Co-design and mixed methods evaluation of an interdisciplinary digital resource for undergraduate health profession students to improve the prevention, recognition, and management of delirium in Ireland: a study protocol.

BACKGROUND: Delirium is a common symptom of acute illness which is potentially avoidable with early recognition and intervention. Despite being a growing concern globally, delirium remains underdiagnosed and poorly reported, with limited understanding of effective delirium education for undergraduate health profession students. Digital resources could be an effective approach to improving professional knowledge of delirium, but studies utilising these with more than one profession are limited, and no evidence-based, interdisciplinary, digital delirium education resources are reported. This study aims to co-design and evaluate a digital resource for undergraduate health profession students across the island of Ireland to improve their ability to prevent, recognise, and manage delirium alongside interdisciplinary colleagues. METHODS: Utilising a logic model, three workstreams have been identified. Workstream 1 will comprise three phases: (1) a systematic review identifying the format, methods, and content of existing digital delirium education interventions for health profession students, and their effect on knowledge, self-efficacy, and behavioural change; (2) focus groups with health profession students to determine awareness and experiences of delirium care; and (3) a Delphi survey informed by findings from the systematic review, focus groups, and input from the research team and expert reference group to identify resource priorities. Workstream 2 will involve the co-design of the digital resource through workshops (n = 4) with key stakeholders, including health profession students, professionals, and individuals with lived experience of delirium. Lastly, Workstream 3 will involve a mixed methods evaluation of the digital resource. Outcomes include changes to delirium knowledge and self-efficacy towards delirium care, and health profession students experience of using the resource. DISCUSSION: Given the dearth of interdisciplinary educational resources on delirium for health profession students, a co-designed, interprofessional, digital education resource will be well-positioned to shape undergraduate delirium education. This research may enhance delirium education and the self-efficacy of future health professionals in providing delirium care, thereby improving practice and patients' experiences and outcomes. TRIAL REGISTRATION: Not applicable.

Alterations and Preservations: Practices and Perspectives of Speech-Language Pathologists Regarding the Intervention of Thickened Liquids for Swallowing Problems.

PURPOSE: The intervention of thickened liquids (TL) is commonly used to reduce aspiration in people with dysphagia. Speech-language pathologists (SLPs) have traditionally believed it is an effective intervention. Recent articles highlight limited evidence, poor acceptance, and a variety of unintended consequences. This study explores if current debates have been reflected in SLP practices and perspectives. METHOD: An e-survey was developed. Participants were recruited via professional associations in Australia, New Zealand, Ireland, the United Kingdom, and the United States. Descriptive and inferential statistics were used to explore the data. Principal component analysis was used to summarize SLP practices and perspectives. RESULTS: The 370 respondents represented mainly experienced, confident, hospital-based clinicians. While 20% of respondents frequently recommend TL, 61% believe it to be a burdensome treatment. "Best treatment" and "It works" beliefs continue to underpin decision making. Those who recommend TL most often are most influenced by penetration, coughing, and their own clinical experience. They are more likely to believe TL is evidence based and effective, reduces aspiration, and improves hydration. Person-centeredness is important among all respondents, although significant numbers would implement TL against patient wishes. Improvements in aspiration status and quality of life rank highly as reasons to discontinue TL. CONCLUSIONS: The results of this study suggest that fewer respondents are regularly using TL. Divergent groups are evident with those frequently employing and believing in the efficacy of TL and those who do not. While current debates are influencing practice, there clearly remains a significant number of SLPs continuing to recommend TL. This study's findings highlight both alterations and preservations in the discipline's approach to TL and calls for SLPs to reframe our thinking regarding this intervention as well as consider alternative options in this treatment space. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24317110.

Informed or misinformed consent and use of modified texture diets in dysphagia.

