JCPSLP Vol 20 No 3 November 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 3 2018

Nutrition, swallowing, mealtimes: Recipes for success

In this issue: From Ghana to Australia - Reflections on an international visit The ICF as a “way of thinking” Feeding infants on high flow nasal cannula oxygen therapy Can water protocols improve dysphagia management outcomes? Implementing standardised mouth cares and a free water protocol in a rehabilitation unit Basic oral care for patients with dysphagia: A special needs dentistry perspective The ‘Dysphagia Kitchen’ student learning experience Cultural responsiveness in a paediatric hospital setting Nutrition and hydration at end of life

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JCPSLP Editor Leigha Dark c/- Speech Pathology Australia

Editorial Committee Maree Doble Emma Finch Rachael Unicomb

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1 December 2018

Nutrition, swallowing, mealtimes: Recipes for success

From the editor Leigha Dark

Contents

W elcome to the November 2018 issue of J CPSLP and the theme “Nutrition, swallowing, mealtimes: Recipes for success”. As speech-language pathologists we are aware of the importance of safe, nutritious, and enjoyable mealtimes. An integral part of our role is ensuring that people with swallowing problems have access to the nutrition and hydration they require, foods and fluids are prepared in accordance with individual abilities, needs and preferences, and supports are offered

105 From the editor 106 Invited reflection and report: From Ghana to Australia – Reflections on the benefits of an international visit and professional networking – Josephine Ohenewa Bampoe 111 The ICF as a “way of thinking”: An exploratory study of Australian speech-language pathologists’ perceptions – Kate Ross, Jane Bickford, and Ingrid Scholten 121 Feeding infants on high flow nasal cannula oxygen therapy: Exploration of speech-language pathologists’ decision-making processes – Rebecca Murphy, Kirsty Harrison, and Celia Harding 129 Just add water: Can water protocols improve dysphagia management outcomes? – Joanne Murray, Allison Barker, and Sebastian Doeltgen 134 The experience of implementing standardised mouth cares and a free water protocol in a metropolitan hospital rehabilitation unit – Maria Schwarz, Inger Kwiecien, Anne Coccetti, and Elizabeth Cardell 142 Basic oral care for patients with dysphagia: A special needs dentistry perspective – Mathew Wei Ting Lim 150 The “Dysphagia Kitchen” student learning experience: From classroom to cookbook – Simone Howells, Petrea Cornwell, Hollie Austin, and Cara Probert 155 Cultural responsiveness in a paediatric hospital setting: People, processes, and practice environments – Claire Xiaochi Zhang and Emma Crawford 164 What’s the evidence? Can bread ever be compatible with a texture modified diet? – Julie A.Y. Cichero and Peter Lam 169 Ethical conversations: Recipes for successful provision of nutrition and hydration at the end of life – Helen Smith and Belinda Kenny 174 Ethical conversations: Ethical decision-making: Should I use this therapy approach? – Suze Leitão 177 Viewpoints: Nutrition, swallowing, mealtimes: Dietitians’ perspectives on recipes for success – Adrienne M Young, Elise Treleaven, and Anna Farrell 180 Around the journals 182 Resource review 183 Top 10: Paediatric feeding and dysphagia management: 10 useful resources to chew on – Pamela Dodrill 184 Correction to: Furniss & Wenger., The use of ultrasound in treating functional speech disorders in school-aged children in a community health setting

in such a way as to promote participation, autonomy and quality of life. We are privileged in this issue to be able to take a biopsychosocial, lifespan approach to this theme and share perspectives not only from speech- language pathologists, but also colleagues from dietetics and special needs dentistry. Personally, I feel very gratified to share this broad and comprehensive issue with you as my last issue as Editor of JCPSLP . I have greatly enjoyed my time working with all members of the editorial, production and publication teams, and with each author and contributor. Taking over from me as Editor is Dr Jae-Hyun Kim. I am very pleased to welcome Jae to the role and wish him and the team all the best as they continue to develop and shape the journal over the next couple of years. To open this issue, Josephine Ohenewa Bampoe shares her reflections on her international visit to Australia as a recipient of the Speech Pathology Australia Majority World Countries and Developing Communities Grant Scheme scholarship. Kate Ross, Jane Bickford and Ingrid Scholten present new findings about Australian SLPs’ perceptions and use of the International Classification of Functioning Disability and Health (ICF). Rebecca Murphy, Kirsty Harrison, and Celia Harding discuss the decision-making processes of SLPs introducing oral feeding for infants on high flow nasal cannula oxygen therapy. Joanne Murray, Allison Barker and Sebastian Doeltgen offer a review of current literature on free water protocols to stimulate discussion within the profession of barriers preventing uptake of this strategy. Maria Schwarz and colleagues follow with insights from the experience of implementing standardised mouth cares and a free water protocol in a metropolitan hospital rehabilitation unit. In the first of several inter- professional perspectives in this issue, Mathew Wei Ting Lim, special needs dentist, describes practical strategies for safely providing individualised oral care to patients with dysphagia. Simone Howells and her colleagues share their process of developing a dysphagia friendly cookbook as part of the “Dysphagia Kitchen” student learning experience. And finally, Claire Xiaochi Zhang and Emma Crawford present the findings of a service evaluation investigating cultural responsiveness within a paediatric hospital setting. In addition to the varied and illuminating articles in this issue of JCPSLP is the inaugural “Viewpoints” column, which replaces the longstanding “Webwords”. In this new column the theme of the issue will be explored from an alternative but complementary perspective to speech-language pathology. In November, we welcome dietitians Adrienne Young, Elise Treleaven, and Anna Farrell as they discuss “Nutrition, swallowing, mealtimes: Dietitians’ perspectives on recipes for success”. It is hoped that these perspectives, and in future issues, those of other multidisciplinary colleagues and stakeholders, will continue to challenge and stimulate our practice as speech-language pathologists.

