Speech-Language Pathology Management for Adults With COVID-19 in the Acute Hospital Setting: Initial Recommendations to Guide Clinical Practice

Purpose This document outlines initial recommendations for speech-language pathology management of adult patients with COVID-19 in the acute hospital setting. Method The authors initially developed these recommendations by adapting those developed for physical therapists working with patients with COVID-19 by Thomas et al. (2020). The recommendations then underwent review by 14 speech-language pathologists and rehabilitation-focused academics representing seven countries (Belgium, Brazil, Canada, Ireland, Japan, New Zealand, the United States). The authors consolidated and reviewed the feedback in order to decide what should be included or modified. Applicability to a global audience was intended throughout the document. Results The authors had 100% agreement on the elements of the recommendations that needed to be changed/modified or added. The final document includes recommendations for speech-language pathology workforce planning and preparation, caseload management, service delivery and documentation, as well as recommendations for the selection of appropriate personal protective equipment and augmentative and alternative communication equipment in the acute care hospital setting. Conclusions Speech-language pathologists play a critical role in the assessment, management, and treatment of patients with COVID-19. Several important considerations need to be made in order to meet the needs of this unique patient population. As more is learned about the impact of the virus on swallowing and communication, the role of the speech-language pathologist on interdisciplinary care teams will remain paramount.

Delegation models in dysphagia management: Current policy, clinical perceptions and practice patterns

Purpose: Delegation to Allied Health Assistants (AHAs) is an effective workforce solution in a number of areas of adult speech-language pathology (SLP) practice. However, reports of AHA delegation in the area of dysphagia management are limited. The aim of this study was to synthesise information from policy documents and current clinical practice to examine the nature of AHA delegation in dysphagia management.Method: A mixed method design involving a document review of 13 policy documents on AHA delegation, and a survey of 44 SLP managers regarding current delegation models.Result: Policy and current practice were largely congruent. Despite policy support for AHA delegation, 77% reported using delegation models but only 26% used them fairly often/very often in dysphagia management. Both policy and survey findings support AHA training prior to task delegation, however, the nature of training was unspecified. Good governance is integral to successful delegation and managers recognised the need to increase standardisation of AHA capability assessment.Conclusion: AHA delegation in dysphagia management is supported by policy and is being implemented in clinical services. However further work detailing governance and training requirements is needed, as well as systematic evaluation of the safety and benefits of these models.

Speech and language therapy for primary progressive aphasia across the UK: A survey of current practice

BACKGROUND

Primary progressive aphasia (PPA) describes a heterogeneous group of language-led dementias. People with this type of dementia are increasingly being referred to speech and language therapy (SLT) services. Yet, there is a paucity of research evidence focusing on PPA interventions and little is known about SLT practice in terms of assessment and provision of intervention.

AIMS

To survey the practices of SLTs in the areas of assessment and intervention for people with PPA.

METHODS & PROCEDURES

A 37-item, pilot-tested survey was distributed electronically through the Royal College of Speech and Language Therapists (RCSLT), Clinical Excellence Networks (CENs) and social media networks. Survey items included questions on care pathways, assessment and intervention approaches, and future planning. Analysis was conducted using descriptive statistics and thematic analysis.

OUTCOMES & RESULTS

A total of 105 SLTs completed the survey. Respondents reported more frequently using formal assessment tools designed for stroke-related aphasia than for dementia. Informal interviews were reportedly always used during assessment by almost 80% of respondents. Respondents were significantly more likely to use communication partner training than impairment-focused interventions. Goal attainment was the most commonly used outcome measure. Respondents provided 88 goal examples, which fell into six themes: communication aid; conversation; functional communication; impairment focused; specific strategy; and communication partner. Additionally, respondents reported addressing areas such as future deterioration in communication and cognition, decision-making and mental capacity, and driving. Ten (9.4%) respondents reported the existence of a care pathway for people with PPA within their service.

CONCLUSIONS & IMPLICATIONS

This survey highlights the range of current PPA assessment and intervention practices in use by the respondents. Communication partner training is commonly used by the surveyed SLTs, despite the lack of research evidence examining its effectiveness for PPA. There is a need to develop evidence-based care pathways for people with PPA in order to advocate for further commissioning of clinical services.

Dysphagia care for adults in the community setting commands a different approach: perspectives of speech-language therapists

BACKGROUND

Descriptions of community-based speech-language therapy (SLT) dysphagia practices and services are underrepresented in the research literature, despite the prevalence of dysphagia in the community. Owing to a globally ageing population and government drives to support people to remain living at home rather than in hospital or aged care, there is a growing need for SLT services to be responsive to the needs of clients living at home in the community, referred to in this study as 'community-based clients'. Exploration of current SLT services and dysphagia care practices for this population may identify ways services can be designed and enhanced to better meet the needs of clients and carers.

