Professional Code of Ethics: The Case of Speech-Language Pathologists in Kuwait

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1 Tareq Alshatti Fauzia Abdalla Fatima Dikrallah Kuwait University, Kuwait Professional Code of Ethics: The Case of Speech-Language Pathologists in Kuwait A ccording to the American Speech-Language- Hearing Association (ASHA, 2003), the Code of Ethics provides a framework ensuring that all obligations and services provided by speech-language pathologists (SLPs) are achieved with the highest standards of integrity and ethical principles (p. 1). The Principles of Ethics, which substantiate the core of the Code, delineate the moral framework that SLPs are required to follow in order to guarantee the ethical implementation of clinical services. Regulation and compliance of ethical standards for the profession are highlighted through education. Instruction on ethical issues is an important part of speech-language pathology curricula throughout the United ABSTRACT: Purpose: Due to a substantial shortage of native (Kuwaiti) speech-language pathologists (SLPs), Kuwait needs SLPs from different nationalities and degree programs. One of the concerns with this approach is that speech and language services provided by governmental and private sectors might not meet international standards of clinical practice. This study explored two types of professional values: the Code of Ethics adopted by the American Speech-Language- Hearing Association (ASHA, 2003) and the SLP s personal code of ethics. Method: A survey instrument using a Likert scale (i.e., agree, not sure, disagree) was designed and administered to 52 SLPs (22 Kuwaitis, 19 Egyptians, and 11 Jordanians) employed in special schools and hospitals in Kuwait. Four of ASHA s (2003) Principles of Ethics were investigated: (a) SLP services; (b) the SLP s responsibility to achieve and maintain the highest level of professional competence; (c) the SLP s responsibility to the public by promoting public understanding of the States and is further reinforced in continuing education classes for practicing clinicians. Any violations of the Code are met with serious repercussions, including censure, a loss of membership or certification, and the publication of blacklisted individuals by ASHA (Pannbacker, 1998). The aforementioned measures ensure high-quality care for clients seeking speech and language services. ASHAcertified SLPs in the United States have been required to follow the ASHA Code of Ethics for decades; however, regulating ethics has been a challenge for countries where speech-language pathology is in its nascent stages. Kuwait is just one example of a country that is grappling with this predicament. professions; and (d) the SLP s responsibility to the profession and his or her relationship with colleagues, students, and allied professions. Results: The findings of the study revealed a mismatch between the SLP s personal code of ethics and ASHA s Code of Ethics. There were no statistically significant differences between the ethics knowledge of Kuwaiti SLPs and that of expatriate SLPs. Conclusion: Various factors may have contributed to this gap in knowledge, including differences in training, the standards of a specific workplace, and lack of a standard definition of what constitutes professional practice in speech-language pathology. Other implications for clinical services and the need for improving training programs are discussed. KEY WORDS: Kuwait, speech-language pathologist, code of ethics, ASHA, clinical services CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE AND DISORDERS Volume Alshatti Spring et 2011 al.: Code NSSLHA of Ethics: SLPs in Kuwait /11/

2 Kuwait is a small nation in the Middle East that is known for its modern cities, islands, and ancient archaeological sites. Similar to other countries in the Gulf region, Kuwait has enjoyed the economic benefits associated with the region s oil boom of recent decades. As of 2009, Kuwait s population was estimated to be just more than 2.5 million, which includes approximately 1.3 million nonnationals (Central Intelligence Agency, 2009). This has resulted in a demographic shift, rendering Kuwaiti citizens a minority within their own country. Expatriates are often employed in service industries such as health care, construction, manufacturing, and retail. In contrast, Kuwaitis prefer employment in the public sector, namely in managerial positions (Ali & Al-Kazemi, 2007). In 1993, speech and language services became widely available to Kuwait s residents. Due to an influx in clients presenting with speech and language deficits resulting from traffic accidents and consanguineous marriages, which is a common practice in the Arab world, there was an increasing need for such services (Radovanovic, Shah, & Behbehani, 1999). Since that time, the need for speech and language services in Kuwait has grown considerably. As with other health care professions, non-kuwaiti SLPs are filling a service that cannot be addressed adequately by the native population. Yet, with the increase in expatriate SLPs, there is growing concern