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how I

.l put research.
Into practice
based practice' sounds
good, but u pdati ng ou r practice as
new information becomes available is
not always easy. The unwieldiness
of public services, long waiting lists
and lack of time to research the
research can all conspire against us.
In the Spring 2000 issue, three
contributors discussed how they put
practice into research. Then we
observed that speech and language
therapists "want to know optinlunl
ti mes for intervention, tech n iq ues
that produce results and caseload
organisation that makes the best
use of limited time". So, once we
know, how do we change our
practice accord i ng Iy?
Our contributors present the case
for evidence based practice - l1li.:;)
you, the jury, must decide.
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how I
, ResearCh is big.' 'Research means
statistics.' 'Research is time
consuming.' That's one perspective,
but what about another? 'I want
Research isn't confined to ivory towers or
weighty journals. Nina Soloff challenges us
to ask, investigate, discuss and share the
everyday questions that add to the evidence
base for our practice.
Gatheri ng the evidence
to do the best for my clients.' 'I want to be sure I' m making a difference.' Index to Recent Literature on Speech and Language. This is a database
'I know I'm making a difference and I want to share it with other people.' of abstracts from over thirty journals. (The only problem is you often
The problem with the word 'research' is that people have precon find there is too much that you want to follow up.)
ceived ideas about what it involves. Sometimes I think the word should b. Use your librarian. Most Trusts have a library with staff who have a great
be abolished completely, and I should have a different job tit le. many skills in searching for articles. Even if you just go in with a word or a
'Evidence-Based Practice Co-ordinator' is a bit of a mouthful, but phrase relating to what you want to look for, they will be able to help you
evidence-based practice is really what we're talking about as it is: identify relevant articles and books, order items from other libraries, and
'... an approach to decision-making in which the clinician uses the best may even train you in doing literature searches. If you don't have a Trust
evidence available, in consultation with the patient, to decide upon the library, try your local council library.
option which suits the patient best.'
(Muir Gray, 1997)
Evidence-based practice is a part of our everyday
working lives (see stages in figure 1). It happens when
you devise, execute and evaluate therapy plans; when
a discussion with a colleague helps you make a clinical
decision; when you read an article in this very maga
zine and apply it to your own situation.
So how can we put Muir Gray's definition into
1. Questions, questions, questions
I believe that for most research to be relevant to
clinical practice, it has to be borne out of clinical
practice. A practical way to start is to capture those
questions that pop into your head in your everyday
work (see figure 2) and then ask yourself what evi
dence you need in order to be able to answer them.
It would be great if every clinician had a notebook
to write those sorts of questions down in. That way,
if you're not able to think about the question there
and then, you can go back to it later. Th is can be a
really rewarding process because, when you're
bogged down with clinical work, you often forget
how creative you can be. It can rekindle your enthu
siasm when you look back through your notebook
and say to yourself, "Did I really think of that...?"
But what counts as evidence? Le May (1999) makes
the point that, while evidence from well-conducted
research is given greatest credibility, practice is, in fact,
informed by many sources of evidence, including:
Evidence based on experiences - this type of evidence
links with the habit of 'question-asking' described
above, and includes reflecting on practice, discussing
Figure 1The stages within evidence-based practice

Deciding what we want to
find evidence about
Accessing the evidence
Appraising the evidence
Using the best available

Evaluating the impact of the
(Ie May, 1999)
Figure 2 Sample questions
What effect does taste have
on swallowing;
What is the incidence! treatment
efficacy of cluttering in people
with Down's Syndrome;

How soon after adenoldectomy/
grommet insertion should we
expect changes in speech
perception/production; That is,
should I delay offering therapy
until the surgery has had time
to 'take effect'?
(Thanks 10 membersof Milton Keynes' Speech and
Language Therapy Service.)
c. Set up journal alerts. If you have internet
access, you can set up a messaging service that
tells you when the latest editions of journals
come out. You can choose which journals to
be told about, so you don't have to be
swamped bye-mails. The e-mail 'alert' links
you to a web-page showing the contents ofthe
journal, giving you further links to the abstracts
of the articles. I mainly use Arnold Publishers
( and Taylor &
Francis (www.tandf.comjournals). The best way
to go about it is to find out who publishes the
journal(s) you're interested in, then search for
their website. They will probably have a link
telling you how to set up the alerting service.
