Dysphagia support in disability services: stakeholder perspectives

Abstract

This paper describes stakeholder perspectives on good practice in dysphagia support in the disability service context. Twelve adults with dysphagia were interviewed. Twenty-four allied health professionals, sixteen family members and seventeen disability support workers (DSWs) completed a questionnaire and three focus groups for DSWs were conducted. Results indicated overwhelming support for a range of service improvements including mandatory training for support workers. Findings will be used to inform an organisational dysphagia support standard and to promote service reform.

Full text

Journal of Clinical Practice in
Speech-Language Pathology
Volume 13, Number 1 2011
Research
Print Post Approved PP352524/00383 ISSN 2200-0259
In this issue:
Understanding ethnography
The value of honours graduates
Participatory research
Implementation of ePortfolios
Why SLPs don’t engage in telehealth
Clinical research: A meeting of minds
Journal of Clinical Practice in
Speech-Language Pathology
Volume 16, Number 3 2014
JOURNAL OF CLINICAL PRACTICE IN SPEECH-LANGUAGE PATHOLOGY
Volume 16, Number 3 2014

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ACER Product Update
ACER offers an extensive range
of specialist resources for both
teachers and speech pathologists
ACER and Sounds for Literacy present the
Cued Articulation App
Consonants and Vowels
by Jane Passy, Helen Botham & John Botham
Australian Council for Educational Research
Cued Articulation
iPad App
Key features:
• Addition to the popular Cued
Articulation series
• Interactive consonant, vowel and
diphthong tables
• Videos and audios of each sound
and gesture
• Examples of each sound within
everyday words
https://itunes.apple.com/AU/app/
id873057924?mt=8
School Entry
Alphabetic and
Phonological
Awareness
Readiness Test
(SEAPART)
Key features:
• Measures pre-literacy skills at the
point of school entry
• Precursor to the popular SPAT-R
assessment
• Takes less than fi fteen minutes to
administer and score
• USB includes PDFs, presentation and
video demo
https://shop.acer.edu.au/acer-shop/
product/990SRT
Astronaut Invented Spelling Test-2
(AIST-2)
Key features:
• Measures phonemic awareness via
spelling attempts
• Provides information about emerging
orthographic awareness
• Can be given to whole classes or
individuals in ten minutes
• By the creator of SPAT-R and SEAPART
https://shop.acer.edu.au/acer-shop/
product/990AIS

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 109
Research
Research is central to our work as speech pathologists. Regardless of whether
we work in clinical practice or academia, research informs what we do and how
we do it. As clinicians, each interaction that we have with clients, families, and
other professionals enables us to gather information that we can use to inform our clinical
decision-making, and evaluate our practice. Similarly, as academics, our work is often
focused on exploring the characteristics/needs of the populations with whom we work,
or the outcomes of our practices, in order to ensure the services we provide are the most
appropriate, timely, effective, and holistic. Our aims and methods will vary, depending on
whether the focus of our research is client-based or a larger scale project, but findings
contribute to the knowledge base within our field of practice.
This issue of JCPSLP is focused on the theme of research. As such, it contains papers
that explore modes of research within speech pathology, as well as papers that describe
the outcomes of research studies in the field. Hersh and Verdon describe two different
modes of research that are both valuable in informing health care practices. Hersh’s paper
discusses action research, while Verdon’s paper provides a description of the way in which
ethnography can be used in speech pathology, with examples from her PhD studies. In
addition, Robinson explores the value of Honours studies in preparing health students to
become research-practitioners.
The research studies within this issue of JCPSLP utilised a range of methods to
explore questions related to clinical and professional practice. Drummond and colleagues
interviewed a client, her mother and a friend to explore their experiences of traumatic brain
injury. Miller and colleagues used a combination of interviews and questionnaires with adults
with dysphagia, allied health professionals, family members and disability support workers to
explore perspectives of good practice in the provision of dysphagia support. Erickson used
interviews and focus groups with speech pathologists to describe the barriers preventing
them from using telehealth and strategies that would support its uptake, and Lewis used
a questionnaire with speech pathology students to examine their perceptions of the value
of ePortfolios as a learning tool. Finally, in her clinical insights paper, Zaga described the
use of an auditing tool and focus groups with different professional groups to improve the
dysphagia management of patients in hospital.
We hope you enjoy reading about research and about the outcomes of particular research
studies within this issue of JCPSLP. This is our final issue as editors of the journal and we
would like to take the opportunity to thank those who have assisted in the publication of
each issue (Lana Busby, Carla Taines, Bruce Godden and the Editorial Committee), as well
as the authors and reviewers who have ensured that the content of each issue has been so
interesting and stimulating for readers. We have really enjoyed the role as co-editors of the
journal and wish David Trembath well as he takes on the position for 2015–16.
From the editors
Jane McCormack and Anna Copley
109 From the editors
110 Understanding the world through
ethnography: The experience of
speech-language pathology
practice in culturally and
linguistically diverse settings –
Sarah Verdon
117 Why should we value honours
graduates? – Caroline Robinson
123 Participants, researchers and
participatory research –
Deborah Hersh
127 “Can you speak English?”: The
effects of social communication
impairment on the life of an
adolescent with traumatic brain
injury – Jessica Drummond,
Michael Curtin and Lucie Shanahan
133 Dysphagia support in disability
services: Stakeholder perspectives
– Rosie Miller, Nick Hagiliassis,
Meredith Prain and Janet Wilson
139 Implementation of an ePortfolio:
Perspectives of speech pathology
students – Abigail Lewis and
Katrina Strampel
147 Telehealth: Why not? Perspectives
of speech-language pathologists
not engaging in telehealth – Jodie
May and Shane Erickson
152 Reducing error in a complex
system: Texture modified diet and
fluid provision – Charissa Zaga and
Joanne Sweeney
157 Webwords 50: Clinical research:
A meeting of minds in SLP/SLT
– Caroline Bowen
159 Top ten resources in an intensive,
group-based intervention setting
for young children with autism
spectrum disorder – Katherine Pye
Contents
www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 109

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 111
Research
110 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
KEYWORDS
ETHNOGRAPHY
PRACTICE
QUALITATIVE
RESEARCH
THIS ARTICLE
HAS BEEN
PEER-
REVIEWED
Sarah Verdon
Understanding the world
through ethnography:
The experience of speech-language pathology practice in
culturally and linguistically diverse settings
Sarah Verdon
Qualitative research in health provides insight
into the experiences, perceptions and
interactions of clients, caregivers, health
professionals and the broader community. In
this paper, the use of ethnography is
discussed as a qualitative research technique
to facilitate the understanding of the practice
of speech-language pathology in different
cultural and linguistic contexts around the
world. A description is provided of the different
types of data collection methods that can be
employed in ethnographic research (such as
observation, interviews, photography, video-
recording, and personal reflection) and their
usefulness in facilitating understanding of
complex practice situations. Important
considerations for designing and undertaking
ethical and culturally appropriate qualitative
research are explored and the benefits of
qualitative research to the speech-language
pathology profession are discussed.
Qualitative health research is a field of research
which focuses on the experiences, perceptions
and interactions of clients, caregivers, health
professionals and the broader community (Morse, 2011).
Qualitative health research acknowledges that there
are different ways of viewing the world. In qualitative
research the key to enhancing understanding is not to
reduce research findings to figures or statistics, but to
expand knowledge by considering multiple viewpoints. In
essence, qualitative research adds “flesh to the bones” of
understanding provided by quantitative research. Qualitative
methods first appeared in health contexts in the form of
ethnographic studies of practices in the 1950s (Morse,
2011). Since then, ethnography has been used to study
practice in a number of health care fields such as nursing
and medicine (for example, Antrobus & Kitson, 1999;
Carroll, Iedema, & Kerridge, 2008).
Ethnography
Ethnography is a type of qualitative research, which involves
the study of people in naturally occurring settings through
observation and data collection methods which capture
ordinary activities and their social meanings. Social scientists
use these observations to write ethnographies. The word
ethnograph simply means folk (ethno) and writing (graph).
Therefore, ethnography is the social science of writing
about particular folk and the activities they undertake.
The aim of ethnographic research is to “try to get inside
the fabric of everyday life” (Silverman, 2011, p. 113).
Ethnographic observation differs from other forms of data
collection in that the researcher must enter the field and
be physically present in the activity that they are trying to
study (Eberle & Maeder, 2011). In entering the field they
experience “the architecture, the furniture, the spatial
arrangements, the ways people work and interact, the
documents they produce and use, the contents of their
communication, the timeframe of social processes and so
on” (Eberle & Maeder, 2011, p. 54). Being present in the
field allows real-time experience and interpretation of events
in a way that reflections, interviews and second-hand
accounts do not.
In ethnographic research the emphasis is typically
placed on exploring and understanding the nature of a
particular social phenomena (for instance, the practice of
speech-language pathology in culturally and linguistically
diverse contexts) rather than testing a specific hypothesis
developed by the researcher (Atkinson & Hammersley,
1994). Ethnographic research usually involves studying a
small number of cases in great detail, rather than seeking
the breadth of a large number of cases or representative
sample as is common in quantitative research (Atkinson &
Hammersley, 1994). The product of ethnographic research
is usually presented in the form of written descriptions and
explanations of the meaning of human activity rather than
quantifiable results (Atkinson & Hammersley, 1994).
There are a number of key elements to effective
ethnographic research: observation, description,
contextualism, process, and flexible research designs
(Bryman, 1988, see Box 1). Achieving the key elements of
effective ethnographic research can be assisted by using
various forms of data collection which together provide
multiple viewpoints of the research site. By shadowing
participants and taking fieldnotes the researcher is trying
to see through the participants’ eyes, but at the same
time it is important not to assume what participants are
thinking or feeling based upon observations. This is why
accompanying fieldnotes with interviews can help to
clarify what was observed and add information about how
participants felt and what their intentions and motivations
were during observed sessions.

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 111
need for this research was highlighted by a review of the
literature in this field which consistently identified speech-
language pathologists’ (SLPs’) challenges when working
with people from culturally and linguistically diverse
backgrounds (Caesar & Kohler, 2007; Stow & Dodd, 2003;
Williams & McLeod, 2012) but provided limited practical
examples and suggestions for modifying practice to
facilitate optimal engagement with this population. The
inability of existing literature to inform the complexities of
practice with people from culturally and linguistically diverse
backgrounds highlighted the need for a new approach to
research in this field. Ethnography was selected as the
most appropriate research method to address the research
problem identified in the Embracing Diversity – Creating
Equality study given its historical use in the understanding
of cultural diversity and its potential to provide insight into
complex everyday activities.
Adopting a theoretical orientation
The use of a theoretical lens aids in providing a scaffold for
interpreting and making sense of the large amounts of
qualitative data collected during ethnographic research. In
the Embracing Diversity – Creating Equality study, cultural
historical activity theory (CHAT) (Engeström, 1987) was
used as the theoretical framework for interpreting and
analysing the data collected. CHAT is a practice-based
approach to academic inquiry that acknowledges the
complexity of human activity systems and provides a
framework for analysing and understanding these
complexities. CHAT divides practice into a number of
elements: object, subject, mediating artifacts, rules,
community and division of labour (see Figure 1). Together
these elements form an activity system that works towards
a desired outcome. The application of CHAT to SLPs’
practice with culturally and linguistically diverse children is
outlined in detail in a paper by Verdon, McLeod, and Wong
(2014).
The essence of ethnography is to describe the details
of mundane activities in every day settings and to find
the extraordinary among the ordinary (Silverman, 2011).
Therefore, careful description and attention to detail is
essential (Bryman, 1988). It can be easy to overlook or feel
it is unnecessary to document certain elements of a setting
if they seem familiar or un-noteworthy to the researcher.
However, detail is the key to effectively capturing the true
nature of what is being observed and understanding the
complexities of a research site. For this purpose, the use
of photographs and audio-visual data can be particularly
useful in capturing detail that may be missed in other forms
of data.
All activity must be situated in a context in order for it
to be interpreted and understood. This is referred to as
contextualism (Bryman, 1988). Multiple forms of data can
be used to assist in capturing the context of a research
site. One particularly useful tool is the writing of personal
reflections by the researcher. This enables a description of
the social, political, physical and organisational context (as
experienced by the researcher) within which the research
site is located.
Undertaking ethnographic
research
Silverman (2011) outlines four main components for
undertaking ethnographic research in order to achieve the
key elements outlined by Bryman (1988):
1. Defining the research problem
2. Adopting a theoretical orientation
3. Using rigorous methods to collect data
4. Using rigorous methods to analyse data
In the following sections, the enactment of these four
elements is described and examples of each are provided
from an ethnographic study entitled “Embracing Diversity –
Creating Equality” (Verdon, in preparation), a multi-site study
of speech-language pathology practice in different cultural
and linguistic contexts around the world undertaken by the
current author.
Defining the research problem
A research problem may be identified either through
professional experience or through a review of the literature.
Both of these elements played a key role in defining the
research problem that initiated the Embracing Diversity
– Creating Equality study. First, the motivation to undertake
this research was instigated through personal and
professional experiences of people with communication
needs in culturally and linguistically diverse settings in
Australia, Vietnam and the United Kingdom. Second, the
Box 1. Key elements of ethnographic observation
1. Observation – seeing activities and interactions through the eyes
of the participants
2. Description – paying close attention to the smallest detail to
uncover deeper understandings and inferences
3. Contextualism – understanding events as they are situated in their
broader physical, social, political and historical context
4. Process – viewing activity as a series of interlocking events
5. Flexible research designs – being open to coming across
unexpected issues rather than adhering to prescribed methods
Note. Adapted from Bryman (1988, pp. 61–66).
Mediating artifact
Community
ObjectSubject
Rules Division of labour
Figure 1. Cultural Historical Activity Theory. Reproduced with
permission from Learning by expanding: An activity-theoretical
approach (Engeström, 1987, p. 78).
Using rigorous methods to collect data
The first step in ensuring rigorous data collection methods
is to consider the ethical issues that may arise through the
research. It is essential that research is approved by the
ethics committee of the host university or organisation.
Such organisations will outline the types of risks to be
aware of and important considerations for minimising
potential harm and maximising benefit to the participants
and the field being studied. For example, the Embracing
Diversity – Creating Equality study involved working with
both children and participants who did not speak English as
their primary language and therefore a number of strategies
were put into place to ensure that informed consent could

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 113 112 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
data obtained during interviews, each was audio-recorded
and transcribed. To ensure rigour in this form of data
collection transcripts were sent back to the participants,
where possible, to gain their approval of the content and
ensure that their meaning was clearly expressed in the
transcript. This is known as member checking (Irvine,
Roberts & Bradbury-Jones, 2008).
Both sources (the audio and the written transcript) should
be used in conjunction when reviewing and analysing data
because the audio-recorded version contains non-verbal
aspects of the interaction such as hesitations and tone of
voice, which can be very useful in understanding the meaning
of spoken utterances. For example, in the Embracing
Diversity – Creating Equality study one participant
described a child’s linguistic competence by saying: “it’s so
ridiculous”. This could be interpreted with a negative
connotation if the words were only read. However, when
listening to the audio-recording it is clear that the participant
is laughing at the interesting patterns of code switching that
occur in their interactions. Therefore, the additional
information provided by the audio-recording changed the
way this utterance was interpreted by the researcher.
Photography
The use of photography in data collection stems from
anthropology, where images were initially used to enhance
the sharing of the researcher’s experiences of other cultures
and communities (Bateson & Mead, 1942). Photographs
are useful in providing an added dimension to data about
cultures, activities, people, or experiences that are
otherwise inaccessible or difficult to share and describe
through other means such as the written word (Grbich,
1999). Photographs can contribute both subjective and
objective data. Photographs should be used as data which
are “one-off, context bound images” (Grbich, 1999, p. 137)
and open to interpretation. In the Embracing Diversity –
Creating Equality study, the use of photographs allowed for
observations of similarities and differences between aspects
of sites, countries, and continents such as the clinic room
set up, resources, tools for assessment, uniforms and so
on. For example, Figures 2a and 2b are photographs of
clinicians’ resource cupboards, one from Asia and one from
North America. It can be seen that these were remarkably
similar between the two sites. On the other hand, the
differences between sites were also made apparent through
the use of photographs. For example, uniforms worn
between sites varied greatly with an SLP from Europe
wearing a scrubs-like hospital uniform (Figure 3a), an SLP
be obtained and that methods of data collection were
culturally safe and appropriate. One strategy for
safeguarding participants was providing the opportunity to
have information and consent forms interpreted in their
primary language. Additionally, it was important to allow for
variation in data collection methods. Participants were given
the option to only participate in aspects of the study in
which they felt comfortable. Participants were free to
withhold consent for any aspect of the study such as
interviews and the taking of photographs.
Conducting rigorous data collection during an
ethnographic study often involves collecting various types
of data including, but not limited to, fieldnotes, interviews,
audio-visual data and personal reflections. Each type of
data fulfills a different purpose and has a unique ability to
add to the larger picture of what is being described and
experienced by the researcher.
Fieldnotes
Fieldnotes are a vital part of ethnographic research
(Wolfinger, 2002). During ethnographic observation, the
researcher determines what aspects of an observed site are
considered worthy of documentation (Wolfinger, 2002).
Thus, structured fieldnotes can be useful in guiding the
research to ensure that the information recorded is
consistent between sites while also allowing for the diversity
of each site to be documented. In the Embracing Diversity
– Creating Equality study, observations were recorded using
both structured fieldnotes (which were designed to facilitate
identification of certain elements of CHAT within sites), as
well as unstructured fieldnotes that were written incidentally
to document events that took place. Structured fieldnotes
were useful in ensuring that basic descriptive information
was gathered about each observed site, such as the
physical context and setting, while also allowing space for
free text observations of events (see Appendix).
Semi-structured interviews
Semi-structured interviews are used to guide conversations
with participants by using open-ended questions to explore
the participants’ experiences and attitudes and to allow for
clarification and discussion of the activities that have been
observed (Al-Busaidi, 2008). In the Embracing Diversity
– Creating Equality study semi-structured interviews were
used to gain insights regarding practice from multiple
viewpoints (SLPs, parents and children) about their
experiences of speech-language pathology. For the
purpose of ensuring accurate recollection and analysis of
Figure 2. Resource cupboard in (a) Asia and (b) North America
(a) (b)

