JCPSLP July 2014_Vol16_no2

Journal of Clinical Practice in Speech-Language Pathology Journal of Clinical ractic i Spe ch-L l

Volume 13 , Number 1 2011 Volume 16 , Number 2 2014

Policy and practice

In this issue: Service provision in brain injury rehabilitation units Enhancing the literacy performance of disadvantaged students Screening, assessing and treating (C)APD SLP services in Fiji Changing the way SLPs diagnose autism Dysphagia management in stroke patients

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Please contact the Publications Officer at Speech Pathology Australia for advertising information. Acceptance of advertisements does not imply Speech Pathology Australia’s endorsement of the product or service. Although the Association reserves the right to reject advertising copy, it does not accept responsibility for the accuracy of statements by advertisers. Speech Pathology Australia will not publish advertisements that are inconsistent with its public image. 2014 Subscriptions Australian subscribers – $AUD106.00 (including GST). Overseas subscribers – $AUD132.00 (including postage and handling). Institutional rate – $AUD330 (including GST). No agency discounts. Reference This issue of Journal of Clinical Practice in Speech-Language Pathology is cited as Volume 16, Number 2, 2014. Disclaimer To the best of The Speech Pathology Association of Australia Limited’s (“the Association”) knowledge, this information is valid at the time of publication. The Association makes no warranty or representation in relation to the content or accuracy of the material in this publication. The Association expressly disclaims any and all liability (including liability for negligence) in respect of use of the information provided. The Association recommends you seek independent professional advice prior to making any decision involving matters outlined in this publication. Copyright ©2014 The Speech Pathology Association of Australia Limited. Contributors are required to secure permission for the reproduction of any figure, table, or extensive (more than 50 word) extract from the text, from a source which is copyrighted – or owned – by a party other than The Speech Pathology Association of Australia Limited. This applies both to direct reproduction or “derivative reproduction”– when the contributor has created a new figure or table which derives substantially from a copyrighted source.

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Brooke Sanderson Asher Verheggen JCPSLP Editors Anna Copley and Jane McCormack c/- Speech Pathology Australia Editorial Committee

Jade Cartwright Natalie Ciccone Deborah Hersh Elizabeth Lea Carl Parsons David Trembath Samantha Turner

Copy edited by Carla Taines Designed by Bruce Godden,

Wildfire Graphics Pty Ltd Contribution deadlines Number 1, 2015 1 August 2014 (peer review) 14 October 2014 (non peer review) Number 2, 2015 3 December 2014 (peer review) 1 February 2015 (non peer review) Number 3, 2015 14 April 2015 (peer review) 30 June 2015 (non peer review)

Advertising Booking deadlines Number 3, 2014 13 August 2014 Number 1, 2015

2 December 2014

Number 2, 2015 2 April 2015

Policy and practice

From the editors Jane McCormack and Anna Copley

Contents

49 From the editors

50 Consumer-focused practice and service perceptions in brain injury rehabilitation units – Kerrin Watter, Paula Addis, Anna Copley and Emma Finch performance of Australian students from disadvantaged backgrounds in their first year of school: A preliminary investigation – Maria Lennox and Marleen Westerveld 66 Screening and assessing for (central) auditory processing disorder and the role of the speech-language pathologist: A survey of Queensland clinicians – Wendy L. Arnott, Caroline A. Henning and Wayne J. Wilson 73 Treating (C)APD and the role of the speech language pathologist: A survey of Queensland clinicians – Wendy L. Arnott, Caroline A. Henning and Wayne J. Wilson 58 Enhancing emergent literacy

M any of you will be aware that the Australian Senate is currently undertaking an inquiry into the prevalence of communication impairment across Australia and the provision of speech pathology services. Some of you may have contributed submissions to this inquiry. Speech Pathology Australia prepared a submission highlighting the prevalence and impact of communication difficulties across the lifespan and the need for holistic and evidence-based service provision. In order to ensure appropriate service provision, there is a need for policies that recognise the extent of the need and that enable speech pathology services to address this through appropriate funds, personnel and infrastructure. The current issue of JCPSLP is timely in that it focuses on the link between policy and practice. Within this issue, Watter and colleagues explored the way in which current speech pathology services are delivered in brain injury rehabilitation units, while Arnott and colleagues investigated current practices in the assessment and management of central auditory processing disorders. In both studies, information gathered from this research has the potential to inform future policy development. In another paper, Lennox and Westerveld evaluated the effectiveness of a pilot program targeting children’s emergent literacy, which had been designed to accommodate current policies and subsequent service provision limitations. Trembath discussed the implications of changes to policy, specifically changes in the DSM-5 relating to the diagnosis of autism spectrum disorders, for speech pathology practice, and Davis and colleagues described the development of a tool to manage dysphagia in thrombolysed patients, when no policies/protocols previously existed. Finally, Hopf provided an overview of service delivery in Fiji and the policies that guide practice in a Majority World (“developing”) Country. Regular columns such as “Ethical Conversations”, “Webwords” and the “Top 10” also focused on the relationship between policy and practice. Policies, whether they be at a service, state or national level, influence and impact our work as speech-language pathologists. However, our work as clinicians and researchers can inform and guide policy development. We hope you enjoy reading this issue which explores some of the ways in which policy and practice interact in the field of speech-language pathology.