AIMS

To explore the nature (i.e., characteristics) of dysphagia services and SLT clinical practices for adults with dysphagia living at home in the community.

METHODS & PROCEDURES

Using a qualitative descriptive approach positioned within an explanatory sequential mixed methods design, this study explored SLT services and practices for adults with dysphagia living in the community to explain further and elaborate on findings from an earlier quantitative study. A total of 15 SLTs working with community-based clients with dysphagia were recruited using purposive representative sampling. Content analysis was used to explore the data.

OUTCOMES & RESULTS

The overarching theme of community commands a different approach and was illustrated by three subthemes that highlighted how and why a different approach to dysphagia care in the community setting was necessary: (1) skills and mindset require adaptation in the community context; (2) values and approaches are different in the community context; and (3) organizational influences impact service delivery in the community context. From the data, it is apparent that the work undertaken in the community setting differs from dysphagia care in other settings and requires adapted SLT skills, values and approaches that encompass holistic care, client autonomy and carer engagement. SLT practices are also informed by organizational influences such as policies and resourcing, which in some services were enablers, while for others these presented challenges.

CONCLUSIONS & IMPLICATIONS

Community-based SLT services must continue to foster flexible, responsive practices by SLTs to ensure the needs of clients and carers are met now and in future.

'It depends': Characterizing speech and language therapy for preschool children with developmental speech and language disorders

BACKGROUND

Several studies have suggested that practitioners hold speech and language therapy (SLT) practice as tacit and consequently it is difficult for the therapist to describe. The current study uses a range of knowledge elicitation (KE) approaches, a technique not used before in SLT, as a way of accessing this tacit knowledge. There is currently no agreed framework that establishes key factors underpinning practice for preschool children with speech and language disorders. This paper attempts to address that gap.

AIMS

To develop a framework of SLTs' practice when working with preschool children with developmental speech and language disorders (DS&LD).

METHODS & PROCEDURES

A mixed-methods approach was adopted for this study. Data were collected iteratively, from 245 SLTs with experience of working with preschool children with DS&LD across sites in England, by means of focus groups and national events. There were three stages of data collection: local sites, specific-interest groups and two national events. KE techniques were used to gather data, with initial data being collected in local site focus groups. Findings from groups were taken to subsequent larger groups where a combination of concept mapping, teach-back and sorting exercises generated a more detailed description of practice, using discussion of consensus and disagreement to stimulate further exploration and definition and provide validatory evidence.

OUTCOMES & RESULTS

This paper provides a high-level framework of therapy for preschool children with DS&LD that makes practice explicit in this area. The framework proposes that therapists' aims for this group of children fall into three categories: addressing children's areas of impairment and skills; achieving functionally meaningful skills and carryover; and supporting adults to provide a supportive communication environment. The exact configuration is shaped by the child's context and needs.

CONCLUSIONS & IMPLICATIONS

The framework highlights themes that are well researched in the literature (e.g., speech) and others that have been little studied (e.g., adult understanding), indicating a disconnect between research evidence and practice. The research also highlights the complex nature of interventions for preschool children with DS&LD and the importance therapists attribute to tailoring therapy to individual needs. The framework provides a scaffold upon which SLTs can focus their clinical practice and encourages the profession to understand and explore better the gaps between research evidence and clinical practice for preschool children with DS&LD.

Speech pathologists and professional interpreters managing culturally and linguistically diverse adults with communication disorders: a systematic review

BACKGROUND

Speech pathologists who work with culturally and linguistically diverse (CALD) adults with acquired communication disorders (ACDs), in predominately English-speaking countries, are legally and ethically bound to work with professional interpreters to overcome language barriers and provide equitable services. As levels of migration and ageing populations continue to rise globally, there will be an increasing need for speech pathologists to work with professional interpreters to manage the growing numbers of CALD adults with ACDs. Speech pathologists and professional interpreters face unique challenges when working together due to the need to focus on the intricacies of communication.

AIMS

This systematic review explores how speech pathologists and professional interpreters work together to manage CALD adults with ACDs by investigating the existing research context and the challenges and strategies reportedly used by these professions.

METHODS & PROCEDURES

A systematic quantitative literature review methodology was used to guide the review process, along with relevant items from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Five online scholarly databases (CINAHL, PubMED, Scopus, ScienceDirect and Web of Science) were searched using key search terms. Study inclusion criteria were: (1) original research reported in English; (2) informed our understanding of speech pathologists and professional interpreters working together; (3) focused on the management of ACDs; and (4) focused on working with CALD adults.

