Scope of Practice for Audiology Assistants

Scope of Practice

View PDF Version

Ad Hoc Committee on the Audiology Assistant Scope of Practice

Table of Contents

• About This Document
• Dedication
• Executive Summary
• Introduction
• History
• Statement of Purpose
• Qualifications for an Audiology Assistant
  • Minimum Recommended Qualifications for an Audiology Assistant
  • Expectations of an Audiology Assistant
• Responsibilities Within the Scope of Practice for an Audiology Assistant
• Responsibilities Outside the Scope of Practice for an Audiology Assistant
• Examples of Practice Settings
• Ethical Considerations
• Liability Issues
• Audiologist Supervisory Role
  • Qualifications for an Audiologist
  • Additional Expectations of the Supervising Audiologist
• Guidelines for Audiologist Supervision of Audiology Assistants
• Recommended Requirements for the Frequency and Amount of Supervision
• Conclusion
• Definitions
• References

About This Document

This scope of practice for the audiology assistant was developed by the American Speech-Language-Hearing Association (ASHA) Ad Hoc Committee on the Audiology Assistant Scope of Practice. Members of the committee were Sharon A. Sandridge (chair), Nancy Cheadle, Susan Fulton, Kristin Gravel, Lyndsey Nalu, Judy Schafer, and Tricia Ashby-Scabis (ex officio). Sharon A. Sandridge, vice president for audiology practice, served as the monitoring vice president. The composition of the ad hoc committee included audiology assistants Sofia Pevzner and Andrea Allen, who have specific knowledge and experience working in this role in clinical practice in schools, health care, and/or private practice.

The document is intended to provide guidance for audiology assistants and their supervisors regarding ethical considerations related to the audiology assistant practice parameters. The document addresses how audiology assistants should be utilized and what specific responsibilities are within and outside their roles of clinical practice. Given that standards, licensure, and practice issues vary from state to state, this document delineates ASHA’s policy for the use of audiology assistants.

Dedication

In loving memory of Steve Ritch (1964–2019), whose dedication, commitment, and perseverance contributed to ensuring integrity and quality in addressing the topic of audiology assistants within ASHA’s structure. Steve was a positive light to all who knew and loved him. #ILoveUs

Executive Summary

This Audiology Assistant Scope of Practice presents a model for the training, use, and supervision of audiology assistants in establishing improved patient care. Audiology assistants are specifically trained support personnel to perform tasks as prescribed, directed, and supervised by ASHA-certified and/or licensed audiologists. Audiology assistants can be used to increase the availability, frequency, and efficiency of services.

Some tasks, procedures, or activities used to treat individuals with communication and related disorders can be performed successfully by individuals other than audiologists if the persons conducting the activity are properly trained and supervised by ASHA-certified and/or licensed audiology assistants. The decision to shift responsibility for implementation of the more repetitive, mechanical, or routine clinical activities to audiology assistants should be made only by qualified professionals and only when the quality of care and level of professionalism will not be compromised. The utilization of evidence and ethical and professional judgment should be at the heart of the selection, management, training, supervision, and use of audiology assistants.

This scope of practice specifies the qualifications and responsibilities for an audiology assistant and indicates the tasks that are the exclusive responsibilities of the audiologist. In addition, the document provides guidance regarding ethical considerations when audiology assistants provide clinical services and outlines the supervisory responsibilities of the supervising audiologist.

Introduction

The Audiology Assistant Scope of Practice provides information regarding the training, use, and supervision of assistants in audiology via a document that ASHA established to be applicable in a variety of work settings. Training for audiology assistants should be based on the type of tasks specified in their scope of responsibility. Specific education and on-the-job training may be necessary to prepare assistants for unique roles in the assistant’s specific professional setting. To review educational requirements for ASHA audiology assistant certification please visit the ASHA Assistants Program webpage.