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 113
theory, CHAT, was used as an analytical framework for
interpreting the collected data. Using the framework, data
were coded and organised into one or more of the six
elements of CHAT (i.e., object, subject, mediating artifact,
rules, community and division of labour). The data contained
within each element were then considered and main
themes arising within each element were identified using
grounded theory. The themes identified within each element
were then considered individually as well as collectively to
create an understanding of the interconnected nature of all
things occurring in the activity system and how they work
with or against each other. Understanding the barriers and
facilitators to practice can be used to identify possible
means to address the challenges identified within the
activity system to improve practice.
A number of different tools can be used to assist in the
analysis of qualitative data. These tools help with organising
and coding large quantities of data into to make sense
of what has been observed and collected. In particular,
computer-assisted qualitative data analysis software
(Silverman, 2011) is often used to facilitate the analysis
of qualitative data. In the Embracing Diversity – Creating
Equality study, NVIVo 9 software (QSR International, 2009)
was used as an organisational tool to assist in the analysis
of interview transcripts, fieldnotes, photographs, video-
recordings, and personal reflections. This software enabled
the systematic coding of all data forms into the six elements
of CHAT. Some data were assigned to more than one
category if appropriate. Coding allowed for the identification
of themes arising in the data and a synthesis of similarities
and differences in speech-language pathology practices
around the world, which will form the findings of the
Embracing Diversity – Creating Equality study (forthcoming).
It is hoped that the results of this study will generate new
insights for engaging in culturally appropriate practice in
speech-language pathology and pave the way for such
methodologies to be used more broadly to address other
areas of need in the profession.
Important considerations when
undertaking qualitative research
There are a number of important considerations for those
attempting to engage in qualitative research for the first
time. The most important aspect of qualitative research to
be acknowledged is its inherently subjective nature. All
experiences, as well as the interpretation and reporting of
data, are undertaken through the lens of the researchers
and their personal, social, and cultural context. While some
from South America wearing a lab coat (Figure 3b) and the
SLP from Asia wearing professional plain clothes (Figure 3c).
Video
Video data enables experiences to be re-lived and shared
with others. Video data are useful in accounting for both the
verbal and non-verbal aspects of communication that may
not be able to be conveyed through transcripts of audio-
recordings or through still photographic images (Grbich,
1999). In the Embracing Diversity – Creating Equality study
video data were use to document therapy techniques used
by SLPs. Video data were useful in capturing the
complexity of such interactions. For example, the use of
ultrasound technology with a child during one session was
recorded to show how the technology worked and how the
SLP interacted with the child and the technology to provide
instruction and feedback on therapy targets.
Personal reflections
Personal reflections provide important insight into how the
researcher thinks, feels and acts. This is important given
that qualitative data are collected, interpreted and reported
using the lens of the researcher (Grbich, 1999). Writing
personal reflections enables researchers to be critically
reflective of their experiences and processes in data
collection. In the Embracing Diversity – Creating Equality
study personal reflections were used to capture the
researcher’s experience of being exposed to such culturally
and linguistically diverse situations. These documents
proved to be useful as they captured the “culture shock”
that is often forgotten after being immersed in a new setting
after a period of time. This quote is an example of a
personal reflection, which describes the experience of
walking through the streets in the location of one of the
research sites: “People lay sick and crying in the streets,
some had even passed out in the heat with no one to give
them medical care. During the day felt quite safe but it was
frightening to go out at night ...” Such reflections provided
insight into the broader context of the research sites which
could not be captured through documentation of the clinical
setting alone.
Using rigorous methods to analyse data
Qualitative data analysis is scaffolded and underpinned by
the use of a theoretical lens or framework. There are
countless theories which have been applied to the study of
practice. Each theoretical lens allows the data to be viewed
from a different perspective with a common purpose, that
is, to gain an understanding of what has been observed. In
the Embracing Diversity – Creating Equality study one such
Figure 3. Clothing/uniforms worn by speech-language pathologists in (a) Europe, (b) South America, and (c) Asia
(a) (b) (c)

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 115 114 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
clinical trials are controlled. Rather qualitative research
provides a more accurate reflection of real-life situations,
which are neither predictable nor controlled. This means
researchers must adapt to fit the reality of the situation,
rather than trying to make it fit predetermined research
goals or outcomes. Rather than a limitation, this could be
argued as a strength of qualitative research.
Benefits of qualitative approaches
to research
Qualitative approaches to research have the potential to
empower researchers to work in different ways to create
new understandings of both professional and client/
participant experiences of care. By allowing insight into
multiple viewpoints, qualitative research can identify
potential opportunities to optimise these experiences.
Practitioners and researchers alike have the opportunity to
employ qualitative techniques such as those outlined in the
current paper. The key to effectively utilising qualitative
research in health and education settings is to think critically
and reflectively about practice with clients and their families
to support the best possible outcomes for people with
communication needs.
References
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in health care. Sultan Qaboos University Medical Journal,
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1461(2007/020)
Carroll, K., Iedema, R., & Kerridge, R. (2008).
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Eberle, T., & Maeder, C. (2011). Organizational
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Engeström, Y. (1987). Learning by expanding: An activity-
theoretical approach. Helsinki, Finland: Orienta-Konsultit.
Grbich, C. (1999). Qualitative research in health: An
introduction. Sydney, Australia: Allen & Uniwin.
Irvine, F., Roberts, G. & Bradbury-Jones, C. (2008)
The researcher as an insider versus the researcher as an
outsider: Enhancing rigour through language and cultural
sensitivity. In P. Liamputtong (Ed.), Doing cross-cultural
research: Ethical and methodological perspectives (pp.
35–48). Dordrecht: The Netherlands: Springer.
Morse, J. M. (2011). What is qualitative health research?
In N. K. Denzin & Y. S. Lincoln (Eds.), The Sage handbook
of qualitative research (4th ed., pp. 401–414). Thousand
Oaks, CA: Sage.
objective data are collected (such as photographs of the
physical setting), the interpretation of what this means and
how it impacts upon the activity being observed is
subjective and constructed through the lens of the
researchers and the theoretical framework being applied to
the research (Silverman, 2011). This can be confronting for
researchers who are used to searching for one “truth” or
“fact” using quantitative research. However, the very nature
of qualitative research is to seek experiences and
understandings of the world through multiple viewpoints, so
this subjectivity is not considered a limitation.
The motivation to undertake qualitative research is
often driven by a theoretical perspective, even if it is
unbeknownst to the researcher. For example, in the case
of the Embracing Diversity – Creating Equality study, the
motivation to undertake the research was driven by the
theoretical perspective that all children deserve equal
access to, and benefit from, services regardless of their
cultural or linguistic background. This perspective informed
the development, implementation and interpretation of the
research. After some reading and conversations with others
in the field using qualitative research, CHAT was selected
as the appropriate framework to structure the study. This
theoretical perspective acknowledges the complex and
diverse nature of practice and the impact of cultural and
historical context upon human activity.
Another important aspect of qualitative research is that
research methods must be flexible (Bryman, 1988). This can
be a challenging paradigm shift from quantitative research
which emphasises that uniformity and replicability are key
elements of a rigorous research design. However, flexibility
can be key to capturing the true nature of a research site
which may not otherwise be discovered if the researcher
maintains a strict regime of data collection methods. This was
especially true in the Embracing Diversity – Creating Equality
study as it would have been in contradiction to the whole
concept of the research, which focused on “embracing
diversity” to keep the methodology the same in all contexts
when at times it was culturally inappropriate to do so. For
example, the initial intention was only to observe practice in
the research site, but the presence of the researcher in the
room and the fact that the researcher was an “insider” in the
world of speech-language pathology meant that on many
occasions in different cultural contexts it was necessary to
become a participant-observer. In these situations the role
of participant-observer was taken on by the researcher to
work with the natural flow of the session rather than against
it, meaning that distance as simply an observer was unable
to be maintained. Either choice by the researcher in such a
situation would have impacted on the session. If participation
was refused it may have appeared rude, culturally
inappropriate or have impacted on rapport and relationship
with the participants. Conversely, choosing to participate in
the activity inevitably changed the very nature of the activity
being studied. Research flexibility was also required when
data collection was unable to be carried out in exactly the
same manner in each site. This was because at some sites
it did not seem culturally or contextually appropriate to
conduct some forms of data collection. For example,
conducting interviews with parents and children was not
always appropriate when a language barrier was present or
when trust had not been established due to a shortage of
time at some sites. These examples demonstrate that the
nature of qualitative research does not allow researchers to
control for unpredicted variables in the way that quantitative

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 115
Sarah Verdon is a speech-language pathologist undertaking
international research regarding practices with culturally and
linguistically diverse children.
Correspondence to:
Sarah Verdon
Research Institute for Professional Practice, Learning,
and Education
Charles Sturt University
Panorama Ave, Bathurst, 2795 NSW, Australia
email: sverdon@csu.edu.au
QSR International (2010) NVivo qualitative data analysis
software. (9th ed.). Doncaster, Australia: Author.
Silverman, D. (2011). Interpreting qualitative data (4th
ed.). London, UK: Sage.
Stow, C., & Dodd, B. (2003). Providing an equitable
service to bilingual children in the UK: A review. International
Journal of Language and Communication Disorders, 38(4),
351–377.
Verdon, S. (in preparation). Embracing diversity, creating
equality (Unpublished doctoral dissertation). Charles Sturt
University, Bathurst, Australia.
Verdon, S., & McLeod, S., & Wong, S. (2014, early
online). Reconceptualising practice with multilingual
children with speech sound disorders: People, practicalities
and policy. International Journal of Language and
Communication Disorders. doi:10.1111/1460-6984.12112
Williams, C. J., & McLeod, S. (2012). Speech-language
pathologists’ assessment and intervention practices with
multilingual children. International Journal of Speech-
Language Pathology, 14(3), 292–305.
Wolfinger, N. H. (2002) On writing fieldnotes: Collection
strategies and background expectancies. Qualitative
Research, 2(1), pp. 85–95.

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Appendix. Data collection record form
Celebrating and supporting cultural and linguistic diversity in the provision of services for multilingual children
with speech sound disorders
Setting: ...........................................................................................................................................................................
Day/date: .......................................................................................................................................................................
Professional participant: ..................................................................................................................................................
Child participant: ............................................................................................................................................................
Family/others present: ....................................................................................................................................................
Environment/setting description
Setting Description Supporting documents/data
Outside
Inside (group/common area)
Inside (individual therapy/work room)
Organisational
Activity description – Cultural Historical Activity Theory framework
Fieldnotes – observations
.......................................................................................................................................................................................
.......................................................................................................................................................................................
Anything especially innovative, interesting, or important?
.......................................................................................................................................................................................
.......................................................................................................................................................................................
Reflections
.......................................................................................................................................................................................
.......................................................................................................................................................................................
To do for next visit?
.......................................................................................................................................................................................
.......................................................................................................................................................................................
Time People Setting Activity Tools used Object of Supporting
activity artefacts

Research
www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 117
KEYWORDS
HONOURS
PRACTICE
KNOWLEDGE
PRACTITIONER-
RESEARCHER
PRACTICE–
RESEARCH
NEXUS
UNDER-
GRADUATE
RESEARCH
THIS ARTICLE
HAS BEEN
PEER-
REVIEWED
Caroline
Robinson
knowledge (Everingham & Irwin, 2001), intuitive knowledge
and self-knowledge (Fish & Coles, 2005). By theorising
about their practice, tacit knowledge is made explicit and
new knowledge is created by allied health professionals
(Bartunek, Trullen, Bonet, & Sauquet, 2003; Higgs, Fish, &
Rothwell, 2004).
Inquiry into practice from within practice enables
practitioners to refine new knowledge, and to identify
gaps in professional knowledge. Research about practice
entails an exploration of professional knowledge, and the
generation of new knowledge contributes to the knowledge
base of the allied health profession (Higgs et al., 2004,
p. 104). “Insider practitioner research” suggests that
practitioners will come to understand their practice more
deeply through researching practice (Fish & Coles, 2005,
p. 162).
Inquiry in a profession begins in the field and a
key purpose of such inquiry is to be translated into
research that is useable (Tierney & Holley, 2008, p. 296).
Honours research is an important mechanism to enable
undergraduate students to research practice and to make a
contribution to professional knowledge. This undergraduate
research experience not only enables a deeper
understanding of practice, but also changes the being
of the allied health student. The challenging experience
of honours precipitates self-actualisation – the realisation
of their potential – as a novice practitioner-researcher.
Honours programs therefore should be considered as much
more than a pathway to gain research knowledge and skills.
Honours graduates have the potential to be practitioner-
researchers who will drive the development of professional
knowledge and ensure a contemporary and sustainable
evidence base for the allied health professions.
Previous honours research has addressed a broad range
of disciplines, but allied health students have not been the
focus of attention. The purpose of this paper is to illuminate
the value of honours in developing critical allied health
practitioners, capable of challenging the evidence base and
contributing to professional knowledge. Ethics approval for
this study was granted by the Human Research and Ethics
Committee, Charles Sturt University (CSU).
Method
Research design
A hermeneutic phenomenological methodology was
chosen for this study. The aim of phenomenological inquiry
is to gain a deep understanding of an individual’s
experience and the meaning of this experience, so it is
Honours programs are a mechanism to
enable undergraduate students to undertake
research. The intimate relationship between
practice and research is an important feature
of embedded honours programs in allied
health. This study used a phenomenological
methodology to explore the experience of
honours, for ten allied health students. Three
interviews conducted at the early, mid and
late stages of the honours journey illuminated
the development of these students as novice
practitioner-researchers. The nine key themes
which emerged can be used to provide a
deeper insight into the value of honours, in
developing allied health practitioners capable
of informing professional knowledge:
“challenging self”; “a different way of being”;
“coping”; “communities of practice”; “self-
actualisation”; “becoming a practitioner-
researcher”; “new perspectives”; “practice–
research nexus”; and “career
decision-making”.
Background
Honours programs in Australia generally take one of two
forms. An “end-on year” or “add-on” honours program
comprises one year of full-time study following on from a
Bachelor degree. An “embedded” or “integrated” honours
program is an integral part of a Bachelor degree and
enables a student to undertake honours without extending
the duration of study (Kiley, Boud, Cantwell, & Manathunga,
2008). Embedded honours programs are often
incorporated into undergraduate allied health courses and
provide students with the opportunity to plan and conduct
a research study in tandem with other subjects and
workplace learning. This intimate relationship between
practice and research enables students to grapple with the
practice–research nexus. The deeply engaging experience
of honours research compels undergraduate students to
reflect on their knowledge and challenge the evidence base,
in order to develop new perspectives on practice and
extend their professional knowledge. This knowledge is
composite and complex as it comprises propositional
knowledge, professional craft knowledge, personal
Why should we value
honours graduates?
Caroline Robinson

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interview, data analysis and subsequent interview was
critical to ensure that the interview questions were authentic
to the students’ experience through their honours journey.
Depending on the duration of the embedded honours
programs (1–2 years), the three interviews for each student
spanned a period of between 9 and 18 months. The
staging of interviews at the early, mid and late stages of
honours enabled insight into the students’ experience over
time and captured their changing perspectives. This
research strategy permitted both prospective and
retrospective reflection on the experience of honours. This
is important because experience is dynamic, dependent on
context and shaped by previous events.
Analysis
A total of 61 individual items were derived from analysis of
the interview data (Figure 1). This extensive list was
collapsed to 28 items, to prioritise the items which were of
importance to the majority of the ten students. This detailed
process entailed a listing of the items derived from each of
the three interviews and a ranking of individual items,
according to the number of students each item was relevant
to. Each item included in the list of 28 was relevant to at
least eight of the ten students. The development of a smaller
number of key themes was essential to achieve clarity
about the students’ experience of honours and to facilitate
a framework for illustrating the phenomenon of honours.
Immersion in the data from the early to late stage interviews
enabled a deep understanding of issues which were most
relevant to the students, at different points in time. This
prolonged immersion, re-reading and questioning of the
data is a vital element of hermeneutic phenomenological
analysis. Themes “emerge” from the data because the data
becomes very familiar to the researcher. The 28 items were
distilled to nine key themes which mapped broadly to the
three stages of the honours journey.
Results and discussion
The nine themes that emerged from this research are
presented in Figure 2. They are a representation of the
complex phenomenon of honours:
• Early stage – “challenging self”, “a different way of being”
and “coping”;
• Mid stage – “communities of practice”, “self-
actualisation” and “becoming a practitioner-researcher”;
highly applicable for researching practice (Grace, Higgs, &
Ajjawi, 2009, p. 115). “Hermeneutics”, derived from the
Greek word meaning “to interpret”, is the theory of
interpretation. Hermeneutics is a distinct research paradigm
concerned not solely with the interpretation of texts, but
more with broadly the interpretation of “human being”.
Hermeneutic phenomenology focuses on the meaning of
being for an individual and how meaning influences
decisions and life choices (Liamputtong, 2010, p. 126). A
hermeneutic phenomenological approach enabled a deeper
understanding of honours as experienced by the allied
health students and a clearer insight into what it means to
be an honours student. The emphasis in this philosophical
approach is finding common ground, shared meaning and
consensus (Loftus & Trede, 2009, p. 62). In this study, the
aim was to develop an interpretation of the students’
experience which is “coherent and useful” (Trede & Loftus,
2010, p. 187).
Participants
Ten honours students were recruited from two Australian
universities – one metropolitan and one regional institution
– by a process of convenience sampling. These
undergraduate allied health students represented speech
and language pathology; podiatry; physiotherapy; and
occupational therapy (Table 1). Students were invited to
participate in the study just prior to commencing their
honours program.
Procedure
A series of three interviews was planned for each of the ten
students, in order to capture their experience at the early,
mid and late stages of the honours journey. The interviews
were conducted individually, face-to-face, at the student’s
place of study. Each interview lasted between 35 and 50
minutes. The format of the interviews was semi-structured
and guided by an interview schedule. The purpose of the
initial interview was to explore the students’ reasons for
enrolling in honours and their early experience of the
program. Interview questions were developed from
unpublished survey data, collected previously from
undergraduate allied health students at the two institutions.
Data from the initial series of interviews informed the
development of the mid-stage interviews; the final-stage
interviews were informed similarly. This iterative process of
Table 1. Demographic data for honours student participants
Age Allied health profession Regional / metropolitan university Qualification on entry to current course Pseudonym
20 Occupational Therapist Regional High school Cassie
21 Physiotherapist Regional High school Emma
20 Physiotherapist Regional High school Jess
21 Podiatrist Regional High school Sarah
32 Speech pathologist Regional BSc(Honours) Maria
21 Physiotherapist Metropolitan High school Lauren
21 Physiotherapist Metropolitan High school Holly
20 Podiatrist Metropolitan High school Ellie
21 Podiatrist Metropolitan High school Nicola
22 Podiatrist Metropolitan 1 year BSc Rachel

