Knowledge and Skills Required for the Practice of Audiologic/Aural Rehabilitation

Introduction

The ASHA scope of practice documents (ASHA, 1996a, 1996b, 2001) indicate that the practice of audiology and speech-language pathology includes providing services for audiologic/aural rehabilitation (AR). ASHA's Preferred Practice Patterns (ASHA, 1997a, 1997b) are statements that include definitions of universally applicable characteristics of AR practice. ASHA requires that individuals who practice independently in this area hold the Certificate of Clinical Competence in Audiology or Speech-Language Pathology and abide by the 1994 ASHA Code of Ethics, including Principle of Ethics II Rule B, which states: “Individuals shall engage in only those aspects of the profession that are within their competence, considering their level of education, training, and experience.”

Both audiologists and speech-language pathologists traditionally have provided rehabilitative services for children and adults with hearing disorders. Because hearing disorders can profoundly affect the acquisition, development, and use of speech and language, audiologists' and speech-language pathologists' roles may be complementary, interrelated, and, at times, overlapping. Inherent in the practice of AR are many areas of knowledge and skills that are fundamental to both audiology and speech-language pathology.

Clinical research and technological advances have expanded the range and increased the complexities of clinical activities that are now considered routine aspects of AR. AR no longer connotes merely speechreading and auditory training to help compensate for loss of hearing sensitivity due to peripheral impairment. It consists of more than a hearing aid orientation and a 30-day trial period. Many audiologists now view AR as a process in which the effects of an extended range of auditory disorders, including tinnitus and disequilibrium, are also addressed. It is an area of clinical endeavor in which global issues such as mode of communication, literacy, and self-advocacy have brought consumers' needs to the forefront. Rehabilitative assessment measures; educational, behavioral, technological, and counseling intervention procedures; and ongoing client-clinician interaction to evaluate and monitor progress are now considered integral aspects of a client-centered rehabilitation model that promotes successful adherence to treatment recommendations and professional accountability. Widespread implementation of neonatal screening programs makes it possible to provide early intervention for infants with diagnosed hearing impairment, ^[1] thereby significantly minimizing delays in speech and language development. In addition, programmable/digital and implantable hearing aids, cochlear and middle ear implants, tinnitus maskers, and an ever-increasing assortment of assistive technologies have provided clinicians with an expanding and flexible array of devices with which to help individuals adjust to and cope with the effects of their specific hearing problems. The communication and psychosocial disadvantages that may be imposed on individuals with hearing problems, on their significant others, on the marital dyad itself, and on family dynamics are also now the focus of those who provide AR services. Society's emphasis on environmental modifications to enhance accessibility for those with physical limitations has also expanded the focus of the clinician's role in AR. Although maximum communication effectiveness continues to be the primary goal of the AR process, the scope of the process now encompasses the whole person, with attention to his or her specific communication needs, behavioral and psychosocial adjustment, and interpersonal, educational, and vocational functioning. The evolving breadth of AR services makes it less and less likely that audiologists and speech-language pathologists have identical roles in AR or that they bring the same knowledge and skills to that process.

The purpose of this document is to provide an updated description of the knowledge and skills audiologists and speech-language pathologists demonstrate in the practice of AR so as to enhance (a) the delivery of services by members of both professions and (b) the collaborative nature of AR.

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Background

The ASHA Committee on Rehabilitative Audiology (ASHA, 1980, 1984) prepared a set of minimal competencies for clinicians who provide AR services. The committee asserted that clinicians' skills, interests, and training typically determine the extent to which they have the necessary competencies to provide AR whether they are audiologists or speech-language pathologists. Although in 1974 the Legislative Council had previously approved a position paper in which the audiologist was identified as the primary provider and supervisor of AR (ASHA, 1974), the Committee on Rehabilitative Audiology made no distinctions between AR providers from the two professions.

