JCPSLP Vol 22 No 1 2020

clinical reasoning and evidence-based interventions (Smith & Kenny, 2015). Clinicians may also need to counter therapeutic nihilism and institutional barriers to holistic care (Chahda et al., 2017). Bennett and colleagues’ (Bennett, Cartwright, & Young, 2019) study found a significant number of speech-language pathologists in aged-care report uncertainty regarding validity of assessments and interventions for older clients and RACF clinicians were least likely to receive direct supervision or mentorship. This suggests speech-language pathologists need greater support to develop and operationalise their skills in RACFs. Finally, little is known about speech-language pathologists’ ongoing mental health needs in RACFs. In aged-care nursing, Woodhead, Northrop, and Edelstein (2016) noted that stress and burnout are frequent, but can be ameliorated through social support. Similarly, effective supervision and training support a healthy mental status (Mitchell, Nicholson, McDonald, & Bucetti, 2011; Pascoe et al., 2015). Given the complex nature of aged-care and data suggesting RACF speech-language pathologists may need greater professional support (Bennett, Young, & Cartwright, 2019; Bennett, Cartwright, & Young, 2019), RACF speech- language pathologist training and mental health needs require greater attention. Potential impact of “ageism” Ageism is discussed as a driver of government and institutional positioning of residents as economically burdensome, passive receivers of care (Bourgeois et al., 2016; Walker & Paliadelis, 2016). Ageist stereotypes in Australian aged-care settings are correlated with negative staff behaviour (Smith, 2019). RACFs are high-risk settings for ageism which may be operationalised as therapeutic nihilism (suggesting limited value treating the elderly) (Hopper, 2003), elderspeak which infantilises residents, and providing limited choice and autonomy (Theurer et al., 2015; Williams et al., 2017). Bennett and colleagues (2019b) did not identify ageist attitudes in Australian speech-language pathologists; however, the limited range of SLP services identified in RACFs may be due to factors beyond the control of individual clinicians (e.g., limited funding allocation for SLP services by RACF management). Conclusion A range of factors influence SLP service delivery in Australian RACFs. These include referral-based contractor delivery models with poor understanding of SLP scope of practice in RACFs (Bennett, Cartwright, & Young, 2019; Bennett, Young, & Cartwright, 2019; Bennett et al., 2016; Bennett et al., 2015a; Chahda et al., 2017; Jeng, 2015). This is compounded by ageist stereotypes across policy, organisation and individual levels (Smith, 2019; Walker & Paliadelis, 2016), and the lack of clinical guidelines (Chahda et al., 2017). The underuse of speech-language pathologists in RACFs means they perform limited roles in practice. This correlates with reduced communication access and quality for residents and less holistic mealtime management (Bennett et al., 2016; Bennett et al., 2015; Bennett et al., 2015a). There is also limited recognition and support for specialty SLP skills in gerontological and palliative care (Bennett, Cartwright, & Young, 2019; Bennett, Young, & Cartwright, 2019; Pascoe et al., 2015). Other workplace challenges include the unknown mental health needs of RACF speech-language pathologists. A disparity exists between best and actual SLP practice in RACFs (Bennett, Cartwright, & Young, 2019). Available

they are typically not included in government investigations of the aged-care workforce which focus primarily on managers and nursing staff (ACWST, 2018; Smith, 2019). Limited SLP roles in practice As noted above, speech-language pathologists are often called in to conduct swallowing assessments in RACFs. Texture modifications are routinely recommended by speech-language pathologists (Bennett, Cartwright, & Young, 2019). Ideally, these recommendations are made in the context of an overall meal management program. However, broader mealtime management is often beyond the scope of contracted referral-based services that are only paid for assessment (Bennett, Cartwright, & Young, 2019; Bennett et al., 2015). Yet, evidence suggests a lack of effective mealtime management can increase the risk of malnutrition, choking and aspiration pneumonia (Bennett, Young, & Cartwright, 2019). Conversely, appropriate and holistic mealtime management can improve nutritional intake, reduce problematic behaviours by residents with dementia and support socially focused communication, contributing to improved QOL (Brush & Calkins, 2008). Bennett and colleagues (Bennett, Cartwright, & Young, 2019; Bennett et al., 2015) suggest a lack of holistic SLP mealtime assessment, and limited facility awareness of mealtimes as a therapeutic context for communication, are common RACF issues. Clear multidisciplinary communication is suggested as one solution (Bennett et al., 2015). Authors suggest that to achieve this, changes to policy, training and staffing are needed, with mealtime management given greater priority (Bennett, Cartwright, & Young, 2019; Bennett et al., 2015). Communication access and quality issues Australian aged-care policy implies the need to support individual expression of care preferences (Prgomet et al., 2017). However, common RACF conditions can reduce communication opportunity and variability (Bennett et al., 2016; Bourgeois et al., 2016; Walker & Paliadelis, 2016; Williams et al., 2017). Literature shows communication exchanges between nursing staff and residents are mostly focused on functional care with elderspeak a common feature (Bennett et al., 2015; Bennett et al., 2015a; Walker & Paliadelis, 2016; Williams et al., 2017). Impoverished communication environments of this kind are reported to reduce resident QOL (Bennett et al., 2016; Theurer et al., 2015). Australian literature suggests communication interventions are not commonly operationalised in RACFs (Bennett, Cartwright, & Young, 2019; Bennett et al., 2015). However, therapies drawing on Montessori principles (Cartwright & Oliver, 2015; Douglas, Brush, & Bourgeois, 2018) demonstrate viability of SLP led facility-wide programs which address issues of loneliness and disengagement and ultimately advance services from entertainment models (Theurer et al., 2015). Lack of recognition of RACFs as a clinical specialty site for speech-language pathologists Little frontline data exists to clarify the specific skills RACF speech-language pathologists employ in daily practice (Bennett, Cartwright, & Young, 2019, Chahda et al., 2017). However, it is suggested the complex nature of this work draws upon clinician experience in gerontological and palliative care beyond entry level training and should be recognised as a specialty field (Bennett, Cartwright, & Young, 2019; Bennett et al., 2015b). Certainly detailed knowledge of disease progressions are needed to support

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JCPSLP Volume 22, Number 1 2020

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