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INT. J. LANG. COMM. DIS.

, JULY AUGUST
VOL.

2010,

45, NO. 4, 510521

Research Report
Knowledge and attitudes of allied health professional students regarding
the stroke rehabilitation team and the role of the Speech and
Language Therapist
Aine Byrne and Catharine M. Pettigrew
Department of Speech and Hearing Sciences, University College Cork, Cork, Ireland
(Received April 2009; accepted July 2009)

Abstract
Background: One of the major barriers to effective team working among healthcare professionals is a lack of
knowledge of each others roles. The importance of understanding Irish healthcare students attitudes towards team
working and each others roles led to the development of this study.
Aims: The aims were to investigate allied health professional students perceptions and experiences of the stroke
rehabilitation team and the role of the Speech and Language Therapist (SLT).
Methods & Procedures: A survey first developed by Felsher and Ross (1994) and further developed by Insalaco et al. (2007)
was adapted to the Irish healthcare setting. The survey was administered to final-year Occupational Therapy (n 23),
Speech and Language Therapy (21) students and Physiotherapy (20) students (64 in total) (a 98.5% response rate).
Outcomes & Results: Results indicate that students had a good understanding of teamwork in the healthcare setting and
the possible benefits and challenges it presents. Students had a strong appreciation for interprofessional collaboration,
with the majority (79%) choosing shared leadership as their preferred option for the stroke rehabilitation team. Further
to this, the team approaches that students felt were most appropriate for the stroke rehabilitation setting were the more
collaborative approaches of interdisciplinary (43.5%) and transdisciplinary (37.1%). The students had clear perceptions
of the SLTs role in aphasia, dysphagia, dysarthria, apraxia and auditory agnosia, but were less knowledgeable of the SLTs
role in the acquired disorders of alexia and agraphia ( p , 0.05). More than half of all students perceived that the SLT is
involved in the treatment of hemispatial neglect (55.5%), depression (71.5%) and visual agnosia (59.4%).
Conclusions & Implications: The results provide valuable information for further developments in interprofessional
education at an undergraduate level. Further opportunities should be provided to students to collaborate with each other,
particularly in their final year of training as, by then, students have a well-established knowledge of their own roles and
would be more capable of sharing this role with other professions. Through this collaboration students would also gain
valuable insight into the importance of teamwork, which they could take with them into their professional careers.
Keywords: allied health professions (AHPs), speech and language therapists, stroke, education.

What this paper adds


What is already known on this subject
Currently, clinical guidelines emphasize the need for team approaches to stroke rehabilitation. However, a lack of
understanding within the team of each others roles can impact negatively on the success of the team.
Interprofessional learning opportunities for allied health professional students can enhance understanding of the
roles of other team members and positively influence their ability to work effectively together.
What this study adds
The results of this study provide valuable insight into student perceptions of each others roles in the stroke
rehabilitation team, providing a firm foundation for further curricular developments in interprofessional education
at an undergraduate level, particularly in Ireland.

Address correspondence to: Catharine M. Pettigrew, Department of Speech and Hearing Sciences, University College Cork, Brookfield Health
Sciences Complex, University College Cork, College Road, Cork, Ireland; e-mail: C.Pettigrew@ucc.ie
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online q 2010 Royal College of Speech & Language Therapists
http://www.informahealthcare.com
DOI: 10.3109/13682820903222791

Student perceptions of stroke teams and the SLT


Introduction
The benefits of stroke units as effective means of stroke
care have been well documented over the past ten to 15
years (Rudd et al. 2005). Furthermore, a recent
Cochrane Review (Stroke Unit Trialists Collaboration
2007) found that patients who receive organized
inpatient care in a stroke unit are more likely to survive,
regain independence, and return home following a
stroke. Findings such as these emphasize the importance of a team approach to stroke rehabilitation thus
making it a key area of focus for the future development
of stroke care.
Boon et al. (2004) describe these team approaches
to healthcare as being on a continuum, ranging from
parallel practice to integrative or transdisciplinary care
(see appendix A). As movement occurs along this
continuum, communication between team members
increases and there is greater emphasis on the treatment
of the whole-person in his/her social and cultural
contexts (Boon et al. 2004). Therefore, team
approaches on the right side of the continuum, that
is, multidisciplinary, interdisciplinary and transdisciplinary, are considered as those which focus on more
patient-centred practice and which would, based on
the World Health Organisations (WHO) International
Classification of Functioning (ICF) (2001) framework,
evaluate outcomes based on improvements in participation and activity levels as well as body functions and
structures.
According to Insalaco et al. (2007), the most
prevalent team models in a rehabilitation unit are the
interdisciplinary and multidisciplinary approaches
(p. 197). These terms are often used interchangeably
when describing team approaches but are nevertheless
two distinct approaches. Multidisciplinary is the term
used to describe a team of professionals who
independently assess and treat individuals and who
report back to each other and collaborate when needed.
The interdisciplinary approach differs from this
approach in that team members have shared goals for
each patient and therefore are all working towards the
same outcome/outcomes. A third approach, transdisciplinary, is adopted when team members work together
during assessment and often, a single team member
carries out the group treatment plan (Insalaco et al.
2007: 197). Currently, clinical guidelines from the
National Stroke Foundation in Australia (2007)
emphasize the need for interdisciplinary approaches to
stroke rehabilitation. In contrast to this, clinical
guidelines from the American Heart Association
(Duncan et al. 2005), as well as guidelines from The
European Stroke Initiative Executive Committee and
the EUSI Writing Committee (2003), the Scottish
Intercollegiate Guidelines Network (2002), and the