History

ASHA has addressed the topic of assistants (formerly referred to as “support personnel”) since the 1960s. In 1967, the Executive Board of ASHA established the Committee on Supportive Personnel, and in 1969, the Legislative Council (LC) approved the document titled Guidelines on the Role, Training, and Supervision of the Communicative Aide (ASHA, 1969). In the 1990s, ASHA established several entities—including committees, a task force, and a consensus panel—and the LC passed a position statement, technical report, guidelines, and curriculum content for support personnel. In 2002, ASHA developed an approval process for speech-language pathology assistant (SLPA) programs. In 2003, ASHA established a registration process for SLPAs. Both the approval process and the registration process were discontinued by vote of the LC because of fiscal concerns. In 2004, the LC passed a position statement on the training, use, and supervision of support personnel in speech-language pathology. Since then, the number of SLPAs has increased—primarily in schools and in private practice settings. Growth has occurred in the utilization of audiology assistants, which led ASHA to create this Scope of Practice for Audiology Assistants.

As part of the Scope of Practice in Audiology (ASHA, 2018), a representative, large-scale group of job incumbents identified and validated the important tasks and critical competencies of an audiology assistant. A large-scale validation effort allows the results of a scope of practice to be quantified, and the validation inventories can reach a large, diversified sample within a short period of time. ASHA secured the services of Professional Testing, Inc. to assist with developing and administering the Audiology Assistant Scope of Practice.

This document does not supersede any legislation or regulation, including existing state licensure laws, nor does it affect the interpretation or implementation of such laws. The document may serve, however, as a guide for developing new laws or, at the appropriate time, for revising existing licensure laws.

Statement of Purpose

The purpose of this document is to define what is within and outside the scope of responsibilities for audiology assistants who work under the supervision of an ASHA-certified and/or licensed audiologist. This document addresses the following aspects:

• parameters for education and professional development for audiology assistants
• audiology assistants’ responsibilities within and outside the scope of practice
• examples of practice settings
• information for others (e.g., special educators, parents, consumers, health professionals, school administrators, payers, regulators, members of the general public) regarding the services that audiology assistants perform
• information regarding the ethical and liability considerations for the supervising audiologist
• supervisory requirements for the audiologist and of the audiology assistant

Qualifications for an Audiology Assistant

Minimum Recommended Qualifications for an Audiology Assistant

An audiology assistant must complete fieldwork under the supervision of an ASHA-certified and/or licensed audiologist. Minimum qualifications for an audiology assistant include the following:

• The audiology assistant has met the minimum educational standards, if required by a state.
• The audiology assistant has the communication and interpersonal skills necessary for the tasks assigned.
• The audiology assistant has a basic understanding of the needs of the populations being served.
• The audiology assistant has successfully completed the training requirements and competency-based skills necessary for the performance of specific, assigned tasks.
• The audiology assistant has met additional requirements established by the employment facility.

Expectations of an Audiology Assistant

• Seek employment only in settings in which direct and indirect supervision are provided on a regular and systematic basis by an ASHA-certified and/or licensed audiologist.
• Adhere to the responsibilities for audiology assistants specified in this document, and refrain from performing tasks or activities that are the sole responsibility of the audiologist.
• Perform only those tasks prescribed by the supervising audiologist.
• Adhere to all applicable state licensure laws and rules regulating the practice of audiology, such as those requiring licensure or registration of support personnel.
• Conduct oneself ethically within the scope of practice and responsibilities for an audiology assistant.
• Actively engage with the audiologist in the supervisory relationship.
• Request training needs for a given work setting or population.
• Obtain information regarding availability and need for liability insurance.
• Actively pursue continuing education and professional development activities.
• Demonstrate knowledge of, and adherence to confidentiality requirements of the work setting.

