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J Head Trauma Rehabil
Vol. 23, No. 5, pp. 273–285
Copyright c
!2008 Wolters Kluwer Health |Lippincott Williams & Wilkins
Collaboration Between
Neuropsychologists and
Speech-Language Pathologists
in Rehabilitation Settings
Jeffrey C. Wertheimer, PhD; Tresa M. Roebuck-Spencer, PhD; Fofi Constantinidou, PhD ;
Lyn Turkstra, PhD; Marykay Pavol, PhD; Diane Paul, PhD
Objective: The purpose of this study was to understand the barriers and facilitators of communication and collabo-
ration between speech-language pathologists (SLPs) and neuropsychologists (NPs) in rehabilitation settings. Method:
Focus groups were held at 3 rehabilitation hospitals. Participants were a convenience sample and were considered
representatives of acquired brain injury rehabilitation teams that include SLPs and NPs. There were a total of 28 SLPs
and 10 NPs in the sample. The study used a semistructured interview guide for the focus group discussions, using
questions centered on major areas known to be related to interdisciplinary collaboration. Written notes and audio
recordings were analyzed for recurring and strongly stated themes. Results: Consistent themes emerged across focus
groups, which included (1) structure of collaboration, (2) perceived roles of NPs and SLPs in assessment and interven-
tion, (3) similarities and differences in training and philosophic perspectives, (4) barriers to successful collaboration,
and (5) facilitators of collaboration. Conclusion: The SLPs and NPs valued the contributions of both professions in
the management of patients with acquired brain injuries. Effective collaboration appeared to be influenced by several
factors and is discussed. It was evident that effective communication was a key and powerful element in success-
ful collaboration. Keywords: acquired brain injury,collaboration,interdisciplinary teams,neuropsychologists,rehabilitation,
speech-language pathologists
INTERDISCIPLINARY TEAMS are playing an in-
creasingly important role in the current healthcare
system. Nowhere is the role of the interdisciplinary team
more important than in rehabilitation settings where a
team of medical and allied health professionals comes
together with the ultimate objective of improving pa-
tient function and independence.1The National Health
Service in the United Kingdom has indicated, “The best
and most cost-effective outcomes for patients and clients
are achieved when professionals work together, learn to-
gether, engage in clinical audit of outcomes together,
From the Department of Behavioral Medicine, Brooks Rehabilitation
Center, Jacksonville, Fla (Dr Wertheimer); Department of Psychology,
National Rehabilitation Hospital, Washington, DC (Dr
Roebuck-Spencer); Department of Speech Pathology and Audiology, Miami
University, Oxford, Ohio, and Department of Psychology, University of
Cyprus, Nicosia (Dr Constantinidou); Department of Communicative
Disorders, University of Wisconsin–Madison (Dr Turkstra); Cerebral
Localization Laboratory, Neurological Institute, Columbia University
Medical Center, New York (Dr Pavol); and Clinical Issues in
Speech-Language Pathology, American Speech-Language-Hearing
Association, Rockville, Md (Dr Paul).
Corresponding author: Jeffrey C. Wertheimer, PhD, Department of Behavioral
Medicine, Brooks Rehabilitation Center, 39 01 University Blvd S, Jacksonville,
FL 32216 (e-mail: Jeffrey.wertheimer@brookshealth.org).
and generate innovation to ensure progress in practice
and service” (as cited in Borrill et al2(p1)).
Inpatient and facets of outpatient rehabilitation rely
on interdisciplinary activities of a treatment team made
up of diverse and specialized medical professionals.
These different specialties typically consist of some
combination of the following: physician, case manager,
social worker, nurse, recreation therapist, physical thera-
pist, occupational therapist, speech-language pathologist
(SLP), audiologist, and psychologist/neuropsychologist
(NP). The Joint Committee on Interprofessional Rela-
tions between the American Speech-Language-Hearing
Association (ASHA) and Division 40 (Clinical Neu-
ropsychology) of the American Psychological Associa-
tion produced guidelines for the structure and function
of interdisciplinary teams for persons with brain injury.3
The guidelines aim to maximize each patient’s potential
for recovery and functional independence. To meet these
goals, team members must work together to address
communication, behavioral, cognitive, and physical
issues, and create integrated and collaborative treatment
plans.
Despite widespread acceptance of the need for
interdisciplinary teams in rehabilitation and their
273
274 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2008
effectiveness in enhancing patient care and outcomes,1
discrepant perceptions among team members exist re-
garding team composition, approach, and structure.4In
addition, confusion regarding the team process and team
member roles has been described in the literature.5–7
Furthermore, overlap exists among team member roles.
A study of physical and occupational therapists in the
United Kingdom8found that role overlap could have
negative consequences, including role insecurity, terri-
torial feelings, and role confusion on the part of col-
leagues and patients. It was seen as inevitable and ac-
ceptable to some degree so long as role delineation
was clear and collaboration between the disciplines was
strong. Attempts to delineate roles more clearly were
felt to be difficult because of increasing demands for
collaboration at a policy level. The authors noted that
role overlap among members of the rehabilitation in-
terdisciplinary team is complex and the way it is man-
aged has significant implications for team dynamics and
effectiveness.
Two other disciplines within the rehabilitation inter-
disciplinary team that have a significant degree of po-
tential overlap are speech-language pathology and neu-
ropsychology. Both disciplines employ language and
cognitive testing in their assessment and treatment of
patients in rehabilitation, with the roles of SLPs and NPs
often complimenting one another.9Despite the signif-
icant amount of overlap between their roles in some
settings, NPs and SLPs often use different language and
cognitive tests, evaluate and treat patients for different
purposes, and use different terminology and concep-
tualizations when describing assessment and treatment
results.
