Identification of emerging areas of clinical practice is important for ensuring the vitality of the professions of audiology and speech-language pathology. Information about emerging areas can guide clinical practice, support professional education and development, inform advocacy, and spur needed research.
Why is it important to stay current with clinical trends? There are a number of reasons. Clinicians may need to perform a new or revised procedure, work with a new population, apply an existing treatment approach to a new population, or use a new service delivery model.
The current scopes of practice for audiology and speech-language pathology may include the new areas of practice—or they may not. The ASHA Code of Ethics provides the overarching guidance for decisions about adopting new areas of practice. As stated in Principle of Ethics II, B, "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." Clinicians also need to refer to state licensure laws because state laws include requirements about permitted practices.
Clinicians typically seek information about new areas of practice by talking to colleagues, attending conferences, reading articles, and participating in journal groups. No formal process exists, however, for identifying emerging areas of clinical practice in communication sciences and disorders or in other fields.
To address that need, an ASHA team developed tools and applied a systematic process to identify emerging areas of practice using a set of guiding questions, a decision-making flowchart based on the answers, and a list of targeted data sources. Guiding questions included:
- Is the practice in the current scope of practice in audiology and/or speech-language pathology? If yes, is the practice applied as described in the scope(s) of practice? If no, are clinicians being asked to perform a new procedure?
- Are new populations being served by clinicians? Or are existing treatment approaches being applied to new populations?
- Is there research to support including the practice as an emerging area of practice?
- Are speech-language pathologists and/or audiologists being excluded from areas of clinical practice that are within their respective scopes of practice?
- Is there a new service delivery model being used?
The process yielded several practice areas in audiology and speech-language pathology that met the criteria for "emerging."
The emerging areas of audiology practice involve an increase in knowledge, skills, and abilities in areas outside of traditional audiologic practice—traumatic brain injury (TBI), blood-screening tests, and the use of otoacoustic emissions (OAEs) in identifying infants at risk for sudden infant death syndrome (SIDS).
Mild Traumatic Brain Injury
As military veterans become more aware of the effects of mild TBI, the need for screening for that condition also will increase. For veterans entering the health care system through audiology services, the audiologist may be asked to perform the initial screening for mild TBI to ensure appropriate referrals to other members of the health care team.
Many audiologists are expanding their knowledge and understanding of etiologies of deafness. This knowledge includes molecular blood screening tests that detect conditions such as Connexin 26, Connexin 30, Pendred syndrome, the mitochondrial A1555T mutation, and cytomegalovirus (CMV) as a cause of hearing loss.
OAEs and SIDS
Emerging research in OAEs may result in a new application of the procedure in identifying children at risk for SIDS. Findings from Ruben, et al. (2007) suggest that infants who died from SIDS had a significant decrease in signal to noise in the right ear. As research results continue to unfold, audiologists may play a more integral role in the identification of risk factors for this syndrome.
Emerging areas identified in speech-language pathology include assessment of patients with esophageal dysphagia, high-speed laryngeal imaging, and an expanded role in hearing screening for infants.
Speech-language pathologists are growing more interested in the assessment of patients with esophageal dysphagia. Patients referred for pharyngeal disorders, once evaluated, may instead have an esophageal disorder, or may have coexisting disorders of the pharynx and the esophagus. SLPs may work with referring physicians to ensure that patients with symptoms such as "choking on food" or complaints of "food sticking" receive a modified barium swallow to assess possible pharyngeal causes and barium swallow studies to determine if the cause is esophageal. Often only a modified barium swallow study is ordered and conducted for these patients—which eliminates assessment of the esophagus, a key anatomical structure.
Until recent years, some SLPs who conducted videofluoroscopic studies failed to screen function below the pharynx because of a perception that the esophagus was not their concern. Nancy Swigert, department head of speech-language pathology at Central Baptist Hospital in Lexington, Ky., notes that "SLPs are educating referring physicians and team members about our scope of practice. As a result, there is a growing acceptance among professionals—referring physicians, radiologists, and SLPs—involved in the assessment and treatment of pharyngeal and esophageal disorders that these two areas are overlapping and interrelated."
High-speed imaging is an emerging technology used in the assessment of voice disorders. "Unlike traditional videostroboscopy, which produces a composite image that is averaged across many cycles of vocal fold vibration, high-speed imaging actually
captures the true cycle-to-cycle vibration of the vocal folds," said Bob Hillman, co-director and research director of the Center for Laryngeal Surgery and Voice Rehabilitation at Massachusetts General Hospital. Only major voice centers are likely to have or purchase high-speed imaging equipment.
Expanded Role in Hearing Screening
SLPs are assuming an expanded responsibility for hearing screening across the life span. ASHA's revised Scope of Practice in Speech-Language Pathology (ASHA, 2007) extended the role of SLPs to infant hearing screening, including otoacoustic emissions screening and family education. ASHA previously recommended that hearing screening practitioners for neonates, infants, and young children from birth to 2 years be limited to certified audiologists or supervised support personnel (ASHA, 1997). As part of the education component, SLPs may provide information to families about typical auditory, speech, and language development. They also can help a family better understand the hearing screening process, the likelihood that their child will have a hearing loss, and follow-up procedures.
Dual Area: Emergency Preparedness
Audiologists and SLPs both have emerging roles in emergency preparedness. They may be responsible for educating the first-response teams or emergency-care providers and for assisting with the development of emergency or disaster preparedness plans. Audiologists can educate first-responders and providers about communicating with individuals who are deaf or hard of hearing and about the likelihood of ear trauma, temporary or permanent hearing loss, and tinnitus among victims on the scene of blast-related incidents.
SLPs can educate first-responders and health care providers about the communication needs of persons who rely on augmentative and alternative communication systems and individuals with intellectual disabilities, dementia, traumatic brain injury, and speech and language impairments.
Audiologists and SLPs also may serve as members of a first-response team to assist individuals with communication or cognitive disabilities in an emergency. First-responders may need the services of audiologists and SLPs following a disaster if they have been exposed to noise, trauma, or other circumstances that may compromise their ability to communicate.
These results can be used to inform practice patterns, professional education and development, advocacy, and research. Clinical areas may be the focus of in-service education programs, be incorporated into academic courses, lead to the development of knowledge and skill statements, and be part of a research agenda or a topic for an evidence-based systematic review.
Areas that were considered but that did not meet the established "emerging" criteria were categorized as expanding or non-emerging. Expanding areas represent practice trends that involve an increasing number of professionals. For additional information about emerging and expanding areas of clinical practice, visit the ASHA Web site. A poster session at the 2008 ASHA Convention will present the results of the project.