81 Services for people with

communication disability in Fiji: Clinical insights – Suzanne Hopf

87 Changing the way we diagnose autism: Implications for policy and practice – David Trembath

90 Management of dysphagia in thrombolysed stroke patients:

Development of a preliminary clinical practice protocol – Jennifer Davis, Elizabeth Cardell and Anne Coccetti

98 A reflection on ethical policy

development: A case example of a hospital patient with dysphagia – Helen Smith and Christina Wilson

103 Webwords 49: Policy, practice and social media – Caroline Bowen

105 Policy and practice top 10 resources – Sheridan Forster

107 Resource review

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Policy and practice

Consumer-focused practice and service perceptions in brain injury rehabilitation units Kerrin Watter, Paula Addis, Anna Copley and Emma Finch

The present study investigated the service provision of speech-language pathologists (SLPs) working in brain injury rehabilitation units (BIRUs), including aspects of consumer- focused service delivery. Currently, there is little published research within SLP BIRU services regarding consumer-focused service delivery models (including client and family education and services to families) and SLP perceptions of services. These areas were investigated via team-based surveys, with SLP teams from eight Australian BIRUs participating. Similarities were found across services in liaison services and methods of education, while differences were evident in regularity of education provision and SLP service perceptions. Consumer-focused service delivery was influenced by service differences (including staffing), the characteristics of BIRU state-wide services and SLPs’ perceptions of services. Barriers and potential solutions to providing increased consumer-focused services in BIRU are presented. Introduction The importance of the role of consumers (i.e., patients, family and carers) in health care is increasingly recognised in Australia. “Ideal” health care provides a people/family- centred service and involves families and carers to assist clients to achieve their maximum potential (National Health and Hospitals Reform Commission, 2009). It also maximises consumer involvement and is responsive to meeting consumers’ needs (Australian Commission on Safety and Quality in Health Care, 2011). Consumer-centred care is recognised as a specific aspect of quality health care, leading to improvements in the quality and outcomes of care, with key principles including dignity and respect, participation in decision- making, communication and collaboration regarding services (Australian Commission on Safety and Quality in Health Care, 2013). Involving families in the rehabilitation process is an important aspect of brain injury rehabilitation (American

Speech-Language-Hearing Association [ASHA], n.d.a; Fleming, Sampson, Cornwell, Turner & Griffin, 2012; MacDonald & Wiseman-Hakes, 2010; Royal College of Physicians and British Society of Rehabilitation Medicine, 2003). Patients have identified that involving their families and peers in rehabilitation, and providing them with education and support is a key component of client-centred rehabilitation (Cott, 2004). Best practice recommendations for delivering consumer- focused speech-language pathology (SLP) services in acquired brain injury (ABI)/traumatic brain injury (TBI) rehabilitation include working with families and carers, and providing education and context-specific services (ASHA, 2004; ASHA, n.d.a; ASHA, n.d.b; Katz et al., 2002; Royal College of Speech Language Therapists [RCSLT], 2006; Ylvisaker, Hanks & Johnson-Greene, 2003). Consumer- focused interventions include communication partner training, skills training, empowering clients and families (MacDonald & Wiseman-Hakes, 2010). Given the range of communication impairments that can arise following ABI/ TBI and the resulting changes to activity and participation, working with clients and their families aims to maximise communication skills and resulting community integration and participation for people with ABI/TBI. It is unknown, however, how SLPs working in specialised sub-acute ABI/TBI rehabilitation (i.e., a brain injury rehabilitation unit [BIRU]) provide consumer-focused services and what influences their practice. Working with families Fleming et al. (2012) investigated the experience of patients and their caregivers/families within a metropolitan BIRU prior to their discharge from the unit (i.e., in the final week of inpatient rehabilitation) via semi-structured interviews. They identified that families of patients in BIRU want increased contact with therapists and increased involvement in therapy activities. Kreutzer, Gervasio and Camplair (1994) examined the psychological functioning of caregivers of adults with TBI, recommending they should have an increased role in rehabilitation, with increased support and participation within the rehabilitation process. A recent study investigating SLP service delivery in Australian BIRUs found varying involvement of families in SLP interventions (Watter, Addis, Copley & Finch, 2014). BIRU SLPs were asked to rate their intervention frequency across a range of interventions, including “family therapy sessions (active family involvement)”. A 5-point descriptive rating scale of “never”, “rarely”, “sometimes –

KEYWORDS BRAIN INJURY CONSUMER SERVICE DELIVERY SPEECH PATHOLOGY SUB-ACUTE REHABILITATION THIS ARTICLE HAS BEEN PEER- REVIEWED

