Professional Autonomy Certification and Licensure in Audiology
May 2018
Barbara Cone
Professional autonomy is a guiding principle for the profession of audiology. This was articulated by James Jerger (1988) as a rationale for doctoral-level training enabling entry into the profession. Our doctor of audiology (AuD) training standard, now in its second decade, was inspired largely by the desire to have audiologists working in health care settings as autonomous professionals—on par with other providers in health care settings, such as optometrists, dentists, chiropractors, nurse practitioners, and medical doctors.
There is still contentious debate, however, about which professional or licensing entities should be responsible for "overseeing" the profession. Some have stated that licensing should define the profession (see, e.g., Brazell, 2015). This position discounts the important role that professional organizations have in maintaining the autonomy of the profession and in maintaining its highest standards. The purpose of this article is twofold: (a) to explore the history and purpose of licensing and certification and (b) to provide support for the argument that certification by a professional organization is, indeed, paramount to the integrity of professional autonomy in audiology. It is through certification by a professional organization that standards can be updated with consideration of contemporary competencies—and that maintenance of these standards can be monitored. The integrity of the profession is promoted by certificate holders' adherence to a code of ethics. Professional oversight through a formally established certification program provides the rationale and data that legislators, other regulators, and insurance companies need in order to recognize audiology as a truly autonomous profession.
Licensure and Certification Explained
First, let us define the terms licensure and certification. The Council on Accreditation Blog (Haynik, 2017) succinctly explains each. Licensure is put in place to provide for public safety and consumer protection. Licensure provides the minimal standards for practice in the state and also sets legal recourse for individuals who have been harmed by those who have misrepresented their credentials or who have not provided services that meet the standards imposed by licensing bodies. Licensing is mandatory.
Certification is voluntary. Certification indicates that the individual has met certain pre-determined standards established by the entity (in this case, a professional organization) offering certification. This may include the passing of a nationally recognized exam.[1] Certifications may be earned from a professional society and must be renewed periodically, generally through completed continuing education units. The person with certification is recognized as someone who is qualified to perform a specialized service—in this case, audiology services. Certification in audiology is offered by both the American Speech-Language-Hearing Association (ASHA Certificate of Clinical Competence in Audiology [CCC-A]) and by the American Board of Audiology (ABA Board Certification in Audiology). The ABA also offers the Pediatric Audiology Specialty Certification (PASC®), the Cochlear Implant Specialty Certification (CISC®), and a certificate program in Tinnitus Management (Certificate Holder-Tinnitus Management, CH-TM). ASHA approves and monitors the Intraoperative Monitoring Specialty Certification (offered by the American Audiology Board of Intraoperative Monitoring).
Both licensing and certification in audiology require documentation of academic qualifications and continuing professional education, and both engender fees. The licensing fees are paid to the state in which the person practices audiology, whereas the certification fees are paid to the professional organization managing the certification program. There is considerable overlap between licensure and certification requirements because state licensure boards rely on professional organizations in order to develop and revise standards for practice. At the present time, all but one (Colorado) state licensing board require that the candidate for licensure provide a passing score on the Praxis® exam. This is also required for certification by ASHA (the CCC-A). Recently, the ABA dropped its requirement for demonstrating a passing score on the Praxis® but does require that candidates for certification provide documentation of their state license.
History
What is the history of certification and licensure for audiology? ASHA has offered a certification program since 1952, but the Certificate of Clinical Competence (CCC) as we recognize it today was created in 1965. ASHA's certification requirements undergo ongoing scrutiny and revision by ASHA's semi-autonomous Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC). The most recent revisions were implemented in 2012. These latest revisions require that all those applying for certification hold a doctoral degree. In 2017, the CFCC conducted a practice analysis and updated the certification standards, which will go into effect in 2020.
The ABA was founded in 1998 and awarded its first American Board of Audiology certificate in 1999. Its specialty certifications in cochlear implants, pediatric audiology, and tinnitus management were first offered in 2004, 2011, and 2017, respectively. As of 2014, the ABA does not require applicants for its certification to pass the Praxis®.
Licensure for audiology was first required in Florida in 1969, and Michigan was the most recent state to require licensure; this took place in 2004. All 50 states and the District of Columbia require licensure.
Controversies
It has been suggested (Brazell, 2015) that the most "widely accepted pathway for credentialing for doctoring professions [based upon the model of medicine] is 1) academic training; 2) clinical training; 3) professional degree; 4) licensure; 5) specialty training (residency); and 6) specialty certification" (p. 70 emphasis added). This was the basis of Brazell's argument that licensure should define the profession.
This model appears to be—if not wrong—incomplete. Professional associations, like ASHA, have the means to engage in standard setting and periodic review of standards to ensure that the professions continue to evolve and meet the increasing needs, via their certifying bodies, of consumers with communication disorders. The licensing boards do not have the resources (or infrastructure) to determine/set standards for competent practice—they rely on the professional organizations to do so. Licensing boards are not meant to represent the profession; they are designed to regulate and monitor for consumer protection.
Another concern about having licensure define the profession of audiology is that state licensure boards can include public members, speech-language pathologists, hearing instrument specialists, medical doctors, and state-appointed officials. For example, in Arizona, the licensing board comprises 12 members, only two of whom are required to be audiologists. This is very different from the history of licensing boards in medicine, dentistry, or optometry that were formerly made up of a majority of individuals who practiced in the profession that they were responsible for licensing. This practice was recently adjudicated by the U.S. Supreme Court in North Carolina State Board of Dental Examiners v. Federal Trade Commission (2015), which ruled that licensing boards comprised of a majority of practicing professionals were anti-competitive and violated Sherman anti-trust laws (Kendall, 2015). Because licensure is primarily for consumer protection and not to "define the profession," a state licensing board may have a majority of non-audiologists serving as members.
