Understanding the value of a doctorate for allied health professionals in practice in the UK: a survey.

BACKGROUND: The need to transform the United Kingdom's (UK) delivery of health and care services to better meet population needs and expectations is well-established, as is the critical importance of research and innovation to drive those transformations. Allied health professionals (AHPs) represent a significant proportion of the healthcare workforce. Developing and expanding their skills and capabilities is fundamental to delivering new ways of working. However, career opportunities combining research and practice remain limited. This study explored the perceived utility and value of a doctorate to post-doctoral AHPs and how they experience bringing their research-related capabilities into practice environments. METHODS: With a broadly interpretivist design, a qualitatively oriented cross-sectional survey, with closed and open questions, was developed to enable frequency reporting while focusing on the significance and meaning participants attributed to the topic. Participants were recruited via professional networks and communities of practice. Descriptive statistics were used to analyse closed question responses, while combined framework and thematic analysis was applied to open question responses. RESULTS: Responses were received from 71 post-doctoral AHPs located across all four UK nations. Findings are discussed under four primary themes of utilisation of the doctorate; value of the doctorate; impact on career, and impact on self and support. Reference is also made at appropriate points to descriptive statistics summarising closed question responses. CONCLUSION: The findings clearly articulate variability of experiences amongst post-doctoral AHPs. Some were able to influence team and organisational research cultures, support the development of others and drive service improvement. The challenges, barriers and obstacles encountered by others reflect those that have been acknowledged for many years. Acknowledging them is important, but the conversation must move forward and generate positive action to ensure greater consistency in harnessing the benefits and value-added these practitioners bring. If system-wide transformation is the aim, it is inefficient to leave navigating challenges to individual creativity and tenacity or forward-thinking leaders and organisations. There is an urgent need for system-wide responses to more effectively, consistently and equitably enable career pathways combining research and practice for what is a substantial proportion of the UK healthcare workforce.

Allied health professional research engagement and impact on healthcare performance: A systematic review protocol.

BACKGROUND: Existing evidence suggests that clinician and organization engagement in research can improve healthcare processes of care and outcomes. However, current evidence has considered the relationship across all healthcare professions collectively. With the increase in allied health clinical academic and research activity, it is imperative for healthcare organizations, leaders and managers to understand engagement in research within these specific clinical fields. This systematic review aims to identify the effect of engagement in research by allied health professionals (AHPs) and organizations on healthcare performance. METHODS: This systematic review has a two-stage search strategy. The first stage will be to screen a previous systematic review examining the effectiveness of engagement in research in health and social care to identify relevant papers published pre-2012. The search strategy used in the previous review will then be rerun, but with a specific focus on allied health. This multi-database search will identify publications from 2012 to date. Only studies that assessed the effectiveness of allied health engagement in research will be included. All stages of the review will be conducted by two reviewers independently, plus documented discussions with the wider research team when discrepancies occur. This systematic review protocol follows the EQUATOR reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols (PRISMA-P). DISCUSSION: The findings of this review will make a significant contribution to the evidence base around the effect of allied health engagement in research on healthcare performance. It will provide insights for clinicians and managers looking to understand the consequences of developing AHP research capability and capacity. The findings of this review will also aim to make recommendations for future evaluation approaches for engagement in research interventions. TRIAL REGISTRATION: This systematic review protocol has been registered with PROSPERO, registration number CRD42021253461. WHAT THIS PAPER ADDS: What is already known on the subject This study will provide valuable evidence for professionals and policymakers seeking to understand engagement in research in the allied health disciplines. Where supported by the data, there may be recommendations for future research regarding specific variables to be considered when planning and evaluating engagement in research in allied health practice. What this paper adds to existing knowledge A previous systematic review identified a positive association between clinician and organization engagement in research and improved processes of care and health outcomes. The reviews' findings have been used as a justification for clinicians and organizations to increase research capacity. That review evaluated literature published before 2012 and the studies that were identified predominantly reported on engagement in research by medics and nurses. An updated review is now required to include research published since 2012. This review will specifically focus on the effect of engagement in research within allied health disciplines. What are the potential or actual clinical implications of this work? Research activity among AHPs is gaining momentum. Given this growth in AHP research activity and the rise in dedicated clinical academic roles, a contemporary review to identify the specific effect of AHP engagement in research on healthcare performance is prudent. The findings will inform clinicians, clinical managers and leaders of the potential impact of research activities by AHP clinicians and organizations. This will support the planning and development of initiatives focused on research capacity, capability and culture within allied health.