Kerrin Watter (top) and Paula Addis

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in the literature (Eames et al., 2010; Leith et al., 2004; O’Callaghan et al., 2011). In O’Callaghan et al.’s study (2011), the majority of carers / family members reported positive satisfaction with education during inpatient rehabilitation, with 74.3% reporting receiving adequate general information, and 72.6% reporting receiving adequate information regarding the progress of their family member. In Leith et al.’s (2004) and Eames et al.’s (2010) studies, a range of similar themes was identified; however, there was diversity in the responses of consumers within each study. Identified themes included information provision and education regarding TBI/ABI (too much, not enough, use of jargon, too general); education on external services and availability (not enough); timing and presentation of information (too early, too late, overwhelming); client-centred factors (poor recall of information, poor comprehension of information). Other factors impacting the perspectives of consumers included the hospital environment, with issues identified including staffing and access (reduced staffing impacting availability for education, changes in staffing impacting education provision, difficulties accessing resources) (Leith et al., 2004; Eames et al., 2010). The variations in consumers’ perspectives regarding their education needs may reflect differences between specific services (e.g., in staffing, availability of resources, individual service provision of clinicians) as well as individual differences of consumers within the rehabilitation process. Additionally, difficulties are seen in the uptake and utilisation of educational information by families during this time (Paterson, Kieloch & Gmiterek, 2001). Gan, Gargaro, Brandy, Gerber and Boschen (2010) suggest that during inpatient rehabilitation, families are dealing with major life changes including the long-term challenge of having a family member with ABI, which may impact their ability to take in and utilise information. This may help explain the differences reported between the education provided by health professionals and families’ perceptions of that education/information (regarding content, type and amount of education provided) (Paterson et al., 2001). The frequency and types of education delivered by BIRU SLPs to consumers and how this compares with patient/family perceptions reported in the literature is currently unknown. SLPs’ service perceptions While research increasingly investigates the perspectives and experiences of consumers accessing ABI/TBI rehabilitation, there is minimal published information relating to allied health perceptions of service in sub-acute ABI/TBI rehabilitation. One general community-based study investigated consumer and allied health staff perspectives of health services in regional Victoria (Rowan, 1998). Both groups identified similar issues (including access, social issues, service delivery and local context issues). However, consumer perspectives focused mainly on outcomes and broader social issues, while staff perspectives emphasised a service delivery context. There has been no research to date examining whether staff perspectives and consumer perspectives of BIRU SLP services (e.g., in regards to education and involvement of families in rehabilitation) are consistent. Within the profession, researchers have investigated the perceptions of SLPs regarding clinical services across a range of disorders and service environments including knowledge of TBI in paediatric SLP services (Hux, Walker & Sanger, 1996); intervention practices for people with

patient dependent”, “often” and “everyday” was utilised. The majority of services (62.5%, n = 5) provided therapy interventions with “active involvement” of family members, “sometimes – patient dependent” with only 37.5% (n = 3) providing this “often”. No services reported working with families as an “everyday” clinical activity. SLP services reported that staffing impacted on overall service delivery, with SLP staffing levels below Australasian Faculty of Rehabilitation Medicine (AFRM) guidelines (2011) in 87.5% (n = 7) of services surveyed. Issues specific to the population and nature of BIRU services further impact upon family involvement with SLPs (e.g., for education or to participate in interventions), including families’ ability to attend the service and the availability of staff. BIRU services are based in metropolitan areas and cater to a large geographical region (e.g., a state- wide service). As the prevalence rate for ABI in Australia is higher for people living outside major cities (2.2%) than for those living in major cities (1.6%; O’Rance & Fortune, 2007), many patients attending BIRU are from a different geographical area, impacting the ability of families to attend the hospital throughout the rehabilitation period. In addition, given that the “typical” TBI population is young (under 30) and male (Katz, Zasler & Zafonte, 2007), their families and partners tend to be of working age / in the workforce and may have difficulties attending the hospital within working hours. Families have identified difficulties accessing allied health staff in BIRU during working hours as a barrier (Fleming et al., 2012). Education provision in inpatient ABI/TBI rehabilitation Uncertainty regarding the future is a key concern reported by people with TBI and their families (Lefebvre, Pelchat, Swaine, Gelinas & Levert, 2005). Overall, families of patients in BIRU want more education, particularly regarding injury, disability, realistic status, prognosis and treatment (Fleming et al., 2012; Lefebvre et al., 2005; Rotondi, Sinkule, Balzer, Harris & Moldovan, 2007), and knowledge on how to access information, education and other services (Leith, Phillips & Sample, 2004). Providing education during inpatient rehabilitation should also assist in addressing other needs reported by clients and families with ABI/TBI. It should empower patients and families, assist in adjustment to changes following injury, provide support during the rehabilitation process and help aid upcoming transitions home (Cott, 2004; Eames, Hoffmann, Worrall & Read, 2010; Fleming et al., 2012; Lefebvre et al., 2005; Rotondi et al., 2007). Education can also impact patient functioning and lead to better health outcomes. In a preliminary study investigating individualised patient education during TBI rehabilitation, positive changes were demonstrated in patient effort, cognitive function and patient satisfaction (Pegg, Auerback, Seel, Buenaver, Kiesler & Plybon, 2005). The perspectives of people with ABI/TBI and their family members/caregivers regarding their education and support needs during inpatient rehabilitation have been investigated, utilising a range of processes including semi-structured interviews (Eames et al., 2010; Rotondi et al., 2007), focus groups (Leith et al., 2004) and surveys (O’Callaghan, McAllister & Wilson, 2011). Consumers’ views regarding education and information provision by health professionals during sub-acute ABI/ TBI rehabilitation varies widely, with both high and low levels of satisfaction and education provision reported