Unfortunately, unless you subscribe to the
journal itself, you usually won't be able to get
the full article on-line, but at least you can see
whether it would interest you enough to ask
your friendly librarian to get it for you.
d. Get 'Athens' access. Your Trust library
may be able to give you a password allowing
you free access to a range of databases which
house journal abstracts. You can log in to the
Athens website ( from
any computer, which means that if you have
internet access in your clinic or at home, you
don't even need to leave your desk to search
for articles. The databases available to Health
Service workers through Athens include
Medline, CINAHL, AMED, EMBAsE, Psyclnfo,
British Nursing Index and NeLH (see glossary).
You may need some training in literature
searching to get the best out of the databases.
cases with colleagues, and using information from articles in e. Read the Royal College of Speech & Language Therapists' publica
professional magazines. tions. Some of the leg-work has been done for you, with a new set of
Evidence ga,thered from clients and / or their carers - either in your own Clinical Guidelines about to be publ ished. Clinical guidelines should be
practice or from studies and articles published by other people. based on the best evidence available. The Royal College uses evidence
Evidence passed on by role models / experts This usually means panels from research as well as consensus from expert panels.
with expert opinions. The Royal College of Speech & Language Therapists'
Clinical Guidelines by Consensus fall into this category. 3. Appraising the evidence
A couple of brief tips on appraising research evidence:
2. Accessing the evidence Set up a journal club, or bring case-relevant articles to discuss at your
This depends on the type of evidence you want to access. Some of it will be supervision sessions if you have them; two or more heads are usually
readily available to you in your everyday work, but the research evidence better than one.
may need some more digging out. There are ways and means, however... All Trusts should now have an R&D (Research & Development) strategy,
a. Get your manager to take out an institutional subscription to the and many will have a research facilitator in post. This person should be ~
ISSN (online) 2045-6174
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~ able to guide you to courses such as CASP (Critical Appraisal Skills
Programme). Alternatively, your Trust should be part of a regional
Primary Care Research Network (PCRN), who may offer free courses. may be able to link you to your regional
Pr imary Care Research Network.
4. Core skills and attitudes
A questioning attitude to existing knowledge and accepted practices
A need to be aware that what we believe to be true mayor may not
reflect what the evidence is telling us
A recognition that we all have gaps in our knowledge
A realisation that there isn't an evidence base for much of what we do.
Lastly, a very useful thing to have is a manager who recognises the
value of evidence-based practice and allows you the time to find things
out. So start writing those questions down ...
Ie May, A. (1999) Evidence-based practice. Nursing Times Clinical
Monographs, 1. Emap Healthcare Ltd.
Muir Gray, J. (1997) Evidence-based healthcare: How to make health pol
icy and management decisions. Edinburgh: Churchill Livingstone.
Royal College of Speech & Language Therapists (1998) Clinical Guidelines
for Speech and Language Therapists by Consensus. RCSLT, London.
Royal College of Speech & Language Therapists (1996) Communicating Quality
2- Professional Standards for Speech and Language Therapists. RCSLT, London.
Biomedical Research Indexing, do Christopher Norris, Downe, Baldersby,
Thirsk, North Yorks, Y07 4PP, tel: 01765 640283, fax: 01765 640556.
Annual rates: CD - Institution 90, individual 70; Printed - Institution
72, individual 50.
Abstract - a summary of the main points of the article
CINAHL - Cumulative Index to Nursing and Allied Health
AMED - Allied and Complementary Medicine
EMBASE - Excerpta Medica
NeLH - National Electronic Library for Health
Researchers at the Speech and Language Therapy
Research Unit pause amongst the protocols to
reflect on their research. All practising clinicians in
a previous or parallel life, what impact has their
resea rch had on thei r approach to practice?
: ~ ; ~ ; : ; ; ~ i ~ ~ : ; ; ~ ~ : ; Weighing the arguments
controlled trial of preschool children in the community and patient will gradually internalise the strategy, relying less on external
now leads the project to follow up those children. As part of her PhD she
carried out a series of in-depth interviews with parents:
What I learned from my qualitative interview study with the parents of
speech / language delayed children would profoundly affect my work
with this client group. I would aim to address three areas of major concern
for parents - the first appointment, their information needs and negotia
tion of treatment. Having your child referred to speech and language
therapy is a 'big deal' to parents. For that reason, the initial appointment
would be with parents alone. This would give them the chance to tell me
about their child and the difficulties and ask questions without worrying
about how their child is coping in an unfamiliar setting. Wherever possi
ble I would see the child at home. I would explain the child's difficulties to
the parents as far as these difficulties are explicable, guiding them
towards information resources available to them. If I would see the child
for therapy, I would find out what role parents could take on and clearly
spell out what I would ask them to do. I would discuss with parents the
form therapy could take, practicalities of the arrangement and difficulties
they might have. From what I heard in the interviews, I believe this
approach in the early stages could reassure, truly inform and motivate
parents as they embark on the therapy process with their children.