OUTCOMES & RESULTS

Ten studies that met inclusion criteria were identified and included in the review. Half of the studies were conducted in Australia. Study designs were either surveys or single-case designs (e.g., case reports or qualitative case studies). Most participants were monolingual, female speech pathologists. Interpreter participants were mainly involved in assessment tasks using face-to-face service delivery. Common challenges reported by participants were speech pathologists being unsure of the accuracies of interpretations by interpreters, and unclear role expectations from both professions. Pre-session briefings and training of both professions were the primary strategies used and recommended.

CONCLUSIONS & IMPLICATIONS

This review identified emerging research relating to speech pathologist and professional interpreter interactions, which were limited predominantly to the perspectives of speech pathologists. Several challenges were reported. While strategies to facilitate interprofessional practice were proposed, the efficacy and utility of the strategies has not been investigated to date. Further in-depth studies are needed to examine how the professions work together, and to explore feasibility and effectiveness of implementing proposed strategies to optimize service delivery to CALD adults with ACDs.

Debriefing about the challenges of working in a remote area: A qualitative study of Australian allied health professionals' perspectives on clinical supervision

Background

The benefits of clinical supervision are more pronounced for health professionals in rural and remote areas. Most clinical supervision studies to date have occurred in metropolitan centres and have used the survey methodology to capture participant experiences. There is a lack of qualitative research that captures participants’ lived experiences with clinical supervision at the frontline.

Methods

Participants were recruited from rural and remote sites of two Australian states using a purposive maximum variation sampling strategy. Data were collected through individual, semi-structured interviews with participants. Data were analysed using content analysis and themes were developed. Sixteen participants from six professions completed the interviews.

Results

Eight themes were developed including the content of supervision, context of supervision, value of supervision, increased need for professional support and unique characteristics of rural and remote clinical supervision.

Conclusions

This study has highlighted the value of clinical supervision for the rural and remote health professional workforce. Furthermore, it has shed light on the unique characteristics of clinical supervision in this population. This information can be used by organisations and health professionals to ensure clinical supervision partnerships are effective thereby enhancing rural and remote workforce recruitment and retention.

Implementation of an extended scope of practice speech-language pathology allied health practitioner service: An evaluation of service impacts and outcomes

PURPOSE

Extended scope of practice roles can address health service challenges and enhance patient services; however there has been limited research of extended scope roles in the discipline of speech-language pathology (SLP). The aim of this study was to examine the clinical outcomes and service impacts of a Speech-Language Pathology Allied Health Practitioner (SLP AHP) led dysphagia and dysphonia service within an Integrated Specialist Ear Nose and Throat (ENT) Service.

METHOD

Low risk referrals were triaged by ENT from the waiting list into the SLP AHP dysphagia and dysphonia clinic. Outcomes from an initial 6-month pilot phase (n = 43) and 6-month implementation phase (n = 158) were evaluated.

RESULT

Approximately 70% of patients managed in the SLP AHP clinic in both phases were discharged without requiring separate ENT appointments. There were no adverse events. In the pilot phase, only 4.3% of medium priority and 10% of low priority referrals were seen within clinically recommended time frames. This improved to 90% in the final three months of the implementation phase.

CONCLUSION

With appropriate governance and risk management, an extended scope SLP AHP service for low risk dysphagia and dysphonia can achieve safe, effective and beneficial changes to ENT service delivery.

Speech Language Pathology Rehabilitation

The speech language pathologist has a vital management role in patients with voice and swallow concerns, as well as stroke patients and patients with fluency problems. This article summarizes the variety of speech and swallow rehabilitation that adult patients may require or seek. The case examples allow the reader to base the clinical decision-making process within the context of a patient presentation and elucidate the role of speech and language pathology services for the primary care provider in order to refer patients with symptoms and concerns to the right provider early in their medical care.

A qualitative case study in the social capital of co-professional collaborative co-practice for children with speech, language and communication needs

BACKGROUND

Effective co-practice is essential to deliver services for children with speech, language and communication needs (SLCN). The necessary skills, knowledge and resources are distributed amongst professionals and agencies. Co-practice is complex and a number of barriers, such as 'border disputes' and poor awareness of respective priorities, have been identified. However social-relational aspects of co-practice have not been explored in sufficient depth to make recommendations for improvements in policy and practice. Here we apply social capital theory to data from practitioners: an analytical framework with the potential to move beyond descriptions of socio-cultural phenomena to inform change.

AIMS

Co-practice in a local authority site was examined to understand: (1) the range of social capital relations extant in the site's co-practice; (2) how these relations affected the abilities of the network to collaborate; (3) whether previously identified barriers to co-practice remain; (4) the nature of any new complexities that may have emerged; and (5) how inter-professional social capital might be fostered.

METHODS & PROCEDURES

A qualitative case study of SLCN provision within one local authority in England and its linked NHS partner was completed through face-to-face semi-structured interviews with professionals working with children with SLCN across the authority. Interviews, exploring barriers and facilitators to interagency working and social capital themes, were transcribed, subjected to thematic analysis using iterative methods and a thematic framework derived.