BACKGROUND: Use of modified texture diets-thickening of liquids and modifying the texture of foods-in the hope of preventing aspiration, pneumonia and choking, has become central to the current management of dysphagia. The effectiveness of this intervention has been questioned. We examine requirements for a valid informed consent process for this approach and whether the need for informed consent for this treatment is always understood or applied by practitioners. MAIN TEXT: Valid informed consent requires provision of accurate and balanced information, and that agreement is given freely by someone who knows they have a choice. Current evidence, including surveys of practitioners and patients in different settings, suggests that practice in this area is often inadequate. This may be due to patients' communication difficulties but also poor communication-and no real attempt to obtain consent-by practitioners before people are 'put on' modified texture diets. Even where discussion occurs, recommendations may be influenced by professional misconceptions about the efficacy of this treatment, which in turn may poison the well for the informed consent process. Patients cannot make appropriate decisions for themselves if the information provided is flawed and unbalanced. The voluntariness of patients' decisions is also questionable if they are told 'you must', when 'you might consider' is more appropriate. Where the decision-making capacity of patients is in question, inappropriate judgements and recommendations may be made by substitute decision makers and courts unless based on accurate information. CONCLUSION: Research is required to examine the informed consent processes in different settings, but there is ample reason to suggest that current practice in this area is suboptimal. Staff need to reflect on their current practice regarding use of modified texture diets with an awareness of the current evidence and through the 'lens' of informed consent. Education is required for staff to clarify the importance of, and requirements for, valid informed consent and for decision making that reflects people's preferences and values.

Obtaining consensus on core components of stuttering intervention for adults: An e-Delphi Survey with key stakeholders.

BACKGROUND: Evidence-based practice involves the synthesis of multiple forms of evidence to inform clinical decision-making and treatment evaluation. Practice- and patient-based evidence are two forms of evidence that are under-represented in the stuttering literature. The collection of such knowledge is essential to support the design and delivery of effective stuttering interventions for adults. AIMS: To build stakeholder consensus on the core components of intervention for adults who stutter, and to establish a guiding framework for the design and development of evidence-based interventions for adults who stutter. METHODS & PROCEDURES: Adults who stutter and speech and language therapists (SLTs) with experience in providing stuttering intervention participated in the three-round e-Delphi Survey focused on: (1) identifying key stuttering intervention components, including principles, practices, and structural and contextual elements; and (2) obtaining group consensus on stuttering intervention components. Statements were categorized using the International Classification of Functioning, Disability and Health (ICF) model adapted to the study of stuttering. OUTCOMES & RESULTS: A total of 48 individuals agreed to participate: 48/48 (100%) completed the Round 1 questionnaire, 40/48 (83%) responded to Round 2 and 36/40 (90%) participated in Round 3. Following content analysis of Round 1, 101 statements were developed, and consensus was achieved on 89 statements perceived as representing the core components of stuttering intervention for adults. Categorization of these statements reflected the key stuttering intervention components relating to personal reactions to stuttering, limitations in life participation and environmental factors. CONCLUSIONS & IMPLICATIONS: Consensus on the core components of stuttering intervention was reached through engagement with key stakeholders. The evidence-based framework presented highlights the range of key intervention components a clinician should consider when designing interventions for adults who stutter. WHAT THIS PAPER ADDS: What is already known on the subject Evidence-based practice endorses the synthesis of multiple knowledge forms including research, practice and patient evidence to support clinical decision-making and treatment evaluation. The stuttering literature is characterized by an over-representation of efficacy evidence, with significantly less practice and patient evidence to guide clinical practice. What this paper adds to existing knowledge This study adds valuable practice- and patient-based evidence for effective stuttering intervention components for adults who stutter. These relate to personal reactions to stuttering, limitations in life participation and environmental factors. What are the potential or actual clinical implications of this work? This research presents a stakeholder-informed framework for stuttering intervention to guide SLTs working with adults who stutter in designing evidence-based interventions. The framework supports the adoption of a person-centred approach to intervention to ensure each client's unique needs, preferences, values and desired outcomes are explored and integrated into therapy.