Anna Copley (top) and Emma Finch

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aphasia (Brown, Worrall, Davidson & Howe, 2011); use of alternative and communication devices in early intervention (Iacono & Cameron, 2009); the perceived barriers to the implementation of evidence based practice (O’Connor & Pettigrew, 2009); and the perspectives of clinical educators and students regarding SLP training and experience in clinical placements (Hall, McFarlane & Mulholland, 2012). However, SLP perceptions of current BIRU services and future service needs have not been formally investigated. It is possible that staff perceptions are well known at a local level, and recorded and addressed via service-specific activities (e.g., business planning, service development, quality activities), but have not been investigated or reported as a whole. Identifying current practice in these areas will provide a basis for future service development, and may lead to further research in these areas. Identifying BIRU SLP needs as a whole may provide a direction for whole-of-service changes and assist in the provision of a unified approach to rehabilitation and research; it may also help support the development of SLPs working in other services which also provide rehabilitation to adults with ABI/TBI (e.g., via general or regional rehabilitation units). This study aims to identify the practice of SLPs within Australian BIRU services in regards to aspects of consumer-focused service delivery and to explore the perspectives of BIRU SLPs on the needs and future development of their services. Methods This study has ethical clearance from the Queensland Health Metro South Human Research Ethics Committee. It is part of a larger study into SLP practice in sub-acute brain injury rehabilitation. The methodology used in this paper has been previously reported (Watter et al., 2014); a summary is presented below. Participants and procedure SLPs working in Australian BIRUs were identified from phone and email contacts, professional databases and interest groups, and contacted via email and/or telephone to participate in a survey of clinical practice. Ten centres were identified across five states in Australia. These centres consisted of nine BIRUs and one inpatient rehabilitation centre that identified itself as providing significant state- wide service to adults with brain injury, and included private and publicly funded centres. SLPs from all ten services agreed to participate in the study and were sent an electronic survey. Reminder emails were utilised to maximise the response rate. SLPs from eight units (encompassing 15.1 full time equivalent SLPs) returned completed surveys and consented to participate in this research, with one response from each BIRU obtained. Responses were completed by a member of the SLP BIRU team (including clinicians and managers) and identified the practice of the BIRU SLP team, not that of individual clinicians. Surveys were completed and returned to the investigator over a four-month period (October 2011 – January 2012). Survey instrument The survey was developed to investigate the service delivery and clinical practice of BIRU SLPs, and grew from a BIRU SLP benchmarking project and quality activity. Survey design was influenced by a study into SLP practice

in inpatient rehabilitation for adults with spinal cord injury (Brougham et al., 2011), and survey questions reflected key areas of SLP service delivery from international SLP ABI/TBI documents and guidelines (ASHA, 2004; RCSLT, 2006). The survey was piloted and reviewed by 2 SLPs who were clinical experts in the area of TBI/ABI rehabilitation. This resulted in changes and clarification to the wording of two questions in the survey. Five areas were investigated via 42 questions; these were: service data and demographics; SLP therapy/ intervention services; education, advocacy and liaison; service delivery and “ideal state” of BIRU SLP services. The survey took approximately 30 minutes to complete. Service delivery and current practice of BIRU SLPs (including service data, demographics and SLP intervention services) are reported in Watter et al. (2014). The current paper further explores the data from the survey, reporting on the sections: (i) Consumer services: Advocacy, liaison and education; Family education and (ii) Service gaps and service enhancements in BIRU SLP services (“ideal state” of services), totalling 18 questions. Section (i) (14 questions) utilised a 3-point frequency rating scale (as suggested by Rattray and Jones, 2007) to rate the frequency of provision of advocacy, liaison and education services, with free text areas available for comments. The remaining four questions in section (ii) utilised free text to maximise information from participants. Data analysis Responses were collated and entered into a Microsoft Excel spreadsheet. Descriptive analysis of the collated survey data identified frequency, percentages and means; content analysis was utilised for data from open-ended questions and involved the identification and count of key themes. All results were reviewed by a second SLP to ensure accuracy and agreement. The percentage agreement initially between the two SLPs was 99.7%; after discussion of the items, 100% agreement was reached. Results Consumer services: Advocacy, liaison and patient education The role of the BIRU SLP in advocacy, liaison and education is summarised in Figure 1. Liaison with community or transition services was identified by 75% (n = 6) of BIRU SLPs as part of their regular service. Liaison with the adult guardian (87.5%, n = 7), advocacy for patients with severe communication impairment (62.5%, n = 5) and providing education/support to other SLPs on brain injury and patient management (75%, n = 6) were performed by the majority of BIRU SLPs “if required”. Informal education was a “regular service” delivered by SLPs to patients by 100% of SLPs (n = 8). Family education All BIRU SLPs (100%, n = 8) reported educating families as part of their service. This occurred formally and informally, via written and verbal methods (including telephone), and was provided by both teams and specific disciplines. SLPs provided information to families on brain injury, behaviour, cognition and communication via a range of education activities, including progress updates of patients, family forums and support groups; education of friends also occurred. Informal education was the most widely used method, delivered to families as a “regular service” (50% of SLPs, n = 4) or “as required” (50% SLPs, n = 4).

