how . . . i put research into practice

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~ \ E v i d e n c e based practice' soundsgood, but u pdati ng ou r practice asnew information becomes available isnot always easy. The unwieldinessof public services, long waiting listsand lack of time to research theresearch can all conspire against us.In the Spring 2000 issue, threecontributors discussed how they putpractice into research. Then weobserved that speech and languagetherapists "want to know optinlunlti mes for intervention, tech n iq uesthat produce results and caseloadorganisation that makes the bestuse of limited time". So, once weknow, how do we change ourpractice accord i ng Iy?Our contributors present the casefor evidence based practice - l1li.:;)you, the jury, must decide. ~

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is big.' 'Research meansstatistics.' 'Research is timeconsuming.' That's one perspective,but what about another? 'I want

Research isn't confined to ivory towers or weighty journals. Nina Soloff challenges us to ask, investigate, discuss and share the everyday questions that add to the evidence base for our practice.

Gathering the evidence the best for my clients.' 'I want to be sure I' m making a difference.' Index to Recent Literature on Speech and Language. This is a databaseI'm making a difference and I want to share it with other people.' of abstracts from over thirty journals. (The only problem is you often

problem with the word 'research' is that people have precon find there is too much that you want to follow up.)about what it involves. Sometimes I think the word should b. Use your librarian. Most Trusts have a library with staff who have a great

abolished completely, and I should have a different job ti t le. many skills in searching for articles . Even if you just go in with a word or aPractice Co-ordinator' is a bit of a mouthful, but phrase relating to what you want to look for, they will be able to help you

-b ased practice is really what we're talking about as it is: identify relevant articles and books, order items from other libraries , andan approach to decision-making in which the clinician uses the best may even train you in doing literature searches. If you don't have a Trust

available, in consultation with the patient, to decide upon the library, try your local council library.which suits the patient best.'

Gray, 1997)practice is a part of our everydaylives (see stages in figure 1). It happens when

devise, execute and evaluate therapy plans; whenwith a colleague helps you make aclinical

when you read an article in this very magaand apply it to your own situation.how can we put Muir Gray's definition into

uestions, questions, questionsthat for most research to be relevant to

practice, it has to be borne out of clinicalway to start is to capture those

pop into your head in your everyday(see figure 2) and then ask yourself what evineed in order to be able to answer them.

be great if every clinician had a notebookthose sorts of questions down in. That way,

think about the question therethen, you can go back to it later. Th is can be a

process because, when you'rewith clinical work, you often forget

you can be. It can rekindle your enthuwhen you look back through your notebook

say to yourself, "Did I really think of that...?"what counts as evidence? Le May (1999) makes

point that, while evidence from well-conductedis given greatest credibility, practice is, in fact,by many sources of evidence, including :based on experiences - this type of evidence

with the habit of 'question-asking' describedincludes reflecting on practice, discussing

Figure 1The stages within evidence-based practice Deciding what we want to find evidence about Accessing the evidence Appraising the evidence Using the best available evidence Evaluating the impact of the evidence (Ie May, 1999)

Figure 2 Sample questions What effect does taste haveon swallowing; What is the incidence! treatmentefficacy of cluttering in peoplewith Down's Syndrome; How soon after adenoldectomy/grommet insertion should weexpect changes in speechperception/production; That is,should I delay offering therapyuntil the surgery has had timeto 'take effect'?(Thanks 10 membersof Milton Keynes' Speech andLanguage Therapy Service.)

c. Set up journal alerts. If you have internetaccess, you can set up a messaging service thattells you when the latest editions of journalscome out. You can choose which journals tobe told about, so you don't have to beswamped bye-mails. The e-mail 'alert' linksyou to aweb-page showing the contents ofthejournal, giving you further links to the abstractsof the articles. I mainly use Arnold Publishers(www.arnoldpublishers.com) and Taylor &Francis (www.tandf.comjournals).The best wayto go about it is to find out who publishes thejournal(s) you're interested in, then search fortheir website. They will probably have a linktelling you how to set up the alerting service .Unfortunately, unless you subscribe to thejournal itself, you usually won't be able to getthe full article on-line, but at least you can seewhether it would interest you enough to askyour friendly librarian to get it for you.d. Get 'Athens' access. Your Trust librarymay be able to give you a password allowingyou free access to a range of databases whichhouse journal abstracts. You can log in to theAthens website (www.athens.nhs.uk) fromany computer, which means that if you haveinternet access in your clinic or at home, youdon't even need to leave your desk to searchfor articles . The databases available to HealthService workers through Athens includeMedline, CINAHL, AMED, EMBAsE, Psyclnfo,British Nursing Index and NeLH (see glossary).You may need some training in literaturesearching to get the best out of the databases.