OUTCOMES & RESULTS

We identified a number of characteristics important for the effective development of trust, reciprocity and negotiated co-practice at different levels of social capital networks: macro-service governance and policy; meso-school sites; and micro-intra-practitioner knowledge and skills. Barriers to co-practice differed from those found in earlier studies. Some negative aspects of complexity were evident, but only where networked professionalism and trust was absent between professions. Where practitioners embraced and services and systems enabled more fluid forms of collaboration, then trust and reciprocity developed.

CONCLUSIONS & IMPLICATIONS

Highly collaborative forms of co-practice, inherently more complex at the service governance, macro-level, bring benefits. At the meso-level of the school and support team network there was greater capacity to individualize co-practice to the needs of the child. Capacity was increased at the micro-level of knowledge and skills to harness the overall resource distributed amongst members of the inter-professional team. The development of social capital, networks of trust across SLCN support teams, should be a priority at all levels-for practitioners, services, commissioners and schools.

Language development, delay and intervention-the views of parents from communities that speech and language therapy managers in England consider to be under-served

BACKGROUND

Evidence-based practice includes research evidence, clinical expertise and stakeholder perspectives. Stakeholder perspectives are important and include parental ethno-theories, which embrace views about many aspects of speech, language and communication, language development, and interventions. The Developmental Niche Framework provides a useful theory to understand parental beliefs. Ethnotheories, including those about language development, delay and interventions, may vary cross culturally and are less well understood in relation to families who may be considered 'under-served' or 'hard-to-reach' by speech and language therapy services. Who is considered to be under-served and the reasons why some families are under-served are complex.

AIM

To describe beliefs and reported practices, in relation to speech and language development, delay and intervention, of parents and carers from a small number of groups in England who were perceived to be under-served in relation to SLT services.

METHODS & PROCEDURES

As part of a wider National Institute for Health Research (NIHR)-funded study (Child Talk), seven focus groups (with a total of 52 participants) were held with parents from three communities in England. Topics addressed included beliefs about language development, language delay and parents' reported responses to language delay. Data were transcribed and analysed using adapted framework analysis, which also drew on directed content analysis.

OUTCOMES & RESULTS

Four themes resulted that broadly matched the topics addressed in the focus groups: language development and the environment; causes and signs of speech and language delay; responses to concerns about speech, language and communication; and improving SLT. These produced some previously unreported ideas, e.g., about how language develops and the causes of delay.

CONCLUSIONS & IMPLICATIONS

The findings are discussed in relation to previous literature and the Developmental Niche Framework. Clinical implications include ideas about issues for SLTs to discuss with families and the need to recognize that parents may see themselves as competent facilitators of language. Suggestions are made for future research, including: expanded investigation of a wider range of under-served groups, an exploration of who parents consult when concerned about their child's language, and how key community figures advise parents in relation to language delay.

Speech pathology as the MasterChef: Getting the right ingredients and stirring the pot

The purpose of this paper is to consider the many influences that have an impact on appropriate speech-language pathology service delivery. The competitive cooking and entertainment television program, MasterChef, is used as an analogy to consider the ingredients, blend and approach required to improve speech-language pathology services. Speech-language pathologists (SLPs) enter the profession with the aim of assisting those with communication and swallowing disorders to have a better quality of life. Thus, we should be restless to continue to improve our services in order to achieve the best influence and outcomes by changing our recipes and ingredients. However, having good technical skills as a SLP is not sufficient in ensuring that the services are the best they can be. We have to consider available resources, customers and service users, who it is that judges our services, whether we are as good as we could or should be, what can help us improve our services, what the appetite is for our services, and how we incorporate evidence-based practice. This paper considers the value of understanding and using information on incidence and prevalence, evidence-based practice and outcome measurement. Blending technical, clinical and academic abilities with personal skills will result in an award-winning menu.

Effective Team Practices: Interprofessional Contributions to Communication Issues With a Parent's Perspective

PURPOSE

This clinical focus article contains a detailed description of how to build effective teams that use interprofessional collaborative practice (IPCP) with special-education professionals, speech-language pathologists, and families of children with severe disabilities.

METHOD

This clinical focus article provides information on using the essential elements of team building and IPCP to provide quality care to families who have children with severe disabilities. The 6 essential elements for team building are described, with suggestions for including families in each: goal-setting, roles and responsibilities, effective and efficient process, communication and interpersonal relationships, collaborative problem solving, and evaluation. The 4 competency domains of IPCP are embedded into each of the team-building elements to demonstrate how teams can implement IPCP.

RESULTS

A case study illustrates the difficulty one parent experienced working with a team across the 6 essential team-building elements when seeking communication services for her child with severe disabilities.