A feedback journey: employing a constructivist approach to the development of feedback literacy among health professional learners.

BACKGROUND: Feedback, if effectively provided by the teacher and utilised by the learner, enables improvement in academic performance. It is clear from current literature that the provision of feedback by teachers is not sufficient on its own to guarantee improvements as early university entrants may not be sufficiently equipped to effectively engage with feedback. Nonetheless, it is critical for health professional students to develop feedback literacy early, in order to prepare them for a professional career of lifelong learning and critical thinking. The overarching aim of this study was to identify a feasible, sustainable approach to improve feedback literacy among students on pre-qualifying health professional programmes. METHODS: The study was divided into two phases. A mixed-methods approach grounded in constructivism was employed. Participants included teachers and learners from the School of Allied Health at X University, and two internationally acclaimed educationalists. In phase 1, first year students were encouraged to use an established online platform to upload modular feedback and develop personal learning action plans aimed at improving academic performance. A follow-up survey highlighted poor engagement with this method. Thus, the second phase focused on the co-construction of a suite of modules to develop these skills, supported by academic staff. Interviews were conducted with participants to review and refine this initiative. RESULTS: Learners' engagement with the first phase of the study was poor. Thus, the second phase provided all stakeholders with the opportunity to feed into the development of a suite of modules, designed to encourage teachers and learners to work in partnership to nurture these skills. All stakeholder groups reported short- and long-term benefits with this approach, but also highlighted challenges towards its implementation. CONCLUSION: The development of feedback literacy among health professional learners is essential. The transferability of such skills has been highlighted in the literature and by all stakeholder groups involved in this study. Finding a balance between introducing these skills at a time early enough to highlight their importance among university entrants is challenging. Further balance must be achieved between the workload required to achieve these skills and current programme demands for both teachers and learners.

Effectiveness of nonpharmacological stuttering interventions on communication and psychosocial functioning in adults: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To conduct a systematic review and meta-analysis of the research evidence examining the effectiveness of nonpharmacological stuttering therapy on communication and psychosocial functioning for adults who stutter. METHODS: A systematic search of nine electronic databases for studies published from database inception to December 2018 was completed to identify randomized controlled trials of interventions for adults with developmental stuttering. Two reviewers independently screened articles and assessed methodological quality using the Cochrane risk-of-bias tool. Treatment outcomes were classified using the International Classification of Functioning, Disability and Health (ICF) framework. RESULTS: The search yielded nine randomized controlled trials, comprising 276 participants, using a diverse range of interventions which were classified into four categories: speech restructuring interventions; speech restructuring plus psychological interventions; interventions with stimulating techniques and interventions targeting anxiety. Meta-analysis showed that interventions did not demonstrate a significant pooled difference when compared to comparison groups in improving speech fluency (standardized mean difference [SMD] = -0.35, 95% confidence interval [CI] -1.14 to 0.45, I2   = 81%, P = .39), overall experience of stuttering (mean difference [MD] = -0.10, 95% CI -0.36 to 0.15, I2   = 0%, P = .43) and quality of life (SMD = -0.32, 95% CI -0.83 to 0.19, I2   = 0%, P = .21). CONCLUSIONS: This article identified a diverse range of treatments and outcome measures for adults who stutter, with meta-analysis highlighting no significant pooled difference between intervention and comparator groups in improving communication and psychosocial functioning.

International expert perspectives on the principles and components of effective intervention for adults who stutter.