with colleagues, and using information from articles in e. Read the Royal College of Speech & Language Therapists' publicamagazines. tions. Some of the leg-work has been done for you, with a new set ofga,thered from clients and / or their carers - either in your own Clinical Guidelines about to be publ shed. Clinical guidelines should be

studies and articles published by other people. based on the best evidence available. The Royal College uses evidencepassed on by role models / experts This usually means panels from research as well as consensus from expert panels.

expert opinions. The Royal College of Speech & Language Therapists'Guidelines by Consensus fall into this category. 3. Appraising the evidence

A couple of brief tips on appraising research evidence:the evidence Set up a journal club, or bring case-relevant articles to discuss at yourdepends on the type of evidence you want to access. Some of it will be supervision sessions if you have them; two or more heads are usually

to you in your everyday work, but the research evidence better than one.need some more digging out. There are ways and means, however... All Trustsshould now have an R&D (Research & Development) strategy,your manager to take out an institutional subscription to the and many will have a research facilitator in post. This per son should be

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003 25
http:///reader/full/www.arnoldpublishers.comhttp:///reader/full/www.arnoldpublishers.comhttp:///reader/full/www.arnoldpublishers.comhttp://www.tandf.xn--comurnals-2u5j/http:///reader/full/www.athens.nhs.ukhttp:///reader/full/www.arnoldpublishers.comhttp://www.tandf.xn--comurnals-2u5j/http:///reader/full/www.athens.nhs.uk


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able to guide you to courses such as CASP (Critical Appraisal SkillsProgramme). Alternatively, your Trust should be part of a regionalPrimary Care Research Network (PCRN), who may offer free courses .http://drsdesk.sghms .ac.ukJ may be able to link you to your regionalPr imary Care Research Network.

4. Core skills and attitudes A questioning attitude to existing knowledge and accepted practices A need to be aware that what we believe to be true mayor may not

reflect what the evidence is telling us A recognition that we all have gaps in our knowledge A realisation that there isn't an evidence base for much of what we do.

Lastly, a very useful thing to have is a manager who recognises thevalue of evidence-based practice and allows you the time to find thingsout. So start writing those questions down ..ReferencesIe May, A. (1999) Evidence-based practice. Nursing Times ClinicalMonographs, 1. Emap Healthcare Ltd.

Muir Gray, J. (1997) Evidence-based healthcare: How to make health policy and management decisions . Edinburgh: Churchill Livingstone.Royal College of Speech & Language Therapists (1998) Clinical Guidelinesfor Speech and Language Therapists by Consensus . RCSLT, London.Royal College of Speech & Language Therapists (1996) Communicating Quality2- Professional Standards for Speech and Language Therapists. RCSLT, London.ResourcesBiomedical Research Indexing, do Christopher Norris, Downe, Baldersby,Thirsk, North Yorks, Y07 4PP, tel: 01765 640283, fax: 01765 640556 .Annual rates: CD - Institution 90, individual 70; Printed - Institution72 , individual 50 .GlossaryAbstract - a summary of the main points of the articleCINAHL - Cumulative Index to Nursing and Allied HealthAMED - Allied and Complementary MedicineEMBASE - Excerpta MedicaNeLH - National Electronic Library for Health

Researchers at the Speech and Language TherapyResearch Unit pause amongst the protocols toreflect on their research. All practising clinicians ina previous or parallel life, what impact has theirresea rch had on thei r approach to practice?M : ~ ; ~ ; : ; ; ~ i ~ ~ : ; ; ~ ~ : ; Weighing the arguments controlled trial of preschool children in the community and patient will gradually internalise the strategy, relying less on externalnow leads the project to follow up those children. As part of her PhD she