CONCLUSIONS

Building teams with IPCP can be effective for including families and creating high-quality outcomes for individuals with severe disabilities.

Mapping speech pathology services to developmentally vulnerable and at-risk communities using the Australian Early Development Census

PURPOSE

The Australian Early Development Census (AEDC) is a population-based measure of children's development across five domains in the first year of formal schooling. In this study, the AEDC data from two domains (Language and Cognitive Skills and Communication Skills and General Knowledge) were used to explore the extent and distribution of vulnerability in communication skills among children in Australian communities. Speech Pathology Australia (SPA) membership data were then used to explore the accessibility of services within those communities.

METHOD

The 2012 AEDC data were accessed for 289,973 children, living in 577 communities across Australia. The number of children identified as "at risk" (10-25(th) percentile) or developmentally "vulnerable" (< 10(th) percentile) in each of the domains was calculated, then the location of communities with high proportions (> 20%) of these children was determined. These data were mapped against the location of paediatric speech-language pathologists (SLPs) to identify the number of communities with little to no access to speech-language pathology services.

RESULT

Across Australia, there were 47,636 children (17.4%) identified as developmentally vulnerable/at risk in Language and Cognitive Skills and 69,153 children (25.3%) in Communication Skills and General Knowledge. There were 27 communities with > 20% of children identified as developmentally vulnerable/at risk in Language and Cognition in their first year of formal schooling. Of those, none had access to speech-language pathology services, according to current SPA membership data. There were also 27 local government areas with > 20% of children identified as developmentally vulnerable/at risk in the Communication Skills and General Knowledge domain. Of these, three had access to SLP(s) and these were in regional/metropolitan areas.

CONCLUSION

The AEDC provides a means of identifying communities where children are performing well and communities which may benefit from population-based prevention or intervention. Given the number of communities within Australia without access to SLPs, there is a need to reconsider how such population-based services could be delivered, particularly in the communities with higher levels of vulnerability in communication development.

Rural speech-language pathologists' perceptions of working with allied health assistants

Workforce shortages are forecast for speech-language pathology in Australia, and will have a more significant impact on rural and remote areas than on metropolitan areas. Allied health (AH) disciplines such as physiotherapy and occupational therapy address the problem of workforce shortages and growing clinical demand by employing allied health assistants (AHAs) to provide clinical and administrative support to AH professionals. Currently, speech-language pathologists (SLPs) don't work with discipline-specific allied health assistants in all states of Australia (e.g., New South Wales). This paper aims to provide insight into the perceptions of SLPs in one Australian state (NSW) regarding working with AHAs. Semi-structured interviews were conducted with eight rural SLPs. Qualitative analysis indicated that participants perceived they had deficits in skills and knowledge required to work with AHAs and identified further training needs. Participants perceived the SLP role to be misunderstood and were concerned about poor consultation regarding the introduction of AHAs into the profession. Ambivalence was evident in overall perceptions of working with AHAs, and tasks performed. While previous research identified benefits of working with AHAs, results from this study suggest that significant professional, economic, and organizational issues need addressing before such a change should be implemented in speech-language pathology.

Facilitating emergent literacy: efficacy of a model that partners speech-language pathologists and educators

PURPOSE

This study examined the efficacy of a professional development program for early childhood educators that facilitated emergent literacy skills in preschoolers. The program, led by a speech-language pathologist, focused on teaching alphabet knowledge, print concepts, sound awareness, and decontextualized oral language within naturally occurring classroom interactions.

METHOD

Twenty educators were randomly assigned to experimental and control groups. Educators each recruited 3 to 4 children from their classrooms to participate. The experimental group participated in 18 hr of group training and 3 individual coaching sessions with a speech-language pathologist. The effects of intervention were examined in 30 min of videotaped interaction, including storybook reading and a post-story writing activity.

RESULTS

At posttest, educators in the experimental group used a higher rate of utterances that included print/sound references and decontextualized language than the control group. Similarly, the children in the experimental group used a significantly higher rate of utterances that included print/sound references and decontextualized language compared to the control group.

CONCLUSION

These findings suggest that professional development provided by a speech-language pathologist can yield short-term changes in the facilitation of emergent literacy skills in early childhood settings. Future research is needed to determine the impact of this program on the children's long-term development of conventional literacy skills.