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 119
(2000) investigated practitioner-researchers in occupational
therapy and suggested that a predisposition to research
was influenced strongly by university undergraduate project
work, and relationships formed with research supervisors
(p. 16). It has also been noted that medical students who
have a positive research experience are more likely to
engage in research or academic medicine as postgraduates
(Solomon, Tom, Pichert, Wasserman, & Powers, 2003, p.
153). The honours experience enables students to learn
about practice through research, but students should also
develop a sense of how they learn. Practitioners with this
insight are the ones who will continue to grow and develop
throughout their careers (Walker, Golde, Jones, Conklin
Bueschel, & Hutchins, 2008, p. 85).
I just think that you’re in this profession for the next I
don’t know how many years and it’s your life and that’s
what you do and I think contributing to it is important,
especially in our field because there isn’t a lot of
research into a lot of things we do. So if most people
did it [honours] then we would have more research in
areas and we would have different interventions for
things. It’s also my own thing as well … like it further
improves you as an allied health professional. (Sarah)
This quote illustrates a commitment to the development of
professional knowledge through honours, and suggests
that knowledge generation is intrinsic to professional
development. This is a vital perception particularly for an
undergraduate student, as allied health professionals are
required to: select and utilise knowledge, to modify existing
knowledge, and to create knowledge in the practice setting
through reflection on practice (Higgs et al., 2004, pp.
90–91). Consistent with the philosophy of care in allied
health, these honours students are motivated by wanting to
help others through their research and practice.
Compiling the evidence, doing the actual research
project and [writing] the research study which people
across the world will be able to look at. Helping
improve the way that stroke rehabilitation is undertaken
or people’s knowledge about it, so that further
developments can occur. I suppose that’s the whole
point of me doing it … to make a contribution to
someone outside of myself as well. (Lauren)
Both learning and research are about making meaning
(Brew, 2003). New perspectives are enabled as a
• Late stage – “new perspectives”, “practice–research
nexus” and “career decision-making”.
The specific focus of this discussion is limited to three of
the nine key themes and represents only a small portion of
a much larger doctoral thesis. The three themes chosen for
discussion are: “becoming a practitioner-researcher”; “new
perspectives”; “practice–research nexus”. These themes
are the three most appropriate to highlight the value of
honours in enabling undergraduate allied health students to
grapple with the practice–research nexus and to become
critical practitioners, capable of making a contribution to
professional knowledge.
Early stage
interview Data analysis
and coding Mid stage
interview Data analysis
and coding Late stage
interview Data analysis
and coding
Total of 61
coded items
Items
prioritised
28 items distilled
to 9 themes
Nine themes mapped to the
three stages of the honours journey
(Figure 2)
Figure 1. Illustration of the process of data analysis
Challenging
self
Late
interviews
Early
interviews
Career decision
making
A different
way of
being
Coping
Research-
practice
nexus
New
perspectives
Becoming a
practitioner-
researcher
Communities
of practice Self
actualisation
Mid
interviews
Figure 2. Thematic representation of the honours experience
Becoming a practitioner-researcher
Honours may be viewed as an opportunity for self-
development, comprising the potential to make a difference
to professional practice through knowledge generation.
Honours therefore sits very comfortably within the context
of contemporary views on professional education, as it
enables an integration of knowing, acting and being
(Dall’Alba, 2009).
The potential for making a contribution to professional
knowledge is a prominent motivating factor for allied health
students contemplating honours study and research about
practice is a vital way of exploring knowledge (Higgs et al.,
2004). The honours experience enables this exploration for
allied health students who seek a challenge and a different
way of learning. A desired outcome of honours is that
the students will be predisposed to incorporate research
into their future clinical practice, or will engage actively in
research as a practitioner-researcher or academic. Cusick

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Dadds (2008) discussed empathetic validity in
practitioner research and this resonates with the experience
of many of the honours students. Research that is high
in empathetic validity “brings about new personal and
interpersonal understanding that touches and changes
hearts as well as minds” (p. 280). It is evident from the
students’ experiences with research participants, that
these relationships engender not only a shift in cognition,
but have an emotional impact too. Experience of working
with clients during workplace learning certainly affords
all undergraduate allied health students the opportunity
to engage with clients, and to develop a deeper
understanding of individual life experience. The issue of
time however, warrants further consideration. Honours
compels students to make the time and space to explore
an area of interest, and to engage with clients as research
participants. As this time is protected in the sense that the
student is unconcerned with delivering treatment in any
sense, the honours experience has the potential to afford
students with the time to talk, the time to reflect, and the
time to develop new understandings.
With clinical placements you don’t really have the time
with someone and it’s all very clinically based. During
honours I had the opportunity to sit down and talk to
them and because they were in their own home, they
felt a lot more comfortable and relaxed talking about
it. I think time plays a big role because that enables
people to relax and there’s no stress of I need to see
another ten patients before lunchtime. (Lauren)
Honours has the exciting potential to enable students
to broaden their horizons, develop new perspectives on
practice and attain new perceptions of life, informed by the
experience of their clients.
Practice–research nexus
Praxis acknowledges that theory and practice are
integrated and individual practitioners develop their own
evolving personal theory about practice (Kilpatrick, 2008).
The practice–research nexus is intrinsic to honours study
and the students may struggle to find a balance between
the priorities of clinical practice and research.
Sometimes you’re just so focused on the research
that you can’t see it, you forget about it [clinical
practice] … it’s kinda like you can’t put it aside. Then
when I go and do the clinics that I do, it puts it a bit
in perspective. It depends on the setting and what
I’m doing but I try and keep them together. If I keep in
my mind that research is a separate thing and I don’t
intertwine it with the clinical side of things, what’s the
purpose of doing research? (Rachel)
This is a fascinating insight into the potential tension
between clinical practice and research. Honours students
have limited clinical experience, but even less research
experience, so it is not surprising that they may find it
difficult to manage this complex juncture. Through the
experience of honours, changing perspectives allow the
students to analyse the relationship between research and
practice.
I think I have a better appreciation of research and how
difficult it really is to do it and I think I really believe in
evidence based practice from doing honours. Why are
we doing what we’re doing [in clinical practice] and
why is that better than doing something else? I think
that’s really important. (Nicola)
consequence of this learning through research and the
student’s being is changed. It is the individual practitioner
who identifies research as a valued object, who constructs
the role in his or her life to attain it and who determines
whether it was worthwhile (Cusick, 2001, p. 15). Research
is integral to being a practitioner-researcher and it is
apparent that the honours students undergo a similar
change.
It’s been really beneficial to see the research that I’m
reading and to look at the population I’m researching
and the same things are coming out. It’s giving me
insight into where the research needs to be. (Jess)
So it’s not going to directly affect my practice but the
aspect of research probably will, because I will keep on
researching different areas. (Maria)
The experience of honours will inform the student’s
practice through the skills developed and knowledge
gained. The acquisition of knowledge and skills however,
cannot ensure learning for an unknown future. Learning
experiences should afford the possibility of developing
qualities in a student which enable authentic being (Barnett,
2004). Through the experience of honours, qualities such
as courage, carefulness, criticality and resilience are
nurtured, within the relative safety of research communities
of practice, in order to allow these honours students to
become novice practitioner-researchers.
New perspectives
As the honours students became increasingly immersed in
their research, and particularly their data collection,
changes in perspective began to emerge. Whether insight
was facilitated by reading the literature and reflecting on
practice, or through relationships with their research
participants, the common focus of these new perceptions
was clinical practice. Considering the intimate relationship
between research and practice for these allied health
students, this is not surprising, but it is pleasing to see that
practice and research are mutually informed through
honours.
It’s given me more ideas about the way you could go
in your clinical work. I quite often think about it when
I see kids … you could do some research on that. I
probably wouldn’t have thought about that before.
(Emma)
The development of empathetic relationships with
their research participants facilitated new perspectives,
as the students gained a deeper insight into the lives of
people with end stage renal disease, stroke, diabetes,
neurofibromatosis and children with a disability.
You realise there’s bigger things than just your normal
life. Knowing more about people’s experiences of
life, being exposed to different coping styles and to
different things that people have to deal with, makes
you think about things differently. To have your eyes
opened a little bit more than you would normally and
share their experiences. That was a really nice aspect
of the whole honours process. (Lauren)
Maria’s perspective was changed not so much by the
children she was researching, but by listening to the
experiences of their parents and carers.
I don’t know what it’s like to have to look at your child
and say well I’ve bestowed this on him. I’m learning a
lot from them [mothers]. (Maria)

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 121
students were clear in their belief that they needed to
further develop their clinical knowledge and skills, prior to
considering any research opportunities. Progression to
clinical practice enables the further development of
professional knowledge and consolidation of skills, and this
is considered (by this group of students) to be the best
foundation on which to develop future research. This aspect
of career decision-making illustrates clearly the students’
understanding of the practice–research nexus. Conceiving
this undergraduate research experience as a mechanism to
enable career planning is certainly not an overt purpose of
honours programs, but this ability is a desirable attribute in
new graduates.
The experience of honours enables students to
develop new perspectives on practice, to evaluate the
interdependence of practice and research in developing
practice knowledge, and provides a firm foundation from
which they can develop to become the future practitioner-
researchers in allied health (Robinson, 2011). In order to
maintain and extend the pool of practitioner-researchers
in allied health, it is important to encourage undergraduate
students to consider honours. This responsibility lies
principally with academic staff, but should also be a
concern for allied health practitioners. Collaboration
between academic staff and allied health practitioners
to form honours supervisory teams is a valid strategy
to develop relevant research projects. If students are
enabled to develop projects informed by both clinical and
occupational areas of interest, more students may be
encouraged to enrol in honours.
Honours provides students with an opportunity to extend
their experience beyond the standard expectation for
undergraduate allied health students of developing skills
as a critical consumer of research (Badger, Daly, & Clifford,
2012). Honours affords a “space” to reflect on practice
and to understand the potential of research in developing
new perspectives on practice. Through the challenge of
honours, an undergraduate student can visualise future
opportunities as an allied health practitioner.
I started to get worried a couple of months ago
because I thought is this it … is this the end for me …
and now it doesn’t feel like it is. The biggest thing I’ve
learnt is that this is only the beginning. (Ellie)
Conclusion
This study explored the experience of ten undergraduate
allied health students as they progressed on their honours
journey. The purpose of the study was to illuminate the
complex phenomenon of honours, which is often conceived
fairly simply as research training. It is clear that the value of
the honours experience extends far beyond the acquisition
of research knowledge and skills. Honours as an
undergraduate research experience enables self-
actualisation and a different way of being, as students
develop new perspectives on practice and challenge the
practice–research nexus. The development of allied health
practitioners who are well positioned to contribute to
professional knowledge generation and evidence-based
practice will strengthen the research foundations of each
allied health profession. Honours graduates should be
valued as novice practitioner-researchers who have the
potential to improve the credibility of the allied health
professions through quality research, increasing the
professions’ position of influence and control over health-
care policy.
It is interesting to see the change in the way the students
contemplated the practice–research nexus as they reached
the end of their honours experience. Where previously
they had viewed the relationship between clinical practice
and research in practical and procedural terms, they now
experienced this relationship from a much more personal
perspective. Although students found it difficult to articulate
the meaning of honours, it was much easier for them to
conceive this shift in their being in the context of clinical
practice.
You just learn so much about reading articles,
researching and really analysing. I’m a lot more
reflective and I’m always asking why. It’s more trying to
understand, which is what I’ve been doing through this
whole process of honours. When I’m talking to patients
I’m a lot more succinct and my communication skills
have got a lot better. So you’re always learning and
gaining new skills even though it’s not specifically
taught to you or talked about by your supervisors …
you just pick it up yourself. (Jess)
I think it just had a massive impact over the last couple
of years. I felt I was much more comfortable locating
evidence and applying this to my practice. I think you
have a greater appreciation for research after doing
it in terms of how it impacts on other clinicians and
on the patients and their families as well. It’s definitely
made me appreciate the value of research more.
(Holly)
This shift of focus over time from the accumulation of
research knowledge and skills, to a development of
“professional being” through practice, is congruent with
contemporary thinking about professional education
(Dall’Alba, 2004). An emphasis on a change of being
characterised by qualities such as receptiveness,
thoughtfulness and humility, rather than the acquisition of
either knowledge or skills, is how Barnett (2004) envisages
learning for an unknown future (p. 259).
Opening your eyes to the understanding of where
people come from. How their experiences are different,
how they view things is different and how they interpret
a questionnaire can be very different. So it’s kind of an
extra dose of all those understandings. It just brings it
all together a lot quicker than I think it would if I hadn’t
have done honours. (Lauren)
The tension between clinical practice and research
is tangible for these allied health students, and seems
to centre on feelings about their general lack of clinical
experience. This tension between research and practice
is mirrored to some extent in the context of nursing
academics. Nurses moving from clinical practice into
an academic position, with the associated research
requirement, perceived this as leading to a loss of clinical
credibility (Kenny et al., 2004, as cited in Andrew, Ferguson,
Wilkie, Corcoran, & Simpson, 2009, p. 608). It is important
to understand the students’ perspective on the practice–
research nexus, as this is fundamental to determining their
early career decision-making.
Summary
Honours graduates may be perceived by allied health
practitioners to be more interested in research than clinical
practice. However, the overriding perception of this group
of honours students was that credibility as an allied health
professional is dependent on clinical experience. The

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 123 122 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
Acknowledgements
I would like to acknowledge the careful guidance and
expert advice from my two doctoral supervisors – Professor
Mike Keppell and Professor Stephen Loftus. I would also
like to acknowledge the ten honours students, who gave
their time willingly to offer me deep insight into their
experiences. This study would not have been possible
without their participation.
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Dr Caroline Robinson is the Courses Director in the School of
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Correspondence to:
Dr Caroline Robinson
Charles Sturt University
School of Community Health
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Albury, NSW, 2640
phone: (02) 6051 9242
email: corobinson@csu.edu.au
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Research
www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 123
KEYWORDS
PARTICIPATORY
ACTION
RESEARCH
ETHICAL
RESEARCH
RESEARCHER-
PARTICIPANT
RELATIONSHIP
APHASIA
RESEARCH
THIS ARTICLE
HAS BEEN
PEER-
REVIEWED
of changed roles and responsibilities. The term “research
subject” suggests a level of passivity, of some intervention
or experiment being done to someone. This may fit a
positivist view of research where there is an external truth
to be found through the process. This approach favours
larger numbers of subjects, often placed into groups (and
ideally recruited into randomised controlled trials), isolating
variables, and with the researcher taking care not to
influence subjects in any way. The term “participant”, on
the other hand, suggests a more active role. In interpretive
research approaches, there is more room for the
individuality of participants, and for them to influence the
direction of the research. This is more typical in qualitative
research which favours smaller numbers and relies on the
trust and rapport between participant and researcher for
quality findings (for example, in an interview situation). In
practice, there is no simple divide between quantitative and
qualitative research in use of the term “participant” and it is
now used widely across different philosophical frameworks
(along with other terms like subject, interviewee,
respondent, informant – depending on the type of study).
For example, in Section 1 (“Values and Principles of Ethical
Conduct”) of the NHMRC National Statement on Ethical
Conduct in Human Research (2007), we see:
The relationship between researchers and research
participants is the ground on which human research is
conducted. The values set out in this section – respect
for human beings, research merit and integrity, justice,
and beneficence – help to shape that relationship as
one of trust, mutual responsibility and ethical equality.
For this reason, the National Statement speaks of
research ‘participants’ rather than ‘subjects’. (p. 9)
Within its remit covering the ethical conduct of all human
research, the National Statement also acknowledges
the very broad use of the term “participants” to include
involvement through survey, interviews, and focus groups;
undergoing testing or treatment; researchers accessing
personal documents; collection or use of body organs,
tissues, fluids; and even “to include those who may not
even know they are the subjects of research; for example,
where the need for their consent for the use of their tissue
or data has been waived by a Human Research Ethics
Committee (HREC)” (p. 7). This point demonstrates a
certain flexibility assigned to the term “participant” but also
that there is a responsibility to participants in all forms of
research, regardless of the degree of their involvement
in the research process. Despite this complex research
climate, it is worth considering what the term “participant”
might entail in speech pathology, what we expect of
In this paper, I examine the role of participants
in research, and their relationships with
researchers. I suggest three reasons to
consider the nature of participation in research:
to direct the ethical decisions, protections
and processes in the research; to ensure the
quality of the research; and to guide the
dissemination, translation and impact of the
research. I illustrate each of these points with
some examples from the field of aphasiology,
and suggest that participatory research
designs offer ways to identify and truly
respond to the needs of our clients.
Whether working clinically or in academic contexts,
speech pathologists are encouraged to undertake
research as part of their practice. Many research
designs depend on the recruitment of participants. While
this appears to be stating the obvious, it is worth stepping
back to consider what the role of the participant entails in a
particular project. A good way of illustrating why this issue
is important is to be found close to home. In the Speech
Pathology Australia Code of Ethics (Speech Pathology
Australia, 2010), section 3.3.8 on Research includes the
need to “respect the rights of research participants” and
to “communicate the results of our research or other
professional advancements in a professional manner to
our colleagues and to the research participants/our clients
where appropriate” (p. 3). This statement represents a
subtle shift over the last ten years. The equivalent section
of the previous Speech Pathology Code of Ethics (2000, p.
7) stated:
We communicate the results of our research or other
professional developments to our colleagues through
recognised scientific channels, so that our colleagues
may form an opinion of the merits of this work before
we present the results to the public.
In this version, there was no specific obligation to inform the
participants of the results of the research in which they had
been involved. This shift is of interest because it forms part
of a wider move within research to revise and perhaps
challenge the relationships between researchers and
participants. What roles might participants now play in our
research?
Birch and Miller (2012) note the shift in terminology in
social research more generally from the “research subject”
to “research participant” with an accompanying expectation
Participants,
researchers and
participatory research
Deborah Hersh
Deborah Hersh

