JCPSLP Vol 20 No 2 July 2018

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

Volume 13 , Number 1 2011 Volume 20 , Number 2 2018

Entrepreneurship in speech-

In this issue: Speech-language pathology professional identity in response to workforce redesign A comparison of three prioritisation approaches for inpatient speech pathology Facial nerve palsy and speech-language pathology intervention using sEMG Administration of Co-Phenylcaine Forte nasal spray during nasendoscopy The use of ultrasound in treating functional speech disorders in school-aged children in a community health setting The views of speech-language pathologists and audiologists on interprofessional collaboration

language pathology

Print Post Approved PP352524/00383 ISSN 2200-0259

Speech Pathology Australia

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. 2017 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 20, Number 2, 2018. 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 ©2018 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.

Level 1 / 114 William Street, Melbourne, Victoria 3000 T: 03 9642 4899 F: 03 9642 4922 Email: office@speechpathologyaustralia.org.au Website: www.speechpathologyaustralia.org.au ABN 17 008 393 440 ACN 008 393 440 Speech Pathology Australia Board Gaenor Dixon President Belinda Hill Vice President Communications Brooke Sanderson Vice President Operations Chyrisse Heine Tim Kittel Marleen Westerveld Maree Doble

Electronic copies of JCPSLP Speech Pathology Australia members are able to access past and present issues of JCPSLP via the Speech Pathology Australia website www.speechpathologyaustralia.org.au/ publications/jcpslp Electronic copies of the full journal or individual articles are available to everyone (members and non-members) at a cost by emailing pubs@speechpathologyaustralia.org.au or by completing the form available from the Speech Pathology Australia website

JCPSLP Editor Leigha Dark c/- Speech Pathology Australia Editorial Committee Maree Doble Emma Finch Samantha Siyambalapitiya Rachael Unicomb Copy edited by Carla Taines Designed by Bruce Godden, Wildfire Graphics Pty Ltd Contribution deadlines Number 1, 2019 1 August 2018 Number 2, 2019 1 December 2018 Number 3, 2019 13 April 2019 Laurelie Wall Cori Williams Shaun Ziegenfusz

Advertising Booking deadlines Number 3, 2018 17 August 2018 Number 1, 2019

1 December 2018

Number 2, 2019 6 April 2019

Entrepreneurship in speech-language pathology

From the editor Leigha Dark

Contents

W elcome to the July 2018 issue of the Journal of Clinical Practice in Speech-Language Pathology. In this full and varied issue we explore various forms of entrepreneurship in speech-language pathology. Many people, upon hearing the word ‘entrepreneurship’, might think of the launching of a profitable small business, private practice, or new technological start up. Indeed, one of the common definitions of entrepreneurship is “the capacity and willingness to develop, organize and manage a business venture along with any of its risks in order to make a profit” (WebFinance Inc, 2018). But profit alone is usually not the sole purpose of business. Rather,

49 From the editor 50 The role of speech-language

pathology professional identity in response to workforce redesign – Rachael O’Brien, Rebecca Mitchell, and Nicole Byrne 57 Clinical judgement just as reliable as an explicit prioritisation tool: A comparison of three prioritisation approaches for inpatient speech pathology – Jo Brady and Katherine Harding 63 Facial nerve palsy and speech- language pathology intervention using sEMG – Terri Herne and Anne Whitworth 70 Administration of Co-Phenylcaine Forte nasal spray during nasendoscopy: Implementing and evaluating this extended scope role for speech-language pathologists – Maria Schwarz, Elizabeth C. Ward, Marnie Seabrook, Anne Coccetti, and Bernard C.S. Whitfield 76 Seeing the big picture: The use of ultrasound in treating functional speech disorders in school-aged children in a community health setting – Rachel Furniss and Thizbe Wenger 83 Speech-language pathologists and audiologists working with deaf or hard of hearing clients in Australia: Views on interprofessional collaboration – Rebecca Smith, Nicole Byrne, and Megan Barr 89 What’s the evidence? Important elements to consider when setting up an ethical allied health practice – Belinda Hill 93 Ethical conversations: The ethics of entrepreneurship in speech-language pathology – Patricia Bradd, Grant Meredith, and Trish Johnson 96 Webwords 61: Entrepreneurship and speech-language pathology – Caroline Bowen 98 Around the Journals 100 Resource review 101 Top 10: Tools to help speech-language pathologists plan and run a private practice – David Kinnane 103 Obituary: In memory of Dr Justine Joan Sheppard – Susan Balandin, Bronwyn Hemsley, Georgia Malandraki, and Hilda Pressman