511
Intercollegiate Working Party for Stroke (2004), stress
that a multidisciplinary team approach is the most
appropriate service for stroke rehabilitation.
According to Langthorne and Legg (2003), the
multidisciplinary stroke rehabilitation team consists of
medical, nursing, physiotherapy, occupational therapy
(OT), speech and language therapy (SLT), and social
work staff. Soklaridis et al. (2007) report that there is
ambiguity with regards to different health professionals
roles and responsibilities. This lack of understanding of
each others roles can impact negatively on the success
of the multidisciplinary team by creating what
Soklaridis et al. (2007) termed interprofessional
tension. Ryan and McKenna (1994) state that such
tensions are believed to contribute to work dissatisfaction and poor interprofessional communication, with
negative implications for patient care.
Hall and Weaver (2001) state that while each health
care professional learns about their role through their
professional education, when faced with working as
part of a team they have poor understanding of the
other members roles. Nisbet et al. (2008) found that a
pre-qualification interprofessional learning programme
for medical, nursing, and allied health professional
students resulted in enhanced understanding of the
roles of other team members and positively influenced
their ability to work effectively together. The need for
such education was first highlighted by Felsher and
Ross (1994), and more recently in a similar study by
Insalaco et al. (2007). Both of these studies investigated
the perceptions of final year OT, SLT and physiotherapy (PT) students towards stroke rehabilitation teams
and the SLTs role. The results of these studies
suggested that students had a fairly good understanding
of the concepts of rehabilitation and teamwork, but a
lack of recognition/understanding of team members
knowledge and training. Insalaco et al. (2007) advised
that students need further knowledge about the
specialities of the other professionals that they will be
working with. Such knowledge of students attitudes
towards each others disciplines is vital to ensure that
stereotypes and role confusion do not exist as students
enter their professional careers. Furthermore, knowledge surrounding students ideas and perceptions of
teamwork in the rehabilitation setting is especially
useful as it is so well documented that teamwork is an
integral part of health care services (for example,
Strasser et al. 2008).
The importance of understanding students attitudes towards teamwork and knowledge of each others
roles has led to the development of the current study.
Furthermore, despite the widely acknowledged view
that coordinated, team-based stroke care can result in
patients being more likely to survive and regain
independence, multidisciplinary team provision for

Aine Byrne and Catharine M. Pettigrew

512
stroke patients in Ireland is of a limited and usually
non-specialist nature (Irish Heart Foundation 2008).
The aim of this study was therefore to adapt Insalaco
et al.s (2007) study to the Irish population,
investigating the knowledge and attitudes of final year
allied health professional students towards teamwork in
the rehabilitation setting and specifically, the perception of the SLTs role in this team. Such research has yet
to be undertaken in this country, and thus the results of
this study provide valuable information for further
developments in interprofessional education at the
undergraduate level.
Methods
Subjects
Twenty-one final-year students from the Speech and
Language Therapy course and 23 final-year students
from the Occupational Therapy course at University
College, Cork, were recruited as well as 20 final-year
students from the Physiotherapy course at University of
Limerick. Both the OT and SLT students had
experienced interdisciplinary coursework with each
other over the duration of their undergraduate course,
and similarly, the PT students experienced shared
coursework with OT students at their institution
(University of Limerick). In addition to this, each
participating OT and SLT student had participated in
an interprofessional education workshop with medical
students as part of their third year modules at
University College, Cork. Ethical approval for this
study was granted from the Clinical Research Ethics
Committee of the Cork Teaching Hospitals.
Survey
The survey used in this study was adapted from Insalaco
et al.s (2007) survey, with permission obtained from
the authors and Elsevier, Inc. publishing. This survey
was originally developed using part of a survey
completed by Felsher and Ross (1994), which
investigated the perceptions of PT, OT, and SLT
students on the role of the SLT in stroke rehabilitation
in South Africa.
The survey in this study consisted of three sections.
Section A related to the students previous experiences
of stroke rehabilitation teams and interprofessional
collaboration. Section B focused on which approach to
teamwork the students consider the most appropriate
for stroke rehabilitation teams and the possible
advantages/disadvantages of working in such a team.
This section also presented the students with a case
study of a patient in order to investigate their opinions
on team leadership. Finally, Section C investigated the

