Deconstructing Clinical Practice and Searching for Scientific Foundations: Examining decision-making scaffolds underpinning intervention choices by speech and language therapists

Introduction: Speech and language therapy (SLT) is purported to be a scientifically-based discipline. A commitment to scientific practice is currently best represented by practicing in an evidenced-based way, specifically by the use of research evidence, yet studies examining the use of research evidence both within the profession and across disciplines, consistently suggest that research is less than influential in guiding practice decisions. This suggests practice may not be scientific. Furthermore, unscientific practice may be represented by the use of pseudoscientific and / or non-scientific therapies. Aim: The aim of this research was to explore professional knowledge and decision-making scaffolds in SLT clinical practice with special attention paid to scientific underpinnings. The intention was to gain an authentic understanding of the role of science in practice and thus, a deeper appreciation of the nature of SLT practice. Methodology and Methods: A mixed-methodology approach was undertaken targeting SLTs working in Ireland. The initial quantitative phase consisted of an electronic survey (n=271) focussing on therapy choices in disability and dysphagia, reasons for use and non-use of these therapies, and factors influencing decision-making. The subsequent qualitative phase utilised three focus groups (n = 48). Group one consisted of SLTs working in a disability setting, group two of SLTs working in an acute hospital setting and group three of SLTs working in a community setting. Data were analysed using a variety of techniques including descriptive statistics and inferential statistics for the survey data, and thematic analysis for the focus group data. Results: The therapies SLTs always-use in both areas of practice represent limited approaches to intervention. In disability, practice is effectively represented by seven high-use predominantly augmentative and alternative communication therapies; in dysphagia the three high-use therapies are mainly bolus modification techniques. A limited range of reasons explained use. Across all areas of practice and all therapies and techniques, client suitability and clinical experience dominated as the main reasons interventions were always used. The principal reasons for not using therapies were lack of training, lack of knowledge and lack of suitability. A clinical lifespan is suggested with early-years clinicians being most dependent on external sources, specifically colleagues, to inform decision-making. Clinicians in the middle years of their careers appear more autonomous while those in the later years appear to branch out to external sources again, most specifically research evidence. Disability and dysphagia clinicians are significantly different in their use of all reasons for use and non-use with the exception of clinical experience. Scientific reasons are not well represented in either area of practice. Moreover, there is an apparent disconnect between attitudes and practice. For example, respondents demonstrate clear research values generally but not when therapy-specific reasoning is explicated. Three main themes were identified from focus group data: practice imperfect; practice as grounded and growing, and; critical practice. Practice as defined by clinicians is grey-zoned, eclectic, experimental, developmental and pragmatic, being primarily pivoted upon a clinician’s tool bag and experimental practice. This tool bag is composed predominantly of population-specific experience and facilitates the clinician to construct individualised interventions. Clinicians demonstrate scientific thinking but do not automatically reference scientific scaffolds unless explicated. Conclusion: Clinical practice is narrowly defined being predominantly scaffolded upon a limited range of therapies and case evidence and practical evidence. Practice is also constructed by SLTs as experimental and flexible. Scientific practice as characterised by research evidence is not evident in this study, however clinicians may operate scientifically through the use of scientific behaviours including experimentation, trial and error and on-going learning. This understanding of practice has implications for the dominant model of evidence-based practice

‘We don't have recipes; we just have loads of ingredients’: explanations of evidence and clinical decision making by speech and language therapists

Rationale, aims and objectives: Research findings consistently suggest that speech and language therapists (SLTs) are failing to draw effectively on research-based evidence to guide clinical practice. This study aimed to examine what constitutes the reasoning provided by SLTs for treatment choices and whether science plays a part in those decisions. Method: This study, based in Ireland, reports on the qualitative phase of a mixed-methods study, which examined attitudes underpinning treatment choices and the therapy process. SLTs were recruited from community, hospital and disability work settings via SLT managers who acted as gatekeepers. A total of three focus groups were run. Data were transcribed, anonymized and analysed using thematic analysis. Results: In total, 48 participants took part in the focus groups. The majority of participants were female, represented senior grades and had basic professional qualifications. Three key themes were identified: practice imperfect; practice as grounded and growing; and critical practice. Findings show that treatment decisions are scaffolded primarily on practice evidence. The uniqueness of each patient results in dynamic and pragmatic practice, constraining the application of unmodified therapies. Conclusion: The findings emerging from the data reflect the complexities and paradoxes of clinical practice as described by SLTs. Practice is pivoted on both the patient and clinician, through their membership of groups and as individuals. Scientific thinking is a component of decision making; a tool with which to approach the various ingredients and the dynamic nature of clinical practice. However, these scientific elements do not necessarily reflect evidence-based practice as typically constructed

