Deconstructing Clinical Practice and Searching for Scientific Foundations: Examining decision-making scaffolds underpinning intervention choices by speech and language therapists

Abstract

Introduction:
Speech and language therapy (SLT) is purported to be a scientifically-based discipline. A commitment to scientific practice is currently best represented by practicing in an evidenced-based way, specifically by the use of research evidence, yet studies examining the use of research evidence both within the profession and across disciplines, consistently suggest that research is less than influential in guiding practice decisions. This suggests practice may not be scientific. Furthermore, unscientific practice may be represented by the use of pseudoscientific and / or non-scientific therapies.

Aim:
The aim of this research was to explore professional knowledge and decision-making scaffolds in SLT clinical practice with special attention paid to scientific underpinnings. The intention was to gain an authentic understanding of the role of science in practice and thus, a deeper appreciation of the nature of SLT practice.

Methodology and Methods:
A mixed-methodology approach was undertaken targeting SLTs working in Ireland. The initial quantitative phase consisted of an electronic survey (n=271) focussing on therapy choices in disability and dysphagia, reasons for use and non-use of these therapies, and factors influencing decision-making. The subsequent qualitative phase utilised three focus groups (n = 48). Group one consisted of SLTs working in a disability setting, group two of SLTs working in an acute hospital setting and group three of SLTs working in a community setting. Data were analysed using a variety of techniques including descriptive statistics and inferential statistics for the survey data, and thematic analysis for the focus group data.

Results:
The therapies SLTs always-use in both areas of practice represent limited approaches to intervention. In disability, practice is effectively represented by seven high-use predominantly augmentative and alternative communication therapies; in dysphagia the three high-use therapies are mainly bolus modification techniques. A limited range of reasons explained use. Across all areas of practice and all therapies and techniques, client suitability and clinical experience dominated as the main reasons interventions were always used. The principal reasons for not using therapies were lack of training, lack of knowledge and lack of suitability. A clinical lifespan is suggested with early-years clinicians being most dependent on external sources, specifically colleagues, to inform decision-making. Clinicians in the middle years of their careers appear more autonomous while those in the later years appear to branch out to external sources again, most specifically research evidence. Disability and dysphagia clinicians are significantly different in their use of all reasons for use and non-use with the exception of clinical experience. Scientific reasons are not well represented in either area of practice. Moreover, there is an apparent disconnect between attitudes and practice. For example, respondents demonstrate clear research values generally but not when therapy-specific reasoning is explicated.
Three main themes were identified from focus group data: practice imperfect; practice as grounded and growing, and; critical practice. Practice as defined by clinicians is grey-zoned, eclectic, experimental, developmental and pragmatic, being primarily pivoted upon a clinician’s tool bag and experimental practice. This tool bag is composed predominantly of population-specific experience and facilitates the clinician to construct individualised interventions. Clinicians demonstrate scientific thinking but do not automatically reference scientific scaffolds unless explicated.

Conclusion:
Clinical practice is narrowly defined being predominantly scaffolded upon a limited range of therapies and case evidence and practical evidence. Practice is also constructed by SLTs as experimental and flexible. Scientific practice as characterised by research evidence is not evident in this study, however clinicians may operate scientifically through the use of scientific behaviours including experimentation, trial and error and on-going learning. This understanding of practice has implications for the dominant model of evidence-based practice.