identifying and creating value for stakeholders is an important driver. In our profession value may take the form of enhanced outcomes for patients and clients, increased equity of service access, improved efficiency and sustainability of services, powerful advocacy, and social capital in the form of empowered and connected communities. As such, all speech-language pathologists have the potential to be entrepreneurial in their thinking and work; perhaps by contributing to a quality improvement project, implementing a service enhancement, trialing a new therapeutic idea or building a professional network, if not in the more traditional sense of building a business. In the first article, Rachael O’Brien and colleagues explore the ways in which workforce change influences speech-language pathologists’ professional identity. Jo Brady and Katherine Harding, consider the reliability of three different methods for prioritising services and managing resource allocation. Terri Herne and Anne Whitworth, report on the outcomes of an intensive, individualised service for patients with facial nerve palsy (FNP) based on mime and neuromuscular re-education involving the use of surface electromyography (sEMG) and mirror feedback. In their article, Maria Schwarz and colleagues examine the extended scope role of SLPs in medication administration, outlining the process undertaken within one service to obtain rights for the administration of Co-Phenylcaine Forte nasal spray to low risk patients during nasendoscopy. Rachael Furniss and Thizbe Wenger explore the use of ultrasound as an adjunct to traditional articulation therapy in children diagnosed with speech sound disorders. In the final article, Rebecca Smith and her colleagues present the views of speech-language pathologists and audiologists on inter-professional collaboration. To finish this editorial I have both welcomes and a farewell to share. Firstly, I am very pleased to congratulate and welcome to the editorial committee Dr Maree Doble, Dr Emma Finch, Dr Rachael Unicomb and Mr Shaun Ziegenfusz. This issue however is the last instalment of the popular and longstanding column, Webwords, authored by Dr Caroline Bowen. Dr Bowen wrote the first Webwords column in 1999, when the journal was known as ACQ (Acquiring Knowledge in Speech, Language and Hearing) , and over the last 19 years has not missed an issue. Here we are at Webwords 61, and one need only read the range of Webwords titles to appreciate not only how far the profession has come (e.g., the first Webwords was titled “Getting to know the internet”), but also the extraordinary depth and breadth of information curated by Dr Bowen. Topics have encompassed all SLP range of practice areas, professional issues, ethics and evidence-based practice, clinical practice across the lifespan, mental health, Aboriginal and Torres Strait Islander perspectives, consumer advocacy, the National Disability Insurance Scheme and social media. I am but one in a long list of ACQ/JCPSLP editors who have had the pleasure of working with Dr Bowen, delighting each time a Webwords instalment appeared in the inbox; conversational, witty, sharply insightful, impeccably researched, polished and topical. In 2012, as part of Webwords 42, Dr Bowen wrote: The first three Webwords columns appeared in ACQ in 1999, the International Year of the Older Person and the year that Speech Pathology Australia celebrated its 50th birthday. It continued to thrive when the association turned 60 in 2009, but we will need to think about a succession plan (or a wake) for the ageing Webwords some time between now and the association’s 70th and the author’s 75th in 2019. Well, that time is now. A succession plan will be unveiled in the next issue. However, it is a less a wake that is required and more a celebration of the enormously valuable contribution of Dr Bowen to the speech-language pathology profession. On behalf of JCPSLP teams past and present I extend a huge thank you and warmest wishes to you, Dr Caroline Bowen.

49

JCPSLP Volume 20, Number 2 2018

www.speechpathologyaustralia.org.au

Entrepreneurship in speech-language pathology

The role of speech-language pathology professional identity in response to workforce redesign Rachael O’Brien, Rebecca Mitchell, and Nicole Byrne

The introduction of assistants in speech- language pathology is a workforce change that includes modification of the roles and responsibilities of speech-language pathologists (SLPs). Resistance to working with assistants is prevalent, and there has been little research into the perceived impact of working with assistants on SLPs’ professional identity. This paper explores SLPs’ perceptions of their professional identity in response to working with assistants. Semi-structured interviews were conducted with 20 SLPs in New South Wales, Australia. Findings indicate that working with assistants may be perceived as a potential threat to the SLP professional identity as a result of challenge to the values and distinctiveness of the professional group. Participants’ sense of professional identity was impacted by the real or perceived threat presented by the introduction of assistants. perceptions of significant workforce redesign will contribute to understanding the future speech-language pathology profession. Introduction Changes in health care workforces encompass modifications to the roles and responsibilities of health care professionals (Bach, Kessler, & Heron, 2007). This includes the introduction of assistant roles which are designed to enhance efficiency within overstretched health systems with finite resources. An assistant in allied health (hereafter “assistant”) is a vocationally trained person whose role is to support the work of tertiary trained allied health professionals, with either a single- or multi-disciplinary focus. The work undertaken by assistants in speech- language pathology can be clinical or non-clinical (Lizarondo, Kumar, Hyde, & Skidmore, 2010) and they may be employed in all settings in which speech-language pathologists (SLPs) work, including both adult and paediatric settings, across a full range of practice areas. Consideration of professional identity construction and how it can shape