that the professional ethics of SLPs in Kuwait may not be on par with international standards, negatively impacting service delivery within Kuwait. Regulation of clinical services was and remains a challenge due to a shortage of ASHAcertified SLPs and a lack of specific standards for practice in Kuwait. In response to these challenges, Kuwait University initiated a new bachelor s-level speech-language pathology training program in The program s design follows the British model of speech-language pathology education, where the bachelor s degree is the practicing degree. The 4-year degree focuses on clinical education in speechlanguage pathology, with less emphasis on liberal arts education. Presently, there are more than 30 graduates of the program practicing in hospitals and educational settings throughout Kuwait. The program also provides three practica/internship courses, which cover the professional code of ethics. Research is currently underway assessing the current state of speech-language pathology practice in Kuwait and how to best ensure that services rendered meet international standards as outlined by ASHA and other renowned organizations. The goal of the present study was to investigate the professional ethics of SLPs practicing in Kuwait and whether these values in any way contradict ASHA s Code of Ethics. A desired outcome of the study was to gain insight into the ethical standards of Kuwait s SLPs and to determine the impact (if any) this has on the quality of speech and language services in the country. We undertook the study in order to answer the following two questions: Are there existing conflicts between the professional ethics practiced by SLPs in Kuwait and the ASHA Code of Ethics? Are there differences in professional ethics, as understood by Kuwaiti versus expatriate SLPs? METHOD Procedure A 37-item survey based on the ASHA Code of Ethics served as the foundation for the study (refer to Appendix). Participants were required to rate their agreement with ASHA s four Principles of Ethics, which were divided into four parts: (a) SLP services (15 questions); (b) professional competence (6 questions); (c) public promotion and understanding of the profession (6 questions); and (d) responsibility to the profession and relationship with colleagues, students, and allied professions (10 questions). A 3-point Likert scale (i.e., agree, not sure, disagree) was used to measure participants agreement with the survey statements. The survey was accompanied by a demographic questionnaire, which all respondents were required to complete. A draft survey and a letter describing the project were sent to the Ministries of Health and Education seeking consent. Following approval for the study, 70 packets (including an envelope, study information, demographic questionnaire, and survey) were mailed to head SLPs at special education schools, as well as the national Salem Al Ali Center for Speech and Hearing, for distribution among their staff. A total of 52 completed surveys were returned and were used in the study. Four incomplete surveys were received but were excluded from the final data set. Demographic information was used descriptively for the purposes of the study. Survey ratings were averaged to provide an indication of the participants agreement or disagreement with each statement. Participants The general characteristics of the study participants are listed in Table 1. Nationals from Kuwait, Jordan, and Egypt were represented in the study (N = 52). Kuwaiti SLPs made up the greatest number of survey respondents, accounting for 42.3% of the total. Egyptian and Jordanian SLPs represented 36.5% and 21.2% of respondents, respectively. The participants ranged in age from < 23 to > 40 years of age. Approximately 60% of the study participants were age 31 and older. In contrast to SLPs in the United States, it is quite common for practicing SLPs in Kuwait to hold just a bachelor s degree. A majority of the SLPs (94.2%) in our study held undergraduate degrees, but very few had a master s degree, and one participant reported having only a high school diploma. Sixty-four percent of respondents reported working in a special education school; the remaining 36% were employed in a hospital. Participant work experience ranged from 1 month to > 10 years (M = 7.4 years, SD = 5.5). A total of 77% of respondents reported at least 1 year of work experience (n = 40). 12 CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE AND DISORDERS Volume Spring 2011

