FEATURE ON PEER SUPPORT

So crazy about all

ut I would not be caught dead with jewellery in my While the concept of introducing peer ears (Misheard lyrics at www.amiright.com/misheard/artist/ review to Speech & Language Therapy in simonpaul.shtml) Paul Simons actual words in the song Still Crazy Practice appealed, editor Avril Nicoll was After All These Years were a more thoughtful But I would not be convicted by a jury of my peers. Perusing some of the keen to avoid the known pitfalls of the exchanges on online e-groups or talking to people who have peer review for a journal article, you could be forprocess. However, hearing about other undergone given for thinking differently - but there are many reasons to the potential of peer support and a lot of information systems of peer support has convinced her explore around to help you achieve a system that works for you. With work playing such a central role in many peoples lives, that it will be possible to do this in an and continuing professional development now an integral open and constructive way. part of what we do, Erik de Hann argues that peer consulta-

A MODEL OF PEER SUPPORT

tion is an approach entirely in keeping with the spirit of our times (p.xv). In his book Learning with colleagues: an action guide to peer consultation he discusses (p.xvi) how this involves: entering into a deeper relationship with your colleagues in order to learn from them being vulnerable and openly discussing your strengths and weaknesses finding the limits of your expertise and exploring the territory beyond those limits together with your colleagues seeing this process of searching and exploration as an integral part of your work. In this issues My Top Resources for lifelong learning (back page), Tracey Righton explains how she has taken this route with a critical friend. She says this kind of relationship needs mutual trust and respect, and an expectation that this process will grow, change and develop over time. In Trafford, peer support started on a one-to-one basis, then changed two years ago into a professional support group system, with groups chosen according to caseload type and ranging from three to seven members meeting every six weeks. The usual focus of the discussion has been cases, good practice and clinical problems and successes. Although the system was good, clinical lead Terrie Murphy felt it could be even better. She explains, Rather than a hierarchical model where an expert hands out advice, I wanted a model where everyone in the group felt they had something to offer everyone else. It was important that any new model should build on the strengths of the existing one. When Terrie questioned staff, they said they liked the cohesive feel of the groups, and the respect and support they offered. They also commented on the listening skills and positive attitude and feedback of members, the skill mix and variety of expertise, and the willingness to share knowledge. Answers to a question about benefits for members were similarly encouraging, as the system is seen to offer the chance to be reflective and offload, to problem solve and exchange practical ideas and to build confidence both as individuals and as teams. Terries evaluation led to some important developments. As some group members met regularly anyway, and so had less to discuss, groups now rotate on an annual basis to keep fresh-

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Illustration by Graeme Howard