The Joint Committee has a primary initiative to pro-
mote collaboration and communication between the NP
and SLP professions. A recent endeavor by this commit-
tee was to better understand each discipline’s perception
of the practice of the other. To do so, committee mem-
bers conducted a survey of SLPs and NPs practicing in
rehabilitation settings.10 The results illustrated the pres-
ence of significant overlap between assessment methods
of NP and SLP and some misperceptions about the roles
and practices of each discipline. Some SLPs observed
that NPs mainly played a consultant role and provided
services primarily in assessment stages of the rehabilita-
tion process. The SLPs were typically perceived as pro-
viding both assessment and treatment across various cog-
nitive functions. Thus, the roles appear to overlap to a
greater extent for assessment than for treatment. Both
professions reported assessing a wide range of cognitive
and communicative domains, but there was a misper-
ception regarding the types of cognitive abilities assessed
and treated by the other.
The overlap between areas of cognition assessed and
types of treatment provided by NPs and SLPs indicates
the need for effective communication and collaboration
between SLPs and NPs in the rehabilitation setting. Such
collaboration is essential to ensure the most efficient
care to patients, reduce fragmentation of services, and
avoid confusion in communicating assessment results
and treatment goals to patients, their caregivers, and
other members of the interdisciplinary team. To date,
however, there have been no studies that specifically ad-
dress the SLP-NP relationship.
To address this research need, the Joint Committee
conducted focus groups at 3 different inpatient rehabil-
itation hospitals employing NPs and SLPs. The primary
objective was to explore assessment, intervention, and
collaboration issues related to the roles of NPs and SLPs
in assessment and treatment, with the goal of dissem-
inating results and generating recommendations to en-
hance collaboration and standards of practice. The focus
groups aimed to explore threats to assessment validity,
identify inefficiencies as they relate to collaborative ap-
proaches, and identify the system characteristics that ef-
fectively enhance patient care. To capture themes most
relevant to practicing SLPs and NPs, we used a qual-
itative research design. Qualitative methods have been
used successfully across many aspects of healthcare, such
as assessing communication styles in nursing,11 assessing
stakeholders’ satisfaction with hospice care,12 and evalu-
ating treatment approaches to dual diagnoses in mental
health settings.13
METHODS
Setting
Three members of the Joint Committee held focus
groups at their institutions. These included 1 rehabili-
tation hospital in the Southeast (focus group A) and 2
rehabilitation hospitals in the Northeast (focus groups
B and C). The participants were a convenience sam-
ple selected on the basis of availability and accessibility.
Nevertheless, they provide examples of acquired brain
injury rehabilitation teams that included SLPs and NPs
and provided a range of care from acute inpatient re-
habilitation to outpatient rehabilitation. All of the pro-
grams were in private nonprofit institutions in urban
settings and utilized an interdisciplinary team approach
based on standardized and functional assessments (in-
cluding the functional independence measure [FIM])
with more than 3 hours of treatment per day for inpa-
tients and more than 1 hour of treatment per week for
outpatients. All institutions held Commission for the
Accreditation of Rehabilitation Facilities accreditation.
One neurorehabilitation program had approximately 60
beds (25 dedicated to brain injury and 35 dedicated to
stroke) within a 140-bed general rehabilitation hospital.
A second institution had a neurorehabilitation program
Collaboration Between Neuropsychologists and Speech-Language Pathologists 275
consisting of 71 beds (40 dedicated to a stroke program
and 31 dedicated to a brain injury program) within a
143-bed general rehabilitation hospital. The third insti-
tution had a 20-bed neurorehabilitation program (as a
section of a 68-bed general rehabilitation program). At all
institutions, NPs and SLPs frequently interacted across
several different programs and in both inpatient and out-
patient settings. Two of the focus group teams employed
NPs as full-time team members whereas one used NPs
as consultants, although even as consultants they were
considered part of the rehabilitation team.
Participants
The SLPs and NPs at each institution were invited to
participate on a voluntary basis in a focus group via flyers
and e-mails. A total of 28 SLPs and 10 NPs participated
(focus group A: 10 SLPs and 3 NPs; focus group B: 11
SLPs and 4 NPs; focus group C: 7 SLPs and 3 NPs).
Work experience ranged from 1 to 16 years for SLPs and
1 to 14 years for NPs.
Before the facilitation of the focus groups, participants
were provided with a list of questions regarding collab-
oration between SLPs and NPs at their institutions, de-
scribed below, and were invited to attend a focus group.
At the meeting, no identifying information was collected
from the participants except their profession. Partici-
pants were given the option to provide their comments
during the focus group or anonymously in writing to the
group facilitator prior to, during, or after the meeting.
Four participants submitted their responses in writing
prior to the group meeting, one of whom also attended
the meeting and provided oral responses, and one par-
ticipant submitted responses after the group meeting.
For the participant who provided both oral and written
comments, her comments were consistent in the 2 for-
mats and so only her oral responses were included. The
other 4 participants’ written responses were consistent
with the themes generated in the focus groups. Although
consistent themes were generated through both means
of collecting data, it was determined that including both
written and oral responses in the final analysis and write-
up is problematic because the content of oral responses
may be influenced by the social dynamics of the groups.
Thus, although there were similarities in themes gener-
ated between the written and group responses, the writ-
ten responses were omitted and only the data obtained
in the focus groups were used for analysis.
Institutional review boards from 2 of the 3 institu-
tions approved this research. At the third, the institu-
tional review board designated the study as exempt. The
ASHA Science and Research Unit, Surveys and Infor-
mation Team reviewed and approved the focus group
questions before the study.
Data collection and analysis
The focus group questions are listed in the Appendix.
The questions were based on previous research con-
ducted by the Joint Committee members10 and cen-
tered on 2 major areas known to be related to interdisci-
plinary collaboration, “Collaboration” and “Assessment
and Interpretation.” Additional questions were included
to identify other variables that might impact the work-
ing relationship between SLPs and NPs. The study used
a semistructured interview guide for the focus group dis-
cussions. The facilitator for each group, an NP from the
Joint Committee, provided participants with the ratio-
nale for the study and then the interview questions. Fo-
cus group meetings lasted between 45 and 60 minutes.
Data were collected using audiotape (group A) and hand-
written notes (groups B and C).