An international study of clinical education practices in speech-language pathology

This study identified the clinical placement and supervisory models used within 45 speech-language pathology professional preparation programs in seven English-speaking countries and the drivers influencing the adoption of these models. University personnel completed an on-line survey about the placement and supervisory models used in their programs, their opinions regarding the effectiveness of the models in developing student competency, and the factors influencing the adoption of different models. Responses from the survey were analysed through descriptive statistics and thematic analysis. "Traditional" placement models such as block and weekly placements, as well as traditional supervisory models utilizing a speech-language pathologist as supervisor in a 1:1 student-to-supervisor ratio were the most widely used in the clinical education of speech-language pathologists. "Non-traditional" models, where the overall structure of the practicum experience or the delivery of supervision within the practicum experience has been altered from the traditional models, were used with differing frequency across countries. The major influences on the adoption of non-traditional models included attitudes about the effectiveness of the models, availability of placements, standards of professional associations, and student learning outcomes, particularly in relation to exposure to clinical sub-groups. Further evidence regarding the effectiveness of both traditional and non-traditional placement and supervisory models needs to be developed. To develop this evidence, consistent terminology and a shared understanding of terminology needs to be established.

A survey of head and neck cancer curriculum in United States speech language pathology masters programs

We surveyed speech language pathology (SLP) programs for head and neck cancer (HNC) training. Program directors of 242 American Speech-Language-Hearing Association accredited masters programs for SLP were contacted regarding curricular HNC material. Directors (n = 120) responded online: six included a required course in HNC, and all but two programs with no required HNC course included HNC topics in other required courses. Thirty-two programs were affiliated with a medical center and/or a teaching hospital. Programs that offered either a required course in HNC or elective courses on HNC were more likely to be affiliated with a medical center and/or a teaching hospital than programs that did not offer a required course in HNC (P = 0.043) or elective courses on HNC (P = 0.007), respectively. Few programs offer a required HNC course but most programs integrate HNC content into the required coursework. Potential strategies to incorporate HNC exposure into formal SLP programs are identified.

Increasing stroke patients' success in self-medication programs using an interdisciplinary cognitive rehabilitation approach

Rehabilitation programs strive to help patients become more independent in all aspects of daily living. Therefore, management of a patient's healthcare requirements should be an integral part of the rehabilitation program, including management of medications. Some rehabilitation programs implement self-medication programs (SMP); however, patients with cognitive deficits are often excluded. This study explored whether patients with cognitive deficits due to stroke could successfully complete an SMP using an interdisciplinary cognitive rehabilitation approach. Twenty-seven stroke patients and 36 debilitated patients with cognitive deficits participated in an SMP. A nurse and a pharmacist educated patients on their medications, and a speech-language pathologist provided cognitive rehabilitation to the stroke patients, which incorporated information from the SMP. Eighty-one percent of the stroke patients successfully completed the SMP, compared to 36% of the debilitated patients. Thus, an interdisciplinary approach to medication management for cognitively impaired stroke patients holds promise.

Management competencies: intrinsic or acquired? What competencies are required to move into speech pathology management and beyond?

Speech pathology managers frequently move into careers beyond their clinical discipline. As practicing speech pathology managers and students of business leadership, we were curious about the nature of career transitions out of speech pathology management. We conducted an exploratory descriptive study investigating the perceived competencies that facilitate such career transitions and when further education is required to effectively equip one for such transition. The perceived skills related to a speech pathology background are identified along with the gaps in competence for moving into general management positions. Career management practices that facilitate this type of career transition are provided as recommendations for career planning.

International and Cross-Cultural Issues: Six Key Challenges for Our Professions

This paper discusses a number of key challenges facing professionals who work with people who have communication disabilities. The challenges are related to working internationally and in a cross-culturally competent way. Each challenge is discussed, drawing on material from a range of sources, including the papers in the final 2003 edition of FOLIA PHONIATRICA ET LOGOPAEDICA ('International and Cross-Cultural Issues'). The challenges discussed cover how experiences from majority world countries can be used to benefit services elsewhere, 'mainstreaming' commitment to cross-cultural competence, learning from relationships with other professionals, influencing research practice, responding to requests to work internationally and finally, dealing with cultural differences that challenge working practices. Some solutions are suggested and additional questions posed.

Service Delivery Options for Secondary Students with Language Disorders

Numerous adolescents are still undetected, unserved, and underserved by speech-language pathologists, resulting in astronomical financial and psychological costs to them and society. The purpose of this article is to provide an overview of past and present service delivery options for adolescents with language disorders. Before illustrating the authors' recommended model, the following background is provided: an overview of the three stages of adolescent development, characteristic expectations and problems for older students with language disorders, and a rationale for adolescent speech-language services. The comprehensive service delivery model for secondary-level speech-language students, designed and reported by the authors, consists of six components: information dissemination, identification, assessment, program planning, intervention, and follow-up. Some of the unique features of the comprehensive model are presenting services as a course for credit, providing grades, and using supportive course titles such as Individualized Communication Class.

A multimethod approach to the evaluation of community preschool speech and language therapy provision

OBJECTIVES

The paper presents a research study investigating the effectiveness and acceptability of community speech and language therapy provision for preschool children with early speech/language delays. As a 'worked example', it demonstrates the value of a multimethod approach to evaluation.