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 125 124 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
Participants and the quality
of research
The quality of quantitative, positivist research is usually
underpinned by concepts of internal validity (truthfulness of
the findings), reliability (whether those findings are robust,
consistent or repeatable) and external validity or
generalisability. These concepts do not translate smoothly
to qualitative research because of the different foundations
upon which it rests – most obviously that it is about
subjective, contextually bound experience and that findings
are interpretations and social constructions. However, this
does not mean qualitative research lacks rigour. The most
widely cited translation of traditional measures of research
quality to qualitative research is that of Lincoln and Guba
(1985) who suggested that internal validity can be reframed
as credibility, external validity as transferability, reliability as
dependability and objectivity as confirmability. Of particular
relevance to the consideration of the role of participants is
the notion of credibility – the fit between what research
participants say or do and how the researchers then
represent that information. The sampling of participants is
an important part of this because the research rests on
accessing those participants who are able to offer the
experience and different viewpoints that the research is
investigating. But also, the practice of member checking is
a crucial aspect of assuring credibility and therefore the
quality of the work. Member checking is taking the data
back to the participants so that they can see if they
recognise their views there, or are able to verify that the
researchers have got it right. Just as objective instruments
need to be well calibrated, or measures need to be
psychometrically tested, so qualitative researchers are the
research instrument and they have a responsibility to collect
data in a trustworthy fashion. Some people offer raw
interview transcripts back for checking, while others offer
aggregated data back through focus groups once a level of
analysis and interpretation has been made. What is of
interest here is the potential power of the participants to
influence the direction of the research through this process.
Carlson (2010) explored this issue based on her own
research experiences and describes a number of instances
where the results of the member checking were not as
expected (for example, one man making major “red pen”
changes through large sections of his interview transcript
removing much of what Carlson thought was most relevant
and replacing it with short notes in the margins). She
suggested a number of tips to enhance the process of
member checking: giving choices in advance about how
it might be done; considering checking sections rather
than the whole transcript; explaining that checking is not
about grammar, fillers or pauses, but rather the ideas in
the interview (this point has implications for how clean the
transcript is, or whether it truly reflects the messiness of
spontaneous speech); informing participants clearly about
the process (for example, that they can add ideas as well
as amend previously stated ones); and finally informing
participants about how the material is to be used in the final
report or publications. Carlson’s suggestions show that
member checking is a negotiated process which should
enhance the rapport between researcher and participant
rather than damage it. It potentially gives participants
considerable input into how data is used. These
suggestions are relevant for participants with aphasia.
Rather than sending a transcript in the post or electronically
to be reviewed, it may be better to go through it in person
(although this is clearly time-consuming). The main ideas
from an interview could otherwise be summarised and
participants when they become involved in research, and
what might be expected of the researcher.
In this paper, I suggest three broad reasons to consider
the nature of participation in research: first, it helps guide
the ethical decisions, protections and processes in the
research; second, it is an important part of assuring
the quality of the research; and third, it guides the
dissemination, translation and impact of the research. I shall
illustrate each of these points with some examples from the
field of communication disorders – specifically aphasiology.
Participants and ethical research
When a research participant is first invited to take part in a
study, he or she needs to know what this commitment will
entail: the purpose, duration of the involvement, the tasks
or activities, any harms or benefits, who is running the
research, how confidentiality is to be maintained, where the
data might be stored, how long for, who else might have
access to it and so on. Such information, along with the
right to withdraw from the study at any time without penalty,
is usually set up well in advance of recruitment because of
the requirements of the ethics committee in the institution
to which the study is affiliated (Israel, 2014). For people who
are communication impaired, consideration of the
participant needs to be upfront in the mind of the
researcher because the process of agreeing to participate,
enshrined in the informed consent procedure, is dependent
on access to all this information. This may mean adapting
the process by which people are recruited, and adapting
the consent forms to be aphasia friendly (Braunack-Mayer
& Hersh, 2001; Kagan & Kimelman, 1995). This topic has
been explored by a number of researchers (Penn, Frankel,
Watermeyer & Müller, 2009; Stein & Brady Wagner, 2006)
and the procedures carefully considered (Jayes & Palmer,
2014). But this is a relatively recent shift in thinking, and for
many years people with aphasia have been excluded from
studies altogether because participation was considered
beyond their capability (Brady, Fredrick & Williams, 2013;
Townend, Brady & McLaughlan, 2007). Not only does this
skew the findings of such research, but it also denies people
the right to be heard and included. Therefore, considering
the ethics of how participants might be recruited, included,
and protected is part of the research process and this, in
itself, shapes the design of the study as well as preparing
the groundwork for participants to feel valued and involved.
In addition to improving access to information and
recruitment, there have been developments in the way
that data might be collected (Dalemans, Wade, van den
Heuvel & de Witte, 2009). For example, Luck and Rose
(2007), in the context of running interviews with people with
aphasia, point out that traditional interviewing techniques,
including a reliance on broad, open-ended questions and
minimal interviewer influence, may not be appropriate.
They argue for “transparency of methods” (p. 210) in data
collection through describing carefully any adaptations
made such as acknowledging in advance the potential for
communication breakdown, discussion of helpful strategies,
video-recording in order to pick up gestures and detailed
transcriptions of total communication use, interviewer
clarifications, word offerings, paraphrasing, funnelling of
questions and so on. Luck and Rose make the important
point that supportive techniques used by interviewers
reduce the reliance on obtaining information from proxies
and make it more likely that people with aphasia can
successfully be participants in research thereby “affirming
that their opinions are valid and attainable” (p. 221). This
has important ethical implications, preserving people’s
autonomy and right to have their views respected.

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 125
established a list of 22 potential research questions.
Interestingly, about 40% of these questions were not ones
which current evidence is able to answer well. As well as
revealing research priorities of people with aphasia, the
researchers took considerable care to summarise the results
of this process in an aphasia-friendly way for their participants
and also to evaluate how accessible that summary was for
the group. Another example of PAR is to be found in the
doctoral work of Carole Pound (2013) which has explored
the experiences of friendship for people with aphasia.
PAR also lends itself well to cross-cultural research. The
recent work of McLellan and colleagues highlights how
these ideas are being used in the area of aphasia in New
Zealand (McLellan, McCann, Worrall & Harwood, 2014).
They use Kaupapa Mãori research (KMR), an Indigenous
research approach which privileges Mãori culture and
knowledge in the process thereby countering the notion
of being researched to actively collaborating and directing
it (Denzin, Lincoln, & Smith, 2008). McLellan et al. write
that their goal is to achieve “more culturally appropriate
and beneficial practices in the delivery of speech-language
therapy services” (p. 455), thereby ensuring that the
research is not simply the collecting of data but also giving
back to the community.
In Western Australia, the Missing Voices Research,
funded by the National Health and Medical Research
Council (2013–2015) and led by Elizabeth Armstrong,
is currently exploring the experiences of Aboriginal
Australian adults with acquired communication disorders.
The research involves several strands (data linkage,
the development of a screening tool, interviews with
stakeholders) but overall draws on a participatory
research approach, working in partnership with Aboriginal
researchers and research assistants, and an Aboriginal
reference group. While the research is ongoing, the
requirement for it to be culturally secure and of benefit to
the participants and communities involved, is uppermost in
the design and running of the study.
Ultimately, the research that has been carried out in
aphasiology, as in other fields, has sought to bring benefit
to participants and to the aphasia community more
broadly. How the results of studies are disseminated and
made accessible to participants varies. Results may be
given directly to consumers, for example, via an aphasia
group in the study by Hinckley et al. (2014), or through
the Australian Aphasia Association Conference, a national
conference for people with aphasia and their families.
Connect (2007) includes an example of an aphasia-friendly
summary of their “Discovery Project”. Research may be
disseminated through a range of stakeholders. This may
bring benefit through the service providers who come into
contact with people with aphasia (Simmons-Mackie et al.,
2007) or through a formal consideration of “knowledge
transfer and exchange” targeting people with aphasia,
clinicians, other service providers, managers and funders
(Kagan, Simmons-Mackie, Brenneman Gibson, Conklin, &
Elman, 2010). By considering research participants early
on in a study, researchers can build their needs into the
design, including how the results of that research might
be disseminated and how the knowledge gained from the
study might be shared.
Conclusion
In this paper, I have raised the role of participants by
exploring the nature of their participation. Depending on the
type of study in question, the participant may be more than
simply being “subject” to the research process. His or her
presented in an aphasia-friendly format. A good example
of this is the study by Davidson, Howe, Worrall, Hickson
and Togher (2008) which explored social participation
and friendships in older people with aphasia. Davidson et
al. summarised the main themes from “stimulated recall
interviews” (where the researcher and participant with
aphasia discussed a video of that participant interacting
with a friend) and presented these back to participants “for
verification and validation” using supported conversation
strategies (Kagan, 1998). Techniques like member checking
not only add to the credibility of the research but they also
give far more voice to the participant and add balance to
the researcher/participant relationship.
Participants and the
dissemination, translation and
impact of research
Finally, how might reconsideration of the participant
influence dissemination, translation and impact of the
research? Clearly, the point made at the start of this paper
about the change in the Speech Pathology Code of Ethics
identifies that participants should be informed of the
outcomes of research to which they have contributed.
Perhaps more fundamentally, there is an argument that
being informed is not sufficient but that, for example, even
in the area of aphasia, research can be “user-led” and even
“user-controlled” (Connect, 2007, p. 10) as described in the
guide by Connect, a UK-based charity for people living with
aphasia. This guide contains many practical suggestions to
support communication at all stages of planning and
engaging in research studies. It encapsulates a satisfying
“about turn” in a field where people with aphasia might
arguably move from being excluded from research studies
to collaboratively shaping them.
Perhaps the most obvious manifestation of this
shift is found in participatory action research (PAR),
which is prominent in a range of health, welfare and
social science fields incorporating emancipatory and
community development aims. While PAR is interpreted
in a variety of ways, (and sometimes overlaps with the
terms “participatory research” or “action research”) it
encompasses research that aims to examine the needs of
marginalised or disempowered groups in order to change
or tackle the barriers that they face (Liamputtong, 2009).
PAR aims not only to generate new knowledge that might
help these groups of people but also to assist them to
take ownership of their own knowledge bases. It involves
collaborative work that should improve the lives of research
participants and the communities from which they come.
This approach entails partnership in the design of a study,
in the data collection, in analysis and interpretation. The
process of being involved in research is itself empowering
and ensures the relevance of a study to the individual
participants and on to local communities. Liamputtong
points out that PAR is a methodology rather than a set of
methods and the important underpinning is its philosophy
of knowledge production and empowerment.
Within the field of communication disorders, these ideas
are now gaining ground. Duchan (2014) argues there are
“both moral and political reasons for shifting our thinking
and our research practices to become more emancipatory”
(p. 3). A good example of this is the work by Hinckley,
Boyle, Lombard and Bartels-Tobin (2014). They adopted a
community-based participatory research approach with 25
members of an aphasia support group to find out what
research topics the group thought were most important.
Through a modified nominal group technique, they

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 127 126 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
informed consent process. International Journal of Speech-
Language Pathology, 16(2), 159–168.
Kagan, A. (1998). Supported conversation for adults with
aphasia: methods and resources for training conversation
partners. Aphasiology, 12, 816-830.
Kagan, A., & Kimelman, M. (1995). Informed consent in
aphasia research: Myth or reality? Clinical Aphasiology, 23,
65–75.
Kagan , A., Simmons-Mackie, N., Brenneman
Gibson, J., Conklin, J., & Elman, R. J. (2010). Closing
the evidence, research, and practice loop: Examples of
knowledge transfer and exchange from the field of aphasia.
Aphasiology, 24(4), 535–548.
Liamputtong, P. (2009). Qualitative research methods
(3rd ed.). Melbourne: Oxford University Press.
Lincoln, Y. S., & Guba, E .G. (1985). Naturalistic inquiry.
Beverley Hills, CA: Sage.
Luck, A. & Rose, M. (2007). Interviewing people with
aphasia: Insights into method adjustments from a pilot
study. Aphasiology, 21, 208–224.
McLellan, K. M., McCann, C. M., Worrall, L. E., &
Harwood, M. L. (2014). “For Mãori, language is precious.
And without it we are a bit lost”: Mãori experiences of
aphasia. Aphasiology, 28(4), 453–470.
The National Health and Medical Research Council,
the Australian Research Council and the Australian Vice-
Chancellors’ Committee. (2007) (updated March 2014).
National statement on ethical conduct in human research.
Commonwealth of Australia, Canberra.
Penn, C., Frankel, T., Watermeyer, J., & Müller, M. (2009).
Informed consent and aphasia: Evidence of pitfalls in the
process. Aphasiology, 23, 3–32.
Pound, C. (2013). An exploration of the friendship
experiences of working-aged adults with aphasia.
Unpublished doctoral thesis, Brunel University. Retrieved
from: http://bura.brunel.ac.uk/handle/2438/7696
Simmons-Mackie, N. N., Kagan, A., Christie, C.,
Huijbregts, M., McEwen, S., & Willems, J. (2007).
Communicative access and decision making for people
with aphasia: Implementing sustainable healthcare systems
change. Aphasiology, 21, 39- 66
Speech Pathology Australia. (2000). Code of ethics.
Melbourne: Author.
Speech Pathology Australia. (2010). Code of ethics.
Melbourne: Author.
Stein, J. & Brady Wagner, L. (2006). Is informed consent
a “yes or no” response? Enhancing the shared decision-
making process for persons with aphasia. Topics in Stroke
Rehabilitation, 13, 42–46.
Townend, E., Brady, M., & McLaughlan, K. (2007).
Exclusion and inclusion criteria for people with aphasia in
studies of depression after stroke: A systematic review and
future recommendations. Neuroepidemiology, 29, 1–17.
involvement may shape early consideration of the ethics
process, the way the research quality is assured and how
findings might be disseminated. Consideration of the
participant opens up debate about the theoretical and
epistemological assumptions that underlie the
methodologies favoured in our discipline. I have focused on
people with aphasia as participants, but, of course,
participants may be colleagues, students, clinicians,
managers and so on. It is useful to consider what
participation entails and the nature of the relationship
between researcher and participant. Different research
questions call for different research approaches, but the
field of speech pathology is now moving to incorporate
research designs which involve participatory research. The
move from “subject” to “participant” serves to widen our
research potential and offers rich opportunities for growth
and new ways to respond to the needs of our clients.
Acknowledgments
I would like to thank the reviewers of this paper who
generously shared useful suggestions and additions to
strengthen the arguments made.
References
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ethics and responsibilities. In T. Miller, M.Birch, M. Mauthner,
& J. Jessop (Eds.), Ethics in qualitative research (2nd ed.,
pp. 94–107). Thousand Oaks, CA: Sage Publishing.
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intervention inequalities. International Journal of Stroke, 8,
193–196.
Braunack-Mayer, A., & Hersh, D. (2001). An ethical
voice in the silence of aphasia: Judging understanding and
consent in people with aphasia. Journal of Clinical Ethics,
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Connect: the communication disability network (2007).
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research and consultation: A guide for researchers and
service providers. London: Connect Press.
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Witte, L. P (2009). Facilitating the participation of people
with aphasia in research: A description of strategies. Clinical
Rehabilitation, 23, 948–959.
Davidson, B., Howe, T., Worrall, L., Hickson, L., & Togher,
L. (2008). Social participation for older people with aphasia:
The impact of communication disability on friendships.
Topics in Stroke Rehabilitation, 15(4), 325–340.
Denzin, N. K., Lincoln, Y. S, & Smith, L. T (2008).
Handbook of critical and indigenous methodologies.
Thousand Oaks, CA: Sage.
Duchan, J. F. (2014). Case studies and their frameworks.
In M. Ball, N. Müller, & R. Nelson (Eds.), The handbook of
qualitative research in communication disorders: In honor of
Jack S. Damico (pp. 3–16). New York: Psychology Press.
Hinckley, J., Boyle, E., Lombard, D., & Bartels-Tobin, L.
(2014). Towards a consumer-informed research agenda
for aphasia: Preliminary work. Disability and Rehabilitation,
36(12), 1042–1050.
Israel, M. (2014). Research ethics and integrity for social
scientists: Beyond regulatory compliance. London: Sage.
Jayes, M., & Palmer, R. (2014). Initial evaluation of the
consent support tool: A structured procedure to facilitate
the inclusion and engagement of people with aphasia in the
Deborah Hersh, PhD, FSPAA, CPSP is associate professor in
Speech Pathology at Edith Cowan University, Perth, Western
Australia and adjunct senior lecturer in Public Health at Flinders
University, South Australia.
Correspondence to:
Deborah Hersh
Speech Pathology
School of Psychology and Social Science,
Edith Cowan University
270 Joondalup Drive, Joondalup, Perth, WA 6027, Australia
phone (61 8) 6304 2563
email: d.hersh@ecu.edu.au