FEATURE ON PEER SUPPORT

these peers...
ness and objectivity. There are fewer groups, each with five or six members and a better balance of skill mix. The biggest change, however, followed a very practical and tailored training day to develop a Solution Focused Reflecting Team process that would help staff improve their support for each other. Drawing on Solution Focused Brief Therapy (see for example Burns, 2005), this model sees a group discuss a specific work difficulty in a structured way in 30 minutes. To keep the focus and ensure each section is covered adequately, a group member takes the role of time keeper, and another the role of process manager. One group member, the presenter, tells their story and explains what help they want. The steps of the process (figure 1) ensure that everyone is clear about their role at a given time and that everyone gets a chance to talk. Figure 1 Solution Focused Reflecting Team process Preparing (pre-meeting) The presenter comes to the group with a specific request for help with a workrelated issue. The presenter outlines the issues. The team members are silent. In turn, each team member asks one question of the presenter to understand the situation more clearly. The presenter can answer the specific question but everyone else is silent. Team members take turns telling the presenter what they have noticed about the issues or the presentation that impresses them. Team members take it in turns to wonder aloud about aspects of the situation and possibilities. The presenter can make notes but is silent. The presenter responds by setting out what s/he is going to do. The other group members are silent. matters can be discussed. The group doesnt replace local individual supervision or other initiatives such as journal clubs, instead operating as an adjunct to existing support systems. It is specific to junior speech and language therapists working with adults but crosses community, acute and rehab teams in three boroughs (five trusts, one private rehab unit). The group usually has about eight people attending for an hour and a half every two months, and the location and chairperson rotate, with the chairperson responsible for the agenda and minutes. Objectives include sharing information on the structures of the different trusts for example referrals, reporting and staffing - as well as discussing specific topics and getting feedback from courses. Sam says the group is also an opportunity to reflect on complex or unusual cases or situations, and it is important that this includes both positive and negative examples. The members reached an agreement on confidentiality to protect members, clients and the profession. Looking over minutes from previous meetings, it is clear that the group fulfils a variety of functions (see examples in figure 1), and that activities such as product reviews or discussion about practice frequently highlight other important issues. Kat Bowers describes the group as fantastic and adds that after the initial planning it has needed very little time in terms of organisation. She is grateful to the various managers concerned for allowing staff the time to attend, and points out that it has been so successful it is now used in recruitment advertising. Sam Livingston adds that, although they have been contacted by speech and language therapists in other boroughs who want to join, the members decided to keep to the three boroughs, as we all really enjoy the discussions that occur in a smaller group. However, plans are afoot to start an e-mail support group for junior therapists to send out general questions to a wider group. Figure 1 Examples of peer support group activity Reviews of resources, for example of a new assessment and how it fits in with existing assessments (led on to consideration of informed consent and how the psychology department could assist) A report on a study day, leading to discussion about a social (as opposed to medical) approach to note writing in the acute setting. Brief debate about joint therapy assessment sessions, and agreement to bring any relevant documentation from different areas to the next meeting. Recommendation of a recent literature review paper in a peer reviewed journal. Feedback on a facilitated user involvement day which included mechanisms to ensure the findings are put into practice. Agreement to share one team's goals resource. Presentation of a case study with brain storming of ideas. Topic based discussion (running groups; report writing).

Presenting (5 mins) Clarifying (8 mins)

the group is also an opportunity to reflect on complex or unusual cases or situations, and it is important that this includes both positive and negative examples.

Affirming (3 mins)

Reflecting (10 mins)

Closing (4 mins)

Terrie enthuses, it is so satisfying. I used to come up with lots of ideas and suggestions for people but with this approach they ultimately arrive at their own solutions. We have to remember that any problem is todays problem and tomorrow it will be something different so developing a solution focus is a skill for life. Junior staff Sam Livingston, a speech and language therapist with the Southwark community team in London, and her colleagues Lucy Wakefield from Lewisham Hospital and Kat Bowers of the Lambeth adult team recognised they would benefit from more support. Their solution was a peer group that provides a forum where clinical and non-clinical

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FEATURE ON PEER SUPPORT / RECOMMENDED READING

Both the Trafford and the London experiences suggest that, whatever the method of peer support chosen, it is important that group members have confidence in it and can see it is making a difference. de Haan (2005) outlines 15 different formal peer consultation methods and suggests a toolbox approach, with a method selected to suit the purpose and the number of people involved. He separates the needs of the profession from the needs of the person, suggesting the first benefits from a uni-disciplinary group and the second from a multidisciplinary composition. The Lambeth, Southwark & Lewisham's peer support group is closest to de Haans Supervision method concentrating as it does on practical issues such as procedures, guidelines, working methods and resources. Learning from success is a method that Terrie Murphy would surely endorse. It recognises that, while it is often easier to identify areas for improvement, it is also important to reflect on and nurture what has gone well. The gossip method also has similarities to the Trafford model in that one member tells a story, then listens while the others discuss it. A main difference is that the issue holder takes a seat outside the circle and turns away from the group to ensure they influence the consultants as little as possible. de Haan says it is eminently suitable for making someone aware of the rules, convictions and assumptions that govern his or her own actions and perceptions. This makes it a method that can help to broaden someones mindset (2005, p.39). Bernie Brophy-Arnott is a speech and language therapy manager in Dundee, working with people with learning disabilities. The department is in the early stages of planning a peer support system that Bernie hopes will be positive for staff as well as for equity of service. Having been on the receiving end of peer review for journal articles she is aware of the importance of a supportive department in taking you through the process. She points out that, although journal peer review is rigorous which is good and allows you to rehearse your argument in preparation for speaking at conferences - it is not a nurturing process. Peer review for journals is generally anonymous and carried out by at least two reviewers with the aim of ensuring objectivity and very high scientific standards. Comments received can vary from the constructive, helpful and logical to the nit-picky and rude. To illustrate how to provide a constructive review, Wager et al. (2002, p.46) take a novel approach with a section on How not to do informal review (Phrase all your remarks as questions, preferably sarcastic ones; Insert exclamation marks at the end of each paragraph; Wherever possible add a personal attack on the intelligence of the writer). While this makes very funny reading there is a serious side to it. Therapists braving the written market put heart and soul into it and, in terms of Speech & Language Therapy in Practice at least, such reviewing styles would be completely unacceptable. Along with other readers, Bernie Brophy-Arnott is enthusiastic about the prospect of peer review in Speech & Language Therapy in Practice, as long as it retains its focus on clients in context and generation of ideas for people to think about. Drawing on the strengths of the models of peer support described, our peer review will be a structured and transparent process. It will be supportive and constructive to authors. It will also guide readers in critical appraisal of evidence that has come from a clinical perspective. While misheard lyrics show we dont always hear what we are meant to hear, with a system that ensures shared understanding of context, careful listening and clear expression, you will not be convicted by a jury of your peers.