Speech Pathology Australia recognises the value of the assistants working within the profession (Speech Pathology Australia, 2016b), but clearly states that assistants are to be considered as having a supplementary role, and never as a replacement for a fully qualified SLP. Speech Pathology Australia further specifies tasks which are the responsibility of SLPs only and are unsuitable for delegation, including assessment, differential diagnosis, clinical problem-solving and therapy planning (Speech Pathology Australia, 2014, 2016a). Current literature suggests that reforms involving assistants may drive a perception that professional roles are at risk and professional expertise undervalued (Nancarrow & Borthwick, 2005; O’Brien, Byrne, Mitchell, & Ferguson, 2013). This constitutes a challenge to professional identity. Professional identity is defined as “the relatively stable and enduring constellation of attitudes, beliefs, motives, and experiences in terms of which people define themselves in a professional role” (Ibarra & Barbulescu, 2010, p. 764). Threats to professional identity have been known to result in behaviour that aims to defend the professional role or leads to professionals exiting organisations. This is particularly likely when the new identity required as a result of the change is inconsistent with the pre-existing professional identity (Schilling, Werr, Gand, & Sardas, 2012). O’Brien and colleagues (2013) provided an initial discussion on the perception of professional identity threat and SLP willingness or otherwise to work with assistants. This current paper extends on this critical issue in relation to professional identity and workforce change in speech- language pathology. Professional identity formation The formation of a professional identity occurs when a person relates to and identifies with a specific professional group with distinct knowledge, attitudes, values and belief systems (Hudson, 2002). Professional identity can determine an individual’s perspective, attitude and behaviour relevant to the work context (Adams, Hean, Sturgis, & Macleod Clark, 2006). Professional identity helps individuals compare and differentiate themselves from others in the workplace (Turner, Hogg, Oakes, Reicher, & Wetherell, 1987), contributes to perceptions of relative status of groups and professions, and impacts on interprofessional interactions. SLPs’ professional identities are shaped by their expectations and experience of the professional group (Mackey, 2007) including training, qualifications and socialisation. They also encompass

THIS ARTICLE HAS BEEN PEER- REVIEWED KEYWORDS ASSISTANTS PERCEPTIONS PROFESSIONAL IDENTITY SPEECH PATHOLOGY WORKFORCE REDESIGN

Rachael O’Brien (top), Rebecca Mitchell (centre), and Nicole Byrne

50

JCPSLP Volume 20, Number 2 2018

Journal of Clinical Practice in Speech-Language Pathology

and colleagues (2017) further explored the paradoxical nature of SLPs’ perceptions of working with assistants and found the importance of consumer focus in the formation of professional perceptions. These findings are consistent with the consumer focus within the professional code of ethics, which identifies the fundamental values of the profession as integrity, professionalism, respect and care, quality standards and continuing competence (The Speech Pathology Association of Australia Limited, 2010). Aims This paper aims to explore the role of professional identity shaping in SLPs’ perceptions of working with assistants. SLPs’ accounts of their perceptions of working with assistants are examined to explore how professional identity contributes to their assessment of this aspect of workforce redesign. The following questions are addressed: 1. How do SLPs perceive their professional identities? 2. How do SLPs describe the values of their profession? 3. What factors pertaining to the introduction of assistants potentially impact professional identity? Method Research design This current study is part of a larger research project investigating how SLPs perceive working with assistants prior to assistants being introduced by the health organisation. Given the exploratory nature of this research, an inductive qualitative methodology was used. Interviews were conducted with SLPs in remote, rural and metropolitan areas to ascertain their perceptions of a workforce redesign involving assistants. Ethical approval was sought and granted by a health-based lead ethics committee as well as the university’s human research ethics committee. Recruitment Given the primary researcher (Author A) is a practising SLP, recruitment was conducted by another party independent of the research to ensure perceived coercion was avoided. Details of the study were provided to a SLP colleague, who disseminated the information to senior SLPs across a public health organisation in New South Wales, Australia. Senior SLPs then distributed this information to their staff, who were invited to contact the researcher directly if interested in participating. Participants Twenty SLPs volunteered to be interviewed. Demographic data are presented in Table 1. Seventeen of the sample were women; three were men, and participants were from community, hospital, or mixed settings. The majority worked full-time and had more than 10 years’ clinical experience. Both adult and paediatric caseloads were represented. Fourteen of the 20 participants reported some experience of working with assistants in their careers;however, this was not part of the selection criteria for participation in this research. Data collection Semi-structured interviews were conducted by a SLP researcher (Author A) to explore perceptions of the introduction of assistants, and participants’ understanding of their role, boundaries, job security and satisfaction. Participants were encouraged to lead and direct the discussion about issues they perceived as most important (Smith, Flowers, & Larkin, 2009). A comprehensive list of