Audio recordings were transcribed and combined with
the handwritten notes into a collective database of indi-
vidual comments from all 3 groups. There were approx-
imately 180 comments generated in total. Participant-
identifying information and interview questions were
removed. The comments were then circulated to the
authors (3 NPs and 2 SLPs). The authors reviewed all
comments and individually identified themes that met
2 of the 3 criteria described by Owen14 for identifying
themes in qualitative research, which were that the ideas
were expressed in 2 or more responses with different
wording and they were repeated 2 or more times us-
ing the same words. Themes generated separately by the
authors had a high degree of overlap. Owen’s third cri-
terion was that the participants’ verbal and nonverbal
behavior indicated that they felt that the themes were
important. This third criterion could not be addressed
because data on nonverbal behavior were not collected.
In all cases, however, participants were observed to be
actively engaged in discussion and generated a substan-
tial number of comments on each theme, suggesting that
they considered these themes to be important.
As described in prior qualitative studies of clinical ser-
vice practice (eg, Todd et al13 ), the themes were then
discussed by the expert team members (the authors) in
a conference call and a face-to-face meeting and com-
pared with their own perceptions and the previous liter-
ature on multidisciplinary rehabilitation. The individu-
ally generated themes with the highest degree of overlap
were given preference. By consensus, the group identi-
fied 5 main themes in the data. The 5 themes expect-
edly fell under the rubric “collaboration,” and although
occasionally interrelated, these themes presented with
nuances that ensued in their being identified as indi-
vidual topics, once again, based on Owen’s criteria.14
Individual responses were then recoded into each of
these themes by one of the authors and then verified
and agreed to by the remaining authors. Themes, the
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276 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2008
original questions, and the raw response data were then
distributed in writing to the original participants in fo-
cus groups A and B to assess their agreement with the
themes. The participants were asked to review the ini-
tial questions, participant responses, and themes, and
respond to the following questions:
1. Do you believe that these themes represent the ma-
jor elements of interdisciplinary collaboration in
general? If no, please elaborate.
2. Do the comments represent your perspective
about interdisciplinary collaboration? If no, please
elaborate.
3. What changes to the themes would you
recommend?
4. What other comments would you like to add?
Five SLPs and 2 NPs responded from focus group A.
Four SLPs and no NPs responded from focus group B.
The respondents indicated that the data and themes ac-
curately represented their intents and comments and rec-
ommended no changes. The participants also reported
that they found the topic and discussion relevant and
interesting and looked forward to learning more about
the results. These comments suggest that the themes
met the third criterion of Owen14 for the identification
of themes, that is, the participants felt that they were
important.
RESULTS
Findings indicate that 5 themes or factors influenced
collaboration between NPs and SLPs. These factors are
summarized in Table 1 and include (1) structure of the
collaboration, (2) perceived roles of NPs and SLPs in
assessment and intervention, (3) similarities and differ-
ences in training and philosophic perspectives of NPs
and SLPs, (4) barriers to successful collaboration, and
(5) facilitators of collaboration. Table 1 also includes sub-
themes that emerged during data analysis. It should be
highlighted that some of the subthemes emerged within
the multiple factors, and although there is some over-
lap between the subthemes as they relate to the main
factors, mentioning them in the respective sections was
warranted. These themes along with the subthemes are
expanded in the following sections, with representative
comments and quotations from the participants.
Theme 1. Structure of the collaboration
The first category comprised comments related to the
institutional structure and philosophy as it related to
collaboration, including shared beliefs about the value
of an interdisciplinary team and the existence of ade-
quate time and resources for collaboration. Subthemes
that were identified included (1) institutional philoso-
phy, (2) standard of practice at the facility, (3) practi-
cal considerations, and (4) insurance issues. Interview
TABLE 1 Core themes generated from
focus group responses
Structure of the collaboration
Institutional philosophy
Standard of practice at the facility
Practical considerations
Insurance issues
Perceived roles (during the assessment and
treatment process)
The contribution of each discipline to the team
The role of each discipline during assessment
and treatment
Impact of theoretical frameworks and
conceptualization
Effects of theoretical philosophy and
background knowledge/orientation on test
selection, interpretation, and test validity
Focus on impairment vs participation
Barriers to effective collaboration
Lack of availability of team member
Lack of availability of reports or records
Physical distance
Inconsistent/different perspectives
Collegiality issues
Facilitators of effective collaboration
Physical proximity
Team meetings
Communication
Availability of information
Collegiality
findings revealed that collaboration was difficult with
NPs and SLPs who were not located in close proxim-
ity to each other, particularly in the context of the in-
creasing demands for patient contact time and reduced
allowance for team consultation/conference times. In-
stitutions that formally recognized the interdisciplinary
team model were seen as more likely to provide the
structure and support for collaboration. Staff’s opinions
about the institutional structure and philosophy were
illustrated by the following comments:
NP: Collaboration depends on the location of staff. Proxim-
ity of offices had a big impact on the depth and effectiveness
of collaboration. There has also been limited time to collab-
orate due to work demands ... Now, with a programmatic
shift [rather than a departmental model], there is increased
opportunity for collaboration; one, by bringing together staff
associated to specific programs from a physical space perspec-
tive, and two, by having more meeting times to converse. The
programmatic approach also permits increased frequency and
time to communicate (for example, within meetings, etc).
SLP: Team conference in the programmatic model provides
good support.
NP: Bottom line, time and space are two of the biggest chal-
lenges to collaboration. Time to do it and space to collaborate.
Collaboration Between Neuropsychologists and Speech-Language Pathologists 277
If staff is just down the hall, it is easier to make the time to
chat; if they are in a different hallway or location, it is difficult
to collaborate.
NP: When staff is brought together on the same floor and in
the same program, I see increased collaboration, increased ease
of collaboration. Once again, time and space are the biggest
issues.
The second category focused on the standard of prac-
tice at the facility, for example, whether or not it was an
established practice for SLPs and NPs to discuss assess-
ment and intervention for individual patients. Typically,
SLPs and NPs completed independent evaluations and
then collaborated on the discussion of results, either for-
mally or informally. In some cases NPs were not regular
attendees at team conferences but instead engaged in
informal discussions with colleagues and were available
for consultation. One of the SLPs summarized her per-
ception about collaboration as follows:
There is ad hoc collaboration. If you need help or assistance, it
is there in a consultation role. Formal communication between
the disciplines is only now being created due to a structural
shift. With the onset of a programmatic model, there will be
increased communication [formally and informally].