Research
www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 127
KEYWORDS
SOCIAL
COMMUNI CATION
TRAUMATIC
BRAIN INJURY
ADOLESCENCE
PRAGMATICS
THIS ARTICLE
HAS BEEN
PEER-
REVIEWED
“Can you speak
English?”
The effects of social communication impairment on the life
of an adolescent with traumatic brain injury
Jessica Drummond, Michael Curtin and Lucie Shanahan
Adolescence is an important period of psychosocial
development involving the interaction of biological, cognitive,
and socio-emotional processes (Santrock, 2010). Adolescents
are developing their own identity and learning the rules of
advanced social interaction as they experience an increase
in communicative contexts and partners (Forgas, Vincze, &
László, 2013; Mikami, Szwedo, Allen, Evans, & Hare, 2010).
The development of advanced social interactions is
underpinned by the four maxims of Grice’s Cooperative
Principle of Conversation (Grice, 1975; Kleinke, 2010):
1. Quantity: the giving of as much information as required
without providing excessive detail;
2. Quality: the provision of information that is believed to be
the truth and for which there is adequate evidence;
3. Relation: a conversation involves all participants making
relevant contributions; and
4. Manner: contributions are given in a brief and orderly
manner, avoiding obscure and ambiguous expressions.
Ciccia and Turkstra (2002) suggested that abnormalities
in cohesion, communication burden, and adequacy
of responses are violations of the maxims of quantity,
relation and manner. These abnormalities are frequently
experienced by people with a traumatic brain injury
(TBI) and can lead to perceptions of these people as
ineffective communicators (Douglas, Bracy, & Snow, 2007;
Marini, Galetto, Zampieri, Vorano, Zettin, & Carlomagno,
2011). Given that the cognitive skills underlying social
communication are still developing during the teenage
years, it follows that adolescents with TBI can have difficulty
mastering effective exchanges of information (Bogart
et al., 2012; Burnett et al., 2011). As a result, they may
ultimately be at a disadvantage when communicating with
their peers because of the reciprocal relationship between
social communication and social competence (Hawley &
Newman, 2010). This could lead to a teenager with TBI
experiencing social isolation (Bogart et al., 2012).
There is a substantial body of research investigating
social communication impairment after a TBI but much of
this has focused on adults. While literature describing the
common sequelae of childhood TBI is now readily available,
there is a relative dearth of empirical literature describing
studies of social communication impairment following
childhood TBI (Anderson, Beauchamp, Rosema, & Soo,
2013). A small number of publications have documented
cognitive and communication impairments post-injury
that result in social dysfunction (e.g: Anderson, Catroppa,
Morse, Haritou, & Rosenfeld, 2009) but the majority of
studies are based on parent and teacher ratings rather
During adolescence teenagers learn the rules
of more sophisticated social interaction. For
teenagers with traumatic brain injury (TBI)
learning these rules is difficult because of the
impairment to cognitive processes underlying
social communication. In the case study
presented in this paper, the social
communication impairment experienced by a
teenage girl with TBI was explored using
semi-structured interviews with the
adolescent, her mother, and a friend. Analysis
revealed that communication breakdown was
a common consequence of the teenager’s
social communication impairment. Strategies
to compensate for the communication
impairment were used by her parents and
friends to limit the extent of the
communication breakdown, but no strategies
were in place to improve the adolescent’s
social communication interactions. It is
proposed that a greater focus on strategies
to develop her social communication skills
would be beneficial, particularly as the
adolescent becomes older and moves on
from the protective environments of her
home and school.
Social communication involves the use of language in
interpersonally appropriate ways to influence people
and interpret events (Olswang, Coggins, & Timler,
2001). According to Turkstra (2000) it is a way to develop
and express identity and to convey information, as well as
provide a medium for the growth of social skills. Successful
social communication requires an understanding of
relationships and people (Togher, Power, Tate, McDonald, &
Rietdijk, 2010). It is also dependent on the co-development
of many cognitive processes, such as memory, planning,
organisation, and perspective-taking (Burnett, Sebastian,
Cohen Kadosh, & Blakemore 2011; Whelan & Murdoch,
2006), which continue to mature during the adolescent
years (Bogart, Togher, Power, & Docking, 2012; Burnett et
al., 2011; Sim, Power, & Togher, 2013; Scherf, Behrmann,
& Dahl, 2012).
Jessica
Drummond (top),
Michael Curtin
(centre) and
Lucie Shanahan

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Data collection procedure
Semi-structured interviews were used to collect data for
this study, providing the opportunity for participants to tell
their story (Smith et al., 2009). The interviews were
audio-recorded and transcribed to aid data analysis. The
interviews were conducted at Mandy’s home on two
separate occasions. The first interview involved Mandy and
Vivienne. This interview took approximately one hour and
focused on Mandy’s perceptions of her brain injury, her
communication, relationships, and personality before and
after the accident. Prior to the second interview, the first
interview was transcribed and read several times to
establish areas that required further discussion.
The second interview took approximately 90 minutes and
involved a joint conversation between Mandy, Vivienne, and
Mandy’s friend Bridget. Many of the questions for Vivienne
and Mandy were based on their responses in the first
interview, seeking elaboration or clarification as a method
of member-checking (Curtin & Fossey, 2007). Bridget’s
questions were related to her friendship with Mandy and
her perception of Mandy’s communication, personality, and
any changes that may have occurred in these domains.
Data analysis
Prior to analysing the data the transcripts were shared
between the three authors and read several times to ensure
familiarisation with the participants’ perspectives.
Descriptive, linguistic, and conceptual comments and key
words were then written on the transcripts and quotes
highlighted according to IPA guidelines (Smith et al., 2009).
Key words and ideas were discussed among the authors
and collaboratively matched with the quotes to form
categories. These were later synthesised according to their
similarity to create themes, which were thought to
encapsulate the message of the participants. Consultation
between the three authors throughout the analysis process
enhanced the trustworthiness of the findings.
To assist with comprehending the data and interpreting
the transcripts a journal was maintained throughout the
study. The first author wrote reflective entries throughout
the research process and shared these with the other
authors to aid understanding of the participants’ story.
The reflections directed the more in-depth, collaborative
IPA analysis. Finlay and Gough (2003) and Johnson and
Waterfield (2004) state that writing in a reflective journal
acknowledges the researcher’s participation in interpreting
and constructing findings, with the understanding that the
researcher inevitably brings his or her own background into
the research process.
Mandy’s story
At the time of the study Mandy was a 14-year-old girl who
lived in a rural town with her parents and two younger
siblings. She was in year nine and prior to her TBI identified
herself as a good runner, with aspirations to be a personal
trainer when she left school. She sustained a mild TBI
approximately 12 months prior to the interview after an
accidental knock to the head at school. Medical file notes
report a loss of consciousness of up to one minute with no
neurological changes noted on CT imaging. Mandy did not
remember the events surrounding the accident.
Mandy’s schoolmates and teachers did not understand
the lasting effects of the TBI because she did not look any
different than before the injury. Her friends believed she
was feigning her complaints of fatigue, headaches and not
being able to keep up with schoolwork. Her brain injury
than ascertaining the adolescent’s perception (Anderson
et al., 2013). The aim of our study was to examine the
impact of social communication impairment on the
life of an adolescent with TBI, from the perspectives
of the adolescent, one of her parents, and a friend. It
was anticipated that the findings could contribute to a
greater understanding of the potential impact of social
communication impairment for adolescents post-TBI.
Methodology and method
Research approach
An interpretative phenomenological analysis (IPA) approach
(Smith, Flowers, & Larkin, 2009) was employed to facilitate
an in-depth investigation of the experience of having a
social communication impairment following TBI, from the
perspectives of an adolescent, her mother, and a friend. IPA
is a research method that investigates how a person
understands and interprets experiences, providing an
insider’s perspective of the experience (Smith et al., 2009).
This research project was granted ethical approval from
the Human Research Ethics Committees of Charles Sturt
University and the relevant health authority.
Recruitment of participants
One adolescent who had a TBI, her mother, and a friend of
the adolescent were purposefully recruited for this study to
facilitate multiple perspectives. This permitted triangulation,
enhancing trustworthiness of the data by acknowledging
more than one view of a phenomenon (Curtin & Fossey,
2007). IPA research is typically conducted with a small
number of participants, allowing for more in-depth
exploration of data (Smith et al., 2009). IPA research is not
about generalisability of findings, but focuses on an involved
understanding of the phenomenon being researched for the
participants in the study. To be eligible for participation in
this study the adolescent had to:
• be aged between 13 to 19 years old with diagnosed
social communication impairment (based on speech
pathology and neuropsychology assessment findings
post-TBI), with awareness of this impairment;
• have sustained the TBI during adolescence;
• have returned to their mainstream school after the injury;
• have age-appropriate IQ and/or receptive language
skills, in order to have the capacity to consent; and
• have no obvious physical impairment as a result of their
TBI, because this project focused on the way the person
behaves in social interactions due to the cognitive
deficits following TBI, rather than motor communication
impairment.
A staff member from a local brain injury rehabilitation
facility developed a de-identified list of adolescents who
met the inclusion criteria. An appropriate adolescent was
chosen from the de-identified list. The staff member then
sent a research information sheet and expression of interest
form to the adolescent and her mother. This adolescent
and her mother each returned a completed expression
of interest form, after which the first author phoned the
adolescent and mother to answer any questions and
arranged a time to meet. At this meeting consent forms
were signed and the interviews commenced. At the end of
this meeting, the adolescent was provided with a research
information sheet and expression of interest form to give to
a friend, to incorporate a third perspective into the study.
For the purposes of this study, the adolescent with TBI was
given the pseudonym Mandy, her mother the pseudonym
Vivienne, and her friend the pseudonym Bridget.

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 129
they don’t even know what I am on about”. The fact that
Mandy required more time to plan her contributions to
conversations meant that the timing of her input sometimes
confused her audience:
Mandy: They’ll be talking about something and then
they’ll be talking about something different and cos I
take ages to think of what I have to say, I just say it and
they’ll go “That was ages ago”.
Vivienne: Mmmmm. We were discussing that ten
minutes ago.
Mandy’s tendency to become tangential in conversation
reflected a common consequence of TBI (Bogart et al.,
2012). In contrast with Grice’s (1975) maxims of effective
communication, Mandy’s irrelevant contributions hindered
the information exchange as her communication partners
had difficulty deciphering her meaning. Since cohesion
within discourse is expected most of the time in typically
developing teenagers (Ciccia & Turkstra, 2002), Mandy’s
failure to make clear links within her conversation may have
led to perceptions from her communication partners that
she was an ineffective communicator (Sim, Power, &
Togher, 2013). For example, Vivienne commented that “She
does get distracted on the simplest things – she [will] start
telling you something else and you think ‘Hang on…why
have you changed?’”, indicating that Mandy got distracted
and was prone to changing the topic without warning.
Vivienne stated that Mandy did not always give sufficient
detail when talking to someone and that Mandy did
not recognise the discrepancy between her own level
of background knowledge on the topic and that of her
listeners. She described the feeling of waiting for Mandy
to provide more detail in order to clarify her meaning: “She
stops [talking] and you go ‘What were you talking about?’
and you’re supposed to know exactly [what she means]
and she goes ‘You know! Bla-bla-bla’.” Consequently,
Mandy deviated from Grice’s (1975) conversational maxim
of quantity because she did not give all the information
required. This potentially led to communication breakdowns
and reduced satisfaction for conversation participants. In
addition, Vivienne described how Mandy’s facial expression
was sometimes incongruous with the tone of the message
she was conveying, thus transmitting ambiguous meaning:
“She’s trying to say something upbeat but her face is
screwed up […] I’m thinking, ‘What?’”
Mandy confirmed that the contradiction between her
facial expression and message could have been due to the
effort she had to apply when concentrating on what she
was saying. However, she was possibly unaware of how
she portrayed herself to others. The mismatch between
Mandy’s words and emotion was also a violation of Grice’s
maxim of manner (Grice, 1975; Kleinke, 2010), and this
could further contribute to communication breakdown.
Theme 2: “When they say a joke I click to
it a couple of days later”
In addition to confusing her communication partners with
her expressive impairment, Mandy had difficulty
understanding non-literal or affective meaning conveyed by
others. For example, Mandy was unsure about the potential
meaning of the facial expression of her communication
partners:
Mandy: You’re death-staring me.
Vivienne: No I didn’t.
Mandy: She’s looking at me like “You weirdo”.
impacted upon her natural running ability because her head
hurt whenever she ran. Since the injury she had doubts
about her potential to be a personal trainer, saying “It just
wouldn’t work, cos I can’t do half the stuff I used to”. Her
overall school performance had deteriorated post-TBI as
she struggled to keep up with her class work.
Mandy experienced a change in her personality and
the way that she communicated with others following
the TBI. She became quieter and showed less emotion
than she did pre-morbidly but felt like she had to “act
happy so people don’t think I am all weird”. In the initial
phase of rehabilitation Mandy participated in a battery of
standardised language, visual perceptual and cognitive
assessments, administered by the treating speech
pathologist, occupational therapist and neuropsychologist.
Assessment results showed that Mandy had problems with
memory, planning, word-finding, using and understanding
facial expression, interpreting jokes and sarcasm, attending
to a topic, providing an appropriate amount of information
to her listeners, and self-evaluating her communication
performance. These difficulties were particularly prominent
when Mandy was tired or had a headache.
Findings and discussion
Analysis of participant interviews showed the complex and
multi-faceted effects of Mandy’s social communication
impairment post-TBI. Three themes emerged from the
analysis of the interviews:
• Theme 1: “Half the time they don’t even know what I’m
on about” relates to people not comprehending Mandy;
• Theme 2: “When they say a joke I click to it a couple of
days later” focuses on Mandy’s struggle with high level
language comprehension (e.g. difficulties understanding
figurative language);
• Theme 3: “I can just look in her eyes and go ‘All right,
should we not talk to you today?’” presents strategies
used by Mandy and others to reduce the potential for
communication breakdown.
Theme 1: “Half the time they don’t even
know what I’m on about”
Mandy’s TBI had affected her ability to express meaning
clearly to others, which led to communication breakdown.
Difficulty conveying her message stemmed from a number
of cognitive-linguistic deficits such as: planning and
word-finding difficulties, becoming tangential, and providing
insufficient information. While these difficulties were evident
on formal assessments conducted by the rehabilitation
team prior to this study, observations during the interviews,
and reports from the interview participants throughout the
data collection phase confirmed the persistent nature of
these communication difficulties.
Mandy stated that her friends commented that her
unsuccessful communication attempts were similar to her
speaking in another language:
Interviewer: How do your friends react to that?
Mandy: “Can you speak English?” That’s what they say
to me!
According to Grice’s maxim of relation (Grice, 1975;
Kleinke, 2010), all communication partners are responsible
for establishing shared meaning; however, Mandy indicated
that her listeners did not give timely input when she had
difficulty planning what she wanted to say. She indicated
that her friends were unable to suggest words that they
thought she might be looking for, because “half the time

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Mandy withdrew from difficult communication situations
in an effort to reduce communicative failures. She stated
that she was “not in many conversations at school, [and
says] something when it’s important”. She appeared
not to value or feel confident about her contributions to
conversations. Hence, she made a conscious decision
to forfeit participation in the interactions: “I find it hard to
say things, so I just don’t bother, I just sit there”. Other
researchers (including Bogart et al., 2012; Kelly, McDonald,
& Kellett, 2013; Turkstra, 2000) have referred to the social
isolation that individuals with TBI can face. As these
individuals may lack the ability to take the perspective of
others, they can have problems behaving appropriately
and therefore fitting in. Subsequently, the social interaction
opportunities that would ordinarily foster development of
their communicative competence can be limited.
Bridget took a different approach to handling
communication frustrations involving Mandy. Rather than
ceasing the conversation, Bridget simply chose not to react
to Mandy’s communication impairment.
Interviewer: Do you ever get frustrated with Mandy’s
communication?
Bridget: Sometimes I do but I just get over it.
Interviewer: What about if the topic of conversation
moves on but Mandy brings up an old topic? Do you
react to it or let it go?
Bridget: Just let her go.
While Bridget still felt frustrated about Mandy’s
conversational flaws, she did not react in such a way that
would upset Mandy and make the conversation a negative
experience. Thus, while the communication breakdown still
occurred, it did not intensify into a more unsatisfactory
interaction for Mandy.
A strategy that Mandy used to increase her
communication with people was using online social media.
Interviewer: You seem to use [online] chat a fair bit, is
there any particular reason for that?
Mandy: Just easier, cos I don’t have to verbally say it, I
just type it. I’m pretty quick at typing too so it’s easier,
faster.
Mandy felt more confident to socialise via online chat
because she found it easier to express herself. It was
possible that this form of communication gave Mandy the
advantage of being able to edit her messages before she
sent them. Bridget said that Mandy was “really quick” at
responding when using online chat. This communication
experience was optimised for Mandy because she felt that
this modality was a more successful means of
communication for her.
Conclusion
This study investigated and highlighted the effects of social
communication impairment on the life of an adolescent with
TBI, from the perspective of the adolescent, her mother,
and her friend. It was found that a frequent experience
stemming from Mandy’s post-TBI communication
impairment was communication breakdown. This meant
that for various reasons Mandy and her communication
partners could not easily establish shared meaning. Some
of these breakdowns could be attributed to Mandy’s
expressive communication problems, while other ineffective
communication exchanges occurred when Mandy
misunderstood the meaning of others. Mandy, her family,
and friends have implemented strategies to reduce the
Vivienne: I could be looking at something completely
different and [Mandy will say] “What are you looking at
me for?”, “I’m not”.
At times, Mandy perceived adverse facial expressions from
people around her, and mistakenly believed that they were
thinking negatively about her. This misinterpretation was an
example of an impairment of affective communication,
another common consequence of TBI (McDonald, Rushby,
Li, de Sousa, Dimoska, et al., 2011). Babbage and
colleagues (2011) indicated that skill in affective
communication was important for successful interaction
and that inaccurate relation or perception of emotions
within a message resulted in miscommunication. A potential
reason for Mandy’s trouble interpreting other people’s
sentiments was that she may have had an impairment of
theory of mind, the ability to perceive the intention and
perspective of others, such that she could not accurately
perceive the thoughts, feelings, and intentions of her
communication partners (Im-Bolter, Cohen, & Farnia, 2013).
Mandy’s difficulty recognising her communication
partners’ messages was evident when she misinterpreted
jokes and sarcasm. She admitted that, “when they say a
joke or something, I click to it a couple of days later.” She
indicated that she spent a lot of time trying to decipher the
meaning of a joke. Vivienne and Bridget confirmed this:
Vivienne: Her father says something to her and she
goes “What did he say that for?” and I go “Mandy it
was a joke”.
Bridget: Sometimes like if I say something [as a joke],
she’ll take it seriously.
The understanding of increasingly sophisticated jokes and
sarcasm is an important social skill to be cultivated during
the adolescent years (Nippold, 2007) and is commonly
impaired following a TBI (Byom & Turkstra, 2012; Im-Bolter
et al., 2013). Mandy misunderstood humour from other
people that her typically developing peers comprehended
appropriately. She had delayed or inappropriate reactions
and this led to the communicative exchange being
compromised in effectiveness and mutual satisfaction
(Marini et al., 2011).
Theme 3: “I can just look in her eyes and
go ‘All right, should we not talk to you
today?’”
Various strategies were used by Mandy or her
communication partners to reduce the likelihood of
communication breakdown. These included withdrawal
from negative communication experiences, deciding not to
react to Mandy’s communication mistakes, and using
Mandy’s preferred modes of communication.
Mandy’s mother chose to withdraw from unpleasant
communication opportunities. Vivienne stated that Mandy
lost her temper easily when she was tired or had a
headache and as a result, Vivienne tried to avoid Mandy
in these situations: “I can just look in her eyes and go ‘All
right, should we not talk to you today?’ And it’s the look
in her eye and I know she’s tired, she’s had enough.”
Vivienne knew that when Mandy was fatigued and
irritable, the communicative exchange was less likely to be
effective and fulfilling. Therefore Vivienne discontinued their
interaction and withdrew from the situation. This minimised
the confusion or stress experienced by either party, and
potentially prevented escalation of the situation into a
communication breakdown.