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Patient Education – Informal Patient Education – Formal (SP specific) Patient Education – Formal (general BI) Family Education – Informal Family Education – Formal (SP specific) Family Education – Formal (general BI)

Education/Support to other SPs (BI/pt management) Advocacy for pts with severe communication impairment Community/transition services Workplace/CRS School/TAFE/Study Adult Guardian

Activity Type Figure 1. Education, Advocacy & Liaison No Yes – if required Yes – regular service

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% % BIRU SP services

BI = brain injury; Pt = patient; CRS = Commonwealth Rehabilitation Service

Table 1. Identified service gaps in SLP BIRU services

Table 2. Utilisation of additional SLP services in BIRU

Work practice Service delivery

BIRU SLPs

Suggested activities

Work practice

BIRU SLPs

Suggested activities

37.5% Increased staffing for increased service provision

Patient therapy services

87.5% Increased interventions/intensity/ daily therapy More groups Trials of new therapies

Provide therapy in patient’s home with significant others/children Home visits Facilitation of transition home Liaison with employer or school Follow up services post discharge

Review/change service delivery

50% Home visits

Facilitating transitions Practising skills in home environment with children Better access to families for therapy

37.5% Social network training Social skills training

Therapy services/ interventions

Resource development

25% Not specified

Increased community based interventions Increased functional activities

Research

25% Not specified

Increased links with the MDT/IDT to facilitate incorporating SLP goals into team sessions/groups

Projects/quality activities

25% Not specified

Education

25% Clients/families/carers

Family based services

25% Increased interventions with families/ children Better access to families

Improve staff support

25% Supervision Education

Education

25% To staff

Acute and regional staff

To families Support SLP colleagues (acute, rural) in managing patients with ABI

Completion of non-clinical tasks

12.5% Not specified

12.5% Nil

Additional staffing not required

No response to question No service gaps identified

12.5% Nil

50% Nil

updates and progress reports, setting goals, discussing goal attainment, rehabilitation planning and discharge planning. Service gaps and enhancement BIRU SLPs were asked to identify any “gaps in their current service” and/or “ideas for service enhancement / novel services”, with responses via free text. Four BIRU SLP

IDT = interdisciplinary team; MDT = multidisciplinary team

In addition, all BIRU SLPs (100%, n = 8) reported they were involved in family meetings as a standard part of BIRU services, which included providing information/education, discussing behaviour management, providing rehabilitation

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within SLP ABI/TBI rehabilitation and BIRU service provision (AFRM, 2011; ASHA, 2004; RCSLT, 2006). Differences likely reflect the clinical practice of meeting local demands, individual services differences and availability of other services (e.g., following discharge). This was illustrated by one site which reported specific liaison services (regarding study and work) were “usually followed up by the community team”. Patient education Best practice guidelines (ASHA, 2004; RCSLT, 2006) advocate education as key component of ABI/TBI SLP services; however they do not specify the frequency, amount or type of education that should be provided. All BIRU SLPs (n = 8, 100%) reported educating patients as a “regular” service, with informal education the most popular method. While definitions of education methods (formal versus informal) were not provided to participants in the survey, a general clinical interpretation of this was anticipated by SLPs working within a specific health rehabilitation setting, and clarification was not sought by respondents. While we cannot guarantee uniform interpretation by SLPs, it appears that SLPs are broadly providing patient education services that address current best practice guidelines. Given the range of cognitive and communication difficulties patients can experience during this phase of their rehabilitation, including difficulties learning and retaining new information and changes to insight (Ponsford, 2012), providing “formalised” education at this point in time may not be as appropriate as providing patients with information and education that is informal and in a context of regular clinical interactions. Pegg and colleagues (2005) demonstrated that providing individualised education during TBI rehabilitation has a positive impact on rehabilitation; SLPs appear to be matching service provision to meet the needs of the consumer group. Family education Providing education to families of individuals with ABI/TBI is reported to be a key component of the SLP’s role in ABI/ TBI rehabilitation (ASHA, 2004; RCSLT, 2006; National Stroke Foundation, 2010). However, according to the results of the current study, it appears that services may not be meeting this aspect of best practice. While all SLPs provided education to families, differences were seen in frequency and types of education provided. Only 50% (n = 4) reported providing informal education as a “regular” service; formal education was provided “regularly” by 37.5% (n = 3). SLPs identified that formal family education programs regarding ABI/TBI occur within BIRUs; however these may not regularly involve SLPs. Further, when identifying service gaps and “ideal” BIRU SLP services, only 25% of SLPs surveyed (n = 2) identified improving services by involving families (including better access to families, providing increased education and better family involvement in therapy). There appears to be a discrepancy between best practice recommendations, service provision and service perception; however, the reasons are unknown. Potential reasons may reflect SLP survey responses that families are receiving education from other sources (e.g., via team processes); families may not be available regularly to SLPs or requesting education; families may have already received education in the acute setting.

