Shades of Grey: Navigating the space between regulated & unregulated professionals in rehabilitation

Rehabilitation professionals face daily ethical dilemmas that involve privacy, confidentiality, professional competence, conflicts of interest and questions related to self-disclosure – to name but a few. Most human services professions have ethical codes or guidelines that focus on various areas of professionalism. The majority of professionals in the rehab industry are no different. There is an exception, those that are unregulated.

With an increasing demand for rehab services matched with a need to minimize costs the industry refined its methodology of service delivery. In Ontario the rehab field utilizes unregulated professionals such as rehabilitation therapists to fill some of that need. The rehab therapist role can be defined as one that functions to integrate rehabilitation treatment recommended and delegated by regulated providers such as speech-language pathologists (SLPs) and psychologists. In addition to the administrative benefits, the rehab therapist is able to reinforce the rehabilitation ethos by integrating recommendations of an entire multi-disciplinary team (Pullenayegum et al., 2005). Are there challenges to having unregulated providers? There can be. The chart below outlines some of the advantages and disadvantages perceived by SLPs in a study conducted by O’Brien et al., 2013.

 

Advantages Disadvantages
Reduced administrative workload

Allow the SLP to see more clients

Decrease waiting lists

Clients receive more one-on-one time

Maximize cost-benefit

Limited training in SLP skills

Not bounded by code of ethics

Lack of clear role boundaries

Extending the rehab therapist role inappropriately

 

At the other end of the spectrum there are treatments and strategies for cognitive and behavioural challenges. These are often more abstract in nature, certainly more difficult to operationalize. A psychologist can recommend a treatment for a client based on a cognitive behavior therapy (CBT) model. The psychologist can delegate the delivery of a strategy or said treatment to a rehab therapist. If the client refuses to engage in CBT can the rehab therapist introduce another strategy? There is a continuum of care and treatments that licensed professionals are able to delegate to the rehab therapist. On the surface, many of the treatments that physiotherapists prescribe seem to be objective. A specific muscle needs treatment; a course of exercises are prescribed – so many reps, so many sets and you’re on your way. Can you swap one exercise for another if it works the same muscle? The answer seems obvious. Not so fast. The form, the technique – the exercise itself may be contraindicated.

Despite the best of intentions and preparation the typical therapy session rarely goes as planned. Inevitably treatment will not be able to be provided as prescribed. In these scenarios, can the rehab therapist exercise their clinical judgment to alter the prescribed treatment to meet the demands of the situation in front of them? It is here where roles can quickly and easily become blurred. Within these shades of grey there is the potential for extending the rehab therapist role inappropriately.

There are provisions in place to protect the client and professional alike. Licensed clinicians invariably have a regulatory body setting standards for the profession. For example, the College of Psychologists of Ontario is the governing body for Psychologists and Psychological Associates in Ontario. The College’s mandate is to protect the public’s interests by setting and monitoring practice standards and ethical behaviour of the profession of psychology. For unlicensed service providers, there is no regulatory body to set minimum levels of education, training and competence or to establish and monitor professional and ethical standards of conduct and hold unregulated providers accountable for the services they provide.

Within these shades of grey, there is the potential for extending the rehab therapist role inappropriately

The College of Psychologists of Ontario includes directives for when their members supervise unregulated providers: “The supervising member assumes professional responsibility for the all the work of the supervisee, which, by virtue of the supervisory relationship becomes the delivery of psychological services. Thus the supervisee must comply with the same laws, regulations and standards of practice which govern the supervisor and it is the supervisor’s responsibility to see that they do so.”

The College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO) developed a set of guidelines for SLPs who work with supportive personnel, such as a rehab therapist. To summarize:

  • Personnel who assist SLPs in the delivery of clinical services to clients must work under the direction of the SLP
  • The work to be performed by the supportive personnel is assigned by the SLP
  • The supervising SLP ensures that the unregulated service provider has the education, training and experience commensurate with the services provided
  • The SLP performs his/her supervisory activities in an accountable manner

Those professionals who are not yet regulated can take steps to broaden their skill set and bridge the gap between themselves and their licensed colleagues. The Vocational Rehabilitation Association of Canada (VRA) administers a registration process for a number of professional designations. The VRA states,

“The registration process is an effective means of communicating to clients and industry agencies that members have achieved and demonstrated a recognized level of professional competence in the field of rehabilitation.”

Obtaining the Registered Rehabilitation Professional (RRP) designation is one such example. The RRP designation is recognized nationally recognized. It is awarded following a review and evaluation of the applicant’s university education, employment experience directly related to the rehabilitation field and references from peers and supervisors. Of note registrants must have the following academic core competencies:

  • Assessment Approaches
  • Disabling Conditions and/or Disadvantaged Groups
  • Intervention and Strategies
  • History, Values and Systems Related to Human Services
  • Professional Ethics
  • Communication Skills/Interviewing/Helping Skills

 

What should the rehab therapist do in a situation where they cannot carry out treatment as recommended or when faced with uncertainty when providing therapy?

The VRA’s code of ethics instructs the professional on boundaries of competence: “Vocational Rehabilitation Professionals will practice only within the boundaries of their competence, based on their education, training, supervised experience, credentials, and appropriate professional experience. Vocational Rehabilitation Professionals will not misrepresent their role or competence to clients.”

To prepare for the delivery of clinical services under the direction of a licensed professional Munn and colleagues (2013) suggest a practical 3-stage process for the rehab therapist that includes:

  • Having the technique or intervention demonstrated, or explained when demonstration is not possible
  • Having the rehab therapist demonstrate the technique or intervention until competent
  • Ongoing feedback, refinement and documentation between the rehab therapist and supervising clinician

We must accept the complexity that is service delivery in the rehab industry. Innovative initiatives come with a myriad of triumphs and challenges. Tried and tested tools allow the rehab therapist to transform daily ethical dilemmas into clinical excellence, a must for the client. Communication, feedback and collaboration form the triad that is harmony in motion between the rehab therapist and supervising colleague.

Originally published in the Vocational Rehabilitation Association of Canada‘s magazine, Rehab Matters.

References

College of Audiologists and Speech-Language Pathologists of Ontario. (2007). Use of supportive personnel by speech-language pathologists. Obtained from http://www.caslpo.com/Portals/0/positionstatements/supportpersonnelfinal.pdf

Knight, K., Larner, S., & Waters, K. (2004). Evaluation of the role of the rehabilitation assistant. International Journal of Therapy and Rehabilitation,11(7), 311-317.

McGuire, S. (1996). Subtle Boundary Dilemmas: Ethical Decision Making for Helping Professionals. Hazelden Educational Materials, Center City, Minnesota.

Munn, Z., Tufanaru, C., & Aromataris, E. (2013). Recognition of the health assistant as a delegated clinical role and their inclusion in models of care: a systematic review and meta‐synthesis of qualitative evidence. International Journal of EvidenceBased Healthcare11(1), 3-19.

O’Brien, R., Byrne, N., Mitchell, R., & Ferguson, A. (2013). Rural speech-language pathologists’ perceptions of working with allied health assistants. International journal of speech-language pathology, (0), 1-10.

Pullenayegum, S., Fielding, B., Du Plessis, E., & Peate, I. (2005). The value of the role of the rehabilitation assistant. British journal of nursing14(14), 778-792.

Vocational Rehabilitation Association of Canada. (2010). Code of Ethics. Obtained from http://vracanada.com/documents/code_of_ethics_final2010.pdf

 

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