Responsibilities Within the Scope of Practice for an Audiology Assistant

The supervising audiologist retains full legal and ethical responsibility for the patients/clients/students whom they serve but may delegate specific tasks to the audiology assistant. The audiology assistant may execute specific components of a plan of care developed by the audiologist. Goals and objectives listed on the plan of care and implemented by the audiology assistant are only those within the audiology assistant’s scope of responsibilities and are tasks that the supervising audiologist has determined the audiology assistant has the training and skill to perform. The audiologist must provide at least the minimum specified level of supervision to ensure quality of care to all persons served. The amount of supervision may vary and must depend on the complexity of the case and the experience level of the assistant. The use of an audiology assistant is optional, and an audiologist should enlist the services of an audiology assistant only when appropriate and adhere to the ASHA Code of Ethics.

Provided that the training, supervision, and planning are appropriate, the following four overarching duty areas may be delegated to an audiology assistant:

1. Participate in patient care/services and in educational settings
2. Perform hearing device maintenance
3. Maintain the audiology clinic
4. Engage in professional activities and advocacy

The four duty areas and 32 tasks were identified during the Scope of Practice meeting and are illustrated in Table 1.

Table 1. Duties, tasks, and steps performed by audiology assistants

Responsibilities Outside the Scope of Practice for an Audiology Assistant

There is potential for misuse of an audiology assistant, particularly when responsibilities are delegated by administrative or nonclinical staff without the approval of the supervising audiologist. It is highly recommended that the ASHA Audiology Assistant Scope of Practice (ASHA, 2022) and the ASHA Assistants Code of Conduct (ASHA, 2016) be reviewed with all personnel involved when employing an audiology assistant. It should be emphasized that an individual's hearing and/or balance concerns/disorders may preclude the use of services from anyone other than an ASHA-certified and/or licensed audiologist. The audiology assistant should not perform any task without the knowledge and approval of the supervising audiologist. The patient/client/student should be informed that they are receiving services from an audiology assistant under the supervision of an ASHA-certified and/or licensed audiologist.

The audiology assistant should NOT engage in the following activities:

• represent themselves as an audiologist
• provide a diagnosis based on test results
• interpret results
• counsel patients/clients/students/families
• recommend or fit devices
• participate in formal parent conferences, in case conferences, or on any interdisciplinary team without the presence of the supervising audiologist or other designated audiologist
• provide interpretative information to the patient/client/student/family, or others regarding the patient/client/student status or service
• write, develop, or modify the plan of care of a patient/client/student in any way
• assist with patients/clients/students without following the individualized plan of care prepared by the certified audiologist and/or without access to supervision
• sign any formal documents (without the co-signature of supervising audiologist)
• make referrals for additional service
• disclose clinical or confidential information either orally or in writing in accordance with patient privacy laws

Examples of Practice Settings

Under the specified guidance and supervision of an ASHA-certified audiologist and/or licensed audiologist, an audiology assistant may provide services in a wide variety of settings, which may include, but are not limited to, the following:

• public, private, and charter elementary and secondary schools
• early intervention settings
• hospitals (inpatient and outpatient)
• residential health-care settings (e.g., long-term care and skilled nursing facilities)
• nonresidential health-care settings (e.g., home health agencies, adult day care settings, clinics)
• private practice settings
• university/college clinics
• research facilities
• corporate and industrial settings
• patient/client/student residences
• telepractice, hybrid onsite/telehealth rural outreach centers

Ethical Considerations

ASHA strives to ensure that its members and certificate holders preserve the highest standards of integrity and ethical practice. The ASHA Code of Ethics (ASHA, 2016) sets forth the fundamental principles and rules considered essential to this purpose. The ASHA Code of Ethics applies to every audiologist who is (a) a member of ASHA, regardless of certification status; (b) a nonmember holding the ASHA Certificate of Clinical Competence; and (c) an applicant for membership or certification.