students perceptions of what the SLTs role is in stroke


rehabilitation.
Some modifications were made to the survey
completed by Insalaco et al. (2007). These included
small changes such as using the terms speech and
language therapist and physiotherapist instead of
speech and language pathologist and physical
therapist, respectively. The word check was also
replaced with tick in order to reflect Irish English
rather than American English. The other, more
significant changes that were made included the
addition of two further questions to Section A, focusing
on students previous experiences of teamwork.
Definitions of the team approaches in Section B were
also expanded slightly to provide further clarification of
the differences between these teams. Another change
made was the omission of Section C of Insalaco et al.s
(2007) survey, as this section was included in a different
study completed by Insalaco et al. and did not,
therefore, correspond to the aims of this particular
study. As a result of this, Section D of Insalaco et al.s
study became Section C of this study. The final change
made was the expansion of the three-point scale
anchored with agree, undecided and disagree to a
five-point Likert scale which included strongly agree,
agree, undecided, disagree and strongly disagree.
This reverted back to the original scale used by
Felsher and Ross (1994) and was made in order to
improve test retest reliability, as recommended by
Insalaco et al. (2007).
Procedure
In coordination with the appropriate Year Heads at
each College, the surveys were distributed to each of the
three groups by the investigator during a lecture period.
Permission was obtained from their module coordinators and heads of department prior to conducting
surveys and appropriate times for distribution of
surveys were agreed upon. Information sheets were
emailed to all students before the agreed date for
completion of surveys. Consent forms were distributed
in person to the participants prior to distributing
surveys. Students were then asked to answer the surveys
independently. When finished, surveys were collected
by the investigator.
Data analysis
The survey responses were collated and entered into
SPSS software (Version 15.0) for analysis. Descriptive
statistical analyses were carried out initially to
summarize the data effectively and facilitate data
interpretation. Further, inferential statistical analyses
of the data included the non-parametric measures

Student perceptions of stroke teams and the SLT


of Kruskal Wallis one-way analysis of variance
(ANOVA), to compare group means across variables.
Any significant results found through the completion of
Kruskal Wallis ANOVA were further analysed using
post-hoc tests (Mann Whitney U-test) with Bonferroni
adjustment, in order to determine which data sets
differed from each other (SLT versus OT, PT versus
OT, or PT versus SLT). In addition to Kruskal Wallis
ANOVAs, simple Chi-square (x 2)-test was used to
investigate possible associations between variables.
Non-parametric measures were used as the data
consisted mainly of nominal and ordinal scales.
Responses to the comments/opinions sections of
the survey questions were collated and transcribed.
A qualitative descriptive approach was used to provide
analysis of the responses. According to Sandelowski
(2000) qualitative description is the method of choice
when straight descriptions of phenomena are desired
(p. 339). Content analysis of the data was undertaken
through the systematic application of codes. This
involved reading the responses and underlining relevant
phrases. These relevant phrases or codes were then
further analysed and themes were generated based on
the codes that most commonly occurred throughout the
data. Finally, examples of each theme were identified
and illustrated in table form.
Results
There was a 98.5% response rate (64/65) to the surveys.
Of the 64 surveys completed, 23 were from OT
students, 21 from SLT students and 20 from PT
students.
Section A: Biographical data
While 100% of SLT and PT students reported having
experience of working with stroke patients, this was true
for only 82.6% (19/23) of OT students. Related to this,
69.6% (16/23) of OT students had worked with stroke
patients with communication difficulties, compared to
85.0% (17/20) of PT students. On the other hand,
100% (21/21) of SLT students had experience of
working with stroke patients with physical impairments. All three student groups reported high levels of
contact with other professionals during their clinical
placements, with 85.7% (18/21) of SLT students
reporting contact with PTs or OTs and 87% (20/23)
and 95% (19/20) of OT and PT students reporting
contact with SLTs, respectively.
Section B: Teamwork
All students across the three groups had previous
clinical experience of working as part of a team. While