Corinne Dobinson is developing software for people with dysarthria
to support independent practice:
/t was important that the software provided maximum potential for
transfer and generalisation of the strategies to change speaking rate
and improve intelligibility. In my literature search I discovered motor
learning principles relating to short and long-term learning, transfer
and generalisation.
These prinCiples would influence my use of feedback in clinical practice.
While instrumentation and verbal feedback in the speech and language
therapy clinic provide useful information, there is a potential for feed
back overkill. Frequent feedback is likely to be more helpful in the early
stages of motor learning. By providing increasingly less feedback the
feedback from the therapist or instrumentation.
In speech and language therapy we appreciate the importance of self
monitoring in developing this internalisation, but the literature suggests
that the focus of self-monitoring should be different at earlier and later
stages. In the early stages of self-monitoring it is beneficial to focus on the
process of the strategy. This might be the method used to reduce speak
ing rate. When the process becomes more natural to the speaker, then the
focus should shift to an outcome goal. This might be a specified speaking
rate or level of intelligibility. These principles help us to clarify the appro
priate use of feedback and self-monitoring in motor speech therapy.
Yvonne Wren is investigating the use of computer software as a therapy
tool in the school context for children with phonological difficulties:
In a recent study, I worked in partnership with several primary schools.
The schools were approached because they had a pupil with a phono
logical impairment. All schools were initially keen to participate as they
were told they had a two in three chance of th is child receiving eight
weekly sessions of therapy in school. However, they were also told that in
order to participate they would need to provide someone (teacher, assis
tant or volunteer) who could work with the child for three 30 minute ses
sions per week. At this point, all schools took a sharp intake of breath'
In my previous role working as a speech and language therapist in a cluster
of mainstream primary schools, I endeavoured to get assistant support
to back up work I was carrying out with a child. Generally this was
agreed to but, in all too many instances, this support tailed off as the
weeks went by. The Christmas play, swimming trips and preparing dis
plays were all given priority over the speech and language therapy work.
In the research study however, after schools had regained their breath,
we discussed the ways in which they would benefit, such as assistants
and teachers gaining new ideas of how to work with children with
phonological impairments while waiting for speech and language ther
apy advice. We also highlighted the benefit to the child - that there
would be someone, possibly in their classroom, who could highlight
ISSN (online) 2045-6174
how I
therapy targets throughout the school day. Provided we tried to fit with
their needs regarding days and times to visit and were flexible about
who worked with the child, almost all schools agreed to commit some
one to work on the project, Moreover, the assistants were committed to
the three sessions per week throughout the whole eight week period
and their comments at the end of the study were positive with regard to
the skills they had acquired and the importance of their role in helping
the child move on with their speech,
In my future practice, I would be more intent on requesting a commit
ment from schools to contribute to the child's speech and language ther
apy support. Heads and Special Educational Needs Coordinators may
consider this impossible at first but it can be done in most circumstances
and the benefits to the child are worth the effort,
Rosemarie Hayhow is studying the process and outcomes of the
Lidcombe program with children who stutter:
The evaluation of a specific therapy approach requires that the therapy
is used according to a protocol whether within a single site or across
sites, Similarly, if we are to refer to an evidence base to support our
choice of therapy then we must administer that therapy in the same way
as the researchers so that their results are applicable to our work, That
sounds straightforward but in practice it is hard to do, There are all sorts
of events that conspire to make it difficult to comply with pre-deter
mined time schedules, therapy progressions, record keeping and so on,
There is also being a speech and language therapist, We are a creative
bunch, we like to be flexible and able to respond to a client's expressed
needs, For some therapists, years of working with ill-conceived pro
grammes, poor equipment and minimal theoretical support have led to
the development of a pragmatic and eclectic approach, We are not tech
nicians but thinking, feeling and interacting practitioners, Researching a
specific therapy programme has highlighted for me the extent of the
conflict, for myself and others, between being a creative practitioner
and a systematic, protocol-directed administrator of a treatment. To
complicate things further, these are not mutually exclusive positions,
Therapy may work best when the essential components are rigorously
adhered to but presented in a manner that is adapted to best suit indi
vidual clients, Creative problem solving within the framework of the