BACKGROUND: While evidence-based practice is widely endorsed by researchers, clinicians and professional bodies as a guiding framework for the provision of quality care to clients, the reliance on efficacy evidence may overshadow the benefits of other knowledge forms in supporting intervention design and evaluation. Due consideration needs to be given to varied forms of evidence, including practice and patient evidence. Stuttering intervention for adults is one area in which there is a significant shortage of practice-based research literature. AIMS: This study aimed to add to practice evidence by exploring the perspectives of international researchers and clinical experts on the components of effective stuttering intervention. This practice-based evidence will be used to inform the multi-stakeholder co-design of an evidence-based stuttering intervention for adults. METHODS & PROCEDURES: Criteria defining expertise were developed based on a review of the literature. Experts were recruited using purposive sampling and snowballing. Seventeen international experts were approached, of which 10 completed semi-structured interviews. Interview questions were developed and centred on five topics: the nature of stuttering; efficacy evidence base; intervention techniques, principles of effective intervention; and outcome measurement. OUTCOMES & RESULTS: Inductive thematic analysis identified three overarching themes: 'One size doesn't fit all', 'A really collaborative relationship where we are both bringing our sense of expertise to this' and 'Some of the most frustrating things'. CONCLUSIONS & IMPLICATIONS: These findings emphasize the complexity of stuttering intervention, the need for individually tailored treatments and the role of multiple factors, beyond therapeutic technique, that influence treatment outcomes. Findings also demonstrate the benefit of collecting practice-based evidence to support clinical decision-making and intervention evaluation. What this paper adds What is already known on the subject Evidence-based practice involves the synthesis of multiple forms of knowledge, including research, practice and patient evidence to support clinical decision-making and intervention evaluation. Research evidence for stuttering intervention effectiveness is the dominant form of knowledge in stuttering literature, while other forms such as practice and patient evidence are less represented. What this paper adds to existing knowledge This study provides valuable practice evidence for effective stuttering intervention components, including individually tailored intervention, person-related factors and therapeutic alliance. It highlights the need to consider multiple forms of knowledge to guide the design and evaluation of intervention. What are the potential or actual clinical implications of this work? Clinicians should adopt a person-centred care approach when designing and evaluating an intervention for adults who stutter. Multiple factors beyond therapeutic technique influence treatment outcomes and should be incorporated into any intervention for adults who stutter.

Do stroke clinical practice guideline recommendations for the intervention of thickened liquids for aspiration support evidence based decision making? A systematic review and narrative synthesis.

RATIONALE: Aspiration is a common sequela post stroke as a result of oropharyngeal dysphagia. It is primarily managed using the poorly empirically supported intervention of thickened liquids. Where evidence is limited, clinicians may rely on clinical practice guidelines to support decision making. The purpose of this systematic review and narrative synthesis was to evaluate the evidentiary bases of recommendations made by stroke clinical practice guidelines regarding the thickened liquids intervention. METHODS: A systematic review was conducted on stroke clinical guidelines retrieved via searches conducted across a range of databases including Academic Search Complete, CINAHL, MEDLINE, and the Cochrane Library as well as through association websites. Guidelines were eligible for inclusion if they focused on adult stroke populations, made recommendations relating to the thickened liquid intervention and were published between January 2010 and December 2018. Four independent reviewers rated methodological quality using the AGREE-II instrument. Intervention recommendations were extracted and analysed using the Criteria for Levels of Evidence Reported from the Canadian Stroke Best Practice Recommendations and a novel framework examining the appropriateness of the supporting evidence. RESULTS: Thirteen clinical guidelines were included in the review. Methodological quality was variable with seven rating as good-excellent overall. Thirty recommendations regarding the intervention were extracted. Of these, 16 recommendations were classed as a recommendation to use the treatment and all guidelines made this recommendation. Much of the evidence used to scaffold recommendations did not directly support the intervention. CONCLUSIONS: Despite the limited evidence base for the thickened liquid intervention, there was consensus among stroke guidelines in recommending it. This is despite limited empirical support. Furthermore, much of the evidence used to support recommendations was not appropriate, suggesting less than satisfactory evidence-based practices in formulating recommendations. In this case, clinical guidelines may not be reliable decision-support tools for facilitating clinical decision making.