513
a high percentage of students in all three groups had
experience of a multidisciplinary team (MDT)
(SLT 95.2%, OT 100%, PT 95%), less experience was reported of interdisciplinary teams (IDT)
(SLTs 28.6%, OTs 40.9%, PTs 45%). Of the
three approaches, students reported the least experience
of transdisciplinary teams (TDT) (SLT 9.5%,
OT 4.5%, PT 45%). Further to this, Chi-square
analysis revealed a significant association between
student group (PT versus non-PT) and experience of
TDTs (x 2(1, n 64) 12.799, p , 0.01).
When asked which team approach the students
considered to be most appropriate for stroke
rehabilitation, a Kruskal Wallis ANOVA revealed no
significant differences between the students responses
(as a whole group) to the three types of teams (IDT,
MDT, TDT) ( p . 0.05). Overall, IDT appeared to be
the most popular choice with 43.5%, followed by TDT
with 37.1% and MDT with 19.4%. When analysed
by profession, however, there were mixed results.
For example, Chi-square analysis revealed a significant
association between student group (SLT versus nonSLT) and chosen team approach (IDT versus nonIDT), such that SLTs tended to choose IDT more than
MDT or TDT (x 2(1, n 21) 6.000, p 0.05).
In contrast to this, OT students chose TDT more than
IDT or MDT, also resulting in a significant association
(x 2(1, n 22) 5.063, p , 0.05). Responses within
the PT group were more evenly spread across the three
types of team approaches (MDT 26.3%,
IDT 36.8%, TDT 36.8%) ( p . 0.05).
Chi-square analysis was conducted to determine if
there was an association between students previous
experiences of teamwork and their preferred team for
stroke rehabilitation. The results indicated a significant
association between students who had experience of
IDTs, who then chose IDT as their preferred approach
(x 2(1, n 63) 12.390, p , 0.01). There was no
association between students having experience of TDT
or MDTs and then choosing them as their preferred
approaches ( p . 0.05).
Qualitative analysis of the comments provided by
some students regarding the most appropriate team
approach identified a number of common themes
(Table 1). The first of these was the opinion of some
students that TDTs are difficult to establish. Some
students felt that because of this, IDT would be better
suited to stroke rehabilitation, but others were of the
opinion that teams should persevere and undergo
training that would allow TDTs to work properly.
Another common theme identified was patient-centred
teams, with students reporting that IDT and TDTs
appear to be more patient-centred and therefore allow a
more holistic approach to patient care. In contrast to
this, another theme identified was professional skills,

Aine Byrne and Catharine M. Pettigrew

514
Table 1.

Themes identified in comments to question on preferred team approach for stroke rehabilitation

Theme identified

Illustrations of theme

TDTs are difficult to establish

I feel a TDT approach is the ideal one, however it is often an unrealistic goal . . . (SLT student 8)
TDT is not easy to achieveoften difficulties with sharing roles . . . (OT student 8)
it is more patient centred if team members can share assessment etc (PT student 6)
TDT is the most client centred and allows for others to understand OT/PT/SLT role, refer
appropriately and view the client holistically (OT student 13)
[MDT] better because each member actually sees assesses and treats the pts [patients] and reports back
accordingly (PT student 3)
IDT may be more applicable than TDT as specialist ax (assessment) of skills may still need to be applied
by that professional (OT student 14)
the more communication and sharing of ideas within a team the better for the patient (PT student 9)
With IDT I feel that there would be more communication in the team and clients goals would be more
widely known and adhered to (SLT student 20)

Patient-centred teams

Professional skills

Communication

with a number of students reporting that it is necessary


for each profession to work directly with the patient as
the patient is in need of each professions specialist
skills. These comments were made with specific
reference to TDTs and how some students felt that
they were highly unsuitable to stroke rehabilitation.
The final theme identified was communication, which
students recognized as being a key component of
teamwork, regardless of the team approach. Theoretical
coding identified these themes as being under the code
family of management. This incorporates the establishment of patient centred teams, with good
communication and an appreciation for each members
professional skills, all of which students indicated as
being important for team approaches.
Advantages of teamwork
There was high agreement across all student groups that
the advantages of teamwork include that (1) it is an
experience in participatory learning (90.6%,
n 58/64), (2) it provides a focus on goals that
enables necessary direction for mutual efforts (93.8%,
n 60/64), (3) it is a holistic approach to team
management (96.8%, 61/64), and (4) it provides an
opportunity for exchange of ideas from different frames
of reference (100% n 64/64) (Table 2). However, a
Kruskal Wallis ANOVA found a significant difference
between groups in their perception of the advantage
Table 2.

of an overlap of services performed by more than one


team member (x 2(2, n 64) 6.244, p , 0.05).
Post-hoc analyses (with Bonferroni adjustment) revealed
that it was SLT students who indicated a higher
agreement than PT students in relation to this
advantage (U 124, p , 0.05).
Two common themes were identified in the
responses to the comments section. These were
communication and guidelines/management. Most
students (60%, n 9/15) who provided comments felt
that the advantages of teamwork would not be seen if
there was not good communication between team
members. Further to this, some students reported that
team guidelines or team training would be necessary in
order for advantages to be seen. These themes were
again grouped under the code family of management,
which indicates the need for well-established management practices and interaction between team members
for the advantages of teamwork to be realized.
Disadvantages of teamwork
Kruskal Wallis ANOVA found no significant differences between professional groups in students opinions
of the perceived disadvantages of teamwork
( p . 0.05). Altogether nearly 80% (50/64) of students
agreed or strongly agreed that communication
problems are a possible disadvantage of teamwork.
Over 60% of students identified problems with role