therapy may be needed to deal with the inevitable difficulties that arise
when specific strategies or actions are integrated into diverse lives, And
so this brings us back full circle to the importance of knowing which
components of a treatment are essential,
Julia Wade is investigating the use of Automatic Speech Recognition
software with people with aphasia:
I recently had the task of carrying out in-depth interviews to determine
what recipients of computer-based therapy thought of the therapy
received, Training in conducting these interviews gave me the following
knowing how to ask genuinely open questions and avoid putting
words in people's mouths
being aware of my professional 'baggage' or framework and learning to put
this to one side in an attempt to encourage the person to communicate
what matters to them rather than what I believe matters to me,
I carried out 11 interviews, six with people with aphasia and five with
their carers, The experience was a revelation! Despite having been a
therapist for eight years, and having had people with aphasia on my
caseload throughout this time, I had never had (or never created?) the
opportunity to listen to a series of personal accounts of what it was to
live with aphasia and receive therapy. I suddenly wished this experience
had happened years ago, Ialso felt embarrassed at the thought that, by
failing to set aside enough time when first meeting a client to listen to
what they had to say (instead of frantically assessing their communication
skills), I had no doubt at times suggested inappropriate therapy goals,
The effect has been to change the way I go about taking a case history
entirely. I now go prepared with what I think of as my 'blank sheet'
mindset and ask the person to tell me about themselves and their apha
sia, and perhaps what they might be expecting or hoping for, from me
specifically or from therapy in general, This way, I get their story much
more efficiently than if I went through all the detail of a case history
form, More importantly, I get what matters to them.
Sue Roulstone is the Co-Director of the Research Unit:
Reading my colleagues' contributions, I was struck by the similarities and
how they parallel my own experience, The process of setting up research
projects has taught me to pay attention to detail and to be explicit
about my rationale, expectations, decisions and outcomes, I've seen the
benefits of that in my relationships with research participants, Listening
to participants (therapists, parents and patients) talk about their experiences
of therapy, I am also clear that their rationale, expectations, decisions
and outcomes are often miles away from mine, By surfacing and exploring
our different perspectives we stand much more chance of establishing a
working partnership and achieving goals together, D
Susie Parr and Carole Pound from the London Connect Centre
are at the forefront of aphasia research. Avril Nicoll caught up
with them at an Aberdeen study day on improving services for
people with severe aphasia. She contemplates the opportunities
we all have to put their research into practice, whatever our
client group.
hat is the reality of aphasia
in the UK? Students learn
Setti ng you rself free
that it is an acquired lan
guage impairment which
can t a k ~ different forms depending on the area of the brain that has that enables them to draw on their resilience and resourcefulness, to
been affected, Services focus scarce resources on the acute period and, have control, to take advantage of new opportunities and choices, and
occasionally, on short episodes of rehabilitation, usually based in a hos celebrate their successes?
pital. Whether informal or formal, assessment involves asking bewil Looking through the eyes of the person with aphasia is a useful place
dered people to do bizarre things with everyday objects, to start to redefine it in a meaningful way: long-term bewilderment, iso
Frustration, guilt, exasperation, panic and inadequacy are just some of lation, frustration, 1055 of confidence, self-respect, self-esteem and moti
the strong emotions experienced by therapists working with people vation, 1055 of roles and responsibilities, 1055 of the tools and opportuni
with severe aphasia, We have the best understanding among health pro ties for choices and 1055 of control - in short, social exclusion,
fessionals of what aphasia is and how it impacts on everyday life, 50 how
do we make the changes in our practice that will make us more effective 'Do you want soup, Brenda?' asks the nurse, 'NO' she says very firmly and
and fulfilled in our work? How do we begin to support people in a way places her hand over her mat. She makes her face express disgust. Her ~
ISSN (online) 2045-6174
everything this takes practice, writing a direct, user-friendly report to
clients or parents is a relatively simple way of modelling good practice,
putting the client in a position of control, ensuring that we understand
each other, and reducing jargonistic reports that are difficult for other
professionals to understand.
Recognising that not everyone can come to Connect, staff have been
exploring alternatives for isolated people with aphasia who no longer
want or need speech and language therapy. The Conversation Partner
Outreach Scheme volunteers are not there to be speech and language
therapists or friends, but to be a conversation partner. Disability, equali
ty, health and safety and communication partner training is provided.