Table 3. Other BIRU SLP services in an “Ideal setting”

Work practice

BIRU SLPs

Suggested activities

SLP therapy services

25% Computer use retraining

Formal vocational specific training Better family involvement in therapy

Team/clinic services

37.5% Increased community rehabilitation Increased transition services Concussion clinics Rapid multidisciplinary outpatient clinics Follow up reviews Formal vocational specific training Transition programs

Education

25% Education of friends

Increased family education Increased formal support groups for families/patients

Research

25% Not specified

Professional issues

12.5% Supporting regional clinicians Increased quality projects Increased taking students

Advocacy

12.5% Consultation re: decision-making ability Supporting patients in the legal system

Not applicable to service

12.5% Nil

services (50%) did not identify any gaps in their current service or identify ideas for enhancement of their current service; one service did not respond to the question (12.5%). Of the three sites that reported gaps or service enhancement ideas, four key areas for service improvement were identified (see Table 1): service delivery (n = 3), therapy services/interventions (n = 3), services to families (n = 2) and education/support (n = 2). BIRU SLPs were asked to comment on (a) how they would utilise additional SLP services (i.e., one full-time SLP), and (b) other services they thought BIRU SLPs should provide in an “ideal setting”. The majority of SLPs (87.5%, n = 7) responded to each of these questions, with one team reporting that (a) was not required and that (b) was not applicable. Responses are reported in Table 2 and Table 3. Discussion The present study investigated the clinical practice of BIRU SLPs in regards to providing specific aspects of consumer- focused services (including advocacy, liaison and education) and explored SLPs’ perspectives on the needs and future

development of their services. Advocacy and liaison

SLPs reported performing a variety of liaison and advocacy roles for consumers, including providing education and support to other professionals, liaising with external services and advocating for patients (with families, within teams and with other services). These services reflect core practice

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Barriers and solutions to providing consumer-focused services Reduced involvement of families with BIRU SLPs (e.g., in clinical interventions and in the provision of education) may result from a variety of factors. These include geographical considerations for family access, availability of working families to attend services within regular hours, the capacity of the service and service demands. Families have identified difficulties accessing allied health staff in BIRU during working hours (Fleming et al., 2012); the SLPs surveyed currently provide services only within regular working hours. For services with reduced staffing levels, providing education to families may be a lower clinical priority than providing therapy services to patients. This was demonstrated by one site which reported, “we offer limited services to families of patients as most of our resourcing is allocated to direct patient intervention”. Alternatively, it may be that SLPs are underestimating their service provision. In the survey, SLPs identified they provided education and liaison to families via regular team-based activities with families, including family meetings, information and planning meetings, family forums and via the phone. SLPs are likely providing education to families not as a stand-alone activity or via specific interventions, but as part of other regular service provision. To improve family access to SLP services, SLPs may need to consider the use of more creative, flexible service delivery models (e.g., extended hours of service, telehealth), and involve the broader allied health team. Teams need to employ consumer-centred approaches in order to provide best practice and achieve optimal client gains. Empowerment of consumers should drive the mode of intervention, and requires flexibility of practice and thinking, as well as use of emerging technologies such as telehealth to engage remotely located or otherwise unavailable families of clients. Service gaps and enhancements While only a small number of services identified “gaps” in their current service provision (37.5%, n = 3), 87.5% of services (n = 7) identified areas for service improvement via increased staffing and in providing “ideal services”. Most services (87.5%, n = 7) identified positive changes to patient services with increased staffing (e.g., increased therapy services, increased intensity), 50% of services (n = 4) identified changes to service delivery/team-based services with increased staffing. This is unsurprising, as many services had previously identified difficulties in providing intensive therapy services to certain patient groups, given reduced SLP staffing levels in BIRU (in Watter et al., 2014). Changes to current practice suggested by respondents to provide an “ideal” service involved team-based services, SLP-specific interventions/services, research activities and education. Many of these suggestions reflect variations in BIRU services and services available for patients following discharge (e.g., increased community/transition services, follow-up services). They also demonstrate the need for expanded brain injury services in growing fields (e.g., concussion clinics) and consumer-focused services (e.g., rapid response clinics). The range of responses outside of “traditional” SLP services demonstrates the holistic and team-focused nature of BIRU SLP rehabilitation. Differences between reported service delivery and staff perceptions may reflect personal perspectives of service

provision. While there seems to be a discrepancy between the perception of a service versus the reality of service provision, the impact of staff perception of providing a good service within the resources available needs to be considered. As one site reported, even though their staffing was below recommended levels (“we have about half staffing suggested by AFRM”), they were positive about the service they provided: “we do an amazing job”. Limitations Limitations of this study have previously been reported (Watter et al., 2014) and include small sample size, as there are only a small number of BIRU services within Australia; uncertainty regarding the level of collaboration for responses on the team-based survey; and service differences impacting service delivery and service needs, including changing staffing levels, cover for extended leave and changing models of care. Investigations into BIRU services in Australia will always be constrained by the small number of services; however, the response rate of 80% of services should ensure a comprehensive representation of existing services. The small number of services also prevents formal statistical analysis, impacting results and types of conclusions that can be drawn from the data. Conclusion This paper provides a preliminary investigation into the clinical practice of BIRU SLPs in providing specific aspects of consumer-focused services, as well as their perceptions of their service and future service needs. Similarities were found across BIRU services in many areas of consumer- focused service provision, including the use of informal education methods and liaison services; differences were seen in regularity of education provision and service perceptions of SLPs. Factors influencing consumer-focused service delivery included service differences, factors specific to BIRU state-wide services and SLP service perceptions. Differences in perceived service gaps and “ideal” services may be linked to different service delivery models and access to other brain injury services following discharge, as well as staff perceptions of their service. Given the findings, further investigation into SLP consumer-focused services and their perceptions of services are warranted; with future research directions including comparisons between SLP and consumer perspectives, investigations into “best practice” education provision for consumers in ABI/TBI (regarding frequency, types, amount), and whole-of-service development opportunities. Acknowledgements The authors would like to thank the BIRU SLPs from facilities across Australia for their participation in this study and for sharing their valuable time, and staff from the Speech Pathology Department, Princess Alexandra Hospital and Centre for Functioning and Health Research for their support with this project. References American Speech-Language-Hearing Association. (2004). Preferred practice patterns for the profession of speech- language pathology . Retrieved from http://www.asha.org/ docs/html/pp2004-00191.html American Speech-Language-Hearing Association. (n.d.a). Traumatic brain injury: Benefits of speech-language pathology services . Retrieved from http://www.asha.org/ public/speech/disorders/TBIslpBenefits.htm