agreed standards of practice and behaviour which are encouraged by universities, professional associations (e.g., Speech Pathology Australia, 2011) and employers (e.g., employer’s code of conduct). Speech-language pathology can be considered a community of practice (Ferguson & Armstrong, 2004; Wenger, 1998), by way of its shared practices, goals and language. Wenger (1998) suggests that dynamic change in a community of practice occurs at the boundaries of the community (in this instance, the profession), and so it is suggested that by examining the activity occurring at these boundaries, the potential future scope of professional practice for speech-language pathology may be found – for example, by considering advanced scope of practice at the upper end of the professional boundary (e.g., Fibreoptic Endoscopic Evaluation of Swallow [FEES]). While reforms involving contested professional boundaries have been addressed in research into other professions (Nancarrow & Borthwick, 2005), past studies are scant in relation to changes in professional identity consequent to the introduction of new occupational groups that may be perceived as being on the lower end of the professional boundaryinto speech pathology. It is acknowledged that unclear definition of the assistant role, and subsequent uncertain delineation between that and the SLP role may contribute to threatened professional identity. This paper therefore aims to build awareness that perceptions of workforce redesign are not only informed by the sense of self as an individual, but also by the sense of belonging to a distinct professional group (Haslam, 2014). Speech-language pathologists’ perceptions of assistants Assistants are utilised by SLPs internationally. Aspects of these assistant roles include direct care of lower complexity patients as well as provision of administrative support, thus allowing professionals to concentrate on more complex clinical needs (Lizarondo et al., 2010). It has been shown that perceptions of working with assistants in allied health research are consistently ambivalent. Specific to speech- language pathology, McCartney and colleagues (2005) conducted a case study of speech-language therapists working with assistants in the United Kingdom and found both benefits and “disbenefits” to working with assistants. For example, participants in their study identified that working with an assistant contributed to ensuring that SLPs’ clinical reasoning and rationales were sound and well articulated, but also resulted in less time for the SLPs to plan their own caseload. The authors noted that the perceptions of SLPs in their study were similar to those reported in a study by Van der Gaag and Davies (1993) more than ten years previously. In this study SLPs were notably conservative in their willingness to share tasks with assistants, a finding that was attributed to the fact that members of the SLP profession had less experience and exposure to working with assistants at that time (Davies & Van der Gaag, 1992; Van der Gaag & Davies, 1993). O’Brien and colleagues (2013) explored the perceptions of SLPs in one local health district in Australia and found that SLPs with previous exposure to working with assistants were generally more positive towards working with assistants than those with no previous exposure (O’Brien et al., 2013). They suggested the need for positive perceptions to ensure the sustainability of such a workforce redesign and offered professional identity as a framework for understanding such perceptions. More recently, O’Brien

51

JCPSLP Volume 20, Number 2 2018

www.speechpathologyaustralia.org.au

Table 1. Participant demographics (n=20)

Table 2. Themes and subthemes

Characteristic

% (Number)

Professional identity

Professional identity threat

Clinical setting Generalist clinicians with majority paediatric component Acute adult inpatient Brain injury rehabilitation Inpatient and / or outpatient rehabilitation

Professionalism

Threat to professionalism

Clinical autonomy and critical thinking Threat to clinical autonomy

50% (10) 20% (4) 15% (3) 15% (3)

Client focus and advocacy

Threat to client focus and advocacy

Theme 1: Professional identity The identity that emerged was of an organised, strategic and ethical professional, with high standards of behaviour and practice. Participants focused on the subthemes of SLP professionalism, clinical autonomy and client focus as key pillars of their professional identity. A range of skills were identified as enabling these professional qualities: “your typical speech pathologist… Somebody that’s got all the range of characteristics from somebody that can be … systematic, and statistical, to somebody that’s innovative and interpersonal, and a great communicator, and sensitive” (Participant #3). Professionalism Professionalism and maintenance of professional standards were viewed by participants as being integral to their role and as contributing to job satisfaction (i.e., a job well done led to being more satisfied). Participants valued and were protective of their clinical discretion and critical thinking skills as contributing to their ability to perform their role as a professional, as illustrated in the following quote: “it is my call as to whether I feel based on that screening, whether their language skills are normal or not … that’s still a clinical judgement I think as to whether that’s normal or not…” (Participant #20). fundamental principle of being a SLP, claiming it to be their ethical, legal and professional responsibility to ensure high standard care. Participants emphasised that achieving clinical outcomes efficiently is one measure they used to ascertain their level of effectiveness, as in this example: “A good speech pathologist can be very effective very quickly and is the best person … who is going to get through the waiting list and deal most effectively with it” (Participant #20). The level of clinical control and decision-making experienced by most participants contributed to the construction of the professional identity as an effective and independent clinician. Some participants explained effectiveness as being indicative of a thorough understanding of complexity and quality of care: “a lot of knowledge across a really broad caseload with little time to bring that … develop that knowledge in a way… it’s crossing multiple sites, it’s working with all the disciplines, it’s working independently…” (Participant #6). Participants discussed tensions arising from large caseloads, intensive clinical need and service access issues, including long waiting times. Despite participants reporting professional and clinical autonomy in their current service delivery models, they also described their frustration at being unable to implement professionally identified best practice due to service limitations (e.g., session limits or discharge policies): “You can’t follow… guidelines of dosage for your clients and intervention and stuff like that, Clinical autonomy and critical thinking All participants regarded clinical outcomes as a

Caseloads

Adult caseload Paediatric caseload

50% (10) 50% (10)

Working hours Full-time Part-time

75% (15) 25% (5)