METHODS

The paper examines how the research findings of a pragmatic randomized controlled trial (RCT), a survey questionnaire and qualitative in-depth interviews, which were the methods used in the evaluation, overlap and complement each other.

RESULTS

There was little evidence to establish the effectiveness of the speech and language therapy provided in the trial. This lack of difference was reflected in responses of parents to items on the questionnaire. The findings of the RCT, questionnaire and interviews all cast considerable doubt on the prospect of spontaneous resolution of the children's difficulties. Although the RCT showed few differences between the children allocated to immediate therapy or 'watchful waiting', the questionnaire and interviews revealed the circumstances in which the parents felt that these intervention strategies had been acceptable and unacceptable.

CONCLUSIONS

Although the trial provided information about the progress of the children, the questionnaire and interview components highlighted the advantages and limitations of the intervention from the viewpoint of parents, thereby helping to explain the RCT findings. Thus, the study demonstrates how a multimethod approach to evaluation can yield useful information to explain the findings of RCTs.

Four decades of speech-language pathology in India: changing perspectives and challenges of the future

The paper traces the evolution and current status of speech-language pathology in India in its clinical and training aspects.

Speech therapy in Brazil: forty years of existence, two decades of recognition

The history of speech therapy in Brazil is presented, outlining the creation of the first course, the courses of Master's degree and the current situation, along with the main responsible aspects for it.

Treatment program planning by speech therapists in Taiwan

Speech-language pathology is a rapidly growing profession in Taiwan. To assess its autonomy and maturity, a survey on the treatment program with the help of a 14-item questionnaire was conducted among 90 speech therapists from health care settings. Questions about the planning of the treatment program, its components, and the employed therapeutic methods were addressed in the study. The survey findings helped clarify the current role of speech therapists in Taiwan.

Japanese speech therapy (logopedics) education after the presentation of the education guidelines in the 1995 IALP general assembly

The background of the education system for Japanese speech therapists (logopedists) is reported. It took nearly 40 years for speech therapists and medical doctors to come to a consensus in order to define the status and educational system for the 1997 Law for Japanese Speech Therapists. Unfortunately, the IALP Education Guidelines of 1995 received little respect in the process of long negotiation. The present situation and the future goals for Japanese speech therapists are discussed.

Speech-language pathology in Malta: meeting local needs in a global perspective

Education in logopaedics and patterns of service delivery for the communication-disordered have expanded over the past decade in the Maltese Islands to address local needs, culture and circumstances. This paper provides an overview of the expansion of trained staff, caseloads and mode of service delivery. Various strategies are reported as having been adopted by the relatively underresourced training establishment to ensure the preparation and maintenance of competent and accountable practitioners, as recommended by the International Association of Logopedics and Phoniatrics. The success in training is perceived as being the result of the collaborative approach adopted with local service providers and expatriate colleagues. Strategic plans to strengthen the profession and service provision are also discussed.

Emerging issues in Israel: commentaries in a global context

Communication disorders in Israel is a well-established professional field, requiring academic training and dual certification in speech pathology and audiology. Entry level is a BA in communication disorders (comparable to a MA degree in the USA) and 1 year of work under supervision. It is possible to continue studies towards higher degrees (MA and PhD). We face the same problems as in the rest of the world with need for trained professionals in the social services and the need to deal with multilingual and multicultural issues.

Speech-language pathology in the Philippines: reflections on the past and present, perspectives for the future

The field of speech-language pathology in the Philippines has come a long way since its inception in 1978. This article provides an overview of the profession, including a description of the distribution, work settings, and scope of practice of the speech-language pathologists in the Philippines. It highlights the strengths and unique aspects of the profession such as the experience of working with bi-/multilingual clients, honed clinical reasoning, family involvement, and exposure to inter- and transdisciplinary approaches to service delivery. Further, this paper discusses issues and challenges that need to be addressed for continued growth of the profession.

Emerging issues in speech therapy in Iran

This report is a short review of the form and content of speech and language therapy services and the trend of their institutionalization in Iran. A summary of formal education in speech and language therapy in Iran as originated by establishing a 4-year BS rehabilitation program in the College of Rehabilitation Sciences in Tehran is given. Since then, speech and language rehabilitation programs have been expanding both in size and quality, resulting in about 1,000 speech therapists practicing in hospitals and rehabilitation centers throughout the country. The expansion of graduate programs at MS level in three different institutions and a prospective PhD program are also adding to the quality of these services. The content of the theory courses and clinical practice courses as well as research on specific speech and language disorders and cross-linguistic studies are briefly described.