carried out a series of in-depth interviews with parents:What I learned from my qualitative interview study with the parents ofspeech / language delayed children would profoundly affect my workwith this client group. I would aim to address three areas of major concernfor parents - the first appointment, their information needs and negotiation of treatment. Having your child referred to speech and languagetherapy is a 'big deal' to parents. For that reason, the initial appointmentwould be with parents alone. This would give them the chance to tell meabout their child and the difficulties and ask questions without worryingabout how their child is coping in an unfamiliar setting. Wherever possi-ble I would see the child at home. I would explain the child's difficulties tothe parents as far as these difficulties are explicable, guiding themtowards information resources available to them . If I would see the childfor therapy, I would find out what role parents could take on and clearlyspell out what I would ask them to do. I would discuss with parents theform therapy could take, practicalities of the arrangement and difficultiesthey might have . From what I heard in the interviews, I believe thisapproach in the early stages could reassure, truly inform and motivateparents as they embark on the therapy process with their children.Corinne Dobinson is developing software for people with dysarthriato support independent practice:/t was important that the software provided maximum potential fortransfer and generalisation of the strategies to change speaking rateand improve intelligibility. In my literature search I discovered motorlearning principles relating to short and long-term learning, transferand generalisation.These prinCiples would influence my use of feedback in clinical practice.While instrumentation and verbal feedback in the speech and languagetherapy clinic provide useful information, there is a potential for feedback overkill. Frequent feedback is likely to be more helpful in the earlystages of motor learning. By providing increasingly less feedback the

SPEECH & LANGUAGE THERAPY IN PRAOICE AUTUMN 2003

feedback from the therapist or instrumentation. In speech and language therapy we appreciate the importance of selfmonitoring in developing this internalisation, but the literature suggests that the focus of self-monitoring should be different at earlier and later stages. In the early stages of self-monitoring it s beneficial to focus on the process of the strategy. This might be the method used to reduce speak-ing rate. When the process becomes more natural to the speaker, then the focus should shift to an outcome goal. This might be a specified speaking rate or level of intelligibility. These principles help us to clarify the appropriate use of feedback and self-monitoring in motor speech therapy. Yvonne Wren is investigating the use of computer software as a therapytool in the school context for children with phonological difficulties:In a recent study, I worked in partnership with several primary schools.The schools were approached because they had a pupil with a phonological impairment. All schools were initially keen to participate as theywere told they had a two in three chance of th is child receiving eightweekly sessions of therapy in school. However, they were also told that inorder to participate they would need to provide someone (teacher, assis-tant or volunteer) who could work with the child for three 30 minute ses-sions per week. At this point, all schools took a sharp intake of breath'In my previous role working as a speech and language therapist in a clusterof mainstream primary schools, I endeavoured to get assistant supportto back up work I was carrying out with a child. Generally this wasagreed to but, in all too many instances, this support tailed of f as theweeks went by. The Christmas play, swimming trips and preparing dis-plays were all given priority over the speech and language therapy work.In the research study however, after schools had regained their breath,we discussed the ways in which they would benefit, such as assistantsand teachers gaining new ideas of how to work with children withphonological impairments while waiting for speech and language therapy advice. We also highlighted the benefit to the child - that therewould be someone, possibly in their classroom, who could highlight
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therapy targets throughout the school day. Provided we tried to fit withtheir needs regarding days and times to visit and were flexible aboutwho worked with the child, almost all schools agreed to commit someone to work on the project, Moreover, the assistants were committed tothe three sessions per week throughout the whole eight week periodand their comments at the end of the study were positive with regard tothe skills they had acquired and the importance of their role in helpingthe child move on with their speech,In my future practice, I would be more intent on requesting a commitment from schools to contribute to the child's speech and language therapy support. Heads and Special Educational Needs Coordinators mayconsider this impossible at first but it can be done in most circumstancesand the benefits to the child are worth the effort,Rosemarie Hayhow is studying the process and outcomes of theLidcombe program with children who stutter:The evaluation of a specific therapy approach requires that the therapyis used according to a protocol whether within a single site or acrosssites, Similarly, if we are to refer to an evidence base to support ourchoice of therapy then we must administer that therapy in the same wayas the researchers so that their results are applicable to our work, Thatsounds straightforward but in practice it is hard to do, There are all sortsof events that conspire to make it difficult to comply with pre-determined time schedules, therapy progressions, record keeping and so on,There is also being a speech and language therapist, We are a creativebunch, we like to be flexible and able to respond to a client's expressedneeds, For some therapists, years of working with ill-conceived programmes, poor equipment and minimal theoretical support have led tothe development of a pragmatic and eclectic approach, We are not technicians but thinking, feeling and interacting practitioners, Researching aspecific therapy programme has highlighted for me the extent of theconflict, for myself and others, between being a creative practitionerand a systematic, protocol-directed administrator of a treatment. Tocomplicate things further, these are not mutually exclusive positions,Therapy may work best when the essential components are rigorouslyadhered to but presented in a manner that is adapted to best suit individual clients, Creative problem solving within the framework of thetherapy may be needed to deal with the inevitable difficulties that arisewhen specific strategies or actions are integrated into diverse lives, Andso this brings us back full circle to the importance of knowing whichcomponents of a treatment are essential,