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Invited reflection and report From Ghana to Australia: Reflections on the benefits of an international visit and professional networking Josephine Ohenewa Bampoe

Services for people with communication disability in Majority World countries are limited. The need for such services seems to be gaining much attention in some Majority World countries such as Ghana. The University of Ghana commenced its Master of Science in Speech & Language Pathology program in 2016. I received Speech Pathology Australia’s grant for Majority World Countries and Developing Communities. This paper reports on the benefits of the visit I undertook to Australia in May 2018 and reflects on the value of building global professional networks for improving rehabilitation services. C ommunication is a fundamental human right (McEwin & Saantow, 2018). Article 19 of the Universal Declaration of Human Rights states that “Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers” (United Nations, 1948). Habilitation and rehabilitation, hereafter referred to as rehabilitation, offer people with communication disability (PWCD) the opportunity to maximise their communication potential and to enable communication access for all. The United Nations Convention of Rights for Persons with Disabilities (United Nations, 2006) clearly delineates the right of people with disabilities to access rehabilitation services. The World Health Organization, through reports such as the World Report on Disability (World Bank & World Health Organization, 2011) and the Global Disability Action Plan 2014–2021 (World Health Organization, 2015), promotes the development of rehabilitation services for people with disability throughout the world. Recent initiatives such as the International Communication Project are beginning to engage influencers and policy-makers at high levels globally to build awareness and advocate for developments in rehabilitation for PWCD. Despite the need for governments to “organize, strengthen and extend comprehensive habilitation and rehabilitation services and programs” (Article 26; United Nations, 2006), rehabilitation services in Majority World countries are often extremely limited (Wylie, McAlister, Davidson, & Marshall, 2013). Improvement to rehabilitation

for people with communication and swallowing difficulties in the Majority World is urgently needed. About me I am a Ghanaian speech and language pathologist (SLP) and lecturer in the newly established Master of Speech Pathology program at the University of Ghana. There is a lack of services for children and adults with communication disability in Ghana and therefore our program aims to build the workforce of speech and language pathologists in the country to enable improvements to rehabilitation services for PWCD. Speech Pathology Australia (SPA) has established the Majority World Countries and Developing Communities Grant Scheme, which seeks to support the development of speech and language therapy services in Majority World countries by funding projects such as the establishment of a professional body/associations and attendance at relevant conferences and seminars, internationally or within the applicant’s Majority World country. I was the privileged recipient of one such SPA grant to support my attendance at the 2018 Speech Pathology Australia National Conference,“INSPIRE – “INSpiring Practice Innovation, Research and Engagement” in Adelaide, Australia. I also attended the Asia Pacific Education Collaboration in Speech Language Pathology (APEC–SLP) meeting held prior to the conference which provided me with further opportunity to learn about clinical education and the use of simulation in clinical training, and to meet and develop relationships with speech pathology educators across Australia. While I was in Australia, I also spent 10 days in Perth, observing and engaging with speech pathology colleagues at Edith Cowan University (ECU) and The Autism Association of Western Australia, to learn more about approaches and systems for clinical education and early intervention used in Australia. My context – Ghana The country of Ghana is in the huge, westward bulge of the continent of Africa. It lies just above the equator, sharing its borders with Ivory Coast on the west and Togo on the east. The present population is approximately 27 million people. This is the country that, until 6 March 1957, was known as the Gold Coast, with Accra as its capital. Ghana is a multilingual society and has about eighty languages (Languages of Ghana, n.d.). The language for education is English. International collaborations including remote collaborations and support, visits to other countries, and