3 Table 1. General characteristics of the study participants. Participant background Percentage Number Nationality Kuwaiti Expatriate Age group < 23 years to 26 years to 30 years to 35 years to 40 years > 40 years Education High school Bachelor Master Job setting Hospital Special education school RESULTS This section examines Kuwaiti and expatriate SLPs level of agreement with 37 statements based on the ASHA Code of Ethics. Details of each of these statements can be found in the Appendix. All of the data from the questionnaires were coded and entered into a database. SPSS software (SPSS, Inc., 2008) was used to analyze the data. General descriptive statistics such as frequency distribution crosstabulations and chi-square (χ 2 ) tests for independence were used to explore the professional ethics followed by SLPs practicing in Kuwait. Percentages of agreement were also analyzed, and comparisons were made between the two groups of clinicians (Kuwaiti vs. expatriates). Only p values.01 were considered to be statistically significant. Knowledge of Professional Code of Ethics Among SLPs in Kuwait Principle of Ethics I. Principle I statements address the welfare of clients and participants in research studies. As evident from Figure 1, the SLPs in our study showed high levels of agreement (> 90%) for Statements 1, 2, 3, 6, 11, 12, and 14. For example, in relation to Statement 1, Individuals shall provide all services competently, agreement was 96.2% among Kuwaiti and expatriate SLPs. In contrast, the SLPs demonstrated moderate scores for Statements 8, 13, and 15, and much lower levels of agreement (< 65%) for Statements 5, 7, and 9. Principle of Ethics II. Regarding Principle II, which relates to upholding professional competence, the SLPs tended to respond similarly. Notably, 100% of the participants agreed that clinicians should continue their professional development throughout their careers (Statement 18). A total of 96.2% of the SLPs were in agreement that service providers should ensure that equipment used is working and properly calibrated (Statement 21). Both groups had a high percentage of agreement for Statement 16, requiring service providers to hold a Certificate of Clinical Competence (total 90.4%), and Statement 17, requiring individuals to engage in only aspects of the profession that are within the scope of their competence, considering their level of education, training, and experience (total 92.3%). On the other hand, only 65.4% of the SLPs agreed that clinical services should be delegated to certified clinicians only or assistants who are appropriately supervised (Statement 19). A relatively low level of agreement (59.6%) was also seen for Statement 20, Individuals shall not require or permit their professional staff to provide services or conduct research activities that exceed the staff member s competence, level of education, training, and experience. Figure 1. Kuwaiti and expatriate speech-language pathologists (SLPs ) agreement with 15 statements from American Speech-Language-Hearing Association (ASHA) Principle of Ethics I. Average group percentages are shown. Alshatti et al.: Code of Ethics: SLPs in Kuwait 13

4 Principle of Ethics III. Principle III statements address the SLP s role in promoting an accurate public understanding of communication sciences and disorders. Overall, all of the SLPs demonstrated a relatively high percentage of agreement for most of the Principle III statements (see the Appendix for details on the statements). The SLPs as a group had a percentage of agreement > 93% for all Principle III statements except for Statement 23 ( Individuals shall not participate in professional activities that constitute a conflict of interest ), which showed 82.7% agreement. Principle of Ethics IV. Principle IV relates to the SLP s relationship with his or her colleagues, students, and members of allied professions. In sum, most participants illustrated a relatively strong agreement with the majority of the presented statements. In 8 out of 10 questions, both Kuwaiti and expatriate SLPs responded with a mean percentage of agreement 95%. However, agreement was lower (86.5%) for Statement 31 regarding assigning credit to those who contribute to a publication/product and for Statement 34 (86.5%) regarding exercising independent professional judgment in the provision of professional services, regardless of referral source or prescription. Professional Ethics as Understood by Kuwaiti Versus Expatriate SLPs A series of chi-square tests for independence (with Yates continuity correction) were conducted on the entire distribution to determine if the two groups of SLPs differed in their agreement regarding the statements pertaining to ASHA s professional Code of Ethics. Table 2 provides the percentages of Kuwaiti versus expatriate SLPs who agreed with each of the 15 statements pertaining to Principle I. The expatriate SLPs were clinicians who were trained in Jordan or Egypt. Overall, the two groups tended to respond comparably, whether demonstrating a high or low percentage of agreement. As evident from Table 2, no statistically Table 2. Percentage of Kuwaiti and expatriate speech-language pathologists (SLPs ) agreement with 15 statements associated with the American Speech-Language-Hearing Association s (ASHA s, 2003) Principle of Ethics I. Item Kuwaiti SLPs Expatriate SLPs χ 2 df p S1 95.5% 96.7% S2 95.5% 93.3% S3 95.5% 96.7% S4 81.8% 93.3% S5 54.5% 66.7% S6 95.5% 93.3% S7 68.2% 60.0% S8 77.3% 80.0% S9 68.2% 62.1% S % 86.7% S % 96.7% S % 100.0% S % 76.7% S % 96.7% S % 83.3% Note. Chi-square tested on entire distribution was not significant, p >.01. reliable group differences were found for any of the 15 statements of Principle I. Table 