The third category related to practical considerations
of collaborative efforts to optimize the patient’s rehabil-
itation experience. For example, team members could
have different roles depending on the patient’s needs,
such as when the NP needed to focus on behavioral
intervention and the SLP focused on cognitive rehabili-
tation, with each reinforcing the other’s goals. One NP
stated:
The SLP does a good job in managing the speech difficul-
ties and cognitive rehabilitation [treatment], while we tend to
address the behavioral issues and the objective neurocogni-
tive data and how it relates to the functional strengths and
limitations.
Another practical issue influencing collaboration is re-
lated to the patient’s stage of recovery. It was stated that
there could be a greater need for frequent collaboration
in inpatient rehabilitation than in outpatient rehabili-
tation. Participants noted that NPs and SLPs discussed
practical issues such as mutual referrals and referrals to
community sources after discharge, depending on the
patient’s needs.
The fourth category included comments about limita-
tions in insurance reimbursement and the resulting neg-
ative impact on clinical practice and collaboration. Par-
ticipants reported that cotreatment was not reimbursed,
demands for patient contact hours were so great that
there was no time for team meetings, team-meeting par-
ticipation was not reimbursed, and for some services (eg,
cognitive rehabilitation and early intervention for chil-
dren) there was no insurance reimbursement at all. The
importance of insurance reimbursement is reflected in
the following statement:
SLP: Everyone is booked all of the time due to increased needs
for billing time, because of reimbursement issues. It is hard to
carve out time for the NP and the SLP to coordinate a time
to meet. So, we have to resort to communicating via emails
and through reviewing each other’s reports rather than having
face-to-face consultations.
Along the lines of insurance issues, one NP indicated:
[Insurance reimbursement] does come into play upon dis-
charge from the inpatient services. For example, we often find
that we end up to referring to SLPs on an outpatient basis
[instead of NPs providing the service or instead of cognitive
rehabilitation therapists who are not also SLPs] because NPs
and non-SLP cognitive rehabilitation therapists have a diffi-
cult time receiving reimbursement for their services—with some
types of insurance.
This is an interesting point, but it is not generalizable
to all institutions because SLPs typically deliver cogni-
tive rehabilitation at most rehabilitation centers. At this
particular institution, there are cognitive rehabilitation
therapists who have different credentials, which conse-
quently impact reimbursement.
There appears to be more availability for reimburse-
ment of SLP services than for NP services, particularly
for cognitive rehabilitation. It is likely that reimburse-
ment will impact the extent to which both NPs and SLPs
can provide services, but general comments in the fo-
cus groups tended to point out the difficulties that NPs
have with reimbursement and its impact on collabora-
tion. Specifically, other comments from the participants
related to the following points: (1) cotreatment is not
reimbursed; consequently, 1 service tends to take the re-
sponsibilities of working with the patient more so than
the other; (2) it is often the case that in the inpatient
team conference/family conference, reimbursement is
absent, and as a consequence, NPs may be limited to
how frequently they can attend, which leads to reduced
interactions between the NP and team; (3) early inter-
vention services are not reimbursed, which limits the
amount of opportunities to implement such interven-
tion; and (4) the SLP often cannot collaborate with NP
“because the patient does not have a psych benefit and
can’t afford to pay out of pocket,” as stated by a speech
therapist.
Theme 2: Perceived roles in assessment and treatment
Focus group members perceived NPs and SLPs to
have different but overlapping roles, reflecting differ-
ences in their training and expertise. The subthemes that
were identified in this domain included (1) the contri-
bution of each discipline to the team and (2) the role of
each profession during assessment and treatment. With
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278 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2008
regard to the former, and as an example, SLPs could
focus on language and swallowing issues and rely on
NPs for the comprehensive evaluation of cognitive func-
tions, including attention and concentration, memory,
executive functions, and visuospatial functions; brain-
behavior correlations; behavior management plans; and
consultation regarding emotional adjustment or psychi-
atric diagnoses. The NPs were seen as providing infor-
mation that would aid in determining the patients’ neu-
rocognitive strengths and limitations and their ability to
participate in treatment, whereas SLPs were viewed as
providing information related to speech, language, and
swallowing functions as well as formal treatment inter-
vention. Some comments may reveal a misperception
that certain areas of cognition are the sole domain of
1 discipline. Notably, however, it was apparent that the
focus group participants made some comments related
to neuroanatomical correlates of cognitive functions in
an attempt to be humorous when depicting what they
perceived as particular strengths in areas of assessment
for each discipline. This difference is illustrated by the
following quotations:
NP: SLPs own the temporal lobes in the context of speech;
NPs look broadly at the geography of the brain, describing
domains of cognitive testing across domains and how various
domains impact other functions, in addition to intellectual
and emotional functioning.
SLP: SLPs rely on NPs to sort out the frontal lobe.
SLP: SLPs rely on NPs to assist with behavioral management.
We as speech pathologists do not get training in behavioral
management [in academia], and we rely on the NPs to assist
the team in behavioral management issues.
NP: I look at the SLP to explain speech functions in greater
depth. We use SLPs to understand speech pathology even
more: speech apraxia and speech pathology, etc.
These differences in expertise were viewed as positive
factors in the development of an integrated treatment
plan for an individual patient and were fostered by on-
going communication between SLPs and NPs on the
team. As 1 participant commented:
It is important to exchange information and to tap differ-
ent knowledge bases. We can benefit from differences in
discipline/staff experiences in various treatment settings, train-
ing, and team dynamics. For example, an SLP may have more
experience in discriminating verbal apraxia from nonfluent
aphasia than an NP.
Collaboration via ongoing communication about the
patient’s cognitive status is very important, especially
if the SLP is more focused on language or swallowing
issues.
In addition to differences in roles and expertise, there
were also areas of overlap in both assessment and in-
tervention, as both SLPs and NPs could be involved in
cognitive assessment and treatment. These overlapping
areas could be facilitators or barriers to interdisciplinary
collaboration, as discussed later in the results.