Years of clinical experience Less than 10 years 10–20 years Greater than 20 years

35% (7) 20% (4) 45% (9)

questions was written based on a literature review of perceptions of working with assistants, but as the participants themselves were invited to lead the discussion, not all questions were asked in each interview. The question set evolved as knowledge grew throughout data collection (Smith et al., 2009). A sample of the interview questions is provided in the Appendix. Data analysis The qualitative principles of interpretative phenomenological analysis (IPA) were followed to examine how participants made sense of their experiences. Transcripts were examined, data assigned themes, and similarities and differences noted within and across transcripts (Smith et al., 2009). Themes were revisited many times as analysis moved from concrete to conceptual interpretation. Given that two of the authors (Authors A and C) are SLPs, it is acknowledged that a pre-existing professional perspective is brought to the research. In the interview context there was also a large degree of “insider knowledge” resulting from the interviewer being a SLP; shared assumptions and technical vocabulary of the profession rarely required clarification. Use of NVivo 10 qualitative data analysis software enabled efficient management and manipulation of the large amount of data (QSR International, 2012). Rigour All participants were invited to view and check the accuracy of their own transcripts; however, none accepted this offer. All authors were given copies of transcripts and discussed the representative nature of the dataset coding. A sample of transcripts was coded independently by two authors with 90% interrater reliability regarding category codes. Definitions of themes were finalised by consensus. Results Despite varying overall perceptions of the workforce change, it was apparent that issues of professional identity were consistent across participant reports. The analysis identified two overarching themes: (a) the presence of attitudes, beliefs and behaviours that characterised the SLP professional identity, and (b) reports of real or perceived threat to that identity. Further subthemes under each themes were also identified (Table 2).

52

JCPSLP Volume 20, Number 2 2018

Journal of Clinical Practice in Speech-Language Pathology

you just can’t. You’re basically not following the evidence base just due to the restrictions that you’ve got in the workforce” (Participant #11). Notwithstanding challenges in implementing evidence- based practice, participant accounts strongly indicated that their sense of professional identity came from being able to implement best practice and achieving clinical outcomes for clients. These reports contributed to the SLP identity of an organised and strategic professional, skilled in clinical prioritisation and time management. Client focus and advocacy Participants discussed client focus and advocacy as key components of the SLP professional identity, particularly in relation to vulnerable clients. They noted attempts to increase self-efficacy and service access for clients, as well as their responsibility for advocating for appropriate access to other services, in addition to assessment, therapy, clinical management and outcomes. One participant stated, “We really try and focus on that collaboration… It’s like, ‘what do you want to work on? I’ll support you to do it’” (Participant #11). Theme 2: Professional identity threats Analysis suggested that the introduction of assistants was perceived as a potential threat, in theory and/or practice, to the professional identity of SLPs. Threats were particularly aligned with clinical autonomy, client focus and advocacy. Threat to professionalism The introduction of assistants, perceived as being pursuant to economic efficiencies, was interpreted as degradation of the professional role by deskilling the professionalworkforce and devaluing established roles. The following quote highlights this sentiment, “De-skilling … And, not just de-skilling but losing … recognition for the role, the speech pathology role” (Participant #16). Some participants held reservations regarding assistants’ ability to provide an appropriate level of clinical care required to maintain outcomes for clients. This was based on the belief that assistants lack appropriate knowledge and training to undertake such tasks. The introduction of assistants was presented by some participants as providing a cheaper, less effective and less professional method of service provision, “They don’t have that training. They’re not a speech pathologist; they’re not the person who’s actually qualified…” (Participant # 20). Some participants saw merit in the idea of assistants working with clients where intervention requires no significant modification, again highlighting the perception of difference between the skills and knowledge of the SLP and assistant: It would have to be something within some fairly limited constraints about what somebody who doesn’t have the benefit of a four-year speech path degree could handle... that doesn’t really require novel thought, doesn’t really require a whole lot of active modification. (Participant #9) Being a SLP was a defining category referring largely to qualifications and expected skill sets, quality management and outcomes, and professional behaviour. Recognition of the distinct and unique professional role of an SLP was an important factor raised by participants. One participant stated: “we’ve fought for so long to be recognised as equals of physios and things like that and then to say well, someone else could do my job, that sort of could be a little