AR, in all probability, has represented the area of clinical endeavor in which the audiologist's and speech-language pathologist's knowledge and skills have been the most closely related and strongly inter-twined. Traditionally, AR has been defined as services and procedures for facilitating adequate receptive and expressive communication in individuals with auditory dysfunction. These services and procedures are intended for those persons who demonstrate a loss of hearing or who function as such in communication situations. The Committee on Rehabilitative Audiology (ASHA, 1984), in fact, defined AR as a series of activities and services (see Appendix). More recent trends and definitions, however, depict AR as an ongoing facilitative process in which the client is viewed within the context of his/her psychosocial environment, and in which he or she actively engages (Erdman, Wark, & Montano, 1994; Gagné, Hétu, Getty, & McDuff, 1995; Hyde & Riko, 1994; Noble, 1996; Noble & Hétu, 1994; Stephens, 1996). This ecological approach focuses on the whole person and emphasizes general well-being. In view of the expanding scope of AR activities and because rehabilitation is best viewed as an ongoing process in which clients engage, rather than simply as specific services that clinicians provide, the Working Group on Audiologic Rehabilitation adopted the following definition for the purposes of this document:

Audiologic/aural rehabilitation (AR) is an ecological, interactive process that facilitates one's ability to minimize or prevent the limitations and restrictions that auditory dysfunctions can impose on well-being and communication, including interpersonal, psychosocial, educational, and vocational functioning.

With either definition one can, in general, envision the clinician as an audiologist or a speech-language pathologist. The conceptualization of or indeed the scope of practice in AR, however, has expanded such that not all aspects of AR are as likely to be addressed by either an audiologist or a speech-language pathologist as they were 20 years ago.

Several other factors support the current need to distinguish between the knowledge and skills audiologists and speech-language pathologists must have to practice AR. Effective with LC 7-89, audiology and speech-language pathology officially became two separate and distinct professions. The two professions have separate scope of practice statements, separate preferred practice patterns, separate policy-making assemblies within the governance structure of the Association, and separate curriculum and practicum requirements for professionals. The advent of different entry-level degree requirements portends greater independence between graduate programs in audiology and speech-language pathology. In addition, the expanding scopes of practice in both professions make it less likely that clinicians will develop knowledge and skills in areas in which they are less involved or interested. The net effect of these developments is a decrease in the extent to which AR services provided by audiologists and by speech-language pathologists directly overlap.

Given the above considerations, two separate sets of knowledge and skills follow. One identifies the knowledge and skills in AR for audiologists; the second identifies the knowledge and skills in AR for speech-language pathologists. The current and most recently approved Standards for Certification in Audiology (ASHA, 1997c) and in Speech-Language Pathology (ASHA 1993a, 1993b, Council on Professional Standards in Speech-Language Pathology and Audiology, 2000), the current and emergent Scope of Practice Statements (ASHA, 1996a, 1996b, 2001), the Preferred Practice Patterns (PPP; ASHA 1997a, 1997b), and hearing aid fitting guidelines (ASHA, 1998) served as guidelines to identify the specific areas of knowledge and skills for each profession's range of activities in AR.

The Standards for Clinical Certification in the professions delineate those areas of knowledge and skills that entry-level clinicians can be expected to demonstrate. The Scope of Practice Statements list professional activities that define the range of services provided within each profession. These statements are updated periodically to reflect emergent areas of clinical practice. The PPPs describe (a) universally applicable characteristics of activities directed toward individual clients, (b) structural requisites for the practice processes to be carried out, and (c) intended outcomes of practice. The practice pattern statements are updated to reflect research findings and technological advances that are expected to improve the effectiveness of clinical intervention. The Scope of Practice Statements reflect the breadth and depth of clinical practice; the Preferred Practice Patterns describe areas of practice with considerable specificity.

The areas of knowledge and skills identified herein are those which audiologists and speech-language pathologists who provide AR services are, at a minimum, expected to demonstrate. They are not restrictive or limiting of the other areas or levels of knowledge and skills one could or should have. ^[2] The separate sets of knowledge and skills presented herein differ in accordance with the respective profession's Certification Standards, Scope of Practice, and Preferred Practice Patterns. As such, they reflect the knowledge and skills clinicians in each profession are more likely to have as well as the areas of emphasis and levels of expertise generally attributed to each profession. Identification of profession-specific knowledge and skills is expected to strengthen intraprofessional AR service provision and to facilitate interprofessional collaboration and promotion of a view of AR as the interdisciplinary endeavor that it often is. For clinicians whose area of expertise or specialization is AR—and pediatric AR in particular—it is anticipated that the knowledge and skills from both areas may actually define their scope of practice. Graduate students and clinicians with interests in AR can use the document to identify areas for future coursework or continuing education. Those individuals who wish to specialize in all areas of practice in AR will find it useful to visualize the breakdown in areas of knowledge and skills, be it for selection of a graduate program, a profession, specific coursework or clinical training, or continuing education experiences. Graduate programs will find the document useful in curriculum and practicum planning. The document may also be useful in employment settings for determining job descriptions. Finally, should interested groups pursue the establishment of specialty recognition in AR, the areas of skill and knowledge identified herein will be useful guides.