Building a collaborative research community of practice and supporting research engagement in speech-language pathology: identification of stakeholder priorities.

BACKGROUND AND AIMS: Clinician engagement in research has the potential to improve healthcare processes and facilitate evidence-based practice. As a means to encourage clinician research engagement and links between speech-language pathology (SLP) clinicians in practice and researchers in higher education institutions, a national SLP clinician-academic research community of practice was established. The first steps for this newly formed research community was to determine stakeholder aims, to prioritize those aims and specify actions which would help respond to the stated priorities. METHODS: The study was conducted in Ireland and the Irish Association of Speech and Language Therapists acted as a gatekeeper who forwarded a study information sheet and expression of interest form to its membership. A World Café methodology was utilized to gather data and conducted as part of the inaugural meeting where consent was retrieved. As part of this methodology, the participants created and managed their own data with the help of group facilitators. RESULTS: Thirty six members replied expressing interest and 15 participants attended the inaugural meeting. Participants represented both clinical and research communities and identified and prioritized aims for the research community of practice. The aims were, in order of prioritization: Dissemination, Education, Enablers, Networking and Advocacy. Participants agreed that what they labelled as Dissemination was the number one priority for the newly formed research community of practice. In this context Dissemination referred to the identification of research already being conducted by participants and the sharing of that research both within the group and the larger SLP community nationally and internationally. Various actions were proposed to achieve agreed aims and these reflected a variety of targeted (e.g. development of a research database) and generic (e.g. to act as advocates) activities as well as local and national strategies including lobbying for clinical-research posts. CONCLUSION: Clear aims, priorities and actions were identified by SLP clinical and research participants to facilitate the development of a research community of practice. This article presents the results of that exercise and outlines the priorities of participants who identified five aims in total. Dissemination was the number one priority for the newly formed research group and manifested a desire to share information about participants' research activities. The prioritized aims reflect assured thinking and form a solid co-constructed footing for the research community to develop and grow.

The lived experience of stuttering: a synthesis of qualitative studies with implications for rehabilitation.

Purpose: Stuttering is a chronic communication disorder resulting in challenging life experiences for many individuals. This review aimed to integrate qualitative findings on the lived experiences of people who stutter and identify implications for rehabilitation.Materials and methods: A systematic literature search of electronic databases for studies published since 2000 was completed to identify research papers that used qualitative methods to explore the lived experiences of adults who stutter. Forty-five papers were read in full and a final seventeen papers were synthesised using a meta-ethnographic approach.Results: Five themes are described: (i) Avoidance is used to manage stuttering; (ii) Stuttering unfavourably impacts employment experiences; (iii) Stuttering shapes self-identity; (iv) Stuttering leads to negative reactions; and (v) Stuttering impacts relationships adversely.Conclusions: This review identifies the profound and predominantly negative impact that stuttering has on individuals' experiences. Avoidance is a commonly used strategy to manage stuttering with further negative consequences for the individual. To promote person-centred care and enhance treatment outcomes, clinicians should be cognizant of the profound impact of stuttering on the individual's life experience and incorporate targeted goals to reflect this when intervening.IMPLICATIONS FOR REHABILITATIONClinicians should be aware of and understand the extent of the impact of stuttering on an individual's life which is typified by various forms of avoidance and challenges in a number of domains including employment, identity formation, relationship development and others' perceptions of the person who stutters.An impairment-based approach to stuttering treatment with adults focusing on the overt aspects of stuttering (i.e., speech behaviours) is not holistic and does not do justice to the spectrum of covert features such as avoidance, and internalised thoughts and feelings that are associated with the condition. Therefore, the adoption of a holistic approach to stuttering intervention is recommended.An understanding of adults' lived experience of stuttering has the potential to inform programme developments for children and adolescents with the same condition and thus employ preventative strategies to reduce the development of negative life experiences at an earlier age.Clinicians should engage with the field of disability studies to strengthen their practice and consider their role in addressing socially-imposed barriers such as negative attitudes impacting on people who stutter.