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American Speech-Language-Hearing Association. (n.d.b). Treatment efficacy summary: Cognitive- communication disorders resulting from traumatic brain injury . Retrieved from http://www.asha.org/uploadedFiles/ public/TESCognitiveCommunicationDisordersFromTBI.pdf Australasian Faculty of Rehabilitation Medicine. (2011). Standards for the provision of inpatient adult rehabilitation medicine services in public and private hospitals . Sydney: Royal Australian College of Physicians. Retrieved from http://www.racp.edu.au/page/racp-faculties/australasian- faculty-of-rehabilitation-medicine/ Australian Commission on Safety and Quality in Health Care. (2011). National safety and quality health service standards . Retrieved from http://www.safetyandquality.gov. au/our-work/accreditation/nsqhss/ Australian Commission on Safety and Quality in Health Care. (2013). Patient and consumer centred care . Retrieved from http://www.safetyandquality.gov.au/our-work/patient- and-consumer-centred-care/ Brougham, R., Spivak David, D., Adornato, V., Gordan, W., Dale, B., Georgeadis, A., & Gassaway, J. (2011). Speech-language pathology treatment time during inpatient spinal cord injury rehabilitation: The SCIRehab project. Journal of Spinal Cord Medicine , 34 (2), 186–195. doi: 10.1 179/107902611X12971826988174 Brown, K., Worrall, L., Davidson, B., & Howe, T. (2011). Exploring speech-language pathologists’ perspectives about living successfully with aphasia. International Journal of Language and Communication Disorders , 46 (3), 300–311. doi:10.3109/13682822.2010.496762 Cott, C.A. (2004). Client-centred rehabilitation: Client perspectives. Disability and Rehabilitation , 26 (24), 1411–22. doi:10.1080/09638280400000237 Eames, S., Hoffmann, T., Worrall, L., & Read, S. (2010). Stroke patients’ and carers’ perception of barriers to accessing stroke information. Topics in Stroke Rehabilitation , 17 (2), 69–78. doi:10.1310/tsrl1702-69 Fleming, J., Sampson, J., Cornwell, P., Turner, B., & Griffin, J. (2012). Brain injury rehabilitation: The lived experience of inpatients and their family caregivers. Scandinavian Journal of Occupational Therapy , 19 (2), 184–93. doi:10.3109/11038128.2011.611531 Gan, C., Gargaro, J., Brandy, C., Gerber, G., & Boschen, K. (2010). Family caregivers’ support needs after brain injury: A synthesis of perspectives from caregivers, programs, and researchers. NeuroRehabilitation , 27 , 5–18. doi:10.3233/NRE-2010-0577 Hall, M., McFarlane, L., & Mulholland, S. (2012). Positive clinical placements: Perspectives of students and clinical educators in rehabilitation medicine. International Journal of Therapy and Rehabilitation , 19 (10), 549–556. Hux, K., Walker, M & Sanger, D.D. (1996). Traumatic brain injury: Knowledge and self-perceptions of school speech- language pathologists. Language, Speech, and Hearing Services in Schools , 27 , 171–184. doi:10.1044/0161- 1461.2702.171 Iacono, T., & Cameron, M. (2009). Australian speech- language pathologists’ perceptions and experiences of augmentative and alternative communication in early childhood intervention. AAC: Augmentative & Alternative Communication , 25 (4), 236–249. doi: 10.3109/07434610903322151 Katz, R., Kennedy, M.R.T., Avery, J., Coelho, C., Sohlberg, M., Turkstra, L. … Yorkston, K. (2002). Evidence