Julia Wade is investigating the use of Automatic Speech Recognitionsoftware with people with aphasia:I recently had the task of carrying out in-depth interviews to determinewhat recipients of computer-based therapy thought of the therapyreceived, Training in conducting these interviews gave me the followingskills: knowing how to ask genuinely open questions and avoid puttingwords in people's mouths being aware of my professional 'baggage' or framework and learning to putthis to one side in an attempt to encourage the person to communicatewhat matters to them rather than what I believe matters to me,I carried out 11 interviews, six with people with aphasia and five withtheir carers, The experience was a revelation! Despite having been atherapist for eight years, and having had people with aphasia on mycaseload throughout this time, I had never had (or never created?) theopportunity to listen to a series of personal accounts of what it was tolive with aphasia and receive therapy. I suddenly wished this experiencehad happened years ago, Ialso felt embarrassed at the thought that, byfailing to set aside enough time when first meeting a client to listen towhat they had to say (instead of frantically assessing their communicationskills), I had no doubt at times suggested inappropriate therapy goals,The effect has been to change the way I go about taking a case historyentirely. I now go prepared with what I think of as my 'blank sheet'mindset and ask the person to tell me about themselves and their aphasia, and perhaps what they might be expecting or hoping for, from mespecifically or from therapy in general, This way, I get their story muchmore efficiently than if I went through all the detail of a case historyform, More importantly, I get what matters to them.Sue Roulstone is the Co-Director of the Research Unit:Reading my colleagues' contributions, Iwas struck by the similarities andhow they parallel my own experience, The process of setting up researchprojects has taught me to pay attention to detail and to be explicitabout my rationale, expectations, decisions and outcomes, I've seen thebenefits of that in my relationships with research participants, Listeningto participants (therapists, parents and patients) talk about their experiencesof therapy, I am also clear that their rationale, expectations, decisionsand outcomes are often miles away from mine, By surfacing and exploringour different perspectives we stand much more chance of establishing aworking partnership and achieving goals together, D

Susie Parr and Carole Pound from the London Connect Centreare at the forefront of aphasia research. Avril Nicoll caught upwith them at an Aberdeen study day on improving services forpeople with severe aphasia. She contemplates the opportunitieswe all have to put their research into practice, whatever ourclient group.

hat is the reality of aphasiain the UK? Students learn Setti ng you rself freehat it is an acquired language impairment which

can t a k ~ different forms depending on the area of the brain that has that enables them to draw on their resilience and resourcefulness, to been affected, Services focus scarce resources on the acute period and, have control, to take advantage of new opportunities and choices, and occasionally, on short episodes of rehabilitation, usually based in a hos celebrate their successes? pital. Whether informal or formal, assessment involves asking bewil Looking through the eyes of the person with aphasia is a useful place dered people to do bizarre things with everyday objects, to start to redefine it in a meaningful way: long-term bewilderment, iso-

Frustration, gui lt, exasperation, panic and inadequacy are just some of lation, frustration, 1055 of confidence, self-respect, self-esteem and motithe strong emotions experienced by therapists working with people vation, 1055 of roles and responsibilities, 1055 of the tools and opportuniwith severe aphasia, We have the best understanding among health pro ties fo r choices and 1055 of control - in short, social exclusion,fessionals of what aphasia is and how it impacts on everyday life, 50 howdo we make the changes in our practice that will make us more effective 'Do you want soup, Brenda?' asks the nurse, 'NO' she says very firmly andand fulfilled in our work? How do we begin to support people in a way places her hand over her mat. She makes her face express disgust. Her

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everything this takes practice, writing a direct, user-friendly report toclients or parents is a relatively simple way of modelling good practice,putting the client in a position of control, ensuring that we understandeach other, and reducing jargonistic reports that are difficult fo r otherprofessionals to understand.