Perceived advantages of teamwork

Possible advantages of teamwork


Teamwork provides an opportunity for the exchange of ideas from different
frames of reference
Teamwork is a holistic approach to team management
There is a focus on goals that provide necessary direction for mutual efforts
Teamwork is an experience in participatory learning
There is an overlap of services performed by more than one team member

Strongly agree or
agree, n (%)
64 (100.0%)
61
60
58
43

(96.8%)
(93.8%)
(90.6%)
(67.2%)

Undecided,
n (%)
0
2 (3.2%)
3 (4.7%)
6 (9.4%)
12 (18.8%)

Disagree or
strongly disagree, n (%)
0
0
1 (1.6%)
0
19 (14.0%)

Student perceptions of stroke teams and the SLT

515

definition, lack of knowledge of roles, time-consuming


meetings and lack of cooperation between members.
Less than half of all students agreed or strongly agreed
that dispute for leadership and professional jealousy are
possible disadvantages (Table 3).
Themes identified in the comments provided
regarding disadvantages to teamwork included structure and role confusion. Many students reported that
as long as a clear team structure was in place, with
consistent guidelines and a strong leader or chairperson
in place, these possible disadvantages can be overcome.
A number of students left comments in relation to
problems of role definition and lack of knowledge of
roles, reporting that it is harder for new professions to
establish themselves within a team setting if there is a
lack of knowledge about what they do, thus
emphasizing a need for team training. The code family
of management was also applied during theoretical
coding of these themes, with students recognizing that
clear management structures are needed within teams in
order to overcome difficulties such as role confusion.
Team leadership
When presented with a hypothetical case study, the
majority of students reported shared leadership as being
the most appropriate option for the patient
(SLT 73.7%, OT 87%, PT 75%), with the
second choice being the doctor (SLT 15.8%,
OT 8.7%, PT 15%) (Figure 1). None of the
students chose the OT, the social worker or the family
as the sole leader of the team. OT students differed
from the other student groups with regard to which
professions should be included in the shared leadership
role. Chi-square analysis revealed a significant association between student group (OT versus non-OT) and
the inclusion of the OT in the shared leadership role
(x 2(1, n 61) 9.856, p , 0.01), such that OT
students tended to include themselves in the shared
leadership role more than the other professions.
Similarly, there was a significant association between
student group (OT versus non-OT) and the inclusion
of the family in the shared leadership role (x 2(1,
n 61) 8.900, p , 0.01), such that OT students
Table 3.
Possible disadvantages of teamwork
Communication problems
Problems of role definition
Lack of knowledge of roles
Time-consuming meeting
Lack of cooperation between members
Professional jealousy
Dispute for leadership of team

tended to include family in the shared leadership role


more than the other professions.
When asked to give reasons for their choice of
leader, the majority of students (62%, 35/62) listed the
patients impairments and the corresponding professional needed in order to treat each impairment.
Further to this, 18% (11/62) of students indicated a
preference for equality within teams, with all members
having equal input. The concept of taking a holistic
view of the patient was evident in the students written
responses, with a number of students (28% 17/62)
recognizing the need for a patient to be both medically
and emotionally stable in order to increase motivation
for rehabilitation. While the majority of students
assigned the shared leadership role according to the
patients presenting impairments, some reported that it
is not feasible to have shared leadership as it is
confusing and it would be better to have one clear
leader.
Section C: Role of the Speech and Language
Therapist
In this section, students were asked to state whether
they strongly agreed, agreed, disagreed, strongly
disagreed, or were undecided about whether the SLT
has a role to play in the treatment of a number of
different impairments. Almost all students strongly
agreed or agreed that the SLT has a role to play in the
treatment of aphasia, dysphagia, dysarthria, apraxia of
speech, and auditory agnosia (Table 4). A high
percentage of students also agreed that the SLT has a
role to play in the treatment of alexia, agraphia,
amnesia, and depression. Furthermore, more than half
of all students perceive that the SLT is involved in the
treatment of hemispatial neglect and visual agnosia.
Between group analysis (Kruskal Wallis ANOVA)
revealed significant differences in the opinions of
student groups regarding the treatment of agraphia
(x 2(2, n 63) 11.755, p , 0.01), alexia (x 2(2,
n 63) 11.390, p , 0.01) and hemispatial neglect
(x 2(2, n 63) 10.838, p , 0.01). Post-hoc analyses
(with Bonferroni adjustment) revealed that it was SLT
students who indicated a higher agreement than OT

