree with. And in private practice everyone can have autonomy with how they work with each client. (Clare)

Private practitioners were conflicted between supporting colleagues’ professional autonomy and concerns that clients were harmed by interventions that were not consistent with their views on evidence based practice. Up to 20 sessions and they’ve achieved nothing. (Renee)

Breaches in confidentiality. Participants discussed dilemmas of client confidentiality that occurred during interactions between speech-language pathologists, general practitioners, and school teachers. One participant experienced an ethical dilemma when she provided a carer with access to a case file. In the file were very, very detailed referrals from the paediatrician and clinical psychologist, with probably comments, and they were their reports. And I wasn’t at liberty; I didn’t know if they had shared those reports with the parents. (Therese)

Debbie described an ethical dilemma where a family refused permission to share communication information with a client’s school. However, Debbie was concerned that her client’s communication problems were impacting upon his academic success. The Learning Support Teacher then called and said okay, so she didn’t have the report, she called and said ‘look this is what I’ve been doing to help this child, from your assessment would you adapt it in

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any way so that I can help this child learn more’. (Debbie)

earning capacity while ensuring that levels of independence did not exceed their competencies.

Reporting to family and community services. Concerns about mandatory reporting to NSW Department of Family and Community Services (FACS) were raised by several participants. NSW speech-language pathologists are required by law to report concerns of harm, neglect, or abuse towards children (NSW Consolidated Acts, Children and Young Persons (Care and Protection) Act, 1998). Ellie discussed concerns about personal and professional ramifications when families identified the source of a child protection notification.

Managing less experienced staff. Rebecca raised concerns about “handing over” clients to less experienced staff members who may not have her level of expertise. While the future of her business depended upon staff members acquiring diverse professional experiences, there were short-term impacts upon individual clients. Debbie identified a need to “sell” new graduate therapy sessions when carers queried their experience.

We’ve got to make a report. But then knowing that we’re working so close with that family, the family would then know that we’re making the report. (Ellie)

Consequently, the family may withdraw from services, excluding a child from communication support, or challenge the speech-language pathologist regarding her notification. Theme 2: Fidelity of business practices Fidelity of business practices incorporated speechlanguage pathologists’ obligations and duties as managers to provide care that met quality standards. Seven participants discussed ethical dilemmas related to fidelity of their business practices. Owners of private practices experienced tension as they managed duties to their business and staff members as well as to the clients of the practice. Five sub-themes, listed in Table II, were included under this theme. Supervision of staff members. Participants described ethical dilemmas concerning appropriate levels of supervision. Kate discussed tensions between the need to maintain occasions of service and provide supervision to less experienced staff members. Getting supervision can be hard as well, especially in private practice. Even with the girls we’ve had to figure out ‘cause we hire a lot of new grads, you know figure out that sort of balance and you feel horrible as an owner ‘cause I need to still see my clients, ‘cause I still need to pay all the bills. (Kate)

Participants acknowledged that practice managers were responsible for the quality of care provided by employees of their business. They also acknowledged that new graduate employees required ongoing support to manage clients with complex communication needs and to meet administrative requirements of the business. Nonetheless, managers needed to juggle potential risks to clients and the professional development needs of staff members with the need to maintain a financially viable business. Time allocated for supervision was time deducted from direct client contact and impacted business earnings. Consequently, participants needed to maximize employees

My sales background kicks in then and my wording around experience turns into, well they’ve only been with us a short time and they’ve developed their experience in another clinic, they’re very good with children and we work very closely together and so you’ll be getting a collective benefit. (Debbie)

Policies to protect business income. Business policies developed for protection of business income and reputation were another source of ethical conflict. Three participants discussed ethical dilemmas regarding implementation of cancellation policies, especially with families who were perceived as financially burdened. Emma discussed tensions between charging clients for a service they did not receive and protecting business income. Charging them a fee if they cancel 2 minutes before the session. We’re 100% strict on charging that fee, which I know a lot of people don’t like. Personally I don’t like charging the fee; however, all our girls are all getting paid all the time, they deserve to be paid. (Emma)

However, policy exceptions were also ethically fraught. One participant raised concerns regarding fairness and consistency in applying cancellation policies, as some families were expected to pay for any missed sessions while others were given exemptions. There’s that fairness and equity where people sort of go, ‘oh well you know this family are usually really good so we’ll let them off but this family are a little bit more inconsistent so we’re not going to let them off ’. (Aimee)

Discharging clients. Ethical dilemmas were reported during discharge planning. Participants perceived a need to identify and discharge clients with a poor prognosis. As a practitioner I don’t want that reputation to come back to me that I wasn’t a good practitioner because I didn’t make any changes to that child. (Clare)

Nevertheless, participants perceived that private intervention was frequently the “only chance” for clients who were on long waiting lists at public healthcare services.