Service delivery and intervention intensity for phonology-based speech sound disorders

Background: When planning evidence-based intervention services for children with phonology-based speech sound disorders (SSD), speech and language therapists (SLTs) need to integrate research evidence regarding service delivery and intervention intensity within their clinical practice. However, relatively little is known about the optimal intensity of phonological interventions and whether SLTs’ services align with the research evidence.Aims: The aims are twofold. First, to review external evidence (i.e., empirical research evidence external to day-today clinical practice) regarding service delivery and intervention intensity for phonological interventions. Second,to investigate SLTs’ clinical practice with children with phonology-based SSD in Australia, focusing on service delivery and intensity. By considering these complementary sources of evidence, SLTs and researchers will be better placed to understand the state of the external evidence regarding the delivery of phonological interventions and appreciate the challenges facing SLTs in providing evidence-based services.Methods & Procedures: Two studies are presented. The first is a review of phonological intervention research published between 1979 and 2016. Details regarding service delivery and intervention intensity were extractedfrom the 199 papers that met inclusion criteria identified through a systematic search. The second study was an online survey of 288 SLTs working in Australia, focused on the service delivery and intensity of intervention provided in clinical practice.Main Contributions: There is a gap between the external evidence regarding service delivery and intervention intensity and the internal evidence from clinical practice. Most published intervention research has reported toprovide intervention two to three times per week in individual sessions delivered by an SLT in a university clinic, in sessions lasting 30–60 min comprising 100 production trials. SLTs reported providing services at intensities below that found in the literature. Further, they reported workplace, client and clinician factors that influenced the intensity of intervention they were able to provide to children with phonology-based SSD.Conclusions & Implications: Insufficient detail in the reporting of intervention intensity within published research coupled with service delivery constraints may affect the implementation of empirical evidence into everyday clinical practice. Research investigating innovative solutions to service delivery challenges is needed to provide SLTs with evidence that is relevant and feasible for clinical practice

Perceptions of hospital-based clinical staff on the role of speech and language therapists in palliative care.

Background: Speech and language therapists (SLTs) are becoming increasingly involved in palliative care through the management of communication and swallowing difficulties. The role of SLTs in this area remains unclear. This research originated in response to a concern raised by SLTs regarding the withdrawal of referrals to SLTs for palliative care patients in an acute setting. Therefore, it is worth exploring how this role is perceived in order to ensure that appropriate service decisions for patients are made. Aims: To explore the perceptions of SLTs and hospital-based clinical staff (doctors, nurses, medical social workers and dieticians; the main referrers), regarding the role of SLTs in palliative care and to present an integrated overview of these perceptions. Methods: An exploratory qualitative research design was used. Access to staff was achieved via an SLT internal to the hospital who acted as gatekeeper. 7 SLTs participated in a focus group and 8 hospital-based clinical staff participated in semi-structured interviews. Data obtained were transcribed, anonymised and analysed using thematic analysis and organised according to thematic networks. Results: Three global themes were identified: SLT Role in Palliative Care; Referral Matters; and Palliative Care Considerations. Findings reflect the complex nature of palliative care. Conflicting perceptions from participants as to what SLTs can offer, SLTs’ lack of confidence, and SLTs’ role in communication often being overlooked emerged as key issues. Conclusions: A lack of certainty regarding the role of SLTs in palliative care prevents referrals to this service. Education of both SLTs and hospital-based clinical staff in the principles of this role are needed at an undergraduate level to increase confidence in this area. Intra-professional guidelines and clear referral pathways are warranted to improve service provision for patients

A Brief discourse in vindication of the antiquity of Ireland in two parts : collected out of many authentick Irish histories and chronicles, and out of foreign learned authors

Pagination avant numérisation : 314 pages. - Titre provenant de la page de titre du document numérisé. Reproduction numérique de l'édition imprimée à Dublin chez S. Powell en 171

A feedback journey: employing a constructivist approach to the development of feedback literacy among health professional learners