KEYWORDS MAJORITY WORLD COUNTRIES PROFESSIONAL NETWORKS SPEECH-

LANGUAGE PATHOLOGY

THIS ARTICLE HAS BEEN PEER- REVIEWED

Josephine Ohenewa Bampoe

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visits to Ghana by professionals from other countries, are essential for the ongoing development and sustainability of the speech-language pathology programs in Majority World countries, like Ghana, where services are limited. Speech-language pathology is a relatively new profession in Ghana, with between 6 and 10 SLPs working in Ghana at any one time. Typically, only half of these are Ghanaian. Recognition of the need for services to support people with communication disability in Ghana started back in 2005 when discussions on training speech and language pathologists began among key players in the medical profession. These conversations included strategies for seeding the profession, such as the creation of scholarships to train Ghanaians to become SLPs with the view that they would return to the University of Ghana to commence a SLP training course. In 2005, the government of Ghana sent two linguistics graduates (my colleague, Clement Amponsah and I) to train as SLPs in the United Kingdom. The University of Ghana now has 3 full-time SLPs in post, which makes it the largest employer of SLPs in the nation. In 2016, the University of Ghana, commenced the first Master of Science (MSc) program in speech-language pathology in the country. It is of note that it took over a decade to get the program to a stage where all the critical elements were in place for a course to commence. The commencement of the MSc SLP program at the University of Ghana has potential for far-reaching effects for PWCD, not only in Ghana but for the continent of Africa where many Majority World countries are found. Partnerships and links with the SLP profession in other countries have been of immense value and support the establishment and implementation of our program in Ghana (Wylie, Amponsah, Bampoe & Owusu, 2016). A range of partner individuals and organizations have helped with strategy development, program planning, funding applications and resources, curriculum development, teaching and clinical supervision. The University of Ghana SLP team has benefited immensely from access to online resources facilitated by the Royal College of Speech & Language Therapists (Bampoe, Amponsah, Owusu, Wylie & Marshall,

Figure 2. University of Ghana

2016). The December 2017 edition of the Speech Pathology Australia magazine SpeakOut has on its cover page a photo of Associate Professor Bronwyn Davidson from Australia during one of those partnership visits, with the first cohort of the SLP MSc program of the University of Ghana (Wylie, Bampoe, Amponsah, Owusu & Davidson, 2017). In October 2017, I met with, Associate Professor Davidson to discuss issues regarding clinical education within our program. Following this meeting, I was keen to learn more about assessment of students’ development of clinical competency in the Australian context and opportunities for inclusion of simulation in clinical education. I had no previous international conference experience. The opportunity to attend the 2018 Speech Pathology Australia National Conference with the support of a SPA Grant opened the doors to my first ever international conference. How do international visits benefit the Majority World countries? Learning is an ongoing process. Stakeholders across all professions are expected to continue to learn (Webster- Wright, 2017). International visits provide multiple learning opportunities not just for the visitor but also for the professionals who reside in the country of visit as information is shared by both. Such visits can broaden the views of professionals working in Australia about

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communication disability, including the importance of working with community members, raising awareness, and understanding issues in creating culturally responsive services. The learning process does not end with the return of the visitor to his/her home country though, as the development of professional networks facilitates the continuation of learning processes remotely. Current research/evidence-based practice An emphasis on evidence-based practice (EBP) exists within and across health care professions (Hoffmann, Bennett, & Del Mar, 2017). Speech-language pathology embraces EBP in its delivery of services for people with communication and/or swallowing disability (SPA, 2010). The Speech Pathology Australia National Conference provides a valuable forum for the dissemination of current research across a range of practice areas in the profession. Increasingly, we are reminded that EBP is “the conscientious, explicit and judicious integration of best available external evidence from systematic research, best available evidence internal to clinical practice, and best available evidence concerning the preferences of a fully informed patient” (Dollaghan, 2007, p. 2). Hoffmann and colleagues (2017) have suggested a relevant fourth realm, that is, that practice is also informed by the practice context. Speech and language pathologists seek to work in line with practices that are, as much as possible, supported by research and international consensus. Attendance at the SPA conference provided me with knowledge of current research and translation of research findings into practice. Knowledge of current and emerging practice in speech pathology is of great benefit to professionals and clients in Majority World countries where there is little research on services for PWCD. Not only are the beneficiaries of EBP our clients, but also our SLP students. Teaching students current research has far-reaching effects in shaping the future of the profession in Majority World countries. Professionals in the Majority World face the challenges of appraising current research findings and adjusting practices to suit their context. The clinician’s expertise and client’s values therefore serve to inform the evidence base for the intervention approach to be applied in contextually relevant and culturally responsive ways. The needs of PWCD in Majority World countries are receiving increased attention (World Health Organization, 2011). It was noteworthy that at the 2018 SPA conference, there were several sessions reporting on work with under served communities, including Aboriginal and Torres Strait Islander people, and people in Majority World countries. These presentations reinforced the growing body of literature that emphasises the importance of developing education programs and services that are culturally safe and responsive (Wickenden, Hartley, Kariyaaranawa, & Kodkara, 2003). The conference provided me with an opportunity to learn about current research in speech pathology; however, it was also an avenue to establish relationships with some of the professionals involved in the research and to consider how research and practice in Australia could be translated to “best practice” in our context. Professional networking Meaningful learning can occur as the result of global health partnerships (Busse, Aboneh, & Tefera, 2014). Opportunities, such as my attendance at the 2018 SPA