3 portrays the percentage of SLPs from the two groups who agreed with each of the six Principle II statements. A drop in the scores was particularly evident for Statements 19 and 20. Again, no significant differences emerged between performance of the Kuwaiti and expatriate SLPs with regard to Principle II. In general, both groups of SLPs showed relatively higher levels of agreement with most of the Principle III and IV statements. Chi-square tests of independence revealed no reliable group differences. DISCUSSION The purpose of this study was to examine knowledge of ASHA s professional Code of Ethics among SLPs in Kuwait, both nationals and expatriates. Speech-language pathology is an emerging field in Kuwait, and efforts are underway to better regulate the provision of speech and language services in the country. This study looked at the knowledge of professional ethics demonstrated by Kuwaiti and expatriate SLPs in order to determine whether this knowledge conflicted with ethical standards as established by an internationally recognized organization such as ASHA. In an effort to illustrate any differences in ethical standards, participants were requested to rate their level of agreement with presented statements based on ASHA s Code of Ethics. All participants scored relatively high for all principles with the exception of Principle I and a few items in Principle II. Although both Kuwaiti and expatriate groups exhibited a high level of agreement on certain statements, it was the low percentage scores that were troubling. Decreased percentages of agreement, which translate into lack of knowledge regarding specific statements, were evident for Statements 5, 7, and 9 when looking at the two groups as a whole. On the surface, identifying low scores on a few statements may seem inconsequential; however, when considering how the professional ethics of Arab SLPs compare to ASHA s ethics, there does appear to be a mismatch. In general, Principles III and IV yielded high levels of agreement from the participants. Table 3. Percentage of Kuwaiti and expatriate SLPs agreement with six statements associated with ASHA s Principle of Ethics II. Item Kuwaiti SLPs Expatriate SLPs χ 2 df p S % 93.3% S % 90.0% S % 100.0% S % 70.0% S % 60.0% S % 96.7% Note. Chi-square tested on entire distribution was not significant, p > CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE AND DISORDERS Volume Spring 2011

5 The second question considered in this study was whether the data would show a difference in responses provided by Kuwaiti versus expatriate SLPs. Analysis of group responses to the statements illustrated that a significant difference could not be found between the two groups. Hence, whether SLPs were from Kuwait or from other Arab countries (Jordan and Egypt), their responses were comparable. Two conclusions can be derived from the present study: (a) SLPs in Kuwait lack knowledge in some areas of the ASHA Code of Ethics, and (b) Kuwaiti and expatriate SLPs possess similar knowledge of ethics. It is disturbing that a mismatch between how the professional ethics of Arab SLPs compare to ASHA s Code of Ethics exists, which could be negatively impacting the effective delivery of speech and language services in Kuwait. Several factors may have contributed to this gap in knowledge, including differences in training, the standards of a specific workplace, and lack of a standard definition of what constitutes professional practice in speech-language pathology. A similar challenge may exist in other countries that are in the early process of establishing speech-language pathology services. It is of utmost importance that such programs consider establishing a national speech and language association to serve as a regulatory body. Such an association could provide workshops and seminars for ethics education as well as eventual licensure of the SLP profession. This would be of benefit for SLPs whose training did not include ethics education. In the case of Kuwait, this is essential because expatriates make up a large percentage of speech and language services providers. Such associations could also serve to provide continuing education opportunities for SLPs, ensuring that services are evidence based and ethical. Close consultation with representatives from internationally recognized associations (such as ASHA) on the successful establishment of such a program may be useful. Moreover, educational institutions in Kuwait and other developing programs should closely review their curricula, ensuring that a professional code of ethics is a key component. ACKNOWLEDGMENTS We extend our appreciation to the clinicians who participated in this research and to the Salem Al-Ali Center for Speech and Hearing and the special education schools for assisting in recruiting candidates for the study. We thank the audience at the Third International Symposium on Communication Disorders in Multilingual Populations in Cyprus for beneficial discussion on the results. We are grateful to Sirad Shirdon for her remarkable research assistantship. Michael Robb deserves a special thank you for