Background: Feedback, if effectively provided by the teacher and utilised by the learner, enables improvement in academic performance. It is clear from current literature that the provision of feedback by teachers is not sufficient on its own to guarantee improvements as early university entrants may not be sufficiently equipped to effectively engage with feedback. Nonetheless, it is critical for health professional students to develop feedback literacy early, in order to prepare them for a professional career of lifelong learning and critical thinking. The overarching aim of this study was to identify a feasible, sustainable approach to improve feedback literacy among students on pre-qualifying health professional programmes. Methods: The study was divided into two phases. A mixed-methods approach grounded in constructivism was employed. Participants included teachers and learners from the School of Allied Health at X University, and two internationally acclaimed educationalists. In phase 1, first year students were encouraged to use an established online platform to upload modular feedback and develop personal learning action plans aimed at improving academic performance. A follow-up survey highlighted poor engagement with this method. Thus, the second phase focused on the co-construction of a suite of modules to develop these skills, supported by academic staff. Interviews were conducted with participants to review and refine this initiative. Results: Learners’ engagement with the first phase of the study was poor. Thus, the second phase provided all stakeholders with the opportunity to feed into the development of a suite of modules, designed to encourage teachers and learners to work in partnership to nurture these skills. All stakeholder groups reported short- and long-term benefits with this approach, but also highlighted challenges towards its implementation. Conclusion: The development of feedback literacy among health professional learners is essential. The transferability of such skills has been highlighted in the literature and by all stakeholder groups involved in this study. Finding a balance between introducing these skills at a time early enough to highlight their importance among university entrants is challenging. Further balance must be achieved between the workload required to achieve these skills and current programme demands for both teachers and learner

Investigating physiotherapy stakeholders\u27 preferences for the development of performance-based assessment in practice education.

Objectives Discrete choice experiments (DCEs) are used in healthcare to measure the relative importance that stakeholders give to different features (or attributes) of medical treatments or services. They may also help to address research questions in health professional education. Several challenges exist regarding the performance-based assessment process (PBA) employed in physiotherapy practice-based education, a process which determines students’ readiness for independent practice. Evidence highlights many commonalities among these challenges, but it is unknown which factors are the most important to stakeholders. The use of DCE methodology may provide answers and help to prioritise areas for development. Thus, this study employed DCE to identify clinical educators’, practice tutors and physiotherapy students’ preferences for developing the PBA process in physiotherapy. Design Attributes (aspects of the PBA process known to be important to stakeholders) were derived from focus group interviews conducted with three groups; physiotherapy students, clinical educators (practising clinicians) and practice tutors (dedicated educational roles in the workplace). These attributes included the PBA tool, grading mechanisms, assessors involved, and, feedback mechanisms. Preferences for each group were calculated using a logistic regression model. Results Seventy-two students, 124 clinical educators and 49 practice tutors (n = 245) participated. Priorities identified centred primarily on the mandatory inclusion of two assessors in the PBA process and on refinement of the PBA tool. Conclusion Employment of DCE enabled the prioritisation of stakeholder-informed challenges related to PBA in physiotherapy practice-based education. This corroborates findings from previous qualitative work and facilitates a prioritised pathway for development of this process.ACCEPTEDpeer-reviewe

Val(8)GLP-1 rescues synaptic plasticity and reduces dense core plaques in APP/PS1 mice

Diabetes is a risk factor for Alzheimer's disease. We tested the effects of Val(8)GLP-1, an enzyme-resistant analogue of the incretin hormone glucagon-like peptide 1 originally developed to treat diabetes in a mouse model of Alzheimer's disease that expresses mutated amyloid precursor protein (APP) and presenilin-1. We tested long term potentiation (LTP) of synaptic plasticity, inflammation response, and plaque formation. Val(8)GLP-1 crosses the blood-brain barrier when administered via intraperitoneal injection. Val(8)GLP-1 protected LTP in 9- and 18-month-old Alzheimer's disease mice when given for 3 weeks at 25 nmol/kg intraperitoneally. LTP was also enhanced in 18-month-old wild type mice, indicating that Val(8)GLP-1 also ameliorates age-related synaptic degenerative processes. Paired-pulse facilitation was also enhanced. The number of beta-amyloid plaques and microglia activation in the cortex increased with age but was not reduced by Val(8)GLP-1. In 18-month-old mice, however, the number of Congo red positive dense-core amyloid plaques was reduced. Treatment with Val(8)GLP-1 might prevent or delay neurodegenerative processes