It is imperative that the supervising audiologist and the assistant behave in a manner that is consistent with the principles and rules outlined in state licensure and in the ASHA Code of Ethics as applicable. The audiologist or hearing scientist takes overall responsibility for the actions of the assistant when they (the assistant) are performing assigned duties. If the assistant engages in activities that violate the ASHA Code of Ethics, then the supervising audiologist may be found in violation of the code if adequate oversight has not been provided. The ASHA Assistants Code of Conduct (ASHA, 2020) outlines the standards of integrity and the expected ethical conduct of audiology assistants.

Review ASHA’s Code of Ethics, as well as ASHA’s Assistants Code of Conduct associated with the ASHA audiology assistants certification. These documents can assist in guiding the supervising audiologist and audiology assistant in their work settings.

Liability Issues

Individuals who deliver services to persons with auditory and balance disorders are potentially vulnerable to accusations of engaging in unprofessional practices. ASHA recommends that audiology assistants secure liability insurance as a protection for malpractice. Audiology assistants should consider the need for liability coverage. Checking for liability insurance coverage is the responsibility of the audiology assistant and supervising audiologist—and needs to be done prior to providing services.

Audiologist Supervisory Role

Qualifications for an Audiologist

ASHA recommends including the following minimum qualifications for an audiologist who will supervise an audiology assistant:

• Holds current ASHA certification and/or current state licensure
• Has completed two hours of professional development in the area of supervision and has the equivalent of 9 months of full-time clinical practice after being awarded certification

Additional Expectations of the Supervising Audiologist

Additional expectations of the supervising audiologist include the following:

• Regularly conducts ongoing competency evaluations of the audiology assistant as required by the work setting.
• Provides and encourages ongoing education and training opportunities for the audiology assistant consistent with competency and skills as well as needs of the patients/clients/students served.
• Develops, reviews, and modifies plan of care for patients/clients/students that audiology assistants implement under the audiologist’s supervision.
• Adheres to the supervisory responsibilities of audiology assistants.
• Retains the legal and ethical responsibility for all patients/clients/students served.
• Adheres to the principles and rules of the ASHA Code of Ethics and/or state licensure.
• Adheres to applicable licensure laws and rules regulating the practice of audiology.

Guidelines for Audiologist Supervision of Audiology Assistants

The supervising audiologist is responsible for designing and implementing a supervision system that protects the patients/clients/students and that maintains the highest possible standards of quality. The amount and type of supervision should meet the minimum requirements according to state regulations and should be increased as needed based on (a) the needs, competencies, skills, expectations, philosophies, and experience of the audiology assistant and their supervisor; (b) the needs of patients/clients/students served; (c) the service setting; (d) the tasks assigned; and (e) other factors. For example, more intense supervision would be required in certain instances—such as the orientation of a new audiology assistant; the initiation of a new program, equipment, or task; or a change in patient/client/student status (e.g., medical complications). Functional assessment of the audiology assistant’s skills with assigned tasks should be an ongoing, regular, and integral element of supervision. Audiologist and audiology assistants should treat each other with respect and should interact in a professional manner.

Adequate time for direct and indirect supervision of the audiology assistant(s) and caseload management must be allotted as a critical part of the audiologist’s workload. The purpose of the assistant-level position is not to significantly increase the caseload size for audiologists. Assistants should be used to deliver services to individuals on the audiologist’s caseload. Diagnosis and treatment for the patients/clients/students served remains the legal and ethical responsibility of the supervisor. Therefore, the level of supervision required is considered the minimum level necessary for the supervisor to retain direct contact with the patients/clients/students. The supervising audiologist is responsible for designing and implementing a supervisory plan that protects consumer care, maintains the highest quality of practice, and documents the supervisory activities.

The supervising audiologist must

• hold a current Certificate of Clinical Competence in Audiology (CCC-A) from ASHA and/or current state licensure,
• have an active interest in the use of and desire to use support personnel, and
• have completed two hours of professional development in the area of supervision and have the equivalent of 9 months of full-time clinical practice after being awarded certification.