The limited collective infrastructure of licensing boards in audiology is another key consideration. Unlike the Federation of State Medical Boards, the National Council of State Boards of Examiners for Speech-Language Pathology and Audiology (NCSB) is not a federation and does not engage in standard setting for the profession of audiology (or speech-language pathology). Approximately half of the licensing boards in audiology (and/or speech-language pathology) belong to NCSB. This is a serious consideration, in that reliance on licensure to define the profession of audiology would mean that the very definition of audiology would no longer be standards based. The only standards that define the profession of audiology are, in fact, certification standards developed by ASHA's Council for Clinical Certification in Audiology and Speech-Language Pathology or AAA's American Board of Audiology (i.e., Board Certification in Audiology).
There are critics of licensure. Bergal (2015) writes, "Supporters of occupational licensing laws, which regulate everyone from doctors and dentists to door repair contractors and auctioneers, say that they [the laws] are necessary to protect consumers and provide oversight. But a growing chorus of critics argues that many state licensing requirements are burdensome and create barriers to competition and job growth" (paragraphs 7 and 8). In this article, Bergal reviews the history of licensure and the political and professional forces that drive it, along with recent attempts by state governments to drastically reduce or eliminate professional licensing. Whereas licensing may be subject to political and lobbying forces within a state legislature, certification by a professional organization can ensure continuity and credibility for the practitioner.
Both state licensure and certification play a vital role in the provision of audiology services. Licensure ensures basic consumer protection and provides a mechanism by which incompetent and/or unethical practitioners may be removed from practice. Certification provides a different level of consumer protection by ensuring that an individual has met standards endorsed by a national professional society. Certification by a professional organization is a fundamental standard among major health professions in this country. Certification does not equal licensure. The credentialing body may revoke certification, but an audiologist can still practice within the profession. If the state revokes licensure, that audiologist, if still practicing, would be in violation of state licensing laws and could experience legal ramifications related to practicing without a license.
The remainder of the article by Brazell (2015) consisted of criticism of the Certificate for Clinical Competence in Audiology (CCC-A) that is offered by ASHA. Yet the author made no mention of the ABA certification program except to note that it should be "voluntary" (as is the CCC-A). This omission is puzzling, considering that the principles of ABA certification are laudatory, per the language used in the Board Certified in Audiology® Handbook:
"Obtaining the Board Certified in Audiology credential represents a commitment to professional standards, ethical practices, and continued professional development. Board certification formalizes and elevates the professional status of the audiologist to consumers, employers, health care institutions, and public and private agencies." (American Board of Audiology, 2016, p. 3)
Note that these ABA certification principles are consonant with CFCC certification principles.
Conclusion
Although licensing is important for consumer protection, it does not and should not define the profession; only professional associations can define—and routinely and systematically update—the profession's scope of practice and standards for practice. Furthermore, state licensing requirements can fluctuate with changes in the political environment.
The CCC-A is the nation's most widely recognized symbol of competency for audiology professionals. ASHA certification is referenced by almost every state board in their regulations. ASHA's certification program has a 60+-year history. The CCC is recognized in 34 states for the purposes of reciprocity or interim practice—and, for that reason, it may aid the practitioner who moves or wishes to work in another state.
Our professional organizations provide stability, vision, and purpose for our profession. It is certification by professional organizations, dedicated to practicing at the highest level, which defines audiology.
About the Author
Barbara Cone, PhD, is professor of Speech, Language and Hearing Sciences at the University of Arizona in Tucson. She obtained her CCC-A in 1978 and is currently a licensed audiologist in Arizona. Dr. Cone is a Fellow of ASHA and served on the Board of Directors as Vice President for Academic Affairs in Audiology from 2014 to 2016.
References
American Board of Audiology. (2016). Board Certified in Audiology® handbook. Reston, VA: Author. Retrieved from http://www.boardofaudiology.org/board-certified-in-audiology/documents/bc-handbook-100116-01_000.pdf [PDF].
Bergal, J. (2015, January 30). A license to braid hair? Critics say state licensing rules have gone too far [Blog post]. Retrieved from http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/1/30/a-license-to-braid-hair-critics-say-state-licensing-rules-have-gone-too-far.
Brazell, T. (2015, May/June). Licensure should define the audiology profession, as it does in other doctoring professions. Audiology Today, 27(3), 70–71.
Haynik, D. (2017, April 11). Help! What are the differences between accreditation, licensing, and certification? [Blog post] Retrieved from https://www.coablog.org/home/2017/4/6/help-what-are-the-differences-between-accreditation-licensing-and-certification.
Jerger, J. (1988, August). Report from the president. Audiology Today, 1(1), 1, 3–4.
Kendall, B. (2015, February 25). Supreme Court affirms FTC antitrust authority over licensing boards. The Wall Street Journal. Retrieved from https://www.wsj.com/articles/supreme-court-affirms-ftc-antitrust-authority-over-licensing-boards-1424881999.
North Carolina State Board of Dental Examiners v. Federal Trade Commission, 547 F. Supp. 13-534 (2015).
[1] The Praxis® exam in audiology, commissioned by ASHA, is administered by the Educational Testing Service. The content of the test is based on a practice and curriculum analysis from data obtained in a national survey of audiologists in both clinical and educational settings.