"I'm walking into the unknown": Qualitative insights into how emotions and lived experience related to multiple sclerosis diagnosis impact on decisions to pursue disease modifying treatment.

INTRODUCTION: People with Relapsing Remitting Multiple Sclerosis (RRMS) are increasingly included as active participants in shared decision making around their treatment options. Choosing a first disease modifying treatment (DMT) is a complex process that often takes place soon after a diagnosis has been given. Patients therefore are often required to make difficult decisions at a time when they are still coming to terms with their illness. This study investigated the views and experiences of recently diagnosed patients with RRMS when they were making their initial DMT choice. METHOD: This was a qualitative study involving in-depth semi-structured interviews with patients with RRMS in a National Health Service (NHS) setting in the United Kingdom. Data were collected from 6 patients and analysis was guided by an Interpretive Phenomenological Analysis (IPA) approach. RESULTS: Initial reactions to diagnosis were characterized by strong emotions and a feeling of despair and hopelessness. Subsequently the DMT decision was shaped by multiple considerations around maintaining normality, and restoring hope and control over one's life whilst reconciling uncertainty around efficacy. Considering the future with a DMT elicited reflections around employment and family planning. CONCLUSION: Emotions and lived experience related to recent MS diagnosis can impact on the initial DMT decision in number of ways. Health care professionals need to understand the lived experience of patients making DMT decisions soon after diagnosis when engaging in shared decision making.

Screening for aspiration risk associated with dysphagia in acute stroke.

BACKGROUND: Stroke can affect people's ability to swallow, resulting in passage of some food and drink into the airway. This can cause choking, chest infection, malnutrition and dehydration, reduced rehabilitation, increased risk of anxiety and depression, longer hospital stay, increased likelihood of discharge to a care home, and increased risk of death. Early identification and management of disordered swallowing reduces risk of these difficulties. OBJECTIVES: Primary objective • To determine the diagnostic accuracy and the sensitivity and specificity of bedside screening tests for detecting risk of aspiration associated with dysphagia in people with acute stroke Secondary objectives • To assess the influence of the following sources of heterogeneity on the diagnostic accuracy of bedside screening tools for dysphagia - Patient demographics (e.g. age, gender) - Time post stroke that the study was conducted (from admission to 48 hours) to ensure only hyperacute and acute stroke swallow screening tools are identified - Definition of dysphagia used by the study - Level of training of nursing staff (both grade and training in the screening tool) - Low-quality studies identified from the methodological quality checklist - Type and threshold of index test - Type of reference test SEARCH METHODS: In June 2017 and December 2019, we searched CENTRAL, MEDLINE, Embase, CINAHL, and the Health Technology Assessment (HTA) database via the Centre for Reviews and Dissemination; the reference lists of included studies; and grey literature sources. We contacted experts in the field to identify any ongoing studies and those potentially missed by the search strategy. SELECTION CRITERIA: We included studies that were single-gate or two-gate studies comparing a bedside screening tool administered by nurses or other healthcare professionals (HCPs) with expert or instrumental assessment for detection of aspiration associated with dysphagia in adults with acute stroke admitted to hospital. DATA COLLECTION AND ANALYSIS: Two review authors independently screened each study using the eligibility criteria and then extracted data, including the sensitivity and specificity of each index test against the reference test. A third review author was available at each stage to settle disagreements. The methodological quality of each study was assessed using the Quality Assessment of Studies of Diagnostic Accuracy (QUADAS-2) tool. We identified insufficient studies for each index test, so we performed no meta-analysis. Diagnostic accuracy data were presented as sensitivities and specificities for the index tests. MAIN RESULTS: Overall, we included 25 studies in the review, four of which we included as narratives (with no accuracy statistics reported). The included studies involved 3953 participants and 37 screening tests. Of these, 24 screening tests used water only, six used water and other consistencies, and seven used other methods. For index tests using water only, sensitivity and specificity ranged from 46% to 100% and from 43% to 100%, respectively; for those using water and other consistencies, sensitivity and specificity ranged from 75% to 100% and from 69% to 90%, respectively; and for those using other methods, sensitivity and specificity ranged from 29% to 100% and from 39% to 86%, respectively. Twenty screening tests used expert assessment or the Mann Assessment of Swallowing Ability (MASA) as the reference, six used fibreoptic endoscopic evaluation of swallowing (FEES), and 11 used videofluoroscopy (VF). Fifteen screening tools had an outcome of aspiration risk, 20 screening tools had an outcome of dysphagia, and two narrative papers did not report the outcome. Twenty-one screening tests were carried out by nurses, and 16 were carried out by other HCPs (not including speech and language therapists (SLTs)). We assessed a total of six studies as low risk across all four QUADAS-2 risk of bias domains, and we rated 15 studies as low concern across all three applicability domains. No single study demonstrated 100% sensitivity and specificity with low risk of bias for all domains. The best performing combined water swallow and instrumental tool was the Bedside Aspiration test (n = 50), the best performing water plus other consistencies tool was the Gugging Swallowing Screen (GUSS; n = 30), and the best water only swallow screening tool was the Toronto Bedside Swallowing Screening Test (TOR-BSST; n = 24). All tools demonstrated combined highest sensitivity and specificity and low risk of bias for all domains. However, clinicians should be cautious in their interpretation of these findings, as these tests are based on single studies with small sample sizes, which limits the estimates of reliability of screening tests. AUTHORS' CONCLUSIONS: We were unable to identify a single swallow screening tool with high and precisely estimated sensitivity and specificity based on at least one trial with low risk of bias. However, we were able to offer recommendations for further high-quality studies that are needed to improve the accuracy and clinical utility of bedside screening tools.