Theme 3: Theoretical perspective of each profession
The participants described 2 general subthemes re-
lated to the theoretical perspectives of each profession:
(1) effects of theoretical philosophy and background
knowledge regarding test selection, validity, and inter-
pretation and (2) outcomes focused on by each profes-
sion: impairment versus participation.
The issue of theoretical philosophy/orientation re-
garding test selection appeared central in many of the
responses. Respondents commented on problems and
solutions regarding test selection and overlap (validity).
Overlap in tests was observed to create problems through
practice effects and constraints on what can be admin-
istered by each profession. Several respondents reported
that communication between SLPs and NPs was essen-
tial to resolving problems with test overlap. Although
there is evidence of effective communication as it re-
lates to approaching assessment, there continues to be
evidence for inefficient collaborative approaches to as-
sessment. This issue emerged frequently in discussion,
with the following quotes provided to illustrate the gen-
eral perspectives of the participants:
NP: There is certainly overlap in the use of assessment instru-
ments and history taking. There is no solution in place, even
after discussing the matter.
SLP: Our arena style evaluation is challenging because the NP
is very formal in testing, which limits the open evaluation ap-
proach used with the younger toddlers for the SLP. We often
want to facilitate responses to see how the child approaches
tasks rather than looking at the specific response; this would
certainly negatively impact NP test scores that seem to be a
priority.
SLP: It is difficult to administer standardized measures due to
limited time and the severity of impairment. We use clinical
impression more so in our evaluations.
SLP: There is overlap in the assessment of attention, memory,
and language.
NP: Some SLPs are trained to administer specific NP mea-
sures and use them in treatment and assessment (e.g., Boston
Naming Test), which compromises the NPs ability to use that
same test in the assessment. Our facility is good about collab-
orating and being in touch with what measures are being used
in other disciplines.
SLP: We’ve historically discussed what tests each discipline
administers and agree not to overlap.
NP: The Peds [Pediatric] unit is really good at
communication—SLP and NP meet for admission and
discharge evals to distribute testing and coordinate. At the
outset of the Peds program, the SLP on the Peds unit is not as
Collaboration Between Neuropsychologists and Speech-Language Pathologists 279
involved in testing cognition as the SLP in the adult unit and
other settings. The SLP and NP acknowledged issues early on,
planned collaboration, and now talk early on in the treatment
course to coordinate/share testing.
Other comments illustrate the role of theoretical phi-
losophy on interpretation of cognitive testing. Respon-
dents appeared much aware of the differences between
the more functional and process-oriented approach typi-
cally used by SLPs and the emphasis on normative com-
parisons and psychometric data used by NPs. These dif-
ferences, however, were not perceived to be a problem.
There were some individuals who noted some benefits
of the different approaches.
SLP: The NP interprets data based on normed scores, primarily,
while the SLP interprets results based on tests and informal
measures (behavior play skills, language samples).
NP: The SLP often relies on percentage accuracy; the NP relies
on standard scores. The NP is more likely to estimate premor-
bid functioning and discuss how tests differ from an estimated
baseline.
NP: This is like the proverbial elephant analogy; some grab
the tail, some grab the trunk, some grab the leg. It is all one
animal, we are just grabbing at different parts and have different
perspectives.
SLP: The SLPs rely less heavily on formal test results as the
determining factor. They integrate test scores and behavioral
responses to determine diagnosis and recommendations.
SLP: We like the neuropsychological evaluations because they
often address practical implications, return to work, prognosis
for recovery, etc. I tend to think what do they need to deal
with today, not how long is it going to be before they go back
to work and will they ever go back to work. The NPs give a
broader perspective.
There were differences between the disciplines with
regard to conclusions drawn from assessment data, such
as whether the focus was to be on documenting impair-
ment versus describing activity/participation issues. The
influence of functional measurements (eg, FIM ratings)
on assessment and interpretation was noted, particularly
the difficulty in comparing results of functional measure-
ments with results of standardized assessment.
NP: There is a difference between our views, as it relates to
impairment and disability. The NP looks at more impairments
(how the patient is impaired relative to other people with simi-
lar demographics and to themselves; e.g., premorbid estimated
functions); whereas, SLPs look at more disability and capability
functionally.
NP: The SLP—often focused on functioning in the environ-
ment. The NP—often focused on degree of impairment and
extent of injury to the brain.
SLP: It is difficult to use standardized tests, as we rely on the
FIM and keep that in mind when administering tests. It is
difficult looking at the standardized results and transforming
them into FIM standards and the goals that are related. It is
sometimes easier to use more informal assessments about their
functioning to write real-world functional goals.
SLP: We do not always see specific test scores in the NP’s
reports. We only see qualitative descriptions instead.
Importantly, some participants observed that the dif-
ferences between impairment ratings and functional
ratings might be discrepant and interfere with clear
communication to patients and families. Differences in
assessment approaches may contribute to this discrep-
ancy, as it is more common for NPs than SLPs to in-
terpret test scores after correcting for demographic nor-
mative information and/or premorbid impairment. This
can lead to different conclusions made by NPs and SLPs
when interpreting levels of impairment or potential dif-
ferences from baseline. Differences in perspective can
lead to differences in how a given patient’s impairments
are interpreted and subsequently how this information
is conveyed to family members, as noted in the previous
section. For example, one NP described a situation in
which the NP provided educational materials to the pa-
tient’s family describing right hemisphere injury and at-
tentional neglect and later learned that the SLP provided
educational materials discussing aphasia and language
impairment to describe the same cognitive impairment.
The following comments illustrate other differences in
assessment and interpretation of results and how these
differences could impact the understanding of the pa-
tient and families:
NP: SLPs are measuring patients using FIMs; NPs measure cog-
nitive performance based on a normative data sample. SLPs
tend to look in terms of more functional ability outside of
use of the norms. NPs are comparing the patient to a norma-
tive sample. SLPs often look at how much assistance they [the
patient] need. Thus, the data described may have a different
appearance between disciplines. Consequently, occasionally,
the patient receives different opinions about their functional
status and may be confused. The patient may challenge an-
other staff member regarding his or her capability based on
the different feedback they receive.