conference, provide an avenue to meet colleagues from other parts of the world. The SPA conference provided me with both professional development and international engagement. I am the clinical coordinator of the newly established Speech & Language Pathology Masters program at the University of Ghana. Clinical education is recognised as a key component in the professional training of speech-language pathologists (Ho & Whitehill, 2009). The challenges of providing quality clinical education experiences in a country that has only six SLPs and few established SLP services are immense. Being a new program, there is a crucial need for support in clinical education in order for the students to graduate as competent and well-trained SLPs. There is also the need to develop programs to support the clinical educators who will supervise the students. Attendance at the 2018 Speech Pathology Australia National Conference helped me to develop professional networks in professional education as I had the opportunity to meet clinical coordinators from other countries (both Majority & Minority worlds). In Majority World countries such as in Ghana where the number of SLPs are few, alternative models of supervision need to be considered. This visit enabled me to consider other models of clinical education relevant to an emerging profession in Ghana such as tele practice and peer learning, although specific systems relevant to our context will need to be developed and evaluated. This international visit has helped to extend my understanding of models of clinical education and assessment of students’ development of clinical competency. Further to this, attendance at the Asia Pacific Education Collaboration in Speech Language Pathology (APEC–SLP) meeting provided a learning opportunity for me to meet university educators in clinical education and share ideas. In addition, the one week visit to Edith Cowan University in Perth, Western Australia, further provided occasions to observe a simulation centre, meet clinical coordinators, observe students on clinical placements and establish new professional networks. Sharing information about Ghana International visits facilitate information sharing. I had the opportunity to share information about Ghana with clinical educators and speech and language pathologists from other countries. An international conference can provide participants from Minority World countries with the ability to learn about contexts that are different from their own and to know more about the realities and challenges faced by colleagues in countries where the profession is emerging. At the APEC–SLP meeting educators learned about services for PWCD and the training of SLPs in Ghana. Australia is a multicultural country and thus, information about service provision in Majority World countries, which are multicultural, helps SLPs in the Minority World to understand how to work with people from similar cultural contexts, such as Ghana. Working across cultures is not easy. It is therefore important to have international partners who understand the context and the cultures in which the professionals in Majority World countries work. Together with my Australian colleague who had worked extensively in Ghana, we gave a lunchtime presentation at the Speech Pathology Australia National Conference on “Developing Effective International Partnerships: The Ghana SLT Experience”. One point we

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different settings were among the most valuable moments of my visit. Seeing students and their clinical educators on placements working with clients allowed me the opportunity to reflect and draw conclusions on how to adapt some practices for the culture and context of Ghana. Reflection on my journey to Australia The profession of SLP is new in Ghana and the training of SLPs is a critical development. However, such developments take time to embed in countries such as Ghana. To make these types of programs sustainable ongoing support from and collaboration with the international community is of immense value. A grant such as the SPA Majority World and Developing Communities grant offers an important and effective contribution to supporting developing programs in Majority World countries like Ghana. To summarise, the key benefits I experienced from my international visit to Australia and professional networking opportunities included: • Two-way sharing of information and experiences • Detailed understanding of how well-established systems of services and education operate in Australia, which allowed me to adapt some of these principles to the new profession of SLP in Ghana • Updating of knowledge to inform and shape EBP within the Ghanaian context • Building a community of learning in relation to services for people with communication disability in both Majority and Minority World countries • Developing and expanding professional networks across the globe, which will provide ongoing support and collaborations across years to come • Exploring and debating the best ways to build research capacity in Ghana. The opportunities afforded me following receipt of the SPA Majority World and Developing Communities Grant have enabled engagement at a global level. In keeping with the SPA Conference theme “INSPRE”, I have experienced inspiration and motivation for continuing to build our approach toward best practice for communication disability rehabilitation in Ghana through our training program at the University of Ghana. Acknowledgements I would like to thank SPA for this great support and for being open to international engagement; the APEC group, Edith Cowan University, and the Autism Association of Western Australia. I would like to acknowledge Associate Professor Bronwyn Davidson and Ms Karen Wylie who helped immensely with the editing of this paper. References Bampoe, J. O., Amponsah, C., Owusu, N. A. V., Wylie, K., & Marshall, J. (2016). A helping hand. Royal College of Speech & Language Therapy Bulletin , October, 18. Busse, H., Aboneh, E. A. & Tefera, G. (2014). Learning from developing countries in strengthening health systems: an evaluation of personal and professional impact among global health volunteers at Addis Ababa University’s Tikur Anbessa Specialized Hospital (Ethiopia). Globalization and Health , 10 (64), 1–7. https://doi.org/10.1186/s12992-014- 0064-x

raised was that if one is looking to partner with groups like SLPs in Ghana, it is important to be clear about what kind of vision the prospective partner has. The presentation provided the opportunity for SLPs from Ghana to share the Ghanaian experience of working with international partners. We shared information on how international volunteers