bit demeaning” (Participant #10). Another shared concern regarding the abilities of individuals in an assistant role, “Because they’re not a speech pathologist, they don’t have a degree” (Participant # 14). Threat to clinical autonomy and critical thinking Participants perceived that management decisions regarding resourcing of speech pathology services devalued both clients and the evidence base to which clinicians are committed. Professional values were framed in terms of the ability to demonstrate consumer focus and achieve clinical outcomes. One participant questioned, “Are we getting good outcomes for the patient? You know you’d have to really look at that” (Participant #5) , while another reiterated “You’d just want to make sure that you maintain the standards of care” (Participant #6). The participants portrayed the profession as having high standards and client-centred values distinctive from other professional and vocational groups, a defining characteristic that participants indicated may be compromised with the introduction of assistants. Threat to client focus and advocacy Delegating clinical tasks to assistants was seen by some participants as decreasing the individualised treatment that most participants valued. For example, delegating clinical tasks to assistants may cause the SLP to have less contact with clients, resulting in poor clinical relationships, as follows: will it increase the efficacy of what’s going on or will it just mean that people that wouldn’t have received a service then get a service because they’ve only got mild problems - rather than a home program they get to see an aide. (Participant #1) I guess speech paths will be able to sit in a room and do a whole lot of stats now, when I think what it should be doing is allowing us to do more specialised intervention, assessment. (Participant #9) Perceptions of poorer clinical relationships with clients were connected to perceptions of decreased consumer focus and the ability to be consumer focused was perceived by participants as being pivotal in ensuring maintenance of high standards of care and client satisfaction with speech-language pathology services. Discussion This paper demonstrates the presence of a strong professional identity for the SLPs involved in the study. Findings show that workforce redesign can impact professional identity and lead to the emergence of professional identity threat. This paper highlights the importance of professional identity in the success, or otherwise, of a planned workforce redesign (Haslam, 2014). Professional identity Our data suggest that SLP professional identity reflects professionalism, client focus and clinical autonomy. Client focus is consistent with findings of O’Brien, Mitchell, and Byrne (2017) who found that consumer focus was a core value for SLPs, and a moderating factor influencing perceptions of the introduction of assistants. This finding was reflected in discussion of standards of care, outcomes, advocacy, and the profession’s ethical values. Participants identified the importance of positive professional relationships with clients in achieving clinical outcomes, given the client-centred nature of the profession. The

53

JCPSLP Volume 20, Number 2 2018

www.speechpathologyaustralia.org.au

emphasis on achieving clinical outcomes and client advocacy speaks to the unique input that SLPs provide. Participants identified more strongly as SLPs than as employees of an organisation which highlights the significance they ascribed to being a SLP, and is consistent with research suggesting that clinicians identify with their profession to a greater extent than their organisation or unit (Ashforth & Mael, 1989). Our findings related to professional identity are particularly important given past research suggesting that there is misunderstanding of the role of SLPs (Byrne, 2008) and that SLPs perceive their role is misunderstood by employers, consumers (O’Brien et al., 2013), and other health professions (Byrne, 2010). Perceptions that employing organisations do not recognise core professional values of consumer focus (O’Brien et al., 2017) may result in heightened sense of professional identity threat regarding decisions relating to workforce and role (McNeil, Mitchell, & Parker, 2013). Participants held a strong sense of their professional distinctiveness, but were not confident that organisational management, other health and education workers, or consumers understood their unique contribution. Blurring of boundaries and poorly defined professional identity has been identified as a source of professional rivalry, tension and hostility within clinical practice (Hudson, 2002). Poor understanding of the SLP role combined with perceptions of decreased valuation of the profession’s expertise may lead to an indistinct professional identity. Turner and Knight (2015) discussed the consequences of an indistinct professional identity, concluding that one of the key features is an inability to strategically react to change. This is an important consideration for the profession given the evolving nature of services and the diversifying future needs of the community. Professional identity threat Participants reported that they felt assistants threatened the three core components of their identity: professionalism, consumer focus and clinical autonomy. Participants were concerned that the introduction of assistants may negatively impact their level of involvement with clients and delivery of intervention, resulting in poorer clinical outcomes. This was seen as a threat to professional identity in terms of limiting SLPs’ ability to maintain a holistic focus on client assessment, intervention and evaluation, consequently impacting the provision of high levels of professional care and ethical practice (i.e., ensuring that intervention is both beneficial and also not causing harm). This research provides one of the first explorations of professional identity threats in speech-language pathology. It will be important for organisations to demonstrate and communicate the positive impact assistants may bring to the profession with a focus on the benefits to consumers, a factor that was found to encourage positive perceptions (O’Brien et al., 2017). With increased overall understanding of the intent of the workforce redesign and better knowledge of existing professional identity and influencing factors for SLPs, organisations can effect positive, rather than enforced change. Similarly, by encouraging interaction between professional bodies (e.g., Speech Pathology Australia) and employing organisations, strategies for change may be identified to create a diverse and dynamic future speech-language pathology workforce (Speech Pathology Australia, 2016b). The introduction of new roles into a profession with a strong and established sense of professional identity has