useful comments on an earlier draft of this paper. REFERENCES Ali, A. J., & Al-Kazemi, A. A. (2007). Islamic work ethic in Kuwait. Cross Cultural Management, 14(2), American Speech-Language-Hearing Association. (2003). Code of Ethics [Ethics]. Rockville, MD: Author. Central Intelligence Agency. (2009). Kuwait. In The world factbook. Retrieved from the-world-factbook/geos/ku.html. Pannbacker, M. (1998). Whistleblowing in speech-language pathology. American Journal of Speech-Language Pathology, 7, Radovanovic, Z., Shah, N., & Behbehani, J. (1999). Prevalence and social correlates of consanguinity in Kuwait. Annals of Saudi Medicine, 19(3), SPSS, Inc. (2008). SPSS for Windows (Version 17) [Compuer software]. Chicago, IL: Author. Contact author: Fauzia Abdalla, Department of Communication Science, College for Women, Kuwait University, P.O. Box 5969, Safat 13060, Kuwait. f.abdalla@ku.edu.kw. Alshatti et al.: Code of Ethics: SLPs in Kuwait 15

6 APPENDIX (P. 1 OF 4). ENGLISH VERSION OF THE STUDY SURVEY BASED ON ASHA S CODE OF ETHICS (2003) Principle of Ethics I: Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or participants in research and scholarly activities and shall treat animals involved in research in a humane manner. Disgree Not Sure Agree S1. Individuals shall provide all services competently. S2. Individuals shall use every resource, including referral when appropriate, to ensure that high-quality service is provided. S3. Individuals shall not discriminate in the delivery of professional services or the conduct of research and scholarly activities on the basis of race or ethnicity, gender, age, religion, national origin, sexual orientation, or disability. S4. Individuals shall not misrepresent the credentials of assistants, technicians, or support personnel and shall inform those they serve professionally of the name and professional credentials of persons providing services. S5. Individuals who hold the Certificates of Clinical Competence shall not delegate tasks that require the unique skills, knowledge, and judgment that are within the scope of their profession to assistants, technicians, support personnel, students, or any nonprofessionals over whom they have supervisory responsibility. An individual may delegate support services to assistants, technicians, support personnel, students, or any other persons only if those services are adequately supervised by an individual who holds the appropriate Certificate of Clinical Competence. S6. Individuals shall fully inform the persons they serve of the nature and possible effects of services rendered and products dispensed, and they shall inform participants in research about the possible effects of their participation in research conducted. S7. Individuals shall evaluate the effectiveness of services rendered and of products dispensed and shall provide services or dispense products only when benefit can reasonably be expected. S8. Individuals shall not guarantee the results of any treatment or procedure, directly or by implication; however, they may make a reasonable statement of prognosis. S9. Individuals shall not provide clinical services solely by correspondence. S10. Individuals may practice by telecommunication (for example, telehealth/e-health), where not prohibited by law. S11. Individuals shall adequately maintain and appropriately secure records of professional services rendered, research and scholarly activities conducted, and products dispensed and shall allow access to these records only when authorized or when required by law. 16 CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE AND DISORDERS Volume Spring 2011

7 APPENDIX (P. 2 OF 4). ENGLISH VERSION OF THE STUDY SURVEY BASED ON ASHA S CODE OF ETHICS (2003) Disgree Not Sure Agree S12. Individuals shall not reveal, without authorization, any professional or personal information about identified persons served professionally or identified participants involved in research and scholarly activities unless required by law to do so, or unless doing so is necessary to protect the welfare of the person or of the community or otherwise required by law. S13. Individuals shall not charge for services not rendered, nor shall they misrepresent services rendered, products dispensed, or research and scholarly activities conducted. S14. Individuals shall use persons in research or as subjects of teaching demonstrations only with their informed consent. S15. Individuals whose professional services are adversely affected by substance abuse or other health-related conditions shall seek professional assistance and, where appropriate, withdraw from the affected areas of practice. Principle of Ethics II: Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence. S16. Individuals shall engage in the provision of clinical services only when they hold the appropriate Certificate of Clinical Competence or when they are in the certification process and are supervised by an individual who holds the appropriate Certificate of Clinical Competence. S17. Individuals shall engage in only those aspects of the professions that are within the scope of their