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 131
McDonald, L. Togher, & C. Code (Eds.), Social and
communication disorders following traumatic brain injury.
Hove, UK: Psychology Press.
Anderson, V., Catroppa, C., Morse, S., Haritou, F., &
Rosenfeld, J. (2009). Intellectual outcome from preschool
traumatic brain injury: A 5-year prospective longitudinal
study. Pediatrics, 124(6), 1064–1071.
Babbage, D. R., Yim, J., Zupan, B., Neumann,
D., Tomita, M. R., & Willer, B. (2011). Meta-analysis
of facial affect difficulties after traumatic brain injury.
Neuropsychology, 25(3), 277–285.
Bogart, E., Togher, L., Power, E., & Docking, K. (2012).
Casual conversations between individuals with traumatic
brain injury and their friends. Brain Injury, 26(3), 221–233.
Burnett, S., Sebastian, C., Cohen Kadosh, K., &
Blakemore, S. (2011). The social brain in adolescence:
Evidence from functional magnetic resonance imaging and
behavioural studies. Neuroscience and Biobehavioural
Reviews, 35, 1654–1664.
Byom, L. J., & Turkstra, L. (2012). Effects of social
cognitive demand on theory of mind in conversations of
adults with traumatic brain injury. International Journal of
Language and Communication Disorders, 47(3), 310–321.
Ciccia, A., & Turkstra, L. S. (2002). Cohesion,
communication burden, and response adequacy in
adolescent conversations. International Journal of Speech-
Language Pathology, 4(1), 1–8.
Curtin, M., & Fossey, E. (2007). Appraising the
trustworthiness of qualitative studies: Guidelines for
occupational therapists. Australian Occupational Therapy
Journal, 54, 88–94.
Douglas, J. M., Bracy, C. A., & Snow, P. C. (2007).
Measuring perceived communicative ability after traumatic
brain injury: Reliability and validity of the La Trobe
Communication Questionnaire. Journal of Head Trauma
Rehabilitation, 22(1), 31–38.
Finlay, L., & Gough, B. (2003). Reflexivity: A practical
guide for researchers in health and social sciences.
Chichester, UK: John Wiley and Sons.
Forgas, J. P., Vincze, O., & László, J. (Eds.) (2013). Social
cognition and communication. New York: Psychology
Press.
Grice, H. P. (1975). Logic and conversation. In P. Cole
& J. L. Morgan (Eds.), Syntax and semantics (Vol. 3,
pp. 41–58). Retrieved from http://www.sfu.ca/~jeffpell/
Cogs300/GricsLogicConvers75.pdf
Hawley, L. A., & Newman, J. K. (2010). Group interactive
structured treatment (GIST): A social competence
intervention for individuals with brain injury. Brain Injury,
24(11), 1292–1297.
Im-Bolter, N., Cohen, N. J., & Farnia, F. (2013). I thought
we were good: Social cognition, figurative language, and
adolescent psychopathology. Journal of Child Psychology
and Psychiatry, 54(7), 724–732.
Johnson, R., & Waterfield, J. (2004). Making words
count: The value of qualitative research. Physiotherapy
Research International, 9(3), 121–131.
Kelly, M., McDonald, S., & Kellett, D. (2013). The
psychological effects of ostracism following traumatic brain
injury. Brain Injury, 27(13–14), 1676–1684.
Kleinke, S. (2010). Speaker activity and Grice’s maxims
of conversation at the interface of pragmatics and cognitive
linguistics. Journal of Pragmatics, 42, 3345–3366.
likelihood and extent of communication breakdown. These
actions included avoiding negative or difficult communi-
cation situations, accepting Mandy’s communication errors,
and using other forms of interaction with which Mandy felt
more confident, such as online chat.
Although this study identified part of the impact of social
communication impairment for Mandy, the limitations of the
research must be acknowledged. This study involved only
one adolescent, her mother, and her friend. Thus, while
the experiences of participants in this study may resonate
with other adolescents with TBI and their significant others,
the current findings cannot be generalised to other people
in this population. Another limitation was that participants
were not interviewed individually. Although this was the
wish of Mandy, Vivienne, and Bridget, the joint interviews
could have impacted upon the degree to which they felt
comfortable giving open and honest responses.
Neither the literature nor the participants in this study
identified strategies for developing effective social
communication skills that allowed Mandy to be more
self-aware and in control of her communication, such as
learning to be more attentive, to recognise the effects
of fatigue on her interactions, and to better interpret
what someone was saying. Rather, the strategies used
by study participants focused on avoiding or ignoring
the impairment. Contemporary literature that addresses
social communication training post-TBI focuses on
communication partner training (see for example Togher,
McDonald, Tate, Power & Reitdjik, 2013); however,
findings of this study suggest that a hybrid approach that
targets individual coping and conversation repair skills
as well as communication partner skills could be useful.
Mandy and her communication partners may benefit from
developing and implementing strategies that improve her
communicative abilities in collaborative verbal interactions,
particularly as these abilities may be necessary as she
grows older, leaves her school and home environment, and
has to communicate with a broad range of people.
The findings of this research provide insight into the
impact of having a social communication deficit post-TBI,
and highlight the tendency of Mandy and her parents/
friends to avoid or ignore her deficit rather than work on
strategies to improve her communication abilities. The study
findings add credence to the small amount of literature that
discusses social communication impairment in adolescents
post-TBI. The limited strategies identified and used by
Mandy, her mother, and friend further highlight the need
for clinicians to identify social communication impairment
in adolescents with TBI and assist the adolescent,
their family, and friends to develop effective strategies
to maintain and support everyday conversations. The
case study presented illustrates the need for therapeutic
interventions that increase an individual’s ability to recognise
and repair communication breakdown, and that provide
communication partners with strategies that can be used
to maintain conversational flow. Such an approach will
help ensure that Grice’s (1975) conversational maxims are
maintained. As the period of adolescence is fraught with
social and relationship demands, any support rehabilitation
professionals can provide to manage social communication
impairment should be implemented.
References
Anderson, V., Beauchamp, M., Rosema, S., & Soo, C.
(2013). A theoretical approach to understanding social
dysfunction in children and adolescents with TBI. In S.

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Smith, J., Flowers, J., & Larkin, M. (2009). Interpretive
phenomenological analysis: Theory, method and research.
London: Sage.
Togher, L., Power, E., Tate, R., McDonald, S. & Rietdijk,
R. (2010). Measuring the social interactions of people with
traumatic brain injury and their communication partners:
The adapted Kagan scales. Aphasiology, 24(6–8), 914–927.
Togher, L., McDonald, S., Tate, R., Power, E., & Rietdijk,
R. (2013). Training communication partners of people
with severe traumatic brain injury improves everyday
conversations: A multicenter single blind clinical trial.
Journal of Rehabilitation Medicine, 45(7), 637–645.
Turkstra, L. S. (2000). Should my shirt be tucked in or
left out?: The communication context of adolescence.
Aphasiology, 14(4), 349–364.
Whelan, B., & Murdoch, B. E. (2006). The impact of mild
traumatic brain injury (mTBI) on language function: More
than meets the eye? Brain and Language, 99, 218–219.
Marini, A., Galetto, V., Zampieri, E., Vorano, L., Zettin, M.,
& Carlomagno, S. (2011). Narrative language in traumatic
brain injury. Neuropsychologia, 49(10), 2904–2910.
McDonald, S., Rushby, J., Li, S., de Sousa, A., Dimoska,
A., James, C., Tate, R., & Togher, L. (2011). The influence
of attention and arousal on emotion perception in adults
with severe traumatic brain injury. International Journal of
Psychophysiology, 82, 124–131.
Mikami, A. Y., Szwedo, D. E., Allen, J. P., Evans, M. A.,
& Hare, A. L. (2010). Adolescent peer relationships and
behavior problems predict young adults’ communication
on social networking websites. Developmental Psychology,
46(1), 46–56.
Nippold, M. A. (2007). Later language development:
School-age children, adolescents, and young adults (3rd
ed.). Austin, TX: Pro-Ed.
Olswang, L. B., Coggins, T. E., & Timler, G. R. (2001).
Outcome measures for school–age children with social
communication problems. Topics in Language Disorders,
21(4), 50–73.
Santrock, J. W. (2010). Adolescence (13th ed.). New
York: McGraw-Hill.
Scherf, K.S., Behrmann, M., & Dahl, R. E. (2012). Facing
changes and changing faces in adolescence: A new model
for investigating adolescent-specific interactions between
pubertal, brain and behavioral development. Developmental
Cognitive Neuroscience, 2, 199–219.
Sim, P., Power, E., & Togher, L. (2013). Describing
conversations between individuals with traumatic brain
injury (TBI) and communication partners following
communication partner training: Using exchange structure
analysis. Brain Injury, 27(6), 717–742.
Jessica Drummond is a speech pathologist and rehabilitation
coordinator at the regional paediatric brain injury rehabilitation
service. She completed this research as an Honours project at
Charles Sturt University. Michael Curtin is the discipline leader of
Occupational Therapy at Charles Sturt University. Lucie
Shanahan is the operational director Sub-acute & Continuing
Care at Albury Wodonga Health. She has had extensive experience
working in paediatric brain injury.
Correspondence to:
Jessica Drummond
email: jessica.a.drummond@gmail.com

Research
www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 133
Given the health risks, it is important that dysphagia be
appropriately managed to optimise individuals’ health and
well-being. Frontline practice experience suggests a number
of barriers to the provision of quality dysphagia services in
the Victorian disability sector. At present, induction training
for DSWs in dysphagia and mealtime assistance is not
accredited and is mandatory in very few Victorian
organisations. Nutrition and swallowing risk screening and
dysphagia-related incident reporting processes are not
implemented systematically across the sector. Further,
awareness of the signs and health impacts of dysphagia is
poor among DSWs, particularly in organisations where
mealtime assistance training is not mandated (Disability
Dysphagia Network, 2008, pers. comm).
Although there have been a number of quality
improvement initiatives in the United Kingdom that have
focused on dysphagia management for people with
developmental disability (Hampshire Safeguarding Adults
Board, 2012; National Patient Safety Agency, 2004, 2007),
quality improvement projects or organisational dysphagia
support standards specific to the Australian disability
service context are decidedly lacking. This study is a step
in addressing that gap, through elucidating client and family
perspectives and expert opinion of AHPs to inform an
evidence-based approach to quality dysphagia support.
Method
A mixed methods approach to data collection was
employed to explore and provide an enriched
understanding of perspectives on dysphagia-related
supports. The intent was to identify, from the perspective of
each of the four participant groups, what “good practice” in
dysphagia services means and what are considered the
most important elements to include in an organisational
standard. Ethics approval was granted by two human
research ethics committees.
Participants
Participants were recruited from the three participating
organisations and comprised 12 adults with dysphagia, 16
family members, 17 DSWs and 24 AHPs. Adults with
dysphagia who were able to give consent and had capacity
to understand and respond to questions relating to their
mealtime needs and preferences were recruited. Adults with
dysphagia comprised six females and six males. Eleven had
a developmental physical and intellectual disability and one
had an acquired neurological condition. Family members
were relatives of adult clients with dysphagia, but not
This paper describes stakeholder
perspectives on good practice in dysphagia
support in the disability service context.
Twelve adults with dysphagia were
interviewed. Twenty-four allied health
professionals, sixteen family members and
seventeen disability support workers (DSWs)
completed a questionnaire and three focus
groups for DSWs were conducted. Results
indicated overwhelming support for a range
of service improvements including mandatory
training for support workers. Findings will be
used to inform an organisational dysphagia
support standard and to promote service
reform.
Dysphagia is a significant health issue for people
with physical and intellectual disability, yet practice
experience suggests a need for strengthened
organisational responses to dysphagia support in the
Victorian disability sector. In recognition of this need, three
disability service organisations collaborated on a dysphagia
quality improvement initiative. The aim of this study was to
understand client, family, allied health professional (AHP)
and disability support worker (DSW) perspectives as a
crucial source of evidence for informing service standards
for supporting adults with dysphagia.
Dysphagia is associated with a number of serious health
risks that include: choking (Thacker, Abdelnoor, Anderson,
White, & Hollins, 2008), respiratory illness (Loughlin,
1989), aspiration pneumonia (Langmore et al., 1998) and
underweight (Kennedy, McCombie, Dawes, McConnell, &
Dunnigan, 1997).
In the developmental disability population, dysphagia
“presents variably as a combination of developmental,
physiological and behavioural problems” (Sheppard,
Hochman & Baer, 2014, p. 929). It is common in adults
with developmental disability (Sheppard, 1991), especially
among those with cerebral palsy and severe and multiple
disabilities (Leslie, Crawford, & Wilkinson, 2009). Data on
the prevalence of dysphagia in people with intellectual
disability are scarce and those that do exist vary widely, in
the range of 8.5–49% (Chadwick & Jolliffe, 2009; Sheppard
& Hochman, 1989) and up to 97% in people with more
severe and profound intellectual disability (Sheppard,
Berman, Kvietok, & Kratchman, 1987).
Dysphagia support in
disability services
Stakeholder perspectives
Rosie Miller, Nick Hagiliassis, Meredith Prain, and Janet Wilson
Rosie Miller
(top) and Nick
Hagiliassis
THIS ARTICLE
HAS BEEN
PEER-
REVIEWED
KEYWORDS
DISABILITY
DYSPHAGIA
ORGANISATIONAL
STANDARD

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 135 134 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
Data analysis
Quantitative data were entered into MSExcel™ and pivot
tables created. To determine if there were significant
differences in reporting between groups, a Kruskal-Wallis
test was performed using SPSS. For qualitative data, two
researchers conducted independent thematic analyses of
interview and focus group data, then, through discussion,
came to a consensus on the final interpretation. An
inductive approach to thematic analysis was employed as
informed by Braun and Clarke (2006).
Results
Results are presented for each of the stakeholder groups
followed by findings of key similarities and differences in
perspectives across these groups. For DSWs, survey and
focus group data are combined. For adults with disabilities,
findings from individual interviews are reported, while for
families and AHPs survey data are reported.
Disability support worker perspectives
Seven major themes emerged from the focus groups with
DSWs: peer support, information and training,
collaboration, staffing, documentation, complexity and
attitudes, with each major theme incorporating a number of
subthemes. Table 3 reports the thematic categorisation of
focus group data.
It was evident that DSWs are presented with a high
degree of complexity when supporting adults with
dysphagia, characterised by challenges in understanding
the needs of people with profound communication
impairments and the dilemma in managing risk in individual
choice. On the latter observation, one group of DSWs gave
examples of people with dysphagia making food choices
that put them at risk of asphyxiation. Informants reported
that supported decision-making processes and accessible
documentation were valuable in helping individuals
understand the risks associated with their choices. The
practical and ethical dilemma in supporting individuals to
enact choices that imply risk is reflected in the following
DSW statement:
I’m not telling you you can’t eat minties, I’m just telling
you I’m not going to be the one to put it in your mouth
… I would never sleep at night thinking I was the one
who put the mintie in your mouth that killed you.
DSWs in two of the three focus groups discussed
challenges they experienced when supervising students
and casual staff, and their concerns for client safety
and continuity of care. DSWs also described their role
in identifying functional changes in clients’ eating and
swallowing abilities and liaising with speech pathologists in
these circumstances.
Peer support emerged as a major theme. Informants
identified experienced DSWs as an important source
of information. DSWs in two of the focus groups also
discussed the value of responsive and on-site speech
pathology.
The importance of effective communication between day
and residential services was highlighted, although some
different perspectives emerged. One focus group described
communication between services as a significant barrier
to meeting the needs of individuals with dysphagia. By
contrast, DSWs in another focus group acknowledged a
responsibility at both a team and personal level to improve
communication with other services involved in supporting
the client. Overall, collaboration was highly valued by DSWs
necessarily of those adults who were participants in the
present study. DSWs all worked in day services and all but
one were permanently employed. AHPs were employed in
adult services.
Recruitment
Participants were recruited indirectly via service managers
from the three participating organisations. Service
managers distributed research packs to eligible adult
clients, family members and DSWs. A hard-copy
questionnaire was included in the research pack for family
members. Managers also forwarded a recruitment email
and on-line survey to AHPs employed in the organisations’
adult services. Written consent was used for adults with
dysphagia and DSWs.
Data collection
There were three main sources of data collection: 1) a
questionnaire administered to families, DSWs and AHPs, 2)
focus groups attended by DSWs, and 3) individual,
semi-structured interviews with adults with dysphagia.
Researchers developed a 20-item questionnaire reflecting
key components in dysphagia management including: staff
training, documentation, meal-assistance, collaboration,
client choice, screening and monitoring, incident reporting
and policy (see Table 4). Questionnaire items were informed
by relevant literature (Stewart, 2003) and the authors’
clinical experience in service provision to adults with
dysphagia. Each item was rated on a 4-point scale from
unimportant to extremely important. A hard-copy survey in
easy English was provided to families and DSWs while a
parallel on-line version was made available to AHPs.
DSWs participated in focus groups to allow for in-
depth exploration of group perspectives and concerns.
DSW viewpoints are particularly underrepresented in
disability research hence the need to attend to this group
in particular. Three focus groups were held, one at each of
the organisations (see Table 1 for focus group questions).
Focus groups were audio-taped and transcribed.
Adults with dysphagia participated in individual interviews
based on the questions reported in Table 2. This allowed for
focused, conversational communication.
Meredith Prain
(top), and Janet
Wilson
Table 1. Focus group questions
Can you tell me about your experiences assisting people who have
difficulties with eating and swallowing?
What are the most important things you need to support people who
have difficulties with eating and swallowing?
Do you have any suggestions for how we could make services better
for people with eating and swallowing impairments?
Table 2. Interview questions
When you have something to eat or drink, do you need someone to
assist you?
How do you like to be assisted at mealtimes? What helps?
How do you like your mealtimes to be?
Is there anything you don’t like or that doesn’t help?
Is there anything that people at X could do to make your mealtimes
better?
Is there anything that people at X could do to make mealtimes better
for other people who have eating and swallowing problems?