Collaborative healthcare education programmes for continuing professional education in low and middle-income countries: A Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 65.

BACKGROUND: Large discrepancies exist between standards of healthcare provision in high-income (HICs) and low and middle-income countries (LMICs). The root cause is often financial, resulting in poor infrastructure and under-resourced education and healthcare systems. Continuing professional education (CPE) programmes improve staff knowledge, skills, retention, and practice, but remain costly and rare in low-resource settings. One potential solution involves healthcare education collaborations between institutions in HICs and LMICs to provide culturally appropriate CPE in LMICs. To be effective, educational partnerships must address the challenges arising from differences in cultural norms, language, available technology and organisational structures within collaborating countries. METHODS: Seven databases and other sources were systematically searched on 7 July 2020 for relevant studies. Citations, abstracts, and studies were screened and consensus was reached on which to include within the review. 54 studies were assessed regarding the type of educational programme involved, the nature of HIC/LMIC collaboration and quality of the study design. RESULTS: Studies varied greatly regarding the types and numbers of healthcare professionals involved, pedagogical and delivery methods, and the ways in which collaboration was undertaken. Barriers and enablers of collaboration were identified and discussed. The key findings were: 1. The methodological quality of reporting in the studies was generally poor. 2. The way in which HIC/LMIC healthcare education collaboration is undertaken varies according to many factors, including what is to be delivered, the learner group, the context, and the resources available. 3. Western bias was a major barrier. 4. The key to developing successful collaborations was the quality, nature, and duration of the relationships between those involved. CONCLUSION: This review provides insights into factors that underpin successful HIC/LMIC healthcare CPE collaborations and outlines inequities and quality issues in reporting.

Evaluation of a manualised speech and language therapy programme for children with social communication disorder: the SCIP feasibility study.

