How do speech and language therapists go about doing their work, and why do they do it that way?

Although my PhD is in the field of implementation, I have a somewhat uneasy relationship with the word.

According to, its etymology can be traced back to Late Latin, meaning ‘a filling up’ in the sense of completion, satisfaction or fulfilment. I like this because, for me, ‘implementation’ is about people doing something because it matters to them and because they are curious to see if it makes a difference. I am uncomfortable with an alternative definition that focuses on compliance, carrying out orders and doing what you have to do in order to get what you want.

Speech and language therapists have many demands on their time and energy, and you don’t have to be among them very long to know that their main motivation is helping their clients. Implementation scientists want to support therapists to integrate research findings into this process, also with the aim of doing the best for clients. But, as sociologist Ray Pawson argues so eloquently (e.g. 2013), implementation is not a passive, one-way process. Rather, it is a cumulative, dynamic chain that depends on the active reasoning and reactions of all involved at different stages in different contexts. It is therefore important that implementation scientists ask how therapists already go about doing their work, why they do it that way, and what the consequences may be.

Within speech and language therapy research, implementation papers that I like include Walden and Bryan (2011), Muttiah et al. (2011), James (2011) and Crais et al. (2006). This is firstly because their research designs recognise the social, interactive and reciprocal aspects of implementation, but secondly because I think they give real clues about how we can improve efforts to support practice change. I am looking forward to exploring this theory further.

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Manualised interventions – can they help us change practice?

“The profession of speech therapy in Great Britain has never taken kindly to the construction of stereotyped programmes of treatment. It perceives therapy to be a creative process in which procedures are used with considerable selectivity.”

This introduction to Jennifer Warner, Betty Byers-Brown and Elspeth McCartney’s 1984 book ‘Speech therapy: a clinical companion’ makes me smile because I instinctively identify with it. Perhaps that is why it has taken me some time to come round to the idea that a manualised intervention is not the same thing as a stereotyped programme.

Health services researchers encourage practitioners to use published interventions which are accompanied by a manual and based on the findings of peer-reviewed research. If this research has been done well, and the theory behind the intervention is clear, it is easy to see the advantages. A manual has to include detailed information and instructions that help therapists and families think about important questions such as: who is it for? why can we expect it to work? how should we use it? what is the point of each component? how much can we adapt it? how can we record progress? how often does it have to be done to be effective?

The  ‘What Works‘ database of interventions for children with speech, language and communication needs shows that relatively few are manualised. Moreover, the reports from the Better Communication Research Programme suggest a vagueness and lack of consistency in describing what we actually do with clients and why. Research efforts are therefore focused on better description of interventions. In my own unit, for example, Alex Pollock is doing some really interesting systematic review work by breaking reported interventions down into component parts and finding that we can usefully compare apples with pears (pp.1-17).

When we are discussing a potential practice change with colleagues, thinking about the principles of manualisation may actually help us to be more creative and selective. The TIDieR checklist and guide was published recently in an effort to improve the description of interventions in research reports. I’d be interested to know if it’s also useful in a practice context (see table 1).

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Smoothing the way for practice change

Journal Clubs are becoming popular as a way for teams to look together at research evidence and decide if practice needs to change as a result. But do we give enough thought to what happens next? Introducing and getting familiar with using a new practice / intervention (or adapting or stopping use of an existing one) takes a lot of work. Paying more attention to implementation might benefit our clients if it leads to us changing our practice more quickly and effectively.

Mulling over an idea before you do anything about it, both on your own and together with other people, is part of making it happen. One of the most useful frameworks I have found for thinking through implementation is Normalisation Process Theory. Unfortunately, while the theory itself is very practical, the wording is too complicated to make this immediately obvious. So, with some trepidation but in the spirit of speech and language therapy, here is my first attempt at an accessible version. (Although I have adapted it from table 1 in Mair et al., 2012, I take full responsibility for any misinterpretation of the original theory!) You will need to amend the questions depending on the ‘thing’ you are discussing, whether you are intending to implement or de-implement it, and to take account of the opinions of all the groups who need to be involved (e.g. clients, user representatives, other professionals).

Normalisation Process Theory is organised into 4 sections, each of which has 4 sub-sections. I have phrased all of these as questions for discussion, and it would be pointless to treat it as a tick-box list. Although there will always be overlap, each sub-section offers a slightly different perspective. This may highlight tensions between members of your team, or between your team and other groups of people, and help you decide where to focus your efforts.

Section 1: Does the new practice make sense?

a) How is the new practice different from what we are doing already?

b) What difference can we expect it to make?

c) What would each of us need to do to get it to happen?

d) What makes the new practice important?

Section 2: Do we want to make the change?

a) Does everyone agree it is a good idea to do this?

b) Are we able and willing to persist with it?

c) Do any of us want to take a lead in showing how it can be done?

d) Do we think it’s right for us to be doing this?