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Knowledge and Skills for Audiologists Providing AR Services

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AR Knowledge and Skills for Speech-Language Pathologists

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Professional Implications

The interdisciplinary nature of AR, particularly in the area of pediatrics where speech and language intervention is crucial, supports the need for additional training/coursework beyond the current minimal requirements for certification for either audiology or speech-language pathology. AR services for children must include the expertise generally provided by an audiologist in addition to the knowledge and skills of a speech-language pathologist. This can be achieved in a number of ways. There are clinicians whose training, interest, and experience easily enable them to demonstrate the requisite knowledge and skills identified herein for both audiologists and speech-language pathologists. Nonetheless, in view of current training models, expanding scopes of practice, and the tendency toward specialty rather than general practice, it is more likely that individual clinicians primarily will have the knowledge and skills representative of their individual profession. Hence, AR in many settings will continue to be provided as an interdisciplinary or transdisciplinary service, with clinicians from both professions providing complementary or supplementary services. In those cases, it is hoped that delineation of the areas of expertise will simplify and expedite service delivery while improving its quality.

As in any area of clinical practice, members of ASHA are bound by the Code of Ethics (ASHA, 1994) to practice within the scope of their particular knowledge and skills. Individuals providing AR services should be especially mindful of this in view of cross-disciplinary expectations from employers. Separation of the areas of knowledge and skills for audiologists and speech-language pathologists should be of help to clinicians in this regard. Speech-language pathologists in nursing home or public school settings, for example, are not required to demonstrate knowledge and skills in the areas of hearing aid fittings or adjustments beyond manual inspections for damage or dead batteries. Ethically, to provide services beyond that level, one must be able to demonstrate that one has the requisite knowledge and skills to do so. It is entirely appropriate to reference the Skills and Knowledge in AR and the ASHA Code of Ethics documents to delimit one's scope of practice in such situations. Conversely, if one does provide services beyond those described in the Scope of Practice for the profession in which one is certified and beyond those areas of AR knowledge and skills delineated for that profession herein, one is similarly bound by the Code of Ethics to be able to demonstrate that one has the requisite knowledge and skills.

In view of the rapid development of technology and emergent research that increases our understanding of the complex needs of those who have hearing problems, the scope of AR continues to grow. Hence, the areas of knowledge and skill required to maintain competency continue to evolve. Practitioners must engage in an ongoing, self-directed process of continuing education that is motivated by career responsibilities and changes. Professionalism mandates that speech-language pathologists, audiologists, and related professional organizations take an active role in the creation of appropriate learning experiences that facilitate the application of new information in the clinical arena. Professionals must assume responsibility for assessing their needs in the area of professional development; moreover, they must assume responsibility for informing employers of areas of needed growth. And employers and program directors must be supportive of professionals' efforts to meet the ever-changing needs of the field.

Opportunities for continuing education are present in a variety of formats: traditional academic coursework, distance-learning, in-service training, workshops, professional meetings/conventions of associations, teleconferences, videoconferences, journal and study groups, self-study, and so forth. Addressing the ongoing and changing needs of individuals with hearing loss requires professionals and learning institutions to demonstrate that they value change, have an ability to adapt, use reflective and systematic thinking practices, and have the ability to establish cross-disciplinary communities of learning (Chawla & Renesch, 1995; Senge, 1990). To achieve this standard in AR, professionals and organizations alike must realize that continuing education is not a luxury but a necessity—a necessity that can only be addressed by professionals and organizations creating plans for growth with an eye on the current and future needs of individuals with hearing loss (Smutz & Queeney, 1990).

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Academic Training Implications

Ideally, the basic knowledge and skills necessary to provide AR should be acquired during academic training. Academic programs quite naturally vary, however, in the extent to which content areas are emphasized in the curriculum. Even within the core curriculum, graduate requirements and certification standards permit clinicians-in-training considerable flexibility in terms of electives and practicum experiences. Across academic programs there is variability in terms of what AR courses are offered and how they are offered; they may be offered as audiology courses or as speech-language pathology courses. Such subtle differences can affect enrollment, the perception of course content, and the perception of AR as an area of practice. Many academic programs do not have specific requirements for students with an interest in AR regardless of whether they are audiology or speech-language pathology students.