NP: Moderate level of impairment on tests may be difficult to
discuss with the family in the context of what functional level
the patient will be going home. Many may ask, what is a better
predictor of functional outcome, FIM ratings or NP tests?
SLP: The NP tends to be more structured and discreet trial
driven than the SLP, resulting in different assessment out-
comes, and sometimes diagnostic decisions are different.
It was also noted that differences in conceptualization
could lead to the same end result. For instance, one in-
dividual noted that while SLP and NP may “conceptual-
ize assessment and treatment differently, but sometimes
what we actually do with the patient looks similar.”
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280 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2008
Theme 4: Barriers to effective collaboration
Multiple barriers were identified within the focus
groups that were believed to limit or pose challenges
to effective communication and collaboration between
NPs and SLPs. The subthemes included (1) lack of avail-
ability of team members, (2) lack of availability of re-
ports or records, (3) physical distance, (4) inconsistent/
different perspectives, and (5) collegiality issues.
The primary identified barrier to collaboration was
the perception that each discipline had limited access
to the other. This perception was held most strongly
by SLPs regarding their ability to access and commu-
nicate with NPs. Specifically, multiple comments were
made that indicated that NPs are not consistently able
to participate in team meetings, family conferences, and
informal communications between SLPs and other team
members.
SLP: I wish the NP could be present at more team conferences.
SLP: SLPs would like NPs present more often at family confer-
ence, but often the NP decides not to attend family conference
at times to avoid discussion of sensitive topics in that setting
and will thus opt to hold separate family conference.
Reasons for reduced access to one another were typi-
cally due to (1) poor physical proximity (ie, individuals
are located in different parts of the hospital) and (2) lim-
ited time to devote to communication due to increased
productivity demands by facilities. An NP underscored
these points when he stated that space and time “are
two of the biggest challenges to collaboration.” In many
settings, NPs are expected to be members of the inter-
disciplinary team but may work in a consultative model
with regard to reimbursement, which limits their ability
to participate in nonbillable activities. Participants also
noted that communication is especially difficult for NPs
or SLPs who work off-site. This limited access reduces the
opportunities for NPs and SLPs to discuss cases, plan
assessments and treatments, and share information and
results. Greater use of e-mail and voice mail communica-
tion was offered as potential solutions to these problems.
In addition to decreased opportunities for interaction
between the disciplines, SLPs expressed some difficulty
in obtaining neuropsychologic test findings and written
reports. It was noted that NP reports are not always easily
located in the medical record or in a place that is easily
accessible by SLPs. A contributing factor to this barrier
could be the NP’s role as “a consultant” on the team. This
difficulty in accessing information led to uncertainty re-
garding whether a patient was previously seen by an NP
and how to obtain this information. Two SLPs indicated:
I am not sure if the NP has seen or assessed certain patients be-
cause I don’t always see the records. I would like more sharing
of patient records and would like more communication about
them.
It’s hard to get actual test scores in NP reports and sometimes
it’s hard to get reports at all... .
These comments are likely driven by the fact that neu-
ropsychology reports and notes, in some settings, are
kept separately from other medical records, per Health
Insurance Portability and Accountability Act (HIPAA)
requirements for mental health records.
There was also indication that the neuropsychology
reports often take longer to be placed in the chart,
which makes it more difficult to obtain the results in
a timely matter. This delay in having access to the re-
port can have an impact on treatment. For instance,
the timing of an assessment is essential in rehabilita-
tion settings where the patient may be recovering at a
rapid rate. One SLP noted, “There is sometimes a de-
lay between the NP test and when cognitive rehabili-
tation starts. The test results may not give an accurate
depiction of where the patient is by the time they start
treatment.” Moreover, if a neuropsychologic evaluation
is conducted much earlier than the start of cognitive
rehabilitation, test results may not provide an accurate
description of the patient’s cognitive abilities at the start
of treatment, leading to difficulty using those results to
plan treatment and to provide education to patients re-
garding cognitive functions. An NP added, “Since there
is a wait list for some of the cognitive rehabilitation
therapists, some of the patients do not get seen within
a reasonable timeframe after the neuropsychological
evaluation.”
As mentioned in the previous section entitled Theoret-
ical Perspective of Each Profession, there were differences in
theoretical perspectives and background knowledge re-
garding test selection, validity, and interpretation. These
differences were noted to be a particular barrier in collab-
oration, and how NPs and SLPs conceptualize cases was
a frequent discussion point. It was noted that NPs and
SLPs frequently use different terminology to describe
their results and may conceptualize assessment results
and patients’ behaviors differently. For example, one
SLP stated, “There may be challenges because of the use
of different language/terminology/definitions of impair-
ment. What does the NP mean by impairment as com-
pared to norms or premorbid expectation?” Different
perspectives in case conceptualization can be found to
impact assessment. In addition to the previously noted
comments, the following points address barriers in this
context:
NP: There are differences in how the same observed impair-
ments are conceptualized and labeled. One might attribute
errors on tests to aphasia or apraxia and others as executive
functioning/working memory impairment. These different
views could impact treatment.
NP: NPs interpret data in the context of etiology; whereas
SLPs do not interpret in the context of lesion and etiology.
Collaboration Between Neuropsychologists and Speech-Language Pathologists 281
NPs tend to look at the anatomical correlates. SLPs do not
appear to differentiate between premorbid and post-morbid.
SLP: SLP memory tests are more general, while NP tests are
more specific, and there could be differences in interpretation
of the results.
With regard to collegiality issues, the barrier that
seemed most relevant appeared to be related to poten-
tial “turf battles” in the cognitive testing arena. One
NP stated, “The nature of collaboration is very good
between disciplines; there is good interdisciplinary cul-
ture, respect between disciplines, and good communica-
tion. There have been turf battles in the past (particularly
with regard to cognitive testing), but there are not any
currently.” Although there was not an indication that
turf battles existed at the 3 institutions where the focus
groups took place, turf battles appear to have existed in
the past and indeed may be relevant at other institutions.