Moving Beyond Traditional Understandings of Evidence-Based Practice: A Total Evidence and Knowledge Approach (TEKA) to Treatment Evaluation and Clinical Decision Making in Speech-Language Pathology.

Evidence-based practice (EBP) is a well-established framework for supporting clinical decision making in the discipline of speech-language pathology. The benefits of using evidence to inform clinical practice are acknowledged by clinicians and researchers alike. Even so, after over two decades of EBP advocacy, much clinical uncertainty remains and models supporting the evaluation of interventions require review and reconsideration. The EBP model, while promoting positive principles, can be argued to be conceptually flawed because it suffers from a lack of attention to and explicit valuing of other forms of knowledge crucial to the formation of realistic and judiciously informed decisions. We propose that the evaluation of interventions would be better supported by an explicit knowledge management approach reflecting a range of evidence and knowledge. One worked example is presented to demonstrate what using such an approach can produce in terms of intervention information.

Navigating the system: Physiotherapy student perceptions of performance-based assessment.

BACKGROUND: Performance-based assessment (PBA) is an integral component of health professional education as it determines students' readiness for independent practice. Stakeholder input can provide valuable insight regarding its challenges, facilitators, and impact on student learning, which may further its evolution. Currently, evidence of stakeholder opinion is limited. Thus, we aimed to explore physiotherapy students' perceptions of performance-based assessment in their capacity as its central stakeholders. METHODS: A qualitative interpretive constructivist approach was employed using focus group interviews for data collection. Six focus groups were completed (n = 33). Inductive thematic analysis was used to explore the data. RESULTS: Two themes were identified. The first outlined perceived inconsistencies within the process, and how these impacted on student learning. The second described how students used their experiential knowledge to identify strategies to manage these challenges thus identifying key areas for improvement. CONCLUSION: Inconsistencies outlined within the current physiotherapy performance-based assessment process encourage an emphasis on grades rather than on learning. It is timely that the physiotherapy academic and clinical communities consider these findings alongside evidence from other health professions to improve assessment procedures and assure public confidence and patient safety.

Plugging the patient evidence gap: what patients with swallowing disorders post-stroke say about thickened liquids.

BACKGROUND: Oropharyngeal dysphagia post-stroke is well known, with its presence increasing the risk of poor outcomes in particular aspiration and aspiration pneumonia. Management to minimize the risk of aspiration and improve swallow safety post-stroke includes the treatment of thickened liquids (TL), an established bolus modification intervention. Despite widespread use, there is a lack of robust empirical evidence and minimal patient evidence as to the experience and acceptability of using thickeners by people who experience dysphagia after a stroke. AIMS: To explore people with swallowing disorders post-stroke experiences of and acceptability regarding the bolus modification treatment of thickened liquids. METHODS & PROCEDURES: A qualitative, descriptive study exploring the experiences of individuals given TL after their stroke. A purposive sample of 14 adults was obtained with data collection and generation through the medium of individual semi-structured interviews. Inductive thematic analysis was used to analyse the data. OUTCOMES & RESULTS: Three overarching themes of 'uncertainty', 'an unpleasant experience' and 'a trade-off' were identified. These themes highlight that participants disliked TL and this dislike may have impacted clinically in terms of adherence, hydration and quality of life. Lack of sensory appeal was important in framing patient dislike. Participants' involvement in and understanding of reasons for prescription of TL was poor leading to uncertainty regarding the treatment. Notwithstanding, some participants felt it was necessary for their stroke recovery. CONCLUSIONS & IMPLICATIONS: TL can be considered a burdensome treatment from multiple perspectives including product palatability, treatment uncertainty and treatment adherence issues. Despite intensely disliking this treatment, some patients ultimately understand why the treatment is prescribed. Improvements in product palatability are required in order to improve adherence and patient quality of life. Consideration of other treatment options and newer products to manage aspiration post-stroke is also warranted.