The relationship between the supervising audiologist and the audiology assistant is paramount to the welfare of the patient/client/student. Because the clinical supervision process is a close, interpersonal experience, the supervising audiologist should participate in the selection of the audiology assistant whenever possible.

Recommended Requirements for the Frequency and Amount of Supervision

The supervising audiologist is responsible for designing and implementing a supervisory plan. This plan must ensure that the highest standard of quality care can be maintained for patients/clients/students. Supervision requirements can vary based upon a variety of factors. The amount and type of supervision should meet the minimum requirements according to state regulations and should be increased as needed based on (a) the needs, competencies, skills, expectations, philosophies, and experience of the audiology assistant and their supervisor; (b) the needs of patients/clients/students served; (c) the service setting; (d) the tasks assigned; and (e) other factors. Treatment of the patient/client/student remains the responsibility of the supervisor. As the relationship between the supervising audiologist and the audiology assistant develops over time, they can decide how and to what extent supervision is needed. For example, greater supervision may be necessary for a medically fragile patient, or when the supervising audiologist and audiology assistant are new to the supervisory relationship.

Types of supervision vary. The most commonly used supervision types are defined below:

Direct supervision means on-site observation and guidance while an audiology assistant is performing a clinical activity. This direct supervision can include the supervising audiologist viewing and communicating with the audiology assistant via telecommunication technology as the audiology assistant provides clinical services—because this situation allows the audiologist to provide ongoing, immediate feedback. Direct supervision does not include reviewing a recorded session at a later time. Payers and state licensure laws may require different levels of supervision and should be consulted prior to initiating services provided by an audiology assistant to ensure compliance with these policies and eligibility for reimbursement.

Indirect supervision is a supervisory style in which the audiologist is not physically located at the same facility or in close proximity to the audiology assistant but is available to provide supervision by electronic means. Indirect supervision activities performed by the supervising audiologist may include, but may not be limited to, demonstration, record review, review, and evaluation of recorded (audiotaped or videotaped) sessions, and interactive television and supervisory conferences that may be conducted by telephone, email, or live webcam. This can also be described as asynchronous supervision.

Supervision times vary based on local and state regulations, as well as by some payers. For information about an individual state’s requirements, if applicable, please visit ASHA State-by-State.

Supervision feedback should provide information about the quality of the audiology assistant’s performance of assigned tasks and should verify that clinical activity is limited to tasks specified in the audiology assistant’s list of ASHA-approved responsibilities. Information obtained during direct supervision may include, but is not limited to, data relative to (a) agreement (reliability) between assistant and supervisor on correct or incorrect recording of target behavior; (b) accuracy in implementation of assigned assessment and treatment procedures; (c) accuracy in recording data; and (d) ability to interact effectively with the patients/clients/students during presentation as well as the application of assigned therapeutic procedures or activities.

An audiology assistant may not provide services that they do not have the skill to provide—in such cases, the supervising audiologist should be performing the clinical task. If, for any reason (e.g., maternity leave, illness, change of jobs), the supervisor is no longer available to provide the level of supervision stipulated at the beginning of the audiology assistant’s hiring, then the audiology assistant may not perform any assigned tasks until an ASHA-certified and/or state-licensed audiologist—with experience and training in supervision—has been designated as the new supervising audiologist.

Conclusion

Through the publication and dissemination of this document, ASHA intends to provide guidance for the use of audiology assistants in appropriate settings, thereby increasing access to timely and efficient audiologic services. It is the responsibility of the supervising audiologist to stay abreast of current guidelines and to ensure the consistently high quality of services rendered.