Section 3: How will we go about it? 

a) Will this change have an impact on our roles or responsibilities, and what training will be needed?

b) Will we have any support from our organisation to make the change happen?

c) Could the new practice make our job easier in any way?

d) Are we confident that the new practice will work?

Section 4: How will we know it’s been worth doing?

a) How will we collect information about any adaptations we make?

b) How will we find out what other people (e.g. clients) think of the new practice?

c) How will we collect and use information about how the new practice has affected us and our work environment?

d) How will we measure benefits or problems resulting from the new practice?

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Questions of efficacy, effectiveness and implementation

When doing research in an applied field such as speech and language therapy, different sorts of questions are needed depending on what you are trying to understand. As with all attempts at categorisation, the following question types have fuzzy and overlapping boundaries. However, in general, when investigating a particular intervention or practice:

Efficacy questions ask:
Can it work? For whom? How? Why?

Effectiveness questions ask:
Does it actually work? For whom? In what contexts? How? Why?

Implementation questions ask:
Does it get done? By whom? In what contexts? How? Why?

It becomes more complicated to explain what we are doing when we ask efficacy, effectiveness and / or implementation questions about a strategy designed to encourage implementation of an intervention or practice! Nonetheless, attention to implementation is vital.

This will not come as a surprise to speech and language therapists. They have long had to ask all these questions of themselves, their clients and other professionals to try to understand whether and how their intervention strategy may be making a difference. Communication impairment impacts on every aspect of life, and all  strategies (whether they are direct or indirect) depend on work being done.

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What does it take to make a practice change, #WeSpeechies?

Making a change in your practice – what does it take?

This is the theme for Twitter’s @WeSpeechies from 20th-26th April 2014, when I will be taking a turn to curate. An hour-long #WeSpeechies tweetchat on Tuesday 22nd at 8pm (BST) includes 5 questions to focus the discussion.

These questions come from work to date on my PhD, where I am exploring practice change in speech and language therapy. Making a change in our practice means integrating or replacing what we are used to doing with something different. We are familiar with how hard this can be from our efforts to support change in our clients’ communication skills and environments. But do we see our own behaviour or contexts in the same light? While there are countless changes we could make, only some will get off the ground, and still fewer will be sustained. Questions 1 and 2 are therefore:

Q1 What have you managed to do differently in practice, and why? #WeSpeechies

Q2 What in your practice has not changed, and why? #WeSpeechies

The research field of ‘implementation science‘ aims to make sure that practitioners can use research knowledge that will benefit their clients. It therefore looks for systematic ways to understand and support practice change. Some implementation studies use psychological behavioural change techniques such as incentives to encourage practitioners to adopt a different approach. Others draw on sociology, to take account of how a practitioner’s actions are always shaped and constrained by circumstances and other people. Whatever way a researcher chooses to investigate implementation, it is clear that changing practice is not a neat and tidy box-ticking event, but a messy and complex social process.  This leads us to the remaining questions:

Q3 Where do your new ideas for practice come from, and how do you share them? #WeSpeechies

Q4 Apart from your own motivation, what influences how you sustain or adapt practice? #WeSpeechies

Q5 How do you decide if a practice change is worth continuing? #WeSpeechies

If you are joining a chat for the first time, guidelines for #WeSpeechies’ Tuesday Chats are here. Just use A1, A2 etc at the start of tweets to show which question you are answering, and always tag your tweets with #WeSpeechies so that all following the chat can see them.

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Life is academic after speechmag

In 2011 it was time to bring Speech & Language Therapy in Practice to a close, and I was faced with the problem of what to do next. At a point where some rational decision making was probably called for, I instead took a leap into the unknown.

After many years in clinical practice and as a user representative in maternity services, my gut feeling was that experience of research might complete a circle. I therefore signed up for a full-time Masters by Research (Health). After completing it, I worked as a research assistant on two projects. One involved interviewing a variety of professionals about their use of alcohol brief interventions with young people. In the other I was tasked with recruiting people and nurses on acute hospital wards to complete surveys about their experience of care. I am now 6 months into an ESRC-funded PhD, through which I am exploring practice change in speech and language therapy.

The shift has been a culture shock, and I continue to find academia’s norms, language and expectations somewhat disorientating and in many ways rather odd. However – particularly when you are entering the murky waters between clients, practice and research – it is an advantage to be able to see situations in new ways that challenge deeply held assumptions. Moreover, I have realised that the lazy characterisation of academics as thinkers and practitioners as doers masks the reality that both roles require deep reflection and action. The challenge is in respecting and making the most of what each has to contribute.

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Preserving the Speech & Language Therapy in Practice archive

Speech & Language Therapy in Practice magazine came to a close at the end of 2011, but its legacy is a wealth of archive material reflecting the growth of the profession.

Being aware of the practical value of the articles – and knowing full well the blood, sweat and tears that go into writing them – I was keen to preserve the archive as a freely accessible resource. As a result, anyone can now access the magazine from 1997-2011, and all complementary material that was previously only available to subscribers via the speechmag website.