BACKGROUND: Children with Social (Pragmatic) Communication Disorder (SPCD) have long-term needs in using and processing social language and have a high risk of later mental health difficulties. A manualised speech and language therapy programme, the Social Communication Intervention Programme (SCIP) provides therapy content for SPCD. A feasibility study is required to derive more precise estimates of key parameters for a future trial of SCIP. AIMS: To assess the feasibility of conducting a substantive randomized controlled trial of SCIP for children with SPCD. METHODS: A questionnaire was distributed to paediatric speech and language therapists in England. Survey questions addressed number of eligible children, routine intervention provision and trial recruitment factors. In the second phase, a single-arm intervention feasibility study was completed. Fifteen speech and language practitioners identified 24 children aged 5-11 years with SPCD. Practitioners received training/supervision to deliver 20 SCIP therapy sessions to each child. At time 1, parents of participating children provided three communication goals; expected steps in each goal were defined. After intervention, parents and practitioners independently rated each goal compared to baseline ability. Two research practitioners compared parent post-intervention commentaries with outcome scores to derive guidance about clinical significance. All practitioners recorded audio commentaries on therapy experiences. Post-intervention interviews were conducted with 6 practitioners and 6 parents. An expert panel completed a Delphi consultation on trial design. RESULTS: Routine practice for SPCD varies widely. Children tend to be embedded in autism provision. Participation in a future trial was well supported provided resources are available to services. Outcomes analysis indicated all children except one made some progress on parent ratings; all children made progress on practitioner ratings. A power analysis for a future trial was carried out using current outcome measure as putative primary endpoint. Practitioners' audio-diaries provided suggestions for training and adaption in a future trial. Outcomes and therapy methods were acceptable to practitioners and parents. CONCLUSIONS: The feasibility study evaluated a novel outcome measure of social communication skills in SPCD. A power calculation indicated a feasible framework for a trial within a realistic period of time. Recommendations for recruitment methods, adaptation of manual and training were supported by practitioners and an expert panel. TRIAL REGISTRATION: Title: Speech-language therapy for child social communication disorderTrial ID: ISRCTN48030419. Date registered: January 1, 2017. Registered retrospectively.

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.

Inequalities in access to health and social care among adults with multiple sclerosis: A scoping review of the literature.

Variations in access to health care are known to contribute to differences in life expectancy, morbidity and health-related quality-of-life across population subgroups. We undertook a scoping review to identify what is known about in-country variations in access to services for adults with multiple sclerosis and to identify gaps in the literature to inform future research and national policies. We searched MEDLINE, CINAHL, EMBASE, PSYCHINFO, SocINDEX and Social Science Abstracts from inception to end of December 2016 for quantitative studies which had investigated differences in access to prevention services, healthcare services, treatments and social care between inequality groups, defined using the PROGRESS-PLUS framework. A total of 4959 unique abstracts yielded 36 papers which met our eligibility criteria. Only 3 studies were cohort studies and only 4 were population-based; most were from the United States (n = 27). There were 6 studies on access to MS focused care and 6 on access to Disease Modifying drugs. There were 3 studies on access to prevention/lifestyle programmes and none on access to welfare services or information support. There were no papers examining inequalities in access for 'vulnerable' groups, such as, those with learning disability. In the available studies, there was evidence of inequalities in access to services with a trend for worse access among men, older age groups, those from lower socio-economic groups or the least educated, non-caucasians, those with mental health problems and those from rural areas. In the studies on access to disease modifying treatments, older age and lower socioeconomic status were consistently associated with a lower rate of uptake, while race and gender were not. Inequalities or disparities in access to all levels of services and treatments will need to be addressed through a strategic research agenda with an emphasis on population-based studies and development and evaluation of interventions to reduce inequality.

Is keep/refer decision making an integral part of national guidelines for the physiotherapy profession within Europe? A review.

BACKGROUND: Keep/refer decision as the ability to independently determine whether a patient's condition is suitable for physiotherapy management (keep) or not (refer), is regarded as an core element in the World Confederation of Physical Therapists' (WCPT) Guideline for Standards of Physical Therapy Practice. However, it is currently unknown how individual European countries have implemented this in their national guidelines. OBJECTIVES: To determine if keep/refer decision making abilities are an integral part of national guidelines for the physiotherapy profession of member countries of the European Network of Physiotherapy in Higher Education (ENPHE). DATA SOURCES: A review was performed including medical databases, the grey literature and personal correspondence with professional ENPHE member associations. To gain the information of interest, all eligible documents were reviewed. RESULTS: 11 national guidelines for the physiotherapy profession could be obtained. Two additional member associations use European guidelines as their national ones. Despite the fact that in the WCPT guidelines keep/refer decision making abilities are clearly described as a core element, there exists huge inconsistency as to how various European (with direct and non direct access systems) countries have included them in their national guidelines. CONCLUSION: Despite the fact that most ENPHE member countries deem a close collaboration between health care professionals important and that physiotherapists should know the limitation of their expertise, keep/refer decision making abilities as explicitly stated in the WCPT guidelines were not included in the majority of guidelines that were reviewed.