Education of speech and language therapists in the Republic of Ireland and in the UK

A brief history of speech and language therapy education in the Republic of Ireland and in the UK is provided, with reference to early 20th century developments. Current practice regarding the regulation and accreditation processes of education courses in the two countries is outlined. A general account of the development of undergraduate curricula of speech and language therapy is provided.

Conducting clinical trials in a constantly changing health care environment

Continuous change and cost containment characterize the current health care system, making conduct of clinical trials and other clinical research difficult. Identification, accrual, and follow-up of patients who move between health care environments such as hospitals, nursing homes, schools and the home is particularly challenging. This article describes a circuit rider approach to patient identification and follow-up that was established by the Communication Sciences and Disorders Clinical Trials Research Group. It also gives suggestions for design of clinical trials in a constantly changing environment.

Evaluation of functional outcomes (speech, swallowing and voice) in patients attending speech pathology after head and neck cancer treatment(s): development of a multi-centre database

Since April 1997, in Melbourne, Australia, speech pathologists have collaborated to establish a prospective database of functional outcomes of speech, swallowing and voice for patients undergoing head and neck cancer treatments. Staff at eight acute care hospitals, all of which offer speech pathology for head and neck cancer services in Victoria, are contributing data, collated centrally, in an agreed pro forma. Early results are given (after 12 months' data collection). The implications for clinically-based research, and the future potential for benchmarking outcomes--by expansion of the rehabilitation database beyond the current participating sites--is discussed. This paper outlines the rationale of establishing the database is multicentered, and explores some of the complexities involved, including the challenges inherent in long-term accurate data collection in the head and neck cancer patient population. This work represents the development of an appropriate, usable tool for data collection on functional outcomes.

Australian speech pathologists' views of what professional practices lead to successful outcomes of therapy

The relative importance attributed to factors perceived by speech pathologists as contributing to successful levels of therapeutic outcomes were addressed in a survey of 372 practicing therapists in Australia. The survey consisted of 42 items derived from interviews with a sample of ten speech pathologists in Sydney. Therapists were asked to rate the importance of each item on a seven-point scale ranging from "not at all important" to "critically important." The findings indicate that the most important ingredients of successful therapy incorporate a mix of support and therapeutic activity outside the clinic; the clinicians' organizational skills and involvement in conducting therapy and their use of techniques; the positive therapeutic relationship between clinician and client; and, finally, the client's attitude to therapy. These findings suggest that speech pathologists, like other allied health professionals, endorse a humanistic or holistic approach to health care. The results provide insights into the practices that should be addressed and fostered in undergraduate speech pathology programs.

Equitable service provision for inclusive education and effective early intervention

This paper illustrates one model of providing an integrated paediatric speech and language therapy service which attempts to meet the demands of both inclusive education and effective early intervention. A move has been made from location-oriented therapy provision to offering children and their families equal opportunities to have appropriate intervention according to need. The model incorporates the philosophy of inclusive education and supports the development of current specialist educational establishments into resource bases of expertise for children with special needs in mainstream schools.

'Excellence for all children' a redefinition of the role of the speech and language therapist

This paper describes two projects relating to a speech and language therapy service to mainstream primary schools. The aim of the projects has been to improve service delivery by collaborative working both at a strategic and operational level. The result has been a redefinition of the role of speech and language therapists within this context.

Collaboration in Glasgow's primary school language units

The quality of collaboration between teachers and speech and language therapists (SLTs) in Glasgow's four primary language units is discussed with reference to a scale of three levels of co-operation: nominal, convenient and committed. Although there are some aspects of the relationships that exist between teachers and SLTs which would be typical of committed co-operation, the overall quality appears to be at the level of convenient co-operation. In particular, inadequate role definition and a lack of structure are discussed with reference to joint work on language development and several suggestions are included as ways forward in this area. The need to evaluate models of working critically is discussed in relation to collaborative working.

Let's talk: a working party for special schools

The Special Schools Working Party was formed in summer 1996 to improve communication channels and foster understanding between speech and language therapist, school and home. It consists of representatives from all three groups in the six schools involved. The Working Party has produced a document which describes everyone's role and agreed procedures for liaison and training. Its greatest benefit lies in the opportunities for discussion and exchange of ideas. In the future the Working Party is planning to audit customer satisfaction of the service and continue to develop ideas for improving its accessibility.

Making team working work--a real life experience

Southern Derbyshire Speech and Language Therapy Department has a team of six specialist speech and language therapists who support children with Specific Language Impairment in their mainstream schools via joint commissioning with education. As the team expanded in October 1995 this coincided with health trust and education changes and produced great instability and insecurity within the team. This paper outlines the implementation of a formal team working package using a facilitator provided by the trust's quality team and shows how it is possible to problem solve and develop within a framework of group rules, such as honesty and openness. Following its success its principles have allowed us to co-operate more effectively with both school staff and the community team and to support colleagues through a re-organisation of their service.