What information is used in treatment decision aids? A systematic review of the types of evidence populating health decision aids.

BACKGROUND: Patient decision aids (DAs) are support tools designed to provide patients with relevant information to help them make informed decisions about their healthcare. While DAs can be effective in improving patient knowledge and decision quality, it is unknown what types of information and evidence are used to populate such decision tools. METHODS: Systematic methods were used to identify and appraise the relevant literature and patient DAs published between 2006 and 2015. Six databases (Academic Search Complete, AMED, CINAHL, Biomedical Reference Collection, General Sciences and MEDLINE) and reference list searching were used. Articles evaluating the effectiveness of the DAs were appraised using the Cochrane Risk of Bias tool. The content, quality and sources of evidence in the decision aids were evaluated using the IPDASi-SF and a novel classification system. Findings were synthesised and a narrative analysis was performed on the results. RESULTS: Thirteen studies representing ten DAs met the inclusion criteria. The IPDASI-SF score ranged from 9 to 16 indicating many of the studies met the majority of quality criteria. Sources of evidence were described but reports were sometimes generic or missing important information. The majority of DAs incorporated high quality research evidence including systematic reviews and meta-analyses. Patient and practice evidence was less commonly employed, with only a third of included DAs using these to populate decision aid content. The quality of practice and patient evidence ranged from high to low. Contextual factors were addressed across all DAs to varying degrees and covered a range of factors. CONCLUSIONS: This is an initial study examining the information and evidence used to populate DAs. While research evidence and contextual factors are well represented in included DAs, consideration should be given to incorporating high quality information representing all four pillars of evidence based practice when developing DAs. Further, patient and expert practice evidence should be acquired rigorously and DAs should report the means by which such evidence is obtained with citations clearly provided.

Why do clinicians choose the therapies and techniques they do? Exploring clinical decision-making via treatment selections in dysphagia practice.

PURPOSE: Speech-language pathologists (SLPs) are assumed to use evidence-based practice to inform treatment decisions. However, the reasoning underpinning treatment selections is not well known. Understanding why SLPs choose the treatments they do may be clarified by exploring the reasoning tied to specific treatments such as dysphagia interventions. METHOD: An electronic survey methodology was utilised. Participants were accessed via the gatekeepers of two national dysphagia special interest groups representing adult and paediatric populations. Information was elicited on the dysphagia therapies and techniques used and on the reasoning for using/not using therapies. Data was analysed using descriptive and non-parametric statistics. RESULT: The survey had a 74.8% response rate (n = 116). Consensus in both treatment selections and reasoning supporting treatment decisions was evident. Three favoured interventions (texture modification, thickening liquids, positioning changes) were identified. The reasoning supporting treatment choices centred primarily on client suitability and clinician knowledge. Knowledge reflected both absent knowledge (e.g. training) and accumulated knowledge (clinical experience). CONCLUSION: Dysphagia practice appears highly-defined, being characterised by group consensus regarding both preferred treatments and the reasoning underpinning treatment selections. Treatment selections are based on two core criteria: client suitability and the SLPs experience/knowledge. Explicit scientific reasoning is less influential than practice-centric influences.

What are the primary influences on treatment decisions? How does this reflect on evidence-based practice? Indications from the discipline of speech and language therapy.