Figure 3. Karen Wylie & I at the 2018 SPA Conference

can be effective collaborating partners in Majority World countries. Our experiences may help SLPs who may want to partner with Majority World countries to consider adjusting practices when working in similar contexts. I also used the opportunity provided by the grant to explore the range of models of support that international partners can offer. Partnering with Majority World countries is much more than about just visiting these countries. Beyond these visits, partners may be willing to share their resources, mentor academic faculty in their roles, sponsor faculty to visit services outside the Majority World country and establish groups of SLPs with an interest in supporting and enhancing the work done in such countries. Observing practices My recent visit to Australia allowed me to observe SLP practices in a Minority World country. A visit to the Early Intervention Centre of the Autism Association of Western Australia in Perth provided me with knowledge about the diagnostic criteria for autism spectrum disorder (ASD) in Western Australia and the intervention approaches used for early intervention. The opportunity to observe a speech pathologist working with children in groups and individually helped me make sense of the literature on early intervention for children with ASD. This visit also helped to ground information obtained during the conference as it was seen being applied in practice. Observing the well-structured nature of the centre highlighted practices that I believe similar centres in Majority World countries can adopt and adapt to improve services for PWCD. The opportunities offered by the staff at Edith Cowan University to observe students on clinical placements in

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therapists in Sri Lanka: Issues in curriculum, culture and language. Folia Phoniatricia et Logopaedica , 55 , 314–32.1 World Bank and World Health Organization (WHO). (2011). World report on disability . World Health Organization: Geneva. World Health Organization (WHO). (2011). World report on disability: Summary . Accessed 28 June 2018: http:// www.refworld.org/docid/50854a322.html World Health Organization (WHO). (2015). WHO global disability action plan 2014–2021: Better health for all people with disability . Geneva: Author. Wylie, K., McAlister, L., Davidson, B., & Marshall, J. (2013). Changing practice: Implications of the World Report on Disability for responding to communication disability in under-served populations. International Journal of Speech-Language Pathology , 15 (1), 1–13. doi: 10.3109/17549507.2012.745164 Wylie, K., Amponsah, C., Bampoe, J. O., & Owusu, N. A. (2016). Sustainable partnerships for communication disability rehabilitation in Majority World countries. A message from the inside. Journal of Clinical Practice in Speech-Language Pathology , 18 (3), 116–120. Wylie, K., Bampoe, J. O., Amponsah, C. A., Owusu, N. A. and Davidson, B. (2017, December). Developing the speech pathology profession in Ghana. Speak Out , 18–19).

Dollaghan, C. (2007). The handbook for evidence-based practice in communication disorders . Baltimore, MD: Paul H. Brookes. Ho, D. W. L., & Whitehill, T. (2009). Clinical supervision of speech-language pathology students: Comparison of two models of feedback. International Journal of Speech-Language Pathology , 11 (3), 244–255. doi:10.1080/17549500902795468 Hoffmann, T., Bennett, S., & Del Mar, C. (2017). Evidence-based practice across the health professions (3rd edition). Elsevier Australia: Chatswood, NSW, Australia. Languages of Ghana. (n.d.). Wikipedia. Retrieved 30 June 2018 from https://en.wikipedia.org/wiki/Languages_ of_Ghana McEwinn, A., & Santow, E. (2018). The importance of the human right to communication. International Journal of Speech-Language Pathology , 202, 1–2. doi:10.1080/1754 9507.2018.1415548 Speech Pathology Association of Australia (2010) Evidence based practice – EBP . Melbourne: Author. Retrieved from http://www.speechpathologyaustralia.org. au/resources/evidence-based-practice United Nations. (1948). Universal declaration of human rights . Retrieved from http://www.un.org/en/universal- declaration-human-rights/ United Nations. (2006). Convention on the rights of persons with disabilities . Retrieved from https://www. un.org/development/desa/disabilities/convention-on-the- rights-of-persons-with-disabilities.html Webster-Wright, A. (2017). Reframing professional development through understanding authentic professional learning. Review of Educational Research , 79 (2), 702–739. doi.org/10.3102/0034654308330970 Wickenden, M., Hartley, S., Kariyakaranawa, S., & Kodikara, S. (2003). Teaching speech and language

Josephine Ohenewa Bampoe is a speech pathologist, lecturer and clinical coordinator in the new Master of Science Speech Pathology program at the University of Ghana, in Ghana.

Correspondence to: Josephone Ohenewa Bampoe University of Ghana phone: (0011) 233 24 0740029 email: jobamp@hotmail.com

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The ICF as a “way of thinking” An exploratory study of Australian speech-language

pathologists’ perceptions. Kate Ross, Jane Bickford, and Ingrid Scholten

The International Classification of Functioning, Disability and Health (ICF) is a compelling framework and classification system with the potential to enhance person- centred care. This mixed methods study investigates the degree to which the ICF is used by speech-language pathologists (SLPs) in Australia and ascertains their knowledge, endorsement, and perceptions of ICF implementation. Survey data were collected from 117 SLPs and analysed statistically and thematically. Respondents rated their knowledge as “good” and reported using the broader ICF framework more than the detailed classification system. Comparison revealed significantly lower ICF knowledge and use in practitioners working with children and in settings serving children, than those in adult based settings or working with adults. The ICF was discussed as being “a way of thinking” and respondents strongly indicated desire to use it further. Education and promotion strategies should aim to enhance ICF uptake and holistic, person-centred care, leading to improved client outcomes and realisation of the 2030 vision of Speech Pathology Australia. A person-centred approach is central to speech- language pathology (SLP) practice (Speech Pathology Australia [SPA], 2011). The International Classification of Functioning, Disability and Health (ICF) (WHO, 2001) is a comprehensive universal framework and classification system that supports such holistic practice. Its reach extends from clinical practice to use in service management, education, research and policy development, with potential to influence all levels of health care systems (WHO, 2013). The many advantages of the ICF contribute to its widespread acceptance. By shifting focus to holistic practice it can assist with clinical reasoning, problem solving and guide goal-setting (Nguyen et al., 2018). The ICF can help to clarify team roles, enhance communication within and beyond teams, and expand practitioners’ perceptions