Volunteers are encouraged to make use of The Aphasia Handbook to
help the person with aphasia find answers to their questions or sources
of further information and support. The volunteers have ongoing super
vision in the form of weekly feedback sheets, one-to-one meetings and
six-weekly support meetings or follow-up training. They are encouraged
to problem-solve: what other communication ramps could you make use
of? what could you do when you get stuck? They visit for six months
once a week for an hour and there is an option to negotiate a second six
month period either with the same or a different volunteer. Having had
variable success with volunteer schemes in the past I can see that, to be
successful, there has to be a very clear role and significant investment of
time in ongoing training and support.
You don't need a full-scale research project to look at change in your
own work environment. To set yourself free, Carole and Susie suggest
you ask yourselves:
What do I currently offer?
What options am I happy with?
What would I like to offer?
What two things could I do to extend opportunities for clients?
What challenges do I predict I might face')
What practical tasks will I need to undertake to carry the project
Parr, S. (in press) What happens to people with severe aphasia? Joseph
Rowntree Foundation.
Practical points: putting
research into practice
1 . Listen to and work from the client's
2. Observe your client in different settings
3. Note down questions as they occur
to you
4. Ensure commitment before you start
5. Bounce ideas off a colleague
6. Re-think your initial interview
7. Improve your negotiation skills
8. Know where to find research evidence
9. Write reports for clients (or their
10. Consider volunteer schemes
~ purse and a glasses case are lying by her mat. The nurse gives some soup
to the woman on Brenda's left, who lifts it from her mat and places it in
the centre of the table. It is getting very hot. The windows are closed
and there is a smell of urine. Brenda looks at me then makes the same
disgusted face, then smiles. Today's menu is written on the white-board
by the door. This is chicken soup. I see a nurse at another table where
three women are sitting, pouring the soup from the plastic cups into
ceramic bowls for them. This doesn't happen for anyone else in the
room. The soup doesn't look or smell very appetising. It smells like a
packet mix. Its appearance is not helped by the plastic cups, pretty much
the same colour as the contents.
Artefact: The leaflet on the care home says: 'Comfort and service ... excellen t
catering and a wide menu choice provided by a qualified chef using
in-house facilities and fresh produce ... '
In research funded by the Joseph Rowntree foundation, Susie Parr doc
umented and tracked the social inclusion and exclusion of Brenda and 19
other people with severe aphasia. The ethnographic study included
three sessions with each person in different settings such as the pub,
swimming pool, a stroke club, therapy, home and shops. Susie made
detailed field and reflective notes, and told it like it was - sights, sounds
and smells. She says that ethnography has the potential to open your
eyes to what's around in everyday settings, to reveal the detail, subtlety
and dynamism of communication, and to suggest relevant interventions.
While we cannot all engage in full-scale research, we can use this kind
of observation with clients of all ages and communication difficulties to
think out of the box and identify possible changes.
Susie found that people with severe aphasia enter many different set
tings and encounter many different people for many years after the
stroke - and after rehabilitation. Exclusion happens everywhere, all the
time. Social exclusion - or inclusion - is evident in communication, access
to opportunity and choice, involvement, the environment, and respect
and acknowledgement, all interacting and influencing each other.
Therapy is not just about supporting change in communication skills, it
is about creating the conditions for participation and inclusion: attend
ing to context, listening to people's stories, reflecting on the social
dynamics of service delivery and developing new opportunities to par
ticipate in health care and life. At Connect, this approach has influenced
everything from the design of the building - free from pictures of the
brain, and with a cafe at its hub - to the way assessment, goal setting
and report writing is done.
Two hours is allowed for the initial interview with two members of
staff either at the Centre or at home, including one-to-one time with
both the client and their partner. This has been identified as both cost
and time effective and is a similar set-up to other specialist services, for
example for young people who stammer attending the Michael Palin
Centre. Although some participants felt they couldn't re-allocate their
time in this way, I was interested because of my experience when inter
viewing people with severe aphasia for the Winter 2001 issue. I had
expected them to last about an hour apiece but, taking my lead from the
interviewees, all four took two hours each.
Perspectives and lives
All Connect staff receive the same training in basic communication skills.
Interviewers need to try to understand the perspectives and lives of peo
ple they meet, and to listen carefully. They have to be skilful in eliciting
and probing ideas through drawing, key words and pictures. This record
of the discussion is kept as a reference and basis for negotiation of goal
setting - a useful tool for any client group. The two interviewers try to
hear what is important for the person with aphasia and their partner,
get an idea of the impact of stroke and aphasia and of their expectations
and aspirations, and start presenting service options. Tea I coffee is
offered, no formal assessment is used and the interview is conversation
At the end, a letter is written to the person with aphasia covering the
content of the discussions and the decisions reached. This is copied with
permission to the GP and other interested parties. Although as with
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