the potential to change the way people view themselves, in both a work and social context (Haslam, 2004). In cases where workforce redesign is likely, perceived threats to professional identity and the impact this has on an individual’s perceived status within the organisation, will be important barriers to overcome. There is evidence that in times of job and employment insecurity, the importance of understanding the role of professional identity in maintaining a positive employment relationship, is great (Alvesson & Willmott, 2002). Considering the tensions and efforts to maintain or increase control during a process of workforce redesign at the level of everyday practice, there is potential for resistance to start with low level discontent but escalate to potential destabilisation and creation of weakness in a work context (Thomas & Davies, 2005). It will be important for the speech-language pathology profession to have a clear message for ourselves, employers and consumers regarding the core features of the SLP professional identity. This will include the ethical standards and evidence base to which the profession is committed, as well as beliefs, values and rationales of the profession. Having this clearly articulated will allow the profession to respond in an informed and coordinated way if challenges to the professional values are experienced (Turner & Knight, 2015). Limitations and future directions Participants in this study were interviewed in a work context and asked to contribute from the perspective of a speech- language pathologist. It is therefore possible that the lines of questioning, context in which it occurred and participant’s degree of understanding of the study purpose and potential implications, may have contributed to heightened sense of professional identity. This factor must therefore be taken into account when interpreting the results. It must also be recognised that this study reflects the views of one group of speech-language pathologists from a focused geographic location and may not be representative of SLPs in other parts of Australia. Replication of this study across different locales and contexts would allow for further in-depth exploration and saturation of the codes, categories and themes. Given the paucity of information or a specific description of the professional identity of SLPs, further study is needed to determine what factors influence existing professional identity and how this identity might impact, or be impacted upon, by workforce redesign. It would also be beneficial to explore in greater detail who professionals perceive to be the source of professional identity threat in the context of workforce redesign (e.g., organisational management or the new occupational group). Another important area for further exploration would be the development of professional identity throughout SLP training and early graduate experiences and the factors that contribute to professional resilience in a changing employment landscape. Conclusion Perceptions of workforce redesign are not only informed by sense of self as an individual, but also by the sense of belonging to a distinct professional group (Haslam, 2014). This study has provided an exploration of speech-language pathology professional identity construction and role in understanding reactions to a workforce redesign. It offers insight into the ways professions and professionals may respond to the introduction of a vocationally trained group. Lessening the sharpness of professional boundaries

54

JCPSLP Volume 20, Number 2 2018

Journal of Clinical Practice in Speech-Language Pathology

distinguishing SLPs was interpreted as a threat to the uniqueness of SLPs role in terms of knowledge, values and professional contribution, and prompted efforts towards maintaining the positive distinctiveness of the SLP role through opposition. Preserving professional boundaries while embracing the potential of workforce evolution remains an ongoing and important challenge for the speech pathology profession. References Adams, K., Hean, S., Sturgis, P., & Macleod Clark, J. (2006). Investigating the factors influencing professional identity of first-year health and social care students. Learning in Health and Social Care , 5 (2), 55–68. https://doi. org/10.1111/j.1473-6861.2006.00119.x Alvesson, M., & Willmott, H. (2002). Identity regulation as organizational control: Producing the appropriate individual. Journal of Management Studies , 39 (5), 619–644. https:// doi.org/10.1111/1467-6486.00305 Ashforth, B. E., & Mael, F. (1989). Social identity theory and the organization. Academy of Management Review , consequences of assistant roles in the public services: Degradation or empowerment? Human Relations , 60 (9), 1267–1292. https://doi.org/10.1177/0018726707082848 Byrne, N. (2008). Current and prospective speech- language pathology students’ reports of exposure to speech-language pathology. International Journal of Speech-Language Pathology , 10 (5), 297–304. https://doi. org/10.1080/17549500802147018 Byrne, N. (2010). Why do students from related professions choose not to enter speech-language pathology? International Journal of Speech-Language Pathology . https://doi.org/10.3109/17549500903464346 Davies, P., & Van der Gaag, A. (1992). The professional competence of speech therapists III: Skills and skill mix possibilities. Clinical Rehabilitation , 6 , 311-323. https://doi. org/10.1177/026921559200600407 Ferguson, A., & Armstrong, E. (2004). Reflections on speech-language therapists’ talk: Implications for clinical practice and education. International Journal of Language & Communication Disorders , 39 (4), 469–507. Haslam, A. S. (2004). Psychology in organizations: The social identity approach . Thousand Oaks, California: Sage Publications. Haslam, S. A. (2014). Making good theory practical: Five lessons for an applied social identity approach to challenges of organizational, health and clinical psychology. British Journal of Social Psychology , 53 (1), 1–20. https:// doi.org/10.1111/bjso.12061 Hudson, B. (2002). Interprofessionality in health and social care: The Archilles’ heel of partnership? Journal of Interprofessional Care , 16 (1), 7–17. https://doi. org/10.1080/13561820220104122 Ibarra, H., & Barbulescu, R. (2010). Identity as narrative: Prevalence, effectiveness, and consequences of narrative identity work in macro work role transitions. Academy of Management Review , 35 , 135–154. https://doi. org/10.5465/AMR.2010.45577925 Lizarondo, L., Kumar, S., Hyde, L., & Skidmore, D. (2010). Allied health assistants and what they do: A systematic review of the literature. Journal of Multidisciplinary Healthcare , 3 , 143–153. https://doi. org/10.2147/JMDH.S12106 14 (1), 20–39. https://doi.org/10.2307/258189 Bach, S., Kessler, I., & Heron, P. (2007). The