of disability, thereby improving health care delivery (Alford, et al., 2015; Pettersson, Pettersson & Frisk, 2012; Vargus- Adams & Majnemer, 2014). Limitations of the ICF include its complex and unwieldy coding systems (Nguyen et al., 2018), unclear terminology (Bornbaum et al., 2015), and absence of classification for the personal factors component (Alford et al, 2015). Associated with these shortcomings is also a lack of provision for capturing subjective experience or quality of life (Pettersson et al., 2012). It can also be challenging to implement and difficult to access expert training in its use (Bornbaum et al, 2015). ICF integration into practice The applicability of the ICF to SLP practice has been discussed in special journal editions, such as Seminars in Speech and Language (2007, 28[4]) and International Journal of Speech Language Pathology (2008, 10[1–2]). Authors have addressed the ICF components theoretically, its general use in clinical practice, and application to specific service populations. The ICF has been used to: investigate the impacts of communication and swallowing impairment on clients’ lives (Baylor, Burns, Eadie, Britton, & Yorkston, 2011); create standardised assessments to capture such impacts (Threats, 2012); and for goal-setting and intervention planning (Bornman & Murphy, 2006). It has also provided a starting point for conceptualising functional intervention, such as the Life-Participation Approach used in aphasia (Chapey et al., 2008). A decade ago the ICF was described as not yet fully integrated into SLP practice (Ma, Threats & Worrall, 2008). This was also an issue in other health professions, such as physiotherapy (Jacob, 2013), occupational therapy (Stewart et al., 2013), and clinical rehabilitation (Wiegand, Belting, Fekete, Gutenbrunner & Reinhardt, 2012). Wiegand and colleagues (2012) found that while the ICF framework and resources had been successfully disseminated in the rehabilitation sector, its implementation was inconsistent. However, the expectation that SLPs will understand and use the ICF is clearly outlined in Speech Pathology Australia’s (SPA) Scope of Practice document (SPA, 2015). University curricula must now demonstrate that student SLPs are learning and using the ICF to meet professional standards prior to graduation (SPA, 2011). Study purpose The ICF clearly relates to a range of SLP practices but despite research into ICF applications, no study has

KEYWORDS ICF

KNOWLEDGE TRANSLATION MIXED METHODS SPEECH- LANGUAGE PATHOLOGY SURVEY THIS ARTICLE HAS BEEN PEER- REVIEWED

Kate Ross (top), Jane Bickford (centre), and Ingrid Scholten

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created and labelled accordingly. Normality testing of interval data influenced the type of inferential test chosen. The Mann-Whitney test (two factors) and Kruskal-Wallis (more than two, including post-hoc testing to reveal specific subgroup differences) were used with the non-parametric data. For the interval and normally distributed data t tests (two factors) and one-way analysis of variance (ANOVA; more than two factors, with post-hoc testing) were run. Significance was established at a p-value of less than .05. Effect sizes were calculated for all inferential tests. Thematic analysis Thematic analysis (Braun & Clarke, 2006) was conducted on responses to open ended questions, with measures taken to enhance rigour. The authors initially analysed and coded 20 questionnaires independently. The derived coding structure was then used by an external colleague to classify responses in five additional questionnaires, with consensus achieved through discussion. The first author then coded all responses using the agreed coding framework. Memos were written during the analytic process to further develop interpretations and understanding. Thematic maps were constructed to visualise the findings and were reviewed multiple times in conjunction with the original data. Results Responses were received from 117 SLPs, with 80 full responses (from 77 females, 3 males) and 37 (gender unspecified) partial responses. Demographics Data included a range of practice demographics (Table 2). Respondents were typically women holding a bachelor’s degree, at the lower end of experience, (mode = 1 year [12 cases]; x = 8 yrs; range 0–40 yrs), practising in a client- focused role with children rather than adults, and working inter-professionally. A statistically significant higher proportion of clinicians from South Australia responded to the survey compared to the wider Australian speech pathology population, consistent with the researchers’ geographical location ( p < .0001). This bias also extended to the sample clinicians’ location, with rural-based clinicians being over represented ( p = .038). Practitioners reported working across multiple areas of practice and in several service areas concurrently, which complicated interpretation. Responses were therefore analysed according to collapsed categories: 1) Area of practice: paediatric focus, adult focus or both and 2) Service delivery: various child settings, mixed settings, community centre and outpatient, acute and rehabilitation. Smaller groups were combined in a final category for inferential analysis. Knowledge of the ICF Practitioners rated their knowledge of the ICF to be: little (N = 18; 16%); basic (N = 30; 27%); good (N = 38; 34%); solid (N = 11; 10%); and comprehensive (N = 15; 13%). Use and perceived utility of the ICF Exploratory factor analysis was used to identify the relationships underlying each of three multicomponent scale questions: components [of the ICF] (Survey section I. 3); adoption [of the ICF] (Survey section I. 4a); and utility [of the ICF] (Survey section II. 2). Two factors were obtained for each section using the Kaiser Meyer Olkin (KMO) statistic, accounting for 56%, 68% and 56% of the variance respectively. One factor was extracted for further adoption (Survey section I. 4b), accounting for 56% of variance.