competence, considering their level of education, training, and experience. S18. Individuals shall continue their professional development throughout their careers. S19. Individuals shall delegate the provision of clinical services only to: (1) persons who hold the appropriate Certificate of Clinical Competence; (2) persons in the education or certification process who are appropriately supervised by an individual who holds the appropriate Certificate of Clinical Competence; or (3) assistants, technicians, or support personnel who are adequately supervised by an individual who holds the appropriate Certificate of Clinical Competence. S20. Individuals shall not require or permit their professional staff to provide services or conduct research activities that exceed the staff member s competence, level of education, training, and experience. S21. Individuals shall ensure that all equipment used in the provision of services or to conduct research and scholarly activities is in proper working order and is properly calibrated. Alshatti et al.: Code of Ethics: SLPs in Kuwait 17

8 APPENDIX (P. 3 OF 4). ENGLISH VERSION OF THE STUDY SURVEY BASED ON ASHA S CODE OF ETHICS (2003) Principle of Ethics III: Individuals shall honor their responsibility to the public by promoting public understanding of the professions, by supporting the development of services designed to fulfill the unmet needs of the public, and by providing accurate information in all communications involving any aspect of the professions, including dissemination of research findings and scholarly activities. Disgree Not Sure Agree S22. Individuals shall not misrepresent their credentials, competence, education, training, experience, or scholarly or research contributions. S23. Individuals shall not participate in professional activities that constitute a conflict of interest. S24. Individuals shall refer those served professionally solely on the basis of the interest of those being referred and not on any personal financial interest. S25. Individuals shall not misrepresent diagnostic information, research, services rendered, or products dispensed; neither shall they engage in any scheme to defraud in connection with obtaining payment or reimbursement for such services or products. S26. Individuals statements to the public shall provide accurate information about the nature and management of communication disorders, about the professions, about professional services, and about research and scholarly activities. S27. Individuals statements to the public advertising, announcing, and marketing their professional services, reporting research results, and promoting products shall adhere to prevailing professional standards and shall not contain misrepresentations. Principle of Ethics IV: Individuals shall honor their responsibilities to the professions and their relationships with colleagues, students, and members of allied professions. Individuals shall uphold the dignity and autonomy of the professions, maintain harmonious interprofessional and intraprofessional relationships, and accept the professions self-imposed standard. S28. Individuals shall prohibit anyone under their supervision from engaging in any practice that violates the Code of Ethics. S29. Individuals shall not engage in dishonesty, fraud, deceit, misrepresentation, sexual harassment, or any other form of conduct that adversely reflects on the professions or on the individual s fitness to serve persons professionally. S30. Individuals shall not engage in sexual activities with clients or students over whom they exercise professional authority. S31. Individuals shall assign credit only to those who have contributed to a publication, presentation, or product. Credit shall be assigned in proportion to the contribution and only with the contributor s consent. 18 CONTEMPORARY ISSUES IN COMMUNICATION SCIENCE AND DISORDERS Volume Spring 2011

9 APPENDIX (P. 4 OF 4). ENGLISH VERSION OF THE STUDY SURVEY BASED ON ASHA S CODE OF ETHICS (2003) Disgree Not Sure Agree S32. Individuals shall reference the source when using other persons ideas, research, presentations, or products in written, oral, or any other media presentation or summary. S33. Individuals statements to colleagues about professional services, research results, and products shall adhere to prevailing professional standards and shall contain no misrepresentations. S34. Individuals shall not provide professional services without exercising independent professional judgment, regardless of referral source or prescription. S35. Individuals shall not discriminate in their relationships with colleagues, students, and members of allied professions on the basis of race or ethnicity, gender, age, religion, national origin, sexual orientation, or disability. S36. Individuals who have reason to believe that the Code of Ethics has been violated shall inform the Board of Ethics. S37. Individuals shall comply fully with the policies of the Board of Ethics in its consideration and adjudication of complaints of violations of the Code of Ethics. Alshatti et al.: Code of Ethics: SLPs in Kuwait 19