Perceived disadvantages of teamwork

Strongly agree or agree, n (%)


50
46
43
42
39
24
24

(78.2%)
(71.8%)
(67.2%)
(65.7%)
(61.0%)
(38.1%)
(37.5%)

Undecided, n (%)
4
7
5
6
11
9
15

(6.3%)
(10.9%)
(7.8%)
(9.4%)
(17.2%)
(14.3%)
(23.4%)

Disagree or strongly disagree, n (%)


10 (15.6%)
11 (17.2%)
16 (25.1%)
16 (25.0%)
14 (21.9%)
30 (47.6%)
25 (39.1%)

Aine Byrne and Catharine M. Pettigrew

516
50

40

30

20

10

0
Shared

Figure 1.

PT

SLT

Psych

Doc

Preferred leadership of the stroke rehabilitation team.

students in relation to the SLT having a role to play in


agraphia (U 115.5, p , 0.01), alexia (U 107.5,
p , 0.01), and hemispatial neglect (U 114.0,
p , 0.01). Similarly, it was found that SLT students
indicated a higher agreement than PT students in the
perception of the SLTs role in the treatment of these
disorders (agraphia, U 103, p , 0.01, alexia,
U 130, p , 0.05, hemispatial neglect, U 115.0,
p , 0.05). Within the SLT group, over 50% of SLT
students considered themselves as having a role to play
in the treatment of hemianopsia, hemiplegia, visual
agnosia, hemispatial neglect and depression, and a
further 28.5% (6/21) agreed or strongly agreed that
they provide treatment for proprioceptive disorders.
Discussion
The aims of this study were to investigate allied health
professional students perceptions and experiences of
the stroke rehabilitation team and the role of the SLT.

Previous experiences of teamwork and working with


stroke patients
Before investigating students opinions and knowledge
of teamwork it was necessary to determine their
previous experiences of teamwork and working with
stroke patients and how these experiences may have
influenced their current thinking on the subject.
In contrast to Insalaco et al.s (2007) study, which
found that SLT students had less experience of working
with stroke patients, this study found that it was OT
students who had the least experience out of the three
student groups. Given that OT is a key component to
stroke rehabilitation (De Wit et al. 2006), this finding
was surprising. While this finding may have been as a
result of difficulty obtaining clinical placements, as a
consequence, OT students had the least experience of
working with patients with communication difficulties.
Despite this, OT students, as well as PT and SLT
students, reported high levels of contact with other

Table 4. Role of the SLT


Impairment
Dysphagia
Dysarthria
Apraxia of speech
Aphasia
Auditory agnosia
Amnesia
Alexia
Depression
Agraphia
Visual agnosia
Hemispatial neglect
Hemiplegia
Hemianopsia
Disorder of proprioception
Dressing apraxia

Strongly agree or agree, n (%)


64
64
62
62
61
51
50
45
40
38
35
24
24
15
6

(100%)
(100%)
(98.4%)
(98.4%)
(95.3%)
(79.7%)
(79.3%)
(71.5%)
(63.4%)
(59.4%)
(55.5%)
(38.7%)
(38.7%)
(23.5%)
(9.4%)

Undecided, n (%)

1
1
3
5
6
14
9
9
10
10
13
15
15

(1.6%)
(1.6%)
(4.7%)
(7.8%)
(9.5%)
(22.2%)
(14.3%)
(14.1%)
(15.9%)
(16.1%)
(21.0%)
(23.4%)
(23.4%)

Disagree or strongly disagree, n (%)

8 (12.5%)
7 (11.1%)
4 (6.4%)
14 (22.2%)
17 (26.6%)
18 (28.6%)
28 (45.2%)
24 (40.3%)
34 (53.1%)
43 (67.2%)