specifically investigated whether, almost two decades after its introduction, SLPs value and use this tool. In order to inform future education in and support for using the tool, the aims of this exploratory study were to determine the current status of the following in relation to Australian SLPs: • knowledge of and support for the ICF • the extent of explicit ICF use • patterns in ICF uptake • perceived advantages and disadvantages • facilitators and barriers experienced in the application of the ICF. Consideration of these findings should help ascertain whether the ICF has instigated a cultural shift from the traditional medical model to a more holistic way of practising in SLP practice. Methods This exploratory mixed methods, survey-based study received ethics approval from the Human Research Ethics Committee of Flinders University (EC00194; # 7133). Return of the online questionnaire, supported by LimeSurvey (Schmitz, 2015), implied consent to participate. All Australian SLPs were eligible to contribute, and recruitment occurred primarily via a SPA newsletter invitation. Research instrument An existing survey (Stewart et al., 2013) was adapted, with permission, to reduce redundancy, add literature-supported detail regarding potential uses and benefits of the ICF, and improve data retrieval processes. The questionnaire comprised of 15 questions divided across three main sections – two sections addressing questions of use and utility, and one gathering work-related demographic information. An outline of the questions for the first two sections is provided in Table 1. Pilot testing suggested that survey completion took 15–20 minutes. Statistical analysis Data were analysed using IBM SPSS (IBM Corp, 2015). Partial data were used where possible. Descriptive statistics were calculated. Chi-square goodness of fit was used to reveal any bias in the data. Exploratory factor analysis was conducted and, where relevant, composite scores were

Table 1. Survey questions

Section

Questions

Sub- questions

Question types

ICF use

1. Duration of

Multiple choice

implementation 2. Knowledge level 3. Use of components 4. Adoption of the ICF 5. Most influential components

7 24

Likert scale

Free response

ICF utility 6. Advantages and disadvantages 7. Perceptions on utility 8. Barriers and facilitators to use

Free response Likert scale

10

Free response

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Table 2. Practice Demographics

Table 3. Factor analysis for components of ICF scale

N Sample %

Factor

General Framework Coding

Area of Practice a

44 31 25

33 23 19

Paediatric focus Adult focus Both

.941 .737 .655 .424

Terminology of ICF Model and framework Definition of ICF Classification system a Core sets for SLP Coding for SLP purposes Checklists a

Service Delivery Setting b Various child settings Mixed settings Community centre and outpatient Acute and rehabilitation Private, university practice or other Multidisciplinary team member c Yes No

.410 .872 .801 .373

30 15 16 22 17

24 12 13 18 14

a Despite low correlation, values were compiled in Coding factor due to theoretical reasoning. Note: Factor loadings <0.35 were suppressed.

65 16

80 20

Table 4. Factor analysis for adoption of ICF scale

Duration of ICF use d ≤ 2 years 3 - 5 years

Factor

29 14 14 26 18

23 11 11 21 14

Clinical Focus

Service/ Management Focus

6 – 10 years 11-20 years ≥ 21 years

Describe activities and participation Describe function Identify and describe environmental factors Identify and describe personal factors Assist with goal-setting Assist with evaluation of therapy outcomes a Assist planning at systems level Assess service quality

1.017 .944 .907

Academic Qualification Undergraduate Masters Doctorate

63 28 10

50 22 8

.897 .672 .418

Role focus e

67 5 1 8 3 3 14

52 4 1 6 2 2 11

Client contact Education Consultation Admin or management Research Other Distributed

.942

.823 .706 .689 .613 .546 .523 .436

Measure attitude and changes Support service management Structure documentation

Facilitate cooperation b Help raise awareness b Guide selection of assessment tools a

.364 .428 .422

Components Used Respondents were asked to what extent they used various components of the ICF in their practice: definition, terminology, model and framework, classification system, coding, core sets and checklists. The two factors obtained for ICF components used were General Framework and Coding (Table 3). Almost two-thirds (N = 71; 64.8%) of respondents reported using the General Framework with clients (definition, terminology, and the framework itself); a fifth (N=24; 22%) reported using the coding, core sets or checklist aspects of the ICF ( Coding factor). Adoption Respondents rated their use of the ICF for 23 specific tasks across a Likert scale. The mode for each stated purpose was “never used”, however the positive responses to this item that were received described use of the ICF in the context of clinical tasks, such as describing activities and a There was substantial overlap between the 6 areas of practice (SPA, 2011); categories were collapsed; n = 75. b Groups were created based on patterns in the data. Private, university practice, or other (mainly mental health and disability) was not theoretically ideal; however, separating settings would have produced very small counts, limiting inferential analysis (n = 81). c n = 81. d n = 80; e These groups were collapsed further into client contact , other , and distributed focus for the purpose of analysis; n = 78.