RATIONALE, AIMS AND OBJECTIVES: Four pillars of evidence underpin evidence-based behavioural practice: research evidence, practice evidence, patient evidence and contextual evidence. However, it is unknown which of these pillars or other factors are used by clinicians such as speech and language therapists (SLTS) when making treatment choices. The aim of this study was to identify the factors underpinning SLTs' treatment decisions and contextualize findings in terms of evidence-based practice (EBP). METHODS: Ethical approval was obtained for the electronic questionnaire-based study. A questionnaire was designed, piloted and then sent via gatekeepers to SLTs to ascertain agreement with a range of statements potentially underpinning treatment choices. RESULTS: A total of 249 respondents completed the survey. The respondents defined themselves as dynamic and pragmatic practitioners with an appreciation for the four pillars of EBP. Using factor analysis, treatment decisions were found to rely primarily on practice evidence and pragmatic considerations. Qualifications, clinical experience and the patient group an SLT works with further influenced attitudes and treatment decisions. Those with additional qualifications and experience were identified as more autonomous, more scientific in their treatment choices and less influenced by patient preferences. CONCLUSION: Factors influencing decision making did not clearly align with the four pillars of EBP, the principal influences being practice evidence and pragmatic constraints. The findings of this study have implications for understanding why specific treatment choices are made. Attempts to improve practice should focus on a range of evidence sources and take into account clinician's specific needs depending on career stage, post-qualification status and patient group factors of their practice.

'We don't have recipes; we just have loads of ingredients': explanations of evidence and clinical decision making by speech and language therapists.

RATIONALE, AIMS AND OBJECTIVES: Research findings consistently suggest that speech and language therapists (SLTs) are failing to draw effectively on research-based evidence to guide clinical practice. This study aimed to examine what constitutes the reasoning provided by SLTs for treatment choices and whether science plays a part in those decisions. METHOD: This study, based in Ireland, reports on the qualitative phase of a mixed-methods study, which examined attitudes underpinning treatment choices and the therapy process. SLTs were recruited from community, hospital and disability work settings via SLT managers who acted as gatekeepers. A total of three focus groups were run. Data were transcribed, anonymized and analysed using thematic analysis. RESULTS: In total, 48 participants took part in the focus groups. The majority of participants were female, represented senior grades and had basic professional qualifications. Three key themes were identified: practice imperfect; practice as grounded and growing; and critical practice. Findings show that treatment decisions are scaffolded primarily on practice evidence. The uniqueness of each patient results in dynamic and pragmatic practice, constraining the application of unmodified therapies. CONCLUSION: The findings emerging from the data reflect the complexities and paradoxes of clinical practice as described by SLTs. Practice is pivoted on both the patient and clinician, through their membership of groups and as individuals. Scientific thinking is a component of decision making; a tool with which to approach the various ingredients and the dynamic nature of clinical practice. However, these scientific elements do not necessarily reflect evidence-based practice as typically constructed.

Evidence-based practice: SLTs under siege or opportunity for growth? The use and nature of research evidence in the profession.

BACKGROUND: Speech and language therapists are encouraged to be evidence-based practitioners in contemporary clinical practice. This apparently signifies their commitment to 'good' practice. An examination of evidence-based practice (EBP) and its adoption in clinical practice is therefore warranted. AIMS: This paper aims to explore EBP, specifically research evidence, as related to the field of speech and language therapy (SLT), using profession specific and cross-disciplinary examples. It asks the reader to consider whether research evidence contributes positively to SLT practice, or adds to the demands placed on clinicians? METHODS & PROCEDURES: A review of the literature on the nature and use of research evidence in the field of speech and language therapy and related health professions was undertaken using multiple databases (Cochrane, Medline, Cinahal, BioMed, Trip, Dare) and the following up of references provided within texts and articles. This paper asks the reader to consider the topic from the perspective of the nature of research produced, the barriers perceived, and the use of research evidence by SLTs and the allied health professions. OUTCOMES & RESULTS: The uptake of research evidence in the profession is similar to other health professions and continues to be problematic. There are multiple reasons why this is so, originating from both the nature and use of research. CONCLUSIONS & IMPLICATIONS: Research evidence is one of the pillars of EBP. Despite problems with the nature and use of such evidence, it has a positive contribution to make to clinical practice as it provides for a scientific touchstone. However, it may be that the speech and language therapist and not the research evidence is the primary pivot upon which scientific practice is based.