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Recovering unpaid fees. One participant raised concerns about appointing debt collection agencies to recover unpaid fees due to the confidential nature of information the practice would need to provide.

Behaviour of other speech-language pathologists. Participants were unsure about how to manage situations where they were aware of unethical behaviour of colleagues or other speech-language pathologists.

Do you meet with a debt collector and how do you pass on that confidential information? (Ellie)

You can ring up Speech Pathology Australia but you don’t look very good, whereas if you get the parent to ring up it’s a natural, her word of mouth thing. (Kate)

Participants were acutely aware of the impact of their business policies on clients. For example, Emma explained; Here I am the big person in admin and I’m the person down on the frontline as well.

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They experienced tensions between the development of policies that were designed to provide fair and impartial processes for financial management and the implementation of these policies with individual clients. Theme 3: Personal and professional integrity Four participants raised concerns regarding personal and professional integrity of colleagues. Participants addressed concerns which arose when staff members left the practice; clients received services from more than one provider and when required to report unethical behaviour of other speech-language pathologists. This theme contained three sub-themes, as detailed in Table II. Leaving a practice. Two participants reported ethical dilemmas when a staff member resigned from their practice, taking clients and resources with them. Anne raised issues concerning the rights of staff members to start their own business vs her rights, as manager, to retain her caseload and resources. Several managers expressed perceived benefits of experienced private practitioners mentoring colleagues who were establishing a new practice. However, financial competition and perceptions that staff members behaved unprofessionally when they resigned from a practice reportedly hindered such professional relationships. I’ve obviously put a number of years in building the good will of this particular practice and for someone to come in and work for a few years and then take part of that good will with them, I have great issues with it. (Anne)

Sharing clients. Conflict arose when participants shared clients with other service providers. Participants were required to manage competition for clients in an ethical manner so that they received holistic care but were retained by the private practice. We’ve got these new multi-disciplinary places popping up, which is wonderful but then if they’re already coming in here for speech then they try and poach them. (Kate)

Theme 4: Accessing and distributing funds fairly and honestly Four participants described ethical dilemmas which arose from accessing and using external funding for services. Participants discussed concerns regarding fair access and use of publically and privately funded schemes to support management of people with disabilities. Under the Australian Governments’ “Better Start for Children with Disability” and “Helping Children with Autism” schemes, children with a diagnosis of Autism Spectrum Disorder, Cerebral Palsy, Fragile X Syndrome, or a moderate or greater vision and/or hearing impairment may access funding for therapy services and resources (Department of Families, Housing, Community Services and Indigenous Affairs, 2012). The issue of marketing and advertising aimed towards clients receiving funding under such schemes concerned participants. Three sub-themes were found under this theme, as presented in Table II–Themes. Speech-language pathologists presenting as specialists. Participants perceived speech-language pathologists advertising as specialists, to attract clients who were recipients of government funding, as problematic, when such claims were not supported by evidencebased practice. We have some therapists that go around calling themselves Autism specialists and then sit there and do flashcards with the child for half an hour and there’s nothing stopping that and there’s nothing regulating. (Kate)

Eligibility for funding. Participants identified further concerns regarding eligibility for funding, specifically where children do not meet criteria for diagnoses and, therefore, do not receive funding to support therapy. And if you score them for that, ‘cause it’s in the grey area, then they fall above the second percentile and there’s no funding. And if you go okay well if I take that off then bang, it makes them on the second percentile, they’ll get some funding and some help. (Debbie)

Funding to support therapy and purchase of resources. Ethical dilemmas were also associated with the use of disability funding to purchase resources to support clients’ intervention programs. One participant found approving resources to be difficult, with no

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specific criteria to support speech-language pathologists’ decision-making. Hence, she needed to evaluate the therapeutic value of a range of items including iPads, toys, computers, desks, and televisions. Under the “Better Start for Children with Disability” and “Helping Children with Autism” schemes, families are able to access funds to support early intervention and purchase of resources, until their child’s seventh birthday (Department of Families, Housing, Community Services and Indigenous Affairs, 2013). Kate described conflict over billing ahead for services, to support clients to receive intervention following their seventh birthday. We sort of bill ahead in terms of that, which you’re not supposed to do but otherwise these children won’t be accessing any services at all. (Kate)

Rebecca questioned whether therapy, funded by a patient’s nursing home, private hospital, or private health insurance, should continue if outcomes were unmet. In private systems sometimes there’s not a waiting list and it might be very difficult to discharge people. But ethically we need to consider if the client has plateaued and if it’s clinically appropriate to continue therapy even if they want it. (Rebecca)

Summary Participants identified ethical dilemmas that occurred at the interface between client needs and business success. Clearly, private practitioners experience many ethical dilemmas in their roles as business managers, employers, and healthcare providers.