Student perceptions of stroke teams and the SLT


professionals during their clinical training. This is in
stark contrast to Insalaco et al.s (2007) findings,
which found that only 23% of final year SLT
students surveyed had previous contact with other
rehabilitation professionals. These findings support
the organization of undergraduate training of these
student groups, which evidently provide students with
valued experiences in interprofessional collaboration.
This fact is further supported by students previous
experiences of teamwork, with 100% of students having
had experience of working in at least one team
structure.
Preferred team approach for stroke rehabilitation
When asked which was their preferred team approach
for stroke rehabilitation, results were surprising in that
no student group chose multidisciplinary teams (MDT)
as their preferred team approach overall, despite the fact
that this is the team approach that the majority of
students have experienced during their clinical training.
Rather, it was interdisciplinary (IDT) and transdisciplinary (TDT) approaches that were favoured by the
students. This is reflective of the strong appreciation
that students have of interprofessional collaboration, as
these team approaches are documented as being more
collaborative and more patient-centred than MDT
(Boon et al. 2004). However, there are differing
opinions in the literature about which of these
approaches is most suitable for stroke rehabilitation.
While TDT is rarely found in hospital and healthcare
settings, this approach is widely acknowledged in the
field of early intervention (Golper 2001) and students
experience of this setting may have prompted them to
choose this approach as the most suitable. Much of the
debate, therefore, surrounds MDT and IDT
approaches. As noted in the introduction, clinical
guidelines from the American Heart Association
(Duncan et al. 2005), as well as guidelines from The
European Stroke Initiative Executive Committee and
the EUSI Writing Committee (2003), the Scottish
Intercollegiate Guidelines Network (2002), and the
Intercollegiate Working Party for Stroke (2004), stress
that a MDT approach is the most appropriate service
for stroke rehabilitation, while it is only the National
Stroke Foundation in Australia (2007) who emphasize
the need for interdisciplinary approaches to stroke
rehabilitation. Furthermore, the recently published
National Audit of Stroke Care in Ireland (NASC; Irish
Heart Foundation 2008) recommends that an MDT
approach be taken with regards to stroke care in Ireland.
These contrasting views may be as a result of the terms
MDT and IDT being used interchangeably, especially
as the NASC, despite recommending that an MDT
approach is most suitable for stroke care, also states that

517
agreed rehabilitation goals (one of the fundamental
characteristics of IDTs) are considered to be one of
twelve key indicators of quality of stroke care.
Despite the confusion surrounding these terms,
clear distinctions must be made between the two team
approaches. Such a distinction was made by Cifu and
Stewart (1999) who conducted a meta-analysis of
eleven Level 1 studies of MDT versus IDT teamwork
and demonstrated that IDTs are associated with more
improved functional outcomes, decreased length of stay
and decreased costs. Moreover, IDT was the only team
approach in the current study that yielded a positive
association between students previous experience and
current opinions on their preferred team approach.
This suggests that students have had particularly
positive experiences of IDTs in practice. Hopefully, as
students enter the healthcare system, they will take these
positive experiences with them. This is especially
important in the Irish healthcare context, as, according
to the NASC (Irish Heart Foundation 2008) much
reform is needed in the coming years, and one of the
main areas of reform will be teamwork. It is reported in
the NASC (Irish Heart Foundation 2008) that while
agreed rehabilitation goals are considered to be one of
twelve key indicators of quality of stroke care, this
occurred for only 22% of Irish stroke teams.
Additionally, it was found that the majority of allied
health professionals did not meet as a team to discuss
new referrals, thus indicating that Irish stroke care
currently provides a multidisciplinary service rather
than a multidisciplinary team service (Irish Heart
Foundation 2008).
Team leadership
Further evidence of students preferences towards
interprofessional collaboration is evident in their
answers to the team leadership question, with a
significant majority choosing shared leadership as the
most appropriate option. While this is not in
accordance with the Council on Stroke of the Irish
Heart Foundation (2000), who recommends that the
physician manage the team, it is similar to the findings
of previous studies that looked at students perceptions
of teamwork, namely Insalaco et al. (2007) and Felsher
and Ross (1994). When asked to give reasons for their
choice of leadership, the majority of students who chose
shared leadership identified the perceived primary
impairments of the patient and assigned the leadership
role to the professional or professionals most qualified
to treat said impairments. This idea of situational
leadership results in no sole leader of the team, rather
the leaders are assigned depending on their level of
involvement with the patient. Nisbet et al. (2008) stress
that as all professions of the stroke rehabilitation team