a Despite low correlation, value was compiled in Clinical Focus factor due to theoretical reasoning. b No clear correlation to either factor; analysed separately. Note: Factor loadings <0.35 were suppressed.

participation (N = 87; 80%) or goal-setting (N = 83; 76%), rather than for management tasks such as service evaluation (N = 35; 33%) or policy-making (N = 21; 19%). This pattern is consistent with the two derived factors of Clinical Focus and Service/Management Focus (Table 4). The questions related to further adoption of the ICF loaded onto a single factor, Education, Appraisal and Support (Table 5). Perceived utility Respondents indicated their regard for the ICF across a range of tasks. Analysis supported two underlying factors: Decision-making and Service Quality (Table 6). The ICF was deemed to promote decision-making (fosters clinical reasoning and decision-making [N = 66; 78% agreement and strong agreement]; and holistic thinking [N = 73; 86%]). However, respondents generally had little opinion (neither agree nor disagree) regarding many of the variables associated with the Service Quality factor, namely whether the ICF clarifies roles (N = 35; 41%), fosters teamwork (N = 31; 37%), brings structure to documentation (N =32; 38%) or enhances ethical service provision (N = 35; 42%).

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Table 5. Factor analysis for further adoption scale

Table 6. Factor analysis for utility of the ICF scale

Factor

Factor

Education, Appraisal and Support

Service Quality Decision-making

.816 .814 .799 .764 .752 .752 .728 .680 .626

.963 .857 .766 .703

Organise results ICF training Mapping assessments Policy making Research data collection Peer counselling Census or survey data Global education Advocacy

Clarifies roles Fosters teamwork Enhances communication Aids interprofessional practice Brings structure to documentation Ethical service provision Helps classify

.686

.627 .494

Note: Factor loadings <0.35 were suppressed.

communication and swallowing issues a

Encourages holistic thinking Fosters clinical reasoning and decision-making b

.660

Patterns in ICF uptake Further analysis explored whether respondents with different professional circumstances varied in their knowledge or use of the ICF. In Table 7, inferential data pertaining to respondents’ location, whether they worked inter- professionally and their area of practice against variables of interest, including those derived from factor analysis, is presented. Neither respondents’ location nor extent of inter-professional practice affected ICF use. However, a significant difference for Clinical Focus was revealed between practitioners with a paediatric focus (mean rank = 30) compared with those working with an adult focus (mean rank = 47). The difference in level of knowledge of the ICF was also significant (paediatric focus [mean rank = 24]; adult focus [mean rank = 36]). Both effect sizes revealed a medium difference (r = –.378; r = .377). That is, practitioners working with children rated their knowledge level lower and reported lower adoption of the ICF for aspects of their practice such as assisting with goal-setting or outcome measurement than practitioners in the adult sector.

.491

.564

Further analyses revealed no significant differences between the five Service Delivery contexts for the items: Establish eligibility ( p = .697); Facilitate cooperation ( p = .078); ICF having great benefits ( p = .357); and Service Quality ( p = .098). Whereas, the following factors had significant difference between groups: Clinical Focus ( p = .024); Service Management Focus ( p = .031); Education, Appraisal and Support ( p = .044); Help Raise a Despite lower correlation the value was included in Service quality following theoretical reasoning. b Grouped with Decision-making factor due to higher correlation and theoretical reasoning. Note: Factor loadings <0.35 were suppressed. Question 10 (“The ICF has great benefits”) did not correlate with either factor and was analysed separately.

Table 7. Patterns in uptake: Location, multidisciplinary team and area of practice

Location

Multidisciplinary team Area of practice b

p -value

Effect size a

p -value

Effect size (r)

p -value

Clinical Focus

.165

–.156

.390

–.097

.012

Service Management Focus

.840

–.194

.710

–.041

.171

Education, Appraisal and Support

.240

–.133

.820

–.025

.110

Establish eligibility

.150

–.164

.070

–.202

.401

Facilitate cooperation

.240

–.133

.370

–.100

.910

Help raise awareness

.610

–.057

.420

–.089

.126

Knowledge

.710

–.042

.770

–.033

.013

Service Quality

.102

.400

.570

–.060

.675

Decision-making

.520

–.074

.910

–.013

.167

ICF has great benefits

.519

–.080

.459

–.090

.353

General Framework

.320

–.111

.470

–.085

.560

Coding

.160

–.156

.280

–.126

.379

a Effect sizes are the r coefficient, excepting Service Quality which is coefficient d . b Area of practice effect sizes were only calculated for post-hoc tests.

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