Discussion Thematic analysis of participants’ accounts of challenging and frequently occurring ethical dilemmas experienced by speech-language pathologists in private practice revealed ethical conflict related to client management, business practices, access to external funding sources, and personal and professional integrity of other speech-language pathologists. Many of these ethical dilemmas may occur in speechlanguage pathology practice in publically and privately funded settings. However, speech-language pathologists working in private practice experience specific ethical dilemmas that stem from business concerns. Interpretation of themes The first theme, balancing benefit and harm, reflected several ethical concerns. Concerns about client management were at the centre of ethical dilemmas under this theme. Many of these ethical dilemmas, including impacts of client and family circumstances, disagreeing with professional decisions by other

speech-language pathologists, quality of intervention services, reporting to FACS, and breaches of confidentiality, may occur in other sectors. These dilemmas are comparable to findings by Kenny et al. (2009) and Buie (1997), who found that speechlanguage pathologists experienced many dilemmas related to client management. These ethical dilemmas may be expected to recur as speech-language pathologists manage complex clients (McAllister, 2006). Given that client management is central to speech-language pathology services provided in both public and private sectors; it is inevitable that dilemmas regarding client management occur in both settings. Nonetheless, the experience of ethical dilemmas may be interpreted differently by speech-language pathologists working in private practices, as they perceive direct responsibility for the policies and procedures implemented in their practices. Under this theme, ethical principles at stake included beneficence and non-maleficence, as ethical dilemmas focused upon the balance between benefit and harm during client management. The second theme was fidelity of business practices. MacKenzie (1992) suggested that ethical dilemmas may arise in private practice, due to a need for the business to make profit in order to survive. In accordance with these claims, private practice owners experienced tensions between running a profitable business and providing quality care to clients. Ethical dilemmas regarding workplace practices may be experienced within the public sector; however, the interpretation of the ethical dilemma may be different in private settings. Kenny et al. (2009) found that speech-language pathologists working in community health centres experienced ethical dilemmas when policy dictated they discharge clients for poor attendance. The policies were linked to waiting list management. When private speech-language pathologists discharged clients for poor attendance, business reputation was raised as an important factor. Tension between the need to see clients and provide supervision for staff members is not unique to private practice. However, unlike their colleagues in public health settings, private practitioners found that time spent providing supervision detracted from opportunities for receiving income. While practitioners in public health settings battled with caseload demands, private practitioners needed to manage financial pressures upon time management. Ethical principles of beneficence, non-maleficence, and professional integrity were at stake in ethical dilemmas reported under this theme. Speech-language pathology business managers were concerned that clients who attended their practice received quality intervention (beneficence) and that staff members did not operate outside their level of competency (professional integrity). Yet it was equally important to balance supervisory availability against client quotas because both clients and employees

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would be negatively impacted by the business’s closure (non-maleficence). Ethical dilemmas concerning personal and professional integrity of other speech-language pathologists were incorporated in the third theme. Kenny et al. (2009) also found that speech-language pathologists working within the public sector experienced ethical dilemmas where professional integrity was at stake in professional relationships. Hence, issues arising around personal and professional integrity are not unique to private practice. However, these dilemmas may manifest differently in private practices. Our participants expressed concerns when speech-language pathologists acquired clients from other practices. The “competition” for clients is a strong motivating force for private speech-language pathologists whose income depends upon retaining consistent caseload numbers. This issue, described by Kate as “fighting for the dollar”, may be a more direct and personal concern for speech-language pathologists working in private practice than those working within publicly funded services, who may be competing for resources to manage existing caseloads rather than acquiring clients. When professional colleagues are perceived to behave unethically, the ethical principles of truth, fairness (justice), autonomy, and professional integrity may be at stake. Dilemmas arising when participants were concerned about unethical behaviour of other speech-language pathologists were troubling because participants perceived limited options were available to manage such situations. Whereas hospitals and community organizations may have internal processes for reporting and managing complaints, private practitioners needed to access external support for these purposes. Hence, for private practitioners, access to dedicated support networks (including Senior Advisors for Professional Practice Issues and Professional Issues, from Speech Pathology Australia) provide important opportunities for seeking advice regarding ethical concerns. The Board of Ethics also has an important role in deliberating upon formal ethics complaints and recommending appropriate courses of action and education. The fourth theme addressed distributing funds fairly and honestly. Dilemmas that involved accessing and distributing external funds were major concerns for the private sector professionals. Publicly-funded services, such as community health centres and disability services, may also access government funding schemes. However, competition for clients who were eligible for funding schemes appeared to increase the susceptibility of private practices to questionable marketing practices. MacKenzie (1992) postulated that ethical dilemmas may arise when private speech-language pathologists market their practices, and our participants expressed concerns about speech-language pathologists marketing themselves as specialists to