Aine Byrne and Catharine M. Pettigrew

518
have individual leadership skills, this method of
situational leadership is highly recommended. Despite
this recommendation and the fact that the students in
this study favoured shared leadership, it is a practice
rarely found in the Irish healthcare setting. Further
investigation of team leadership is therefore warranted
in order to alleviate future difficulties in establishing
effective interprofessional collaboration.
Advantages and disadvantages of teamwork
As well as asking their preferred team approach and
leader, the students in this study were asked about the
perceived advantages and disadvantages of teamwork.
The students had a clear understanding of the possible
benefits of teamwork in the healthcare setting such as it
being an opportunity for learning through exchange of
ideas (Ingram and Desombre 1999). Overall, they
indicated that communication problems and problems
of role definition are the biggest possible disadvantages.
These results indicate that the students surveyed have a
very realistic view of working as part of a team,
especially as good communication is described as being
one of two main factors contributing to effective
teamwork (Golper 2001). These results are similar to
those found by Insalaco et al. (2007). Further evidence
of this realistic view of teamwork was seen in the
comments provided by some students, which described
the need for a clear team structure in order to overcome
any possible problems. Students also noted that the
problem of role definition is harder for newer
professions if there is a lack of knowledge of what
their role is.
Role of the Speech and Language Therapist
Similar to the results found by Felsher and Ross (1994)
and Insalaco et al. (2007), there was general agreement
among the students on the role of the SLT in the
treatment of disorders following stroke with which the
SLT is more commonly involved (for example, aphasia,
dysphagia, dysarthria, apraxia of speech and auditory
agnosia). There was, however, some confusion evident
among PT and OT students with regard to the
treatment of alexia and agraphia, in particular agraphia,
despite these disorders being considered primary areas
of the role of the SLT in stroke rehabilitation (Royal
College of Speech and Language Therapists 2005).
These results were also reported by Felsher and Ross
(1994). In order to ensure adequate referrals and
consistent evidence based practice, the role of the SLT
in the impairments of alexia and agraphia may need to
be more widely acknowledged by all professions
working in stroke rehabilitation.

Opinions further differed between SLT students


and PT and OT students as to the role of the SLT in the
treatment of hemispatial neglect. While this is not
typically considered as part of the role of the SLT and is
included in OT clinical guidelines (National Association of Neurological Occupational Therapists 2004),
it is recommended that all nursing activities and therapy
sessions be modified for the person with hemispatial
neglect to cue attention to the impaired side
(Intercollegiate Working Party for Stroke 2000).
A team approach to the management of this disorder
is therefore necessary to ensure consistent, effective
rehabilitation, with all professionals being aware of
their own roles and responsibilities.
It is widely documented in the literature that a
lack of understanding of other professionals roles can
seriously hamper the success of collaborative working
(Connie-Kerr et al. 1998). The problem of role
definition was also one of the key areas identified by
students in this study that can result in problems for
effective teamwork. It is encouraging to note though,
the realization of some students that problems such as
this can be overcome with adequate guidelines and/or
training. The advantages of team training is well
documented in the literature (Strasser et al. 2008)
with some authors stating that such training is
essential for teams with increased need for collaboration, that is, IDTs and TDTs (Golper 2001). The
most documented method of eliminating role
confusion, however, is through interprofessional
learning (IPL) at an undergraduate level (Hammick
et al. 2007). While most of the students who
participated in this study did have previous exposure
to IPL, the results obtained from the study indicate
that further efforts are needed to prepare students
fully for collaborative working post-qualification. The
systematic review completed by Hammick et al.
(2007) found that clinical practice settings could offer
an effective environment for undergraduate IPL.
While difficulties may be encountered in the
organization of such training due to course structures
and differing practice education settings, this is an
area that warrants investigation by healthcare faculties.
Further to this, Hammick et al. (2007) state that
authenticity and customization of IPL so that it
reflects appropriate and relevant service delivery
settings are necessary in order to provide a positive
experience for the students participating. While
Nisbet et al. (2008) recommend early integration of
IPL into curricula in order to graduate health care
professionals who are capable of working effectively
within the healthcare team environment, the results of
this study suggest that further emphasis on
collaborative working and appreciation of interprofessional roles is also required in students final year

Student perceptions of stroke teams and the SLT


of undergraduate training. At this stage of their
training, students should have a well-established
knowledge of their own role and therefore would be
better equipped to demonstrate this in practice and
also inform other professions of this role.
Conclusion
In conclusion, in order to develop stroke rehabilitation
services in this country it is vital that comprehensive
teamwork be encouraged. The results of this study are
encouraging in that the positive experiences of
interdisciplinary teamwork on clinical placements
have been reported by students from all three
disciplines. In order to maintain and further facilitate
effective teamwork in professional healthcare practice,
emphasis should be placed on team training and
opportunities for interprofessional collaboration at an
undergraduate level. Through this, students would gain
valuable insight into the importance of teamwork as
well as acquiring knowledge of the roles of other
professionals that they will be working with in their
future careers.
Some limitations of this study include the small
sample size and the limited number of responses to the
comments/opinions sections of the survey. Future
research in this area should therefore include more
participants and possibly include more qualitative
methods. Another limitation was that students may not
have initially understood the definitions of each type of
team as these were not explained until the second page
of the survey. Further clarification of the definitions of
team structures should therefore be provided in future
research of this type. Future research may also be
expanded to include students from medical, nursing,
social work or psychology courses in order to allow for
comparisons across all disciplines involved in the stroke
rehabilitation team.
Declaration of interest: The authors report no conflicts of interest.
The authors alone are responsible for the content and writing of the
paper.

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Student perceptions of stroke teams and the SLT


Appendix A: Continuum of team models (Boon et al. 2004)

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