Specifying the AR knowledge and skills audiologists and speech-language pathologists should each have provides considerable clarification to those responsible for developing curriculum and practicum experiences in academic programs. Identifying the requisite knowledge and skills provides academic programs with guidelines in the selection, evaluation, and monitoring of academic and clinical experiences. Furthermore, an outcomes-based approach allows training programs to indicate more clearly to potential employers what to expect from graduating students. This not only increases the credibility of the training program but also improves student performance for at least two reasons. First, employers may be less inclined to impose unrealistic expectations upon the clinician. Second, if the content of the training is properly specified, the clinician should be better prepared to meet the critical demands of the work setting. From the clinician's perspective, such shifts in job-readiness and employer attitudes should lead to increased credibility, effectiveness, and job satisfaction. More important, from the client's perspective these shifts should facilitate improved service delivery and outcomes.

A repeated concern is that the implementation of knowledge and skills will necessarily increase the time required for students to matriculate. This is a legitimate concern in view of rising education costs and declining enrollments at the graduate level. Fortunately, the marked expansion of rehabilitative activities and responsibilities in audiology coincides with the profession's transition to a doctoral-level profession that will facilitate inclusion of academic and clinical experiences designed to maximize students' knowledge and skills in the assessment and management of individuals with auditory disorders. Another important consideration, however, is that not all training occurs at the pre-service level. In fact, it is unreasonable to expect any pre-service training program to be the complete source of knowledge in any profession. We should only expect that pre-service training will provide the emerging professional with the skills for meeting a limited set of client and employer needs and the strategies for acquiring new knowledge and skills on the job. Technological and clinical advancements, as well as changing clinical responsibilities, can result in a demand for additional competencies. From this standpoint, continuing education assumes a prominent role in clinical training. It, therefore, becomes critical that we delineate training and service-delivery guidelines that extend beyond the pre-service level. As such, the areas of knowledge and skills described herein are intended to delineate comprehensive service delivery independent of training method or level.

Appendix ASHA 1984 Definition of Aural Rehabilitation [3]

1. Identification and Evaluation of Sensory Capabilities

   1. Identification and evaluation of the extent of the impairment, including assessment, periodic monitoring, and re-evaluation of auditory abilities;

   2. Monitoring of other sensory capabilities (e.g., visual and tactile-kinesthetic) as they relate to receptive and expressive communication;

   3. Evaluation, fitting and monitoring of auditory aids and monitoring of other sensory aids (e.g., visual and vibrotactile) used by the auditorily handicapped person in various communication environments (e.g., home, work, and school). Such auditory and sensory aids are taken to include all amplification systems (group and individual), as well as such supplementary devices as telephone amplifiers, alarm systems and so on;

   4. Evaluation and monitoring of the acoustic characteristics of the communication environments confronted by the hearing-impaired person.

2. Interpretation of Results, Counseling and Referral

   1. Interpretation of audiologic findings to the student/client, his/her family, employer, teachers, and significant others involved in communication with the hearing-impaired person;

   2. Guidance and counseling for the client, his/her family, employer, caregiver, teachers, and significant others concerning the educational, psychosocial, and communication effects of hearing impairment;

   3. Guidance and counseling for the parent/caregiver regarding educational options available, selection of educational programs, and facilitation of communication and cognitive development;

   4. Individual and/or family counseling regarding acceptance and understanding of the hearing impairment, functioning within difficult listening situations, facilitation of effective strategies and attitudes toward communication, modification of communication behavior in keeping with those strategies and attitudes, and promotion of independent management of communication-related problems;

   5. Referral for additional services (e.g., medical, psychological, social, and educational), as appropriate.

3. Intervention for Communication Difficulties

   1. Development and provision of an intervention program to facilitate expressive and receptive communication;

   2. Provision of hearing and speech conservation programming;

   3. Service as a liaison between the client, family, and other agencies concerned with the management of communication disorders related to hearing impairment.

4. Re-evaluation of the Client's Status

5. Evaluation and Modification of the Intervention Program

Notes