based practice guidelines for cognitive-communication disorders after traumatic brain injury: Initial committee report. ANCDS Bulletin Board. Journal of Medical Speech- Language Pathology , 10 (2), ix–xiii. Katz, D.I., Zasler, N.D., & Zafonte, R.D. (2007). Clinical continuum of care and natural history. In N.D. Zasler, D.I. Katz & R.D. Zafonte (Eds.), Brain injury medicine principles and practice (pp. 3–13). New York: Demos. Kreutzer, J.S., Gervasio, A.H., & Camplair, P.S. (1994). Primary caregivers’ psychological status and family functioning after traumatic brain injury. Brain Injury , 8 , 197–210. Lefebvre, H., Pelchat, D., Swaine, B., Gelinas, I., & Levert, M.J. (2005). The experiences of individuals with a traumatic brain injury, families, physicians and health professionals regarding care provided throughout the continuum. Brain Injury , 19 (8), 585–597. doi: 10.1080/02699050400025026 Leith, K.H., Phillips, L., & Sample, P.L. (2004). Exploring the service needs and experiences of persons with TBI and their families: The South Carolina experience. Brain Injury , 18 (12), 1191–1208. doi:10.1080/02699050410001719943 MacDonald, S., & Wiseman-Hakes, C. (2010). Knowledge translation in ABI rehabilitation: A model for consolidating and applying the evidence for cognitive- communication interventions. Brain Injury , 24 (3), 486–508. doi:10.3109/02699050903518118 National Health and Hospitals Reform Commission. (2009). A healthier future for all Australians . Retrieved from http://www.health.gov.au/internet/nhhrc/publishing.nsf/ Content/nhhrc-report National Stroke Foundation. (2010). Clinical guidelines for stroke management: A quick guide for speech pathology . Retrieved from http://strokefoundation.com.au/site/media/ NSF_concise_guidelines_speech_pathology_2010.pdf O’Callaghan, A.M., McAllister, L., & Wilson, L. (2011). Experiences of care: Perspectives of carers of adults with traumatic brain injury. International Journal of Speech- Language Pathology , 13 (3): 218–226. doi:10.3109/175495 07.2011.549240 O’Connor, S., & Pettigrew, C.M. (2009). The barriers perceived to prevent the successful implementation of evidence-based practice by speech and language O’Rance, L., & Fortune N. (2007). Disability in Australia: Acquired brain injury . Bulletin 55. Australian Institute of Health and Welfare. Retrieved from http://www.aihw.gov. au/publication-detail/?id = 6442468049 Paterson, B., Kieloch, B., & Gmiterek, J. (2001). “They never told us anything”: Postdischarge instruction for families of persons with brain injuries. Rehabilitation Nursing , 26 (2), 48–53. Pegg, P.O., Auerback, S.M., Seel, R.T., Buenaver, L.F., Kiesler, D.J., & Plybon, L.E. (2005). The impact of patient-centered information on patients’ treatment satisfaction and outcomes in traumatic brain injury rehabilitation. Rehabilitation Psychology , 50 (4), 366–374. doi:10.1037/0090-5550.50.4.366 Ponsford, J. (2012). Understanding and managing traumatic brain injury . Retrieved from: http://www. psychology.org.au/publications/inpsych/2012/april/ ponsford/ therapists. International Journal of Language and Communication Disorders , 44 , 1018–1035. doi:10.1080/13682820802585967

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Kerrin Watter and Paula Addis are speech pathologists at the Brain Injury Rehabilitation Service, Princess Alexandra Hospital, Metro South Health. Kerrin is also a PhD candidate with the University of Queensland. Emma Finch is the speech pathology conjoint research fellow between the University of Queensland and Princess Alexandra Hospital, Metro South Health. Anna Copley is a speech pathology lecturer in the Division of Health and Rehabilitation Sciences at the University of Queensland. Rehabilitation of children and adults with cognitive- communication disorders after brain injury [Technical report]. ASHA: Rockville, MD. Retrieved from http://www. asha.org/policy/TR2003-00146.htm injury rehabilitation. Journal of Clinical Practice in Speech- Language Pathology , 16 (1), 7–13. Ylvisaker, M., Hanks, R., & Johnson-Greene, D. (2003).

Rattray, J., & Jones, M.C. (2007). Essential elements of questionnaire design and development. Journal of Clinical Nursing , 16 , 234–243. doi:10.1111/j.1365- 2702.2006.01573x Rotondi, A.J., Sinkule, J., Balzer, K., Harris, J., & Moldovan, R. (2007). A qualitative needs assessment of persons who have experienced traumatic brain injury and their primary family caregivers. Journal of Head Trauma Rehabilitation , 22 (1), 14–25. Rowan, Sue. (1998). Provider and consumer perceptions of allied health service needs. Australian Health Review , 21 , 88–97. Royal College of Physicians and British Society of Rehabilitation Medicine. (2003). Rehabilitation following acquired brain injury: National clinical guidelines . Turner- Stokes, L. (Ed). London: Author. Retrieved from http:// bookshop.rcplondon.ac.uk/contents/43986815-4109- 4d28-8ce5-ad647dbdbd38.pdf Royal College of Speech Language Therapists. (2006). Communicating quality 3: RCSLT’s guidance on best practice in service organisation and provision . Retrieved from http://www.rcslt.org/speech_and_language_therapy/ standards/CQ3_pdf Watter, K., Addis, P., Copley, A., & Finch, E. (2014). Speech pathology clinical practice in sub-acute brain

Correspondence to: Ms Kerrin Watter Speech Pathology Department, PA Hospital Ipswich Rd, Woolloongabba, 4102 Qld, Australia phone: 07 3176 2314 email: Kerrin.Watter@health.qld.gov.au

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