Definitions

accessories – electronic devices that work in conjunction with or independently of hearing devices for safety and/or alerting purposes (e.g., remote microphones, Bluetooth, induction loop, vibrating alarm clock, infrared systems, smoke detectors).

accountability – being legally responsible and answerable for the actions and inactions of self or others during the performance of a task by the audiology assistant.

audiology assistant – an individual who—following academic coursework, clinical practicum, or credentialing—can perform tasks prescribed, directed, and supervised by an ASHA-certified audiologist and/or a licensed professional.

direct supervision – on-site observation of and guidance to the audiology assistant by an audiologist while that audiology assistant is performing an assigned activity. Direct supervision performed by the supervising audiologist may include, but is not limited to, the following: observing a portion of the screening or treatment procedures performed by the audiology assistant, coaching the audiology assistant, and modeling for the audiology assistant. The supervising audiologist must be physically present during all services provided to a medically fragile client by the audiology assistant (e.g., general and telesupervision, the latter of which is defined later in this list). The audiologist can view and communicate with the patient/client/student and audiology assistant live via real-time telecommunication technology to supervise the audiology assistant, thus giving the audiologist the opportunity to provide immediate feedback. This does not include reviewing a recorded session later.

hearing device – an electronic device that enhances auditory and/or sensory stimuli for persons who have auditory deficits (e.g., hearing aids, cochlear implants, frequency modulation [FM] systems)

indirect supervision – a supervisory style in which the audiologist is not physically located at the same facility or in close proximity to the audiology assistant but is available to provide supervision by electronic means. Indirect supervision activities performed by the supervising audiologist may include, but may not be limited to, demonstration, record review, review and evaluation of recorded (audiotaped or videotaped) sessions, and interactive television and supervisory conferences that may be conducted by telephone, email, or live webcam.

interpretation – summarizing, integrating, and using data for the purpose of clinical decision making, which may only be done by audiologists. Audiology assistants may summarize objective data from a session to the family or team members.

medically fragile – a term used to describe an individual who is acutely ill and in an unstable condition. If such an individual is treated by an audiology assistant, 100% direct supervision by an audiologist is required.

screening – a pass/fail procedure to identify, without interpretation, clients who may require further assessment following specified protocols developed by and/or approved by the supervising audiologist.

supervising audiologist – an individual who is an ASHA-certified audiologist and/or a licensed professional and who has completed two hours of professional development in the area of supervision and has the equivalent of 9 months of full-time clinical practice after being awarded certification.

supervision – providing direction and evaluation of the tasks assigned to an audiology assistant. Methods include direct supervision, indirect supervision, and telesupervision.

telepractice – the use of telecommunications technology to deliver professional services at a distance by linking clinician to patient/client/student—or clinician to clinician—for assessment, intervention, and/or consultation.

telesupervision – a supervision method in which the audiologist can view and communicate with the patient/client/student and audiology assistant in real time via Skype, webcam, and similar devices and services. This allows the audiologist to supervise the audiology assistant and to give immediate feedback. Telesupervision does not include reviewing a recorded session later.

References

American Speech-Language-Hearing Association. (2020). Assistants code of conduct [Ethics]. Available from https://www.asha.org/policy/assistants-code-of-conduct/ 

American Speech-Language-Hearing Association. (2016). Code of ethics [Ethics]. https://www.asha.org/code-of-ethics/

American Speech-Language-Hearing Association. (2017). Issues in Ethics: Cultural and linguistic competence. www.asha.org/Practice/ethics/Cultural-and-Linguistic-Competence/

American Speech Language Hearing Association. (2018). Scope of practice in audiology [Scope of Practice]. Available from www.asha.org/policy/ 

American Speech-Language-Hearing Association. (n.d.). ASHA State-by-State. Retrieved from https://www.asha.org/advocacy/state/

Appler, K. (2002). Assistance on Assistants: ASHA's Registration Program for Speech-Language Pathology Assistants. Perspectives: Administration and Supervision, 12. https://doi.org/https://doi.org/10.1044/aas12.3.12  

Committee on Supportive Personnel. (1970). Guidelines on the Role, Training, and Supervision of the Communication Aide. Language, Speech, and Hearing Services in Schools, 1(2), 48-53.