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 135
and attending to individual needs and respecting
preferences and choice. Seven of the twelve informants
provided suggestions for improvements to their mealtime
experience. Suggestions included: being assisted first,
going out for lunch more often, having a quiet mealtime
environment and ensuring support staff are seated, and do
not rush meal assistance.
Tension between individual preferences and
organisational constraints was evident. One adult with
dysphagia indicated they did not like having dinner at an
early and set time each night. Two indicated they preferred
a quiet mealtime environment and acknowledged that
this was not always possible. Two adults with dysphagia
expressed a dislike for having to wait while DSWs attended
to other tasks and one informant indicated they did not like
being assisted by casual staff.
Family perspectives
Sixteen questionnaires from family members were received,
representing a 22% response rate. Two key themes
emerged: the need for training for DSWs and the
importance of understanding and meeting individual needs.
The three items rated extremely important at greatest
frequency were that “training be provided for DSWs in
mealtime assistance” (14/16), “training be provided for
DSWs in the preparation of thickened drinks and texture
across the three focus groups and was identified as an
important area for continuous improvement.
DSWs indicated they valued mealtime guidelines. A
suggestion was made to document effective tips and ideas
from DSWs. DSWs also identified the need for improved
handover processes, particularly when new clients enter a
service.
Training emerged as a key theme, with consensus among
DSWs that training be provided on a regular basis. Some
informants suggested annual updates with a focus on
client-specific information and information sharing among
team members. This theme was corroborated by
questionnaire results (see Table 4) in which one of the top
three items rated by DSWs as extremely important was that
“training be provided for DSWs in mealtime assistance”
(16/17).
The other two questionnaire items rated most frequently
as extremely important by DSWs were that ‘there be
greater emphasis on a multidisciplinary team approach
to supporting people with disabilities with eating and
swallowing difficulties’ (16/17), and “people with disabilities
are consulted as much as possible when their mealtime
guidelines are being developed” (14/17).
Client perspectives
The overwhelming theme that emerged from interviews with
adults with dysphagia was the importance of understanding
Table 3. Thematic categorisation of focus group data
Major themes Subthemes Examples
Peer support Sharing tips and ideas
Information and training Dysphagia and meal assistance Induction workshop is valued
Need for regular training and updates, e.g., at annual staff
training days
Client-specific information Need for regular information sessions to take into account
changing client circumstances
Collaboration Speech pathology Access to responsive and on-site speech pathology
Support workers observe changes in swallowing and refer to
speech pathologist
Others Effective collaboration with all who support the client is important
Staffing Supervision of students, casual and new staff Unsafe practices put clients at risk
Responsibility for client safety
Importance of compliance
Permanent DSWs Leadership role
Documentation Mealtime guidelines Value of clear, accessible guidelines
Documentation of DSW’s ideas
Handover Need for information when new clients enter service
Informed choice Contracts assist clients to learn about risks and empower DSWs
Complexities Acknowledging complexities Range of complex needs
Choice versus risk
Communication barriers Understanding individual preferences
Making adjustments Allocating sufficient time to assist
Accommodating individual preferences
Equipment Need for equipment that meets individual needs
Attitudes Need to foster affirming attitudes towards adults with dysphagia

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 137 136 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
Allied health professional perspectives
Twenty-four responses to the online survey were received (a
response rate could not be determined given indirect
recruitment of AHPs). Results indicated overwhelming
support for all service elements; however the items rated
most often as extremely important were that “training be
provided for DSWs in mealtime assistance” (23/24),
“mealtime guidelines be developed for all people needing
them” (21/24), and “disability organisations have dysphagia
policies” (21/24).
According to the AHPs who completed the survey, DSWs
should be offered continuing educational opportunities in
dysphagia and meal assistance, rather than discrete, one-
off workshops. This group also identified documentation
and compliance with mealtime guidelines as priorities.
modified food” (14/16), and “people who need full meal
assistance get 1:1 assistance at mealtimes” (14/16). A
number of respondents expressed a desire that DSWs
provide individual attention to their relative during meal
assistance and interact in a warm and compassionate
manner. Having DSWs with the skills and knowledge to
meet the needs of people with dysphagia was indicated as
a priority. Respondents highlighted the importance of
compliance with mealtime guidelines and regular training
opportunities to accommodate for high staff turnover.
Seven family members indicated speech pathology
services as the most valuable support for their relative,
including two who called for better access to these
services. Respondents also appreciated speech
pathologists consulting closely with families and respecting
the family’s preferences.
Table 4. Combined questionnaire results – family, DSW and allied health professionals
Unimportant
n(%)
Neither
n(%)
Important
n(%)
Extremely
important
n(%)
Valid
cases
1. Training be provided for support workers in mealtime assistance 0 (0%) 0 (0%) 4 (7%) 53 (93%) 57
2. Training be mandatory for support workers involved in mealtime
assistance
0 (0%) 1 (2%) 12 (21%) 44 (77%) 57
3. Training be provided for support workers in the preparation of
thickened drinks and texture modified food
0 (0%) 1 (2%) 9 (16%) 47 (82%) 57
4. Mealtime assistance training be accredited 1 (2%) 5 (9%) 28 (50%) 22 (39%) 56
5. People who need full mealtime assistance get 1:1 assistance at
mealtimes
0 (0%) 2 (4%) 15 (26%) 40 (70%) 57
6. Mealtime guidelines be developed for all people needing them 0 (0%) 0 (0%) 12 (22%) 43 (78%) 55
7. People with disability are consulted as much as possible when their
mealtime guidelines are being developed
0 (0%) 0 (0%) 15 (27%) 40 (73%) 55
8. Family members are consulted as much as possible when mealtime
guidelines for their relative are being developed
0 (0%) 1 (2%) 25 (44%) 31 (54%) 57
9. The preferences, choices and decisions of people with disability are
paramount when developing mealtime guidelines
0 (0%) 4 (7%) 20 (36%) 32 (57%) 56
10. Mealtime equipment be attractive and aesthetically pleasing 1 (2%) 17 (30%) 22 (38%) 17 (30%) 57
11. Height adjustable chairs be available for people assisting 0 (0%) 5 (9%) 31 (54%) 21 (37%) 57
12. People are meal assisted in supportive environments 0 (0%) 2 (3%) 33 (58%) 22 (39%) 57
13. People with disability are weighed regularly 0 (0%) 3 (5%) 34 (61%) 19 (34%) 56
14. The target weight or healthy weight range of people with disability is
identified and documented
0 (0%) 5 (9%) 32 (56%) 20 (35%) 57
15. Making healthy food choices is encouraged and actively promoted 0 (0%) 2 (3%) 34 (60%) 21 (37%) 57
16. Disability organisations have dysphagia policies 0 (0%) 1 (2%) 9 (16%) 46 (82%) 56
17. Disability organisations have choking incident reporting and referral
procedures
0 (0%) 1 (2%) 14 (24%) 42 (74%) 57
18. Nutrition and swallowing risk screening occurs for people at risk 1 (2%) 1 (2%) 12 (21%) 43 (75%) 57
19. Greater emphasis on collaborative approaches to dysphagia
management
0 (0%) 1 (2%) 17 (30%) 38 (68%) 56
20. Greater emphasis on a multidisciplinary team approach to dysphagia
management
0 (0%) 0 (0%) 20 (35%) 37 (65%) 57

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 137
These findings contribute to our understanding of the
perspectives of key stakeholders in the adult dysphagia
context – an area that has not been previously reported in
the literature. It is important to continue to listen to family
members, support staff and individuals with dysphagia
about their experiences and preferences. This feedback
should inform practice and underpin the continuous
improvement of services. This study has provided evidence
for needed reforms in dysphagia management and gives
direction for achieving service improvements.
Limitations
There are a number of limitations of this study. The
questionnaire was customised and not based on previously
published or validated tools. Due to practical difficulties in
recruiting sufficient numbers from residential facilities, all
DSW participants were day-service employees. The
absence of a balanced perspective from residential and day
services is a limitation that could be redressed in future
research.
The response rate from family members was low and is
a source of potential bias. A number of factors may have
contributed. For example, at the time of the study, very few
adult clients in one of the organisations had active family
contact. The indirect recruitment method held a risk that
service managers might misdirect questionnaires intended
for family members of adults with dysphagia. Postal
questionnaires also typically result in lower response rates
than other methods (Bryman, 2012). Further research into
family perspectives is indicated.
This study lacked power due to the small sample size.
The extent to which findings can be generalised to the
broad population of stakeholders or to other contexts may
be limited.
Conclusion
The purpose of this study was to investigate what “good
practice” in dysphagia management means to key stake-
holders and to identify the most important service elements
to include in organisational standards. Some differences in
perspective between groups were found, but also much
common ground underpinned by a shared concern to
optimise the health and well-being of adults with dysphagia.
Findings indicate strong support from stakeholders for a
range of service improvements and provide useful evidence
with which to advocate for service reform.
Acknowledgements
The authors gratefully acknowledge the Grosvenor
Foundation for funding this project.
References
Braun, V., & Clarke, V. (2006). Using thematic analysis in
psychology. Qualitative Research in Psychology, 3, 77–101.
Bryman, A. (2012). Social research methods (4th ed.).
New York: Oxford University Press.
Chadwick, D. D., & Jolliffe, J. (2009). A descriptive
investigation of dysphagia in adults with intellectual
disabilities. Journal of Intellectual Disability Research, 53,
29–43.
Hampshire Safeguarding Adults Board. (2012). Reducing
the risk of choking for people with a learning disability: A
muti-agency review in Hampshire. Hampshire: Hampshire
County Council Adult Services Department.
Kennedy, M., McCombie, L., Dawes, P., McConnell, K.,
& Dunnigan, M. (1997). Nutritional support for patients with
Similarities and differences
Overall, questionnaire results revealed more similarities than
differences in reporting between groups. There was strong
endorsement of all items overall (see Table 4). An ongoing
approach to training for DSWs in dysphagia and mealtime
assistance emerged as a priority. There was also agreement
across groups that training be mandatory.
DSWs identified a multidisciplinary approach,
consultation with people with dysphagia, peer support,
collaboration and continuity of care as priorities, while family
members identified 1:1 meal assistance as particularly
important. Both groups highlighted the value of speech
pathology services.
Significant differences in the reporting of family members,
DSWs and AHPs emerged on two questions. For question
15, “making healthy food choices is encouraged and
actively promoted”, family members (mean rank = 35.56)
endorsed this more frequently than DSWs (29.76) who
in turn endorsed it more frequently than AHPs (24.08;
chi-square = 6.3, df = 2, p =.04). For the item “greater
emphasis on a multidisciplinary team approach to
dysphagia management” (Q.20) a significant difference
between groups also emerged (chi-square = 11.9, df = 2,
p = .003) with DSWs (37.32), then families (30.09), then
AHPs (22.38) rating this item of high importance. Significant
differences in group reporting were not found for other
questionnaire items.
Discussion
Responses from DSWs, family members and AHPs
indicated overwhelming support for a range of service
improvements in dysphagia management. Information and
training for DSWs emerged as a priority. Given the current
context in Victoria, where a systematic approach to the
provision of education in dysphagia and mealtime support
is lacking, this finding is not surprising. Further, results from
this study indicate that the longitudinal learning needs of
DSWs should be addressed. Although this study has
provided some insight into the training needs of DSWs, it
has not considered how organisations could deliver such
training or what would be appropriate indicators of
competence.
Continuity of care for adults with dysphagia was not
included in the questionnaire but emerged as an issue
from focus group discussions. DSWs discussed the
challenges associated with supervision, the need for
adequate handover and transfer protocols and inter-service
communication. It is recommended that attention be given
to how continuity of care can be optimised in organisational
contexts and that it be described in service procedures or
standards.
The complexity and challenges involved in supporting
adults with dysphagia need to be acknowledged,
particularly at the level of balancing safety within the context
of the person’s preferences and choices.
Given the finding of the importance of peer support,
teams and organisations may wish to consider how
to strengthen opportunities for reflective practice and
collaborative problem-solving for DSWs. Teams could also
consider how to foster and sustain effective partnerships
between all involved in supporting individuals with
dysphagia. For speech pathologists, the study draws
attention to the importance of responsive and sensitive
collaboration with adults with dysphagia, families and
service providers for the provision of quality dysphagia
support.

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 139 138 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
Rosie Miller is a speech pathologist and researcher. Dr Nick
Hagiliassis is manager of evaluation and practice enhancement
at Scope. Dr Meredith Prain is a speech pathologist at Able
Australia. Janet Wilson is a speech pathologist at Yooralla.
Correspondence to:
Rosie Miller
phone: 0401 307 404
email: rosie.miller@monash.edu
intellectual disability and nutrition/dysphagia disorders in
community care. Journal of Intellectual Disability Research,
41, 430–436.
Langmore, S., Terpenning, M, Schork, A, Chen, Y,
Murray, J, Lopatin, D, & Loesche, W. (1998). Predictors
of aspiration pneumonia: How important is dysphagia?
Dysphagia, 13, 69–81.
Leslie, P., Crawford, H., & Wilkinson, H. (2009). People
with a learning disability and dysphagia: a cinderella
population? Dysphagia, 24, 103–104.
Loughlin, G. (1989). Respiratory consequences of
dysfunctional swallowing and aspiration. Dysphagia, 3,
126–130.
National Patient Safety Agency. (2004). Understanding
the patient safety issues for people with learning disabilities.
London: Author.
National Patient Safety Agency. (2007). Problems
swallowing? Resources for healthcare staff: Ensuring
safer practice for adults with learning disabilities who have
dysphagia. London: National Health Service.
Sheppard, J. J. (1991). Managing dysphagia in mentally
retarded adults. Dysphagia, 6, 83–87.
Sheppard, J. J , Berman, L., Kvietok, C. M., & Kratchman,
R. (1987). A dysphagia program for the developmentally
disabled. New York Medical Quarterly, 7, 19–23.
Sheppard, J. J., & Hochman, R. (1989). Clinical
symptoms of dysphagia in mentally retarded individuals.
Paper presented at the American Speech-Language-
Hearing Association Annual Convention, St. Louis, MO.
Sheppard, J. J., Hochman, & Baer, C. (2014). The
dysphagia disorder survey: Validation of an assessment for
swallowing and feeding function in developmental disability.
Research in Developmental Disabilities, 35, 929–942.
Stewart, L. (2003). Development of the nutrition and
swallowing checklist, a screening tool for nutrition risk and
swallowing risk in people with intellectual disability. Journal
of Intellectual and Developmental Disability, 28, 171–187.
Thacker, A., Abdelnoor, A., Anderson, C., White, S., &
Hollins, S. (2008). Indicators of choking risk in adults with
learning disabilities: A questionnaire survey and interview
study. Disability and Rehabilitation, 30, 1131-1138.

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 139
Clinical education
artefacts, together with their reflections on learning” (AeP,
2009, p. 2). The advantages of ePortfolios over traditional
paper portfolios are ease of access, revision and updating,
increased storage capacity, the inclusion of multimedia
materials such as video and audio, use of hyperlinks; and
the development of technological skills (Chou & Chen,
2008; Tochel et al., 2009).
A report documents how countries, such as Wales and
the Netherlands, are using ePortfolios for all citizens (not
just students) to support transitions, career development
and lifelong learning, and recommends Australia follows suit
(Leeson & Williams, 2009).
Speech Pathology Australia (SPA) requires practising
speech pathologists to continue learning and be certified
in a commitment to self-regulation in line with other non-
registered professions (SPA, 2014). An ePortfolio may be
an effective tool for monitoring such a process (Gordon &
Campbell, 2013), yet there is no research exploring this for
speech pathologists (SPs).
In Australia, universities offering speech pathology
programs need to demonstrate to Speech Pathology
Australia how their students meet the entry level
requirement for the profession, using the Competency
Based Occupational Standards for Speech Pathology
(CBOS; SPA, 2011). As well as traditional on-campus
teaching, universities ensure students have clinical
practicums under the supervision of qualified practising
speech pathologists. Students in speech pathology (SP)
courses often report a disconnect between taught theory
and applying that knowledge in clinical settings (Walden,
2010); therefore strengthening clinical practicum–theory
links is important. An ePortfolio can be used as a learning
tool to support students to make these links (Buckley et al.,
2009).
Universities need to evaluate the student’s learning
in the clinical practicum. According to Yorke (2011),
an appropriate and valid assessment would include an
assessment of actual performance along with a record
of performance and a reflection on learning in a portfolio
format. The SP profession has a valid and reliable
assessment of performance in COMPASS® (McAllister,
Lincoln, Ferguson & McAllister, 2013) and the process
of developing an ePortfolio for assessment would further
demonstrate entry-level skills to university staff. For
students, therefore, an ePortfolio is a tool for learning
In order to graduate, speech pathology
students need to effectively apply taught
theory to clients in their clinical practicum.
Following graduation, students showcase
their competency to employers in a
challenging and competitive employment
environment. Once employed, they engage in
lifelong learning, demonstrating ongoing
competency to practice. An ePortfolio is a
collection of artefacts and reflections from
clinical experiences that can be used as
learning, assessment and showcasing tool.
An ePortfolio was embedded across the new
speech pathology course at Edith Cowan
University. Student perceptions of the utility
of the ePortfolio for learning and showcasing
were investigated by questionnaire. Students
were engaged with the ePortfolio, seeing it
more as an organisational than learning tool.
They were negative about the time required
to complete an ePortfolio and did not see the
link with their future career. With additional
support and a more flexible and user-friendly
software platform, an ePortfolio may be of
use as a learning tool for students and for
professional self-regulation.
Paper-based portfolios have been used as an
assessment tool in higher education and to
demonstrate learning for promotion or appraisal in
the workplace for over twenty years (Klenowski, Askew, &
Carnell, 2006). Since the advent of Web 2.0 technologies,
the use of electronic portfolios (ePortfolios) has substantially
increased in many universities across the world (Hallam
& Creagh, 2010), and ePortfolios are used in disciplines
such as teaching, nursing and medicine (Chou & Chen,
2008). The term “ePortfolio” has many definitions in the
literature depending on its context and purpose (Hallam
& Creagh, 2010). The Australian ePortfolio Project (AeP)
defines an ePortfolio as: “an electronically stored collection
(or archive) of a student’s experiences, achievements and
Implementation of an
ePortfolio
Perspectives of speech pathology students
Abigail Lewis and Katrina Strampel
KEYWORDS
EPORTFOLIO
FORMATIVE
ASSESSMENT
PROFESSIONAL
COMPETENCY
STUDENTS
SUMMATIVE
ASSESSMENT
THIS ARTICLE
HAS BEEN
PEER-
REVIEWED
Abigail Lewis
(top) and Katrina
Strampel