Saving and indexing all the articles has been a mammoth task, and there is still work to do. For example, although articles are available individually from 2002, the years 1997-2001 are only accessible at the moment as complete issues.

The archive is hosted on an external site called Scribd, which bills itself as the world’s largest online library. You can search the entire archive from within the Speech & Language Therapy in Practice profile on Scribd. We have also grouped some articles into ‘collections‘ – for example, My Top Resources, Winning Ways, Here’s one I made earlier, How I – to make it easier for you to explore them.

Please enjoy the archive, and encourage your colleagues to do the same. And if you are sharing any information about it via Twitter, use the hashtag #speechmag.

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Ralli round to raise awareness of specific language impairment

RALLI-character"Ralli likes computer games, playing with her friends in the park, and smoky bacon flavoured crisps – BUT Ralli also sometimes finds talking difficult, and she doesn't always understand the words people say. Ralli wants to tell you what this is like and explain what happens."

If you haven't met Ralli yet, have a look at the Raising Awareness of Language Learning Impairments You Tube channel, and subscribe to receive new video updates. This campaign was launched in May by Dorothy Bishop, Gina Conti-Ramsden, Maggie Snowling, Courtenay Norbury and Becky Clark as a resource about specific language impairment for children, families and educators.

As is often the case, it is the young people themselves who provide the most compelling viewing as they explain what it is like to have a specific language impairment. The use of video also tells you a lot about context – for example the bookshelves behind the practitioners in the 'Signs of SLI' video hold an eclectic mix of material from joke books to textbooks on vocabulary and language development, to professional standards – a reminder of the everyday but complex process required to put theory into real world practice. 

Posted in Books, journals and articles, CPD, Professional standards, Service delivery, Speech and language development, Speech and Language Therapy | Tagged , , , , , , , , | Leave a comment

Life and times of a speaking wifie

Catherine Hollingworth may have been a visionary and steely pioneer of the speech and language therapy profession, but in the small Scottish town where she was born she was known straightforwardly as ‘the speaking wifie’.

As part of a drive to recognise and celebrate the achievements of ‘weel kent Brechiners’, Steve Nicoll of the Friends of Brechin Town House gave a fascinating talk on Catherine’s life, work and family history last week. Born in 1904, Catherine came from a family with a culture of high achievement and entrepreneurship, with one of her ancestors credited for taking a stand against the practice of body snatching for medical education in the 1800s.

Catherine’s independent income meant she was able to pursue her interest in drama through studying at RADA. She may have simply developed her drama teaching, but a road traffic accident in Kirriemuir in 1933 led her to use her learning to address the injury to her own speech. This ignited an interest in speech therapy at a time when speech therapists were self-taught and very thin on the ground.

In 1940, while another pioneer of the profession Lionel Logue was supporting King George VI in London, Catherine was appointed as the first Superintendent of Speech and Drama and Speech Therapy in Aberdeen. According to Steve Nicoll, who has spoken to a number of Catherine’s students, her attitude to teaching was disciplined, structured, hard but fair – and she was always right. However, the core values she sought to develop through drama teaching would not be out of place with educational thinking of today: confidence, communication, citizenship, civility, language, personal discipline and personal development. Significantly, Catherine was a great believer in the importance of peer learning, and kept the number of adults involved to a minimum.

In her later years, Catherine came out of retirement to do voluntary work in Dundee with people who had had a stroke. Although some of the specific methods were clearly of their time, it is telling that Catherine recognised the void when people with aphasia were ‘left’ at the end of speech therapy with no help, and she sought in a variety of ways to help re-build their confidence, self-esteem and social contact.

The profession has come a long way, but being aware of where we have come from can be as inspiring for the ‘speaking wifies’ of today as recognising where we are now and where we are going.

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Pam Enderby recognised for lifetime aphasia contribution

Pam Enderby2I was delighted to hear today that Professor Pam Enderby has been given The Robin Tavistock Award 2012 in recognition of her significant lifetime contribution to the field of aphasia. 

In announcing the award, the Tavistock Trust for Aphasia recognise that listing the extent of Pam's contribution and influence would be 'impossible'. However, they make a valiant attempt, giving particular mention to publication of the Frenchay Aphasia Screening Test, Pam's championing of new technology and development of Therapy Outcome Measures, as well as her pioneering work in establishing the Speech and Language Therapy Research Unit at Frenchay Hospital in Bristol. 

Beyond the evidence of specific achievements which have had a direct and sustained impact on people with aphasia, the Trust also try to capture what it is about Pam that makes her "a catalyst, who makes things happen and succeed". They mention her mentoring, capacity to bring people together, energy, compassion, generosity and sense of fun. To this I would add honesty, realism and high expectations of people's capabilities. 

Congratulations Pam – and lang may yer lum reek. 

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