Although “turf battles” were a significant part of the past
for a few of these participants and were seen as barriers
to collaborative relations, there were comments about
the positive nature of collegiality.
Theme 5: Facilitators of effective collaboration
Multiple facilitators to effective collaboration be-
tween SLPs and NPs were identified within the focus
groups. The subthemes included (1) physical proximity,
(2) team meetings, (3) communication, (4) availability
of information, and (5) collegiality. Several of these sub-
themes have been identified in previous sections, even
in the context of being a barrier for some. These sub-
themes, however, were thought to have a particular role
in facilitating successful collaboration, and thus, were
included in this section. There was also a “wish list” of
items that staff reported would likely be helpful in col-
laborative relationships.
One of the main facilitators to effective collaboration
was “access” to each discipline, particularly in the con-
text of informal consultations/interactions. Although lo-
cation of offices was a barrier for some as noted pre-
viously, other participants noted that with convenient
proximity, effective use of consultation ensued. What
appeared evident was that “adequate” proximity was
defined by having the professions on the same floor
at the very least, but the most ideal propinquity was
having these 2 professions residing within the same
hallway, preferably having adjacent offices. Clinicians
agreed that if they were in the same hallway, it would
be feasible to have informal contacts with one another,
enhancing collaboration and patient assessment and
intervention.
SLP: Having the NP and SLP’s office adjacent to one another
increased the frequency and quality of collaboration, due to
increased informal contact.
Team meetings and communication were considered
important facilitators to effective collaboration. With re-
gard to the former, although it appeared that it may be
difficult for the NP to attend team meetings due to rea-
sons discussed in the previous section, both SLPs and
NPs indicated that the team conference is a valuable
venue wherein assessment results and treatment updates
and planning can be discussed.
SLP: Team conference was a good place to discuss the results
of the independent evaluations to assist both disciplines (and
the other team members) in planning for other aspects of the
patients’ treatment.
Communication was deemed essential to optimal pa-
tient care. Communication can facilitate in planning the
assessment battery (to reduce overlap and maintain the
validity of the instruments during testing), treatment,
and factors related to discharge.
NP: On the pediatric unit, the NP and SLP meet before each
case, agree who will give which tests, work together on inter-
pretation, and also meet before discharge to plan discharge
evaluations.
SLP: We look at the goals of the other staff members and
collaboratively address what needs to be done so we do not
overlap too much.
Discussions within the focus groups also revealed
that availability of information was another impor-
tant facilitator. In general, both disciplines stated that
timeliness in generating reports and good chart docu-
mentation (eg, efficient and succinct) are helpful in fa-
cilitating good treatment. A couple of participants stated
that having good organization in the medical records is
beneficial. Although timely turnarounds on reports and
daily notes, efficient and succinct chart documentation,
and discipline-specific sections in the medical charts are
good facilitators, they may not be employed by every
clinician or exist at every institution.
With regard to collegiality, in general, there appears
to be sound, respectful relationships between SLPs and
NPs at each of the institutions where the focus groups
were held. Candid examples from some clinicians at
the institutions provide illustrative comments on this
topic:
SLP: There is a strong professional rapport between speech-
language pathology and neuropsychology.
NP: The nature of collaboration is very good between
disciplines... .
SLP: I think we work really well together.
In the context of facilitators to good collaboration,
there was also a “wish list” discussed with suggestions
for improving collaboration. Some of these suggestions
included the following.
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282 JOURNAL OF HEAD TRAUMA REHABILITATION/SEPTEMBER–OCTOBER 2008
1. There should be quarterly or semiannual meetings
to discuss specific topics and improve communi-
cation between NPs and SLPs. It would be valu-
able to discuss differences in test administration,
interpretation, and conceptualization of cognitive
impairment.
2. Meetings between the SLP and the NP the day af-
ter an evaluation would be helpful in facilitating
treatment and establishing discharge plans.
3. Learning about how each discipline interprets test
data would be helpful. For example, it would be
interesting to identify how differences in data in-
terpretation may exist on the basis of discipline-
specific training backgrounds.
4. Increase informal meetings/collaboration in the
context of discussing approaches to assessment. In
addition, it would be helpful to discuss the results
of the evaluations in greater depth than what a team
conference will typically permit.
SUMMARY AND RECOMMENDATIONS
The purpose of this study was to understand the barri-
ers and facilitators of communication and collaboration
between SLPs and NPs in rehabilitation settings, as they
were perceived by the 2 groups of professionals. The 5
primary themes that emerged were (1) structure of the
collaboration, (2) perceived roles of NPs and SLPs in
assessment and intervention, (3) similarities and differ-
ences in philosophic perspectives of NPs and SLPs, (4)
barriers to successful collaboration, and (5) facilitators of
collaboration. The results indicated that SLPs and NPs
value the contributions of both professions in the man-
agement of patients with acquired brain injuries. Effec-
tive collaboration appeared to be influenced by factors
related to institutional and programmatic issues, finan-
cial considerations, physical proximity, and differences
in theoretical perspectives between the 2 groups. It was
evident throughout the discussions that effective com-
munication was a key and powerful element in building
successful teams and a major facilitator for collaboration.
Recommendations to improve team collaboration
A strong theme that emerged from this study was that
institutional practices play a significant role in enhanc-
ing collaboration. We recommend that rehabilitation
centers consider the following.
a. Facilitating physical proximity and accessibility
among team members. The SLPs and NPs who
work in the same physical area reported more effec-
tive communication and, subsequently, improved
collaboration.
b. Discussing approaches to assessment (such as test
selection) to protect the validity of the tests admin-
istered and to enhance assessment efficiency.
c. Establishing formal team meetings to discuss as-
sessment results, patient goals, patient progress,
and discharge planning. These opportunities seem
to be influenced by the current financial climate,
which focuses on direct patient care and the need
to generate billable hours. Team meetings could in-
crease patient outcomes, which in turn add to the
reputation of the institution.