Care staff perceptions of choking incidents: what details are reported?

BACKGROUND: Following a series of fatal choking incidents in one UK specialist service, this study evaluated the detail included in incident reporting. This study compared the enhanced reporting system in the specialist service with the national reporting and learning system. METHODS: Eligible reports were selected from a national organization and a specialist service using search terms relevant to adults with intellectual disability and/or mental ill health. Qualitative analysis was completed with comparison of themes identified in both sets of reports. FINDINGS: The numbers of choking incidents identified in national reports suggest underreporting compared with the specialist service and varying levels of severity. Themes included trends in timing, care setting and food textures as perceived by staff. CONCLUSIONS: This study demonstrates paucity of detail in reporting in systems without additional question prompts. Adding these questions requires staff to include greater detail which enables learning and risk mitigation to take place.

An exploration of the impact of anti-TNFα medication on exercise behaviour in patients with ankylosing spondylitis.

BACKGROUND: Exercise has traditionally been an important part of the treatment of ankylosing spondylitis (AS) in order to maintain spinal mobility. Additionally, anti-tumour necrosis factor-alpha (TNFα) medication has been proven highly effective in treating the condition. Over recent years, a few papers have shown the synergistic effect of combining anti-TNFα medication with rehabilitation. There is minimal evidence on the perceptions of AS patients on how the medication has affected their exercise behaviour. The aim of the present study was to explore the effects of anti-TNFα medication on exercise behaviour in patients with AS. METHOD: A qualitative approach was adopted to provide a holistic understanding of participants' exercise behaviour while on anti-TNFα medication. Semi-structured interviews were undertaken and transcribed verbatim. Data were analysed using thematic network analysis. Ethical approval and informed consent were obtained. RESULTS: Twenty participants (age range 26-74, disease duration 3-36 years) who had been on the medication for over a year described how their exercise behaviour had improved since being on the medication. They highlighted their motivation and incentives to continue with an exercise programme. The participants had reinstated previous sporting activities, started new ones and regularly undertook physiotherapy exercises. CONCLUSION: The present study provides evidence of the long-term effects of anti-TNFα medication on the exercise behaviour of AS patients. It shows that AS patients are able to sustain a regular exercise programme over a number of years, provides insight into what motivates them to exercise and reveals the incentives that have influenced their choice of activity.

Rehabilitation or compensation: time for a fresh perspective on speech and language therapy for dysphagia and Parkinson's disease?

BACKGROUND: Dysphagia is a common symptom of Parkinson's disease and can have negative consequences for physical health and quality of life. A variety of treatment options are available to clinicians working with people who have dysphagia and Parkinson's disease. These options can be broadly categorized as being compensatory or rehabilitative in nature. AIMS: To explore the evidence behind treatment options available to clinicians working with dysphagia and Parkinson's disease and to draw conclusions about whether compensatory or rehabilitative approaches are likely to provide the best outcomes for our patients. METHODS & PROCEDURES: A critical literature review of compensatory and rehabilitative interventions for dysphagia in Parkinson's disease was undertaken. Relevant studies were analysed for their robustness and potential clinical applications. General conclusions were drawn based on the evidence base identified in this review. MAIN CONTRIBUTION: This review outlines the lack of evidence supporting both compensatory and rehabilitative methods of treating dysphagia in Parkinson's disease. It directs clinicians and researchers towards areas that require further investigation. CONCLUSIONS & IMPLICATIONS: To date, compensatory methods of treating dysphagia in Parkinson's disease have received more research attention than rehabilitative methods and yet neither approach has a strong evidence base. This review argues that rehabilitative methods could possibly have greater potential to increase swallowing safety and improve quality of life in the long-term than compensatory methods alone. However, at present there is a lack of research in this area.

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.

What can management theories offer evidence-based practice? A comparative analysis of measurement tools for organisational context.