Mackey, H. (2007). “Do not ask me to remain the same”: Foucault and the professional identities of occupational therapists. Australian Occupational Therapy Journal , 54 (2), 95–102. McCartney, E., Boyle, J., Bannatyne, S., Jessiman, E., Campbell, C., Kelsey, C., … O’Hare, A. (2005). “Thinking for two”: A case study of speech and language therapists working through assistants. International Journal of Language and Communication Disorders , 40 (2), 221–235. https://doi: 10.1080/136820400016514 online McNeil, K. A., Mitchell, R. J., & Parker, V. (2013). Interprofessional practice and professional identity threat. Health Sociology Review , 22 (3), 291–307. https://doi. org/10.5172/hesr.2013.22.3.291 Nancarrow, S. A., & Borthwick, A. M. (2005). Dynamic professional boundaries in the health care workforce. Sociology of Health and Illness , 27 (7), 897–919. https://doi. org/10.1111/j.1467-9566.2005.00463.x O’Brien, R., Byrne, N., Mitchell, R., & Ferguson, A. (2013). Rural speech-language pathologists’ perceptions of working with allied health assistants. International Journal of Speech-Language Pathology , 15 (6), 613–622. https://doi. org/10.3109/17549507.2012.759623 O’Brien, R., Mitchell, R., & Byrne, N. (2017). Paradoxical perceptions towards the introduction of assistants in speech-language pathology and potential impact on consumers. Scandinavian Journal of Caring Sciences, May 2017 . https://doi.org/10.1111/scs.12437 QSR International. (2012). NVivo qualitative data analysis Software, Version 10. QSR International Pty Ltd. Schilling, A., Werr, A., Gand, S., & Sardas, J. (2012). Understanding professionals’ reactions to strategic change: The role of threatened professional identities. Service Industries Journal , 32 (8), 1229-1245. doi:10.1080/026420 69.2010.531269 Sheldon, K. M., & Bettencourt, B. A. (2002). Psychological need-satisfaction and subjective well-being within social groups. British Journal of Social Psychology , 41 , 25–38. https://doi.org/10.1348/014466602165036 Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis . London: Sage Publications. Speech Pathology Australia. (2010). Code of ethics . Melbourne, Victoria: Author Speech Pathology Australia. (2011). Competency based occupational standards for speech pathologists: Entry level (Revised). Melbourne, Australia: Author. Speech Pathology Australia. (2014). Working with support workers . Position statement. Melbourne, Victoria: Author. Speech Pathology Australia. (2016a). Parameters of practice: Guidelines for delegation, collaboration and teamwork in speech pathology practice . Melbourne, Australia: Author. Speech Pathology Australia. (2016b). Speech Pathology 2030 – Making futures happen . Melbourne, Australia: Author. Thomas, R., & Davies, A. (2005). Theorizing the micro-politics of resistance: New public management and managerial identities in the UK public Services. Organization Studies , 26 (5), 683–706. https://doi. org/10.1177/0170840605051821 Turner, A., & Knight, J. (2015). A debate on the professional identity of occupational therapists. British Journal of Occupational Therapy , 78 (11), 664–673. https:// doi.org/10.1177/0308022615601439

55

JCPSLP Volume 20, Number 2 2018

www.speechpathologyaustralia.org.au

Rachael O’Brien is a speech pathologist and PhD candidate at the University of Newcastle. Prof. Rebecca Mitchell is a psychology trained academic with expertise in organisational behaviour and human interaction in the workplace. Dr Nicole Byrne is a speech pathologist and Senior Lecturer in Speech Pathology at the University of Newcastle. Wenger, E. (1998). Communities of practice: Learning, meaning, and identity . Cambridge: Cambridge University Press. Turner, J. C., Hogg, M. A., Oakes, P. J., Reicher, S. D., & Wetherell, M. S. (1987). A self-categorization theory. In Rediscovering the social group: A self-categorization theory . https://doi.org/10.1111/j.2044-8309.1987. tb00799.x Van der Gaag, A., & Davies, P. (1993). A sound investment? Bulletin of the College of Speech Therapists , 494 , 4–6.

Appendix Sample interview questions 1. What do you think about assistants in speech- language pathology? 2. What makes you feel this way? 3. Do you have any prior experience working with assistants? 4. Do you have any concerns about working with assistants? If yes, what are they? 5. What are some roles you think an assistant might perform in speech-language pathology? In your specific work setting? 6. How do you think your role would change if you were to work with an assistant? 7. What do you think your service would gain if working with assistants? 8. What sort of circumstances or supports do you think the profession would need to make the transition to working with assistants easier for clinicians? 9. Do you think there is a difference between contexts when working with assistants? E.g. would it be easier / harder in a paediatric vs adult setting? Rural vs metropolitan setting? Large department vs small department/ sole clinician?

Correspondence to: Rachael O’Brien University of Newcastle PO Box 282, Raymond Terrace, NSW 2324, Australia phone: +61419610515 email: Rachael.l.obrien@uon.edu.au

56

JCPSLP Volume 20, Number 2 2018

Journal of Clinical Practice in Speech-Language Pathology