In addition to institutional practices, third party pay-
ers need to gain a better understanding of the value
of team meetings and cotreatments. Team meetings al-
low rehabilitation staff members to plan patient care
services more effectively, thus potentially maximizing
rehabilitation outcomes. Therefore, third party payers
should reevaluate reimbursement practices, which often
do not allow for indirect patient care as a billable service.
In addition, limitations in reimbursement for NP ser-
vices in turn restrict access to in-depth neuropsychologic
data provided by NPs and needed by other team mem-
bers and thus limit the NPs’ contribution to treatment
planning and discharge. Again, this putative cost saving
may have a significant adverse effect on rehabilitation
outcomes.
There are similarities and differences between the 2
professions in their scope of practice and theoretical
perspectives on human behavior. The extent of these
similarities and differences and the ability to understand
each other’s theoretical framework seem to be influenced
by academic and clinical preparation and the ability to
clearly communicate issues pertaining to assessment phi-
losophy, testing practices, and treatment planning ap-
proaches. The present study indicates that when these
issues are sorted out explicitly, collaboration benefits.
The results of this study suggest that effective collab-
oration translates into better quality and access to reha-
bilitation services for patients who are the consumers of
these services. If this is true, it will also translate into bet-
ter patient outcomes. This is a key issue to be explored
in future research.
Limitations
A limitation of the sample was that the participants
were not randomly selected from among the rehabili-
tation community but rather were drawn from the au-
thors’ workplaces. These results will generalize best to
settings similar to those sampled, which we feel are
generally representative of large nonprofit rehabilita-
tion hospitals employing NPs and SLPs. These results
may not generalize as well to programs in rural set-
tings, programs that do not employ NPs, programs with
a different financial structure/payer mix, or programs
outside of the United States. This study’s convenience
sample could also bias the results in the direction of
more positive comments, assuming that the authors
Collaboration Between Neuropsychologists and Speech-Language Pathologists 283
who were members of the Joint Committee and who
served as the focus group leaders, held a strong inter-
est and positive perspective on collaboration. That be-
ing said, participants had negative as well as positive
comments, so familiarity with the author did not in-
hibit them from being critical. It would be of interest,
however, to elicit comments from SLPs and NPs in other
locations, such as extended care settings, in which a for-
mal team might not exist. In these settings, factors such as
knowledge about each other’s skills and practices might
have a greater influence on collaboration, and institu-
tional barriers might be even more salient.
Another limitation of the focus group method is that
participants might not feel free to share comments in
the presence of their colleagues. The authors felt that
the benefits of generating topics through discussion out-
weighed this risk and also provided individuals the op-
portunity to submit written comments anonymously
before or following the focus group and to submit com-
ments in the feedback stage of data collection. Four par-
ticipants provided written comments before attending
the focus group, and 1 participant submitted responses
after the group meeting. No participant added or edited
his or her comments at the feedback stage, and in fact,
the feedback only indicated that the data appeared to
accurately and adequately reflect the perspectives of the
participants. It would be of interest, however, to supple-
ment the group discussions with detailed individual in-
terviews, as is often done in qualitative studies, to elicit
any comments that participants might be reluctant to
share in a group.
A third limitation was that only 1 of the 3 groups
was audio recorded. Thus, 2 of the 3 groups relied on
handwritten notes to later interpret the data rather than
having specific quotes to which to refer. Nevertheless,
the themes generated and the subthemes identified were
consistent across focus groups. Thus, the data are repre-
sentative of the themes of all focus group discussions.
A final potential limitation was the number of partic-
ipants in the focus groups. Specifically, at 2 institutions,
there were more than 12 participants in the group. That
slightly exceeds the recommended “ideal size” of be-
tween 6 and 12 participants.15 As a consequence of the
size of the groups, some participants may have had lim-
ited opportunity to engage in the capacity in which they
may have desired to participate. Again, this was not re-
flected in the written comments or during the feedback
stage, which were not influenced by group size or group
dynamics.
Implications and future research
The focus group format appeared to be an effective
and practical mechanism for identifying factors that in-
fluence collaboration between SLPs and NPs. Respon-
dents were strongly supportive of the interdisciplinary
team format. Most negative comments related to the de-
sire to improve communication and collaboration so as
to improve clinician performance and patient outcomes.
Future research should expand the breadth and depth of
this research using methods such as case study scenarios,
which might yield more concrete patient-related sugges-
tions and also include participants from additional re-
habilitation centers. Study of the influence of the in-
terdisciplinary team format on cost-effectiveness and
patient outcomes may be useful in demonstrating to in-
stitutions and insurance companies the benefits of sup-
porting interdisciplinary teams, thus increasing support
for clinician proximity and time for collaboration. This
question may be studied via comparisons of outcomes
from teams with and without physical proximity and
dedicated meeting time. Future research should concen-
trate on the development of viable collaborative team
paradigms, fluid and flexible enough to allow adapta-
tion to the difficulties specific to the respective reha-
bilitation settings. Finally, given that institutional prac-
tices and financial barriers were identified as important
factors influencing collaboration, the inclusion of in-
ternational rehabilitation centers, with medical systems
different than the United States might provide helpful
insights and could be a fruitful line of investigation.
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Collaboration Between Neuropsychologists and Speech-Language Pathologists 285
Appendix
Focus Group Questions
Collaboration
1. What is the nature of the collaboration between speech-language pathologists (SLPs) and neuropsychologists
(NPs) in your setting?
2. What challenges have you encountered during collaborative approaches with the fellow discipline? What success
have you had in resolving these challenges?
3. Please describe any systems or supports that exist that you believe positively influence collaboration.
Assessment and Interpretation
1. Please describe overlapping responsibilities between SLP and NP that result in challenges related to assessment.
a. What threats to test validity have you encountered? (eg, How do your departments account for the admin-
istration of the same tests—practice effects?)
b. How do you try to minimize threats to test validity?
2. What differences between the 2 disciplines do you find in the way test data are interpreted? How do you address
these differences?
Other
1. How does insurance/reimbursement influence your collaborative relationship with the other discipline?
2. What is the major contribution of the SLP and NP on the interdisciplinary team?
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