Drawing on the strengths of the models of peer support described, our peer review will be a structured and transparent process

Acknowledgements
Thanks to all the therapists who contributed to this article (names in bold), and to the readers who have been so enthusiastic in helping me plan the introduction of peer review.

References
Burns, K. (2005) Focus on Solutions A health professionals guide. London: Whurr. de Haan, E. (2005) Learning with colleagues An action guide for peer consultation. Basingstoke: Palgrave MacMillan. Wager, E., Godlee, F. & Jefferson, T. (2002) How to survive peer review. London: BMJ Books.

Resources
The Trafford training was offered by E. Veronica Bliss of Missing Link Support Services ltd, see www.missinglinksupportservice.co.uk. If you would like more information about applying to become a peer reviewer for Speech & Language Therapy in Practice, e-mail the editor avrilnicoll@speechmag.com or call Avril on 01561 377415.

New! Recommended Reading!

Given the overwhelming amount of information available, we need to be selective in what we read. Even then we find that papers do not always include an explicit link between the theory / experiment and its direct or indirect implications for practice. Articles in journals have gone through a painstaking process of peer review but it is ultimately for you, the reader, to judge whether the stated result is a) valid and b) clinically important in other words, why and how the article will change your practice. In this new section, readers explain in around 200 words why they would recommend a particular article from a peer reviewed journal to their colleagues. While this is a personal response that focuses on clinical importance and practicalities, the author may also wish to comment on factors such as study design / validity and statistics / statistical significance. APHASIA / AAC van de Sandt-Koenderman, M.W.M.E. (2004) High-tech AAC and aphasia: widening horizons? Aphasiology 18(3), pp. 245-263. Linda Armstrong is based in Perth Royal Infirmary and works in community settings with people with acquired neurological communication and / or swallowing disorders. She is an RCSLT aphasia adviser. Linda Armstrong says: This article is one of the papers in a special issue of Aphasiology on computers and aphasia. It reminds us that the evidence on the effectiveness of AAC with people with aphasia is limited, despite the first computer-based aid for this clientgroup being reported in 1982 and how computers have developed for general use since then. It encourages people who are working in this area to publish their findings (most of the references in the paper are from the 1990s). The author reviews the available literature on factors influencing the functional usefulness of low-tech AAC for people with aphasia and describes the few computer-based systems available. This paper focuses on the many aspects of the person, their individualised experience of aphasia and their communicative environment, all of which must be taken into account when assessing the persons suitability for AAC - the person with severe aphasia may also, for other reasons, be the person least suited to AAC use. It made me reflect on the timing of AAC introduction (low-tech and high-tech) - it should not be a last resort - and on the amount of training required. As is often the case, the paper concludes that there are still more questions than answers.

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