BACKGROUND: Given the current emphasis on networks as vehicles for innovation and change in health service delivery, the ability to conceptualize and measure organisational enablers for the social construction of knowledge merits attention. This study aimed to develop a composite tool to measure the organisational context for evidence-based practice (EBP) in healthcare. METHODS: A structured search of the major healthcare and management databases for measurement tools from four domains: research utilisation (RU), research activity (RA), knowledge management (KM), and organisational learning (OL). Included studies were reports of the development or use of measurement tools that included organisational factors. Tools were appraised for face and content validity, plus development and testing methods. Measurement tool items were extracted, merged across the four domains, and categorised within a constructed framework describing the absorptive and receptive capacities of organisations. RESULTS: Thirty measurement tools were identified and appraised. Eighteen tools from the four domains were selected for item extraction and analysis. The constructed framework consists of seven categories relating to three core organisational attributes of vision, leadership, and a learning culture, and four stages of knowledge need, acquisition of new knowledge, knowledge sharing, and knowledge use. Measurement tools from RA or RU domains had more items relating to the categories of leadership, and acquisition of new knowledge; while tools from KM or learning organisation domains had more items relating to vision, learning culture, knowledge need, and knowledge sharing. There was equal emphasis on knowledge use in the different domains. CONCLUSION: If the translation of evidence into knowledge is viewed as socially mediated, tools to measure the organisational context of EBP in healthcare could be enhanced by consideration of related concepts from the organisational and management sciences. Comparison of measurement tools across domains suggests that there is scope within EBP for supplementing the current emphasis on human and technical resources to support information uptake and use by individuals. Consideration of measurement tools from the fields of KM and OL shows more content related to social mechanisms to facilitate knowledge recognition, translation, and transfer between individuals and groups.

Assessing adherence to the evidence base in the management of poststroke dysphagia.

OBJECTIVE: To evaluate the reliability and responsiveness to change of an audit tool to assess adherence to evidence of effectiveness in the speech and language therapy (SLT) management of poststroke dysphagia. DESIGN: The tool was used to review SLT practice as part of a randomized study of different education strategies. Medical records were audited before and after delivery of the trial intervention. SETTING: Seventeen SLT departments in the north-west of England participated in the study. SUBJECTS: The assessment tool was used to assess the medical records of 753 patients before and 717 patients after delivery of the trial intervention across the 17 departments. A target of 10 records per department per month was sought, using systematic sampling with a random start. ANALYSIS: Inter- and intra-rater reliability were explored, together with the tool's internal consistency and responsiveness to change. RESULTS: The assessment tool had high face validity, although internal consistency was low (ra = 0.37). Composite scores on the tool were however responsive to differences between SLT departments. Both inter- and intra-rater reliability ranged from 'substantial' to 'near perfect' across all items. CONCLUSIONS: The audit tool has high face validity and measurement reliability. The use of a composite adherence score should, however, proceed with caution as internal consistency is low.

Promoting research use in speech and language therapy: a cluster randomized controlled trial to compare the clinical effectiveness and costs of two training strategies.

OBJECTIVE: To evaluate the clinical and cost effectiveness of two training strategies to promote the use of research evidence in speech and language therapy (SLT) management of poststroke dysphagia. DESIGN: Pragmatic, cluster randomized trial. SETTING: Seventeen SLT departments in north-west England. PARTICIPANTS: Two SLTs from each department received training and cascaded information across their department. Process of care was measured from the notes of 708 patients with acute poststroke dysphagia across eight departments allocated to training strategy A, and 762 patients across nine departments in strategy B. INTERVENTIONS: Strategy A: training on the critical appraisal of published research papers and practice guidelines. Strategy B: strategy A plus training on management of change in clinical practice. MAIN OUTCOME MEASURES: Pre- and post-training adherence to practice guidelines in poststroke dysphagia management, based on a review of case notes. Incremental cost of increased adherence to clinical guidelines. RESULTS: Departments' practice differed in adherence to guidelines. Departments changed following training (F=2.22, df 16, 1436, p=0.004). The effect of training strategy on clinical practice was not significant. Strategy B departments engaged in more activities relating to research use following training than strategy A. Total costs of training averaged l2001, 2892 Euros, $3886 (SD l502, 726 Euros, $975) for strategy A and l3366, 4866 Euros, $6537 (SD l2121, 3066 Euros, $4119) for strategy B. CONCLUSIONS: Training in research implementation in addition to critical appraisal and guideline introduction is associated with increased dissemination activities and awareness of research information, but not with changes in clinical practice within six months of training. The department in which SLTs work influences their use of research. The process of poststroke dysphagia management can be measured using a tool developed from practice guidelines.