Recognising that not everyone can come to Connect, staff have beenexploring alternatives for isolated people with aphasia who no longerwant or need speech and language therapy. The Conversation PartnerOutreach Scheme volunteers are not there to be speech and languagetherapists or friends, but to be a conversation partner. Disability, equality, health and safety and communication partner training is provided.Volunteers are encouraged to make use of The Aphasia Handbook tohelp the person with aphasia find answers to their questions or sourcesof further information and support. The volunteers have ongoing supervision in the form of weekly feedback sheets, one-to-one meetings andsix-weekly support meetings or follo w-up training. They are encouragedto problem-solve: what other communication ramps could you make useof? what could you do when you get stuck? They visit fo r six monthsonce a week for an hour and there is an option to negotiate a second sixmonth period either with the same or a diffe rent volunteer. Having hadvariable success with volunteer schemes in the past I can see that, to besuccessful, there has to be a very clear role and significant investment oftime in ongoing training and support.You don't need a full-scale research project to look at change in yourown work environment. To set yourself free, Carole and Susie suggestyou ask yourselves: What do I currently offer? What options am I happy with? What would I like to offer? What two things could I do to extend opportunities fo r clients? What challenges do I predict I might face') What practical tasks will I need to undertake to carry the project

through?ReferenceParr, S. (in press) What happens to people with severe aphasia? JosephRowntree Foundation. Practical points: puttingresearch into practice1 Listen to and work from the client's

perspective2. Observe your client in different settings3. Note down questions as they occurto you4. Ensure commitment before you start5. Bounce ideas off a colleague6. Re-think your initial interview7. Improve your negotiation skills8. Know where to find research evidence9. Write reports for clients (or their

parents)10. Consider volunteer schemes

purse and a glasses case are lying by her mat. The nurse gives some soupto the woman on Brenda's left, who lifts it from her mat and places it inthe centre of the table. It is getting very hot. The windows are closedand there is a smell of urine. Brenda looks at me then makes the samedisgusted face, then smiles. Today's menu is written on the white-boardby the door. This is chicken soup. I see a nurse at another table wherethree women are sitting, pouring the soup from the plastic cups intoceramic bowls for them. This doesn't happen for anyone else in theroom. The soup doesn't look or smell very appetising. It smells like apacket mix. Its appearance is no t helped by the plastic cups, pretty muchthe same colour as the contents.Artefact: The leafle t on the care home says: 'Comfort and service ..excellen tcatering and a wide menu choice provided by a qualified chef usingin-house facilities and fresh produce .. '

In research funded by the Joseph Rowntree foundation, Susie Parr documented and tracked the social inclusion and exclusion of Brenda and 19other people with severe aphasia. The ethnographic study includedthree sessions with each person in different settings such as the pub,swimming pool, a stroke club, therapy, home and shops. Susie madedetailed field and reflective notes, and told it like it was - sights, soundsand smells. She says that ethnography has the potential to open youreyes to what's around in everyday settings, to reveal the detail, subtletyand dynamism of communication, and to suggest relevant interventions.While we cannot all engage in full-scale research, we can use this kindof observation with clients of all ages and communication difficulties tothink out of the box and identify possible changes.

Susie found that people with severe aphasia enter many different settings and encounter many different people for many years after thestroke - and after rehab ilita tion. Exclusion happens everywhere, all thetime. Social exclusion - or inclusion - is evident in communication, accessto opportunity and choice, involvement, the environment, and respectand acknowledgement, all interacting and influencing each other.

Therapy is not just abou t supporting change in communication skills, itis about creating the conditions for participation and inclusion: attending to context, listening to people's stories, reflecting on the socialdynamics of service delivery and developing new opportunities to participate in health care and life. At Connect, this approach has influencedeverything from the design of the building - free from pictures of thebrain, and with a cafe at its hub - to the way assessment, goal settingand report writing is done.

Two hours is allowed for the initial interview with tw o members ofstaff either at the Centre or at home, including one-to-one time withboth the client and their partner. This has been identified as both costand time effective and is a similar set-up to other specialist services, forexample fo r young people who stammer attending the Michael PalinCentre. Although some participants felt they couldn't re-allocate theirtime in this way, I was interested because of my experience when interviewing people with severe aphasia for the Winter 2001 issue. I hadexpected them to last about an hour apiece but, taking my lead from theinterviewees, all four took two hours each.Perspectives and livesAll Connect staff receive the same training in basic communication skills.Interviewers need to try to understand the perspectives and lives of people they meet, and to listen carefully. They have to be skilful in elicitingand probing ideas through drawing, key words and pictures. This recordof the discussion is kept as a reference and basis for negotiation of goalsetting - a useful tool fo r any client group. The two interviewers try tohear what is important for the person with aphasia and their partner,get an idea of the impact of stroke and aphasia and of their expectationsand aspirations, and start presenting service options. Tea I coffee isoffered, no formal assessment is used and the interview is conversationbased.At the end, a letter is written to the person with aphasia covering thecontent of the discussions and the decisions reached. This is copied withpermission to the GP and other interested parties. Although as with

SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003

how . . . i put research into practice

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