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take advantage of funding schemes. Participants’ concerns about marketing practices may be of specific concern to the private sector where there is a need to match effective advertising with competent, evidence-based practice so that clients are attracted to practices that are well equipped to meet their communication needs. Our findings suggested that it is important for all speech-language pathologists to access continuing professional development activities so that they acquire knowledge and skills required to provide quality care for clients with specialist service needs. Several ethical principles were at stake with this theme, including truth, fairness (justice), and professional integrity. Implications This study is exploratory and findings need to be replicated with further groups of private speechlanguage pathologists. However, an understanding of the types of ethical dilemmas experienced in private practice may equip the profession to educate private practitioners about the specific dilemmas experienced in private practice. Findings may inform the development of resource materials for private speech-language pathologists when they establish, expand, and leave practices. For example, consideration of the ethical issues inherent in attendance and discharge policies and specific needs of employees who may be inexperienced in providing services within the private sector. Professional preparation programs may draw upon the research findings to support students entering the private sector workforce so they have insight into the ethical dilemmas they may encounter in their work. Discussion of strategies to manage such situations may enable new graduates to contribute to a successful business that delivers quality care. Before new graduate speech-language pathologists commence work in private practice, they should investigate the amount and type of supervision available to them, how clients are allocated, and their duties towards clients when they leave the practice. Effective communication and questioning will guide new graduates towards employers who maintain ethically sound business practices. Support for Australian private practitioners and consumers is available through the Code of Ethics (Speech Pathology Australia, 2010) and Ethics Education Package (Speech Pathology Australia, 2002) and by contacting Speech Pathology Australia. Our findings may further contribute to ethics education by providing descriptions of the nature of ethical dilemmas that speech–language pathologists may experience in the private sector. An understanding of these dilemmas may facilitate managers’ reflection upon policies and work processes in individual practices and provide an opportunity for managers to develop pro-active strategies to enhance ethical practice in their work settings.

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Limitations A limitation of the study was the location of participants’ practices. As all participants practised within metropolitan Sydney, it is possible that results may not reflect the experiences of speech-language pathologists working inter-state or in rural and remote locations. Due to recruitment methods, all participants were owners of their practice. Speechlanguage pathologists with novice level experience or those who were employees/sub-contractors of private practices were not recruited. These clinicians may experience different ethical dilemmas related to their roles and responsibilities within the practice. Due to the nature of the research design, the opportunity to observe participants experiencing ethical dilemmas was not available, therefore it is possible that their ethical dilemmas were not described in entirety, or that some were not discussed at all. One participant, who recorded the shortest interview time of just over 15 minutes, appeared uncertain of what constituted an ethical issue. This participant reported less than 5 years professional experience, and, at the time of the interview, was working part-time in private practice. She reported that she did not identify many ethical dilemmas in her work. During this study, interviewers avoided leading participants and did not raise potential ethical dilemmas that may occur in private practice. While it is possible that speech-language pathologists are employed in settings where ethical conflict rarely occurs, this participant may have benefited from direct support to identify ethical dilemmas in her work place. Directions for future research Further research into the ethical dilemmas experienced in private practice would benefit from recruitment of staff members with other roles within practices. New graduate participants may provide further insights into ethical dilemmas in private practice. It may be beneficial to extend the study and investigate dilemmas experienced in rural settings or to investigate experiences of other allied health professionals employed in the private sector. Conclusion Speech-language pathologists working in private practice experience a wide range of ethical dilemmas, including issues around client management, business practices, accessing and distributing external funds, and personal and professional integrity of other speech-language pathologists. Many of the reported ethical dilemmas were similar in nature to those experienced by speech-language pathologists working within public settings (Kenny et al., 2009). However, some ethical dilemmas were also found to be unique to the private setting. It will be of increasing

importance to have knowledge of ethical dilemmas experienced in private practice and to develop strategies and support for speech-language pathologists as the complexity of clients and demand for private services increases. Our findings may provide “real life” cases and vignettes for pre-service and in-service education on contemporary ethical issues.

Acknowledgements The authors would like to thank the speech-language pathologists who shared ethical dilemmas during this study. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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