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 141 140 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
2. My development of competency – uploaded evidence
mapped against CBOS including a STAR-L (Situation,
Task, Assessment, Results, Learning) reflective
comment (AeP, 2009).
3. Record of clinical hours – records of hours, range of
experience and learning contracts.
Method
Participants
In total, 53 students enrolled in years 2–4 of the speech
pathology course at ECU were invited to participate in the
study by announcements in lectures and being sent an
email link to an anonymous online questionnaire.
Information about the project was given and e-mailed to
students. Consent was given by completing the
questionnaire. Repeat emails were sent out and the
questionnaires were open for two months. Ethics approval
was received from the University’s Research Ethics Office
(No: 8307).
The number of participants who responded in each
cohort, their ages and number of years at university are
shown in Table 1. The ePortfolio was used in the course for
18 months before the study commenced. Therefore, fourth
and third-year students had been using the ePortfolio for 18
months, and second-year students for one year.
(process) and a product for the assessment of learning
(Hallam & Creagh, 2010).
While research is limited, there have been studies
that show ePortfolios can be useful to support student
learning; develop reflection, self-awareness and IT skills
(Buckley et al., 2009); and foster increased responsibility
for learning (Tochel et al., 2009). However, students may
find an ePortfolio time-consuming and to ensure students’
engagement it must be aligned with course outcomes,
linked to future careers, have a clear purpose and have
clear guidelines (Buckley et al., 2009). Researchers have
suggested that embedding ePortfolios across a whole
course ensures the greatest benefits (Faulkner, Aziz, Waye,
& Smith, 2013; Woodley & Sims, 2011). Furthermore,
the ePortfolio platform needs to be user-friendly, flexible,
transferable and have easy access (Gordon & Campbell,
2013) as well as be well-designed and have good
organisational support (Tochel et al., 2009).
Student perspectives of ePortfolios have been reported
in United States and the United Kingdom but research is
limited and results are mixed (Buckley et al., 2009; Hallam
& Creagh, 2010). Exploring student perspectives of an
ePortfolio use across different cohorts is also relatively new
(Chambers & Wickersan, 2007). As student participation is
vital to the successful implementation of an ePortfolio, the
investigation of student perspectives is required. Yet there is
very little evidence of student perspectives of the ePortfolio
in Australia (Hallam & Creagh, 2010) and no reports of SP
students’ perspectives. Therefore, this project investigates
students perceptions across a course of the validity of
using an ePortfolio as a tool for learning and for showcasing
their skills to future employers.
ePortfolio implementation
In 2010, an ePortfolio was embedded across the newly
established four-year undergraduate SP course at Edith
Cowan University as a learning tool and assessment task.
The ePortfolio aimed to (a) engage students in collecting
evidence of clinical competencies; (b) reflect upon their
learning to strengthen the theory/clinical practicum links, (c)
develop reflective practice; (d) evaluate their own strengths
and weaknesses in order to set future clinical practicum
goals; and (e) map their own hours across the range of
practice.
The SP course used My Expo as the ePortfolio platform
as it was already in use by nursing and education courses
within the university. A template with detailed assignment
information and marking guides to cover all four years was
developed in MyExpo that students downloaded once in
the second semester of first year. The instructions were
collated into a manual and a frequently asked questions
document was available to students. The workload was
designed to increase in complexity and volume as the
student progressed through the course. Each semester
the assessment was carefully explained to students and an
opportunity to workshop the ePortfolio in a computer lab
was available. The template for the students consisted of
three parts:
1. Reflections on my learning – structured reflections about
their learning on their practicum and about themselves
as a speech pathologist.
Table 1. Number, age and years at university of
students
Student cohort
2nd 3rd 4th
Number of students 14 24 15
My age is:
18–20 1 3 2
21–25 3 3 4
26–30 1 2 0
31–40 0 1 2
above 40 1 2 0
Including this year I have studied at
university for:
2 years 3 0 0
3 2 7 0
4 0 2 8
5 0 1 0
6 + 1 1 0
Questionnaire
This project used a mixed methods approach. Data was
collected via a student questionnaire and additional
qualitative data (not reported) was also collected through
student focus groups. The questionnaire consisted of 4
forced choice questions, 30 statements and 3 free text
questions (see Appendix). The forced choice questions
gathered demographic data and elicited comfort and
confidence levels with technology. The statements were
rated using a 5-point Likert scale from strongly disagree (1)
to strongly agree (5). The statements related to topics such
as engagement with the portfolio, using the technology,

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Technology
Students’ ratings of their comfort and confidence with new
technology are shown in Table 2. The mean score across all
three cohorts indicated students were typically comfortable
with technology and confident they could “work it out”. This
implies an electronic platform would not be a barrier to
participation and engagement in learning. However, in
response to statements about the ePortfolio technology in
particular, students’ responses were mixed. They did not
think the ePortfolio was too technologically challenging, but
most cohorts found the template design, structure and the
platform were difficult to use and navigate (Table 3).
In free text answers each cohort stated the technology
was the most difficult part of utilising the ePortfolio:
“sometimes a page would upload, others it wouldn’t, no
way of personalising it, the more you add the messier it
gets” (third year); “the formatting can be complex and
sometimes it doesn’t work” (fourth year). Suggestions for
improvements included: having an easier platform for the
ePortfolio, faster uploading of evidence, easier ways of
making links and a clearer ePortfolio structure.
Support and training
Third- and fourth-year students were neutral or positive
about the support and training given to use the ePortfolio,
as shown in Table 4. Second-year students did not find the
support documents helpful and were unsure of the
evidence to collect.
support and training given and the educational value of the
portfolio (see Appendix). Some items were adapted from
other questionnaires (Gardner & Aleksejuniene, 2008;
Hrisos, Illing, & Burford, 2008). Free text questions asked
students to identify the most useful components of the
ePortfolio, the most difficult components and suggestions
for improvements in the future use of ePortfolios.
Analysis
For the Likert-scale statements, the average of students’
responses was calculated, with a score below 3 being a
negative response, 3 a neutral response and above 3 a
positive response. The mean scores for each cohort were
then calculated and interpreted with reference to free text
responses. The three statements where this scoring is
reversed are shaded in the tables.
Results
Of the 53 students invited, 25 students participated (overall
response rate 47%) in the study, with 6 second-year
students (response rate 43%), 11 third-year students
(response rate 36%) and 8 fourth-year students (response
rate 53%) completing questionnaires.
Table 2. Comfort and confidence with new
technology
Student cohort
2nd 3rd 4th
When I have to use new technology I am:
Very comfortable 2 2 1
Comfortable 3 5 5
Neutral 0 4 1
Uncomfortable 0 0 1
Very uncomfortable 1 0 0
When I have to use new technology I feel:
Very confident I can work it out 2 0 1
Confident I can work it out 3 7 4
Neutral 0 3 3
Unconfident I can work it out 1 1 0
Very unconfident I can work it out 0 0 0
Table 3. Students’ perspectives of the technology
of ePortfolio
Student cohort
2nd 3rd 4th
The ePortfolio needs too much
technological skills for me to use it 2.0 2.3 2.0
The ePortfolio is easy to use 3.5 3.0 3.7
The template design is easy to navigate
and has a logical structure 3.0 2.5 2.7
The ePortfolio platform is easy to use
and understand 2.5 2.6 3.6
Note. 5-point Likert scale from strongly disagree (1) to strongly agree
(5). The shaded statement is negative therefore scores are interpreted
differently.
Table 4: Students’ perspectives of support and
training
Student cohort
2nd 3rd 4th
I understand how to use the ePortfolio 3.0 3.0 4.1
I am given adequate support from staff
to use the ePortfolio 3.5 3.6 4.1
I know how to get help if I need it with
the ePortfolio 3.5 3.9 4.1
The support documents in the ePortfolio
and on BlackBoard are helpful 2.8 3.4 3.7
I understand what type of evidence to
collect 2.5 3.5 3.6
The feedback given on my ePortfolio has
been useful and I have learned from it 3.0 3.3 3.3
Average : 3.1 3.5 3.8
Note. 5-point Likert scale from strongly disagree (1) to strongly
agree (5).
Suggestions for improvements were having clearer
expectations for each year, giving more training and giving a
booklet of step by step instructions for users. Students also
wanted more information about evidence:
a lot of great information and tutorials have been
provided for the students ... More specific information
about what is acceptable as evidence for third year,
fourth year and the specific level of depth/information
required would be useful. (fourth year)

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Engagement
Students answered questions eliciting their level of
engagement (perceived value, learning achieved and time
invested) with the ePortfolio and the results are shown in
Table 5. Students were positive about the value and
usefulness of the ePortfolio but fourth years felt the
workload was excessive and not a worthwhile investment
Table 6: Students’ perspectives of the educational
value of the ePortfolio
Student cohort
2nd 3rd 4th
The ePortfolio helped me to focus on my
training 3.3 2.5 2.9
The ePortfolio helped me to achieve
learning objectives 3.7 2.8 2.7
Average: 3.5 2.7 2.8
Note. 5-point Likert scale from strongly disagree (1) to strongly
agree (5).
of time. There were several comments about the excessive
time required to manage the technology of the software
platform as well as the requirements of the task itself: “This
system is too time consuming and requires far too much
effort” (third year).
Educational value
Within the questionnaire, educational value statements
explored how students perceived the ePortfolio as an enabler
for developing skills and achieving learning objectives. Table
6 shows the students in the later years of the course did
not see the educational value of the ePortfolio. Many
students recognised the ePortfolio was useful as an
organisational tool rather than a learning tool: “It is a great
way to collate and organise your evidence” (third year).
Table 7. Students’ perspectives of the My reflection
part of the ePortfolio
Student cohort
2nd 3rd 4th
Reflection is a difficult concept to
understand 2.0 2.7 2.4
Reflection on my practicum enables me
to reflect deeply about my learning in clinic 3.7 3.2 4.0
The ePortfolio allows me to exemplify
increasing depth of reflection 3.7 3.1 3.1
The reflections helped me identify my
strengths and areas for improvement
on prac (the clinical practicum) 3.7 3.4 3.1
Average of positive statements: 3.7 3.2 3.4
Note. 5-point Likert scale from strongly disagree (1) to strongly
agree (5). The shaded statement is negative therefore scores are
interpreted differently.
Reflection
Statements relating to the Reflections section of the
ePortfolio (Table 7) suggest that although SP students
understood the concept of reflection they did not perceive
that the ePortfolio contributed to the development of
reflection. Some students thought reflections were one of
the most useful things but others felt there were too many:
“helping me learn how to reflect on my learning” (third year);
“completing too many reflections to meet assessment
criteria that I don’t get much out of” (third year).
Table 8. Students’ perspectives regarding their
development of skills
Student cohort
2nd 3rd 4th
My evidence of competency
The ePortfolio allows me to analyse the
competencies I need to be a graduate
entry level Speech Pathologist as
detailed in CBOS and COMPASS® 3.7 3.4 3.9
The ePortfolio allows me to construct a
repository for the selection of evidence
towards gaining competency 3.7 3.5 3.4
The ePortfolio allows me to evaluate
the evidence I collect 4.0 3.1 3.7
The ePortfolio helps me generate
specific short-term personal learning
outcomes (goals) relating to the
competencies 4.0 3.3 3.4
Average: 3.9 3.3 3.6
My records
Records enables me to see how I’m
progressing towards covering all range
indicators and units of competency 3.7 3.6 3.9
The records allow me to record my
clinical experiences so future
placements/experiences can be planned
to build on these and fill in any gaps 4.0 3.7 3.7
Average: 3.9 3.7 3.8
Note. 5-point Likert scale from strongly disagree (1) to strongly
agree (5).
Development of skills
Students’ perceptions of the use of an ePortfolio to
accomplish specific tasks varied, with students being
positive in second year, less positive in third year, then more
positive in fourth year, as shown in Table 8.
Table 5. Students’ level of engagement
Student cohort
2nd 3rd 4th
In general the ePortfolio is of value and a
useful experience 3.3 3.1 3.1
The ePortfolio is a worthwhile investment
of my time 3.5 2.8 3.0
Average of positive statements: 3.4 3.0 3.1
The ePortfolio involves excessive work 2.8 3.5 4.3
Note. 5-point Likert scale from strongly disagree (1) to strongly agree
(5). The shaded statement is negative therefore scores are interpreted
differently.

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 143
Table 9. Students’ perspectives on the future use
of the ePortfolio
Student cohort
2nd 3rd 4th
I can see how the ePortfolio will be useful
when I graduate as a speech pathologist 4.0 3.1 2.0
I can see how I can use the ePortfolio to
apply for jobs when I graduate 3.3 2.7 2.4
I can see how I can use the ePortfolio in
my working life as a speech pathologist 4.3 3.0 2.3
Average: 3.9 2.9 2.2
Note. 5-point Likert scale from strongly disagree (1) to strongly
agree (5).
An ePortfolio is time-consuming, but
overall a useful experience
Students in later years of the SP course were more
engaged with the ePortfolio but increasingly negative about
the workload required to develop and maintain it. This
finding is consistent with other studies of students who
have utilised ePortfolios, such as those completing
communication and performance studies (Wagner &
Lamoureux, 2006) and trainee doctors (Hrisos et al., 2008).
The time required to complete the ePortfolio needs to be
carefully and progressively increased across a course.
Furthermore, researchers have found staff and students
have different views about the purpose and importance of
the ePortfolio (Hrisos et al., 2008; Wagner & Lamoureux,
2006) so the purpose needs to be made explicit and be
relevant to the students’ current stage in the course.
An ePortfolio is a valuable
learning tool
Students recognise the value of the ePortfolio primarily as
an organisational tool, rather than see the educational
value, particularly students in later years. Jenson and Treuer
(2014) state that students do not clearly understand the
purpose of the ePortfolio as a learning tool, and this means
“perceptions of the role and purpose of the portfolio may
affect the ability of students to engage fully in portfolio use
to develop learning” (Tochel et al., 2009, p. 314).
Students did engage with the ePortfolio and some found
it useful for setting goals and analysing skill development,
which is consistent with other research (Bollinger &
Shepherd, 2010; Devlin-Scherer, Martinelli, & Sardone,
2006; Hrisos et al., 2008) and reflects the statement “users
can be simultaneously sceptical about a portfolio’s intended
purposes and appreciative of what it can deliver for them
personally” (Tochel et al., 2009, p. 314).
SP students in the current study were not generally
positive about the ePortfolio’s value in developing reflection.
Bollinger and Shepherd (2010) found students were positive
if the students were taught reflective skills first. Other
researchers report “the relatively low level of reflection
and personal development planning of learners remains a
challenge” in ePortfolio use (Faulkner et al., 2013, p. 884).
An ePortfolio is beneficial for
lifelong learning
Fourth-year SP students did not recognise the value of an
ePortfolio to promote future employment opportunities,
implying the future value needs to be made more explicit to
students. In other research, students and alumni have
reported the value of ePortfolios to show to prospective
employers and to document growth in their future career
(Devlin-Scherer et al., 2006; Gardner & Aleksejuniene,
2008). Using a platform that is portable and can be used
after graduation would help (Leeson & Williams, 2009).
Students need to be taught the ePortofolio’s use in lifelong
learning (Jenson & Treuer, 2014, p. 54) and “embedding
formative feedback from staff, peers and professional
mentors to encourage and support the development
process can facilitate transforming learners into
professionals” (Faulkner et al., 2013, p. 884).
Students’ comments also varied: “Looking back at
documents assists me to do better for subsequent tasks”
(third year); “setting new goals each semester and then
reflecting on those goals and then creating new goals has
provided me with no benefit” (third year).
Future career
Students did not see the value of the ePortfolio for their
future career either as a showcasing tool or for lifelong
learning (Table 9). Students commented that the ePortfolio
needs to be “something constructive we can take with us
when we graduate” (third year) which was not possible with
the MyExpo platform. Other students wanted more
information about using the ePortfolio in the future: “explain
how we can use it once we are working and for job
applications” (fourth year).
Discussion
The results of the current study are somewhat consistent
with those of Gardner and Aleksejuniene (2008) who
investigated the experiences of a small group of dental
students who opted to complete an ePortfolio task. They
discussed four dimensions of ePortfolios that will now be
discussed in relation to the current study: (a) ePortfolio
learning requires technical skills that are manageable; (b) an
ePortfolio is time-consuming, but overall a useful
experience; (c) an ePortfolio is a valuable learning tool; and
(d) an ePortfolio is beneficial for lifelong learning.
ePortfolio learning requires technical
skills that are manageable
SP students reported being comfortable and confident with
using new technology, but reported the technology was the
most difficult part of using the ePortfolio. Similar findings
were not observed by Gardner and Aleksejuniene’s (2008)
students, who used a different platform and voluntarily
chose the ePortfolio task. Adoption of any new technology
takes time and learners may not see the value in it (Buckley
et al., 2009). Using a more flexible, user-friendly software
platform and a better ePortfolio template would alleviate
some of these frustrations. Students suggested explicit,
timely and detailed training and support along with
appropriate feedback would also better support the use of
the technology.

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 145 144 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
Acknowledgements
This project was funded by an Edith Cowan University
Teaching and Learning grant.
References
Australian ePortfolio Project (2009). ePortfolio concepts for
academic staff [pamphlet]. Retrieved from http://www.
eportfoliopractice.qut.edu.au/docs/AeP_conceptguide_
academic_staff.pdf
Bollinger, D., & Shepherd, C. (2010). Student perceptions
of ePortfolio integration in online courses. Distance
Education, 31(3), 295–314.
Buckley, S., Coleman, J., Davison, I. S., Khan, K.,
Zamora, J., Malick, S., Morley, D., Pollard, D., Ashcroft, T.,
Popovic, C., & Sayers, J., (2009). The educational effects of
portfolios on undergraduate student learning: A systematic
review. Medical Teacher, 31, 282–298.
Chambers, S., & Wickersham, L. (2007). The electronic
portfolio journey: A year later. Education, 127(3), 351-360.
Chou, P. & Chen, W. (2008). From portfolio to E-Portfolio:
Past, present, and future. In K. McFerrin et al. (Eds.),
Proceedings of Society for Information Technology &
Teacher Education International Conference (pp. 22–27).
Chesapeake, VA: AACE.
Devlin-Scherer, R., Martinelli, J., & Sardone, N. (2006).
Twisting the kaleidoscope: Making sense of eportfolios. In
A. Jafari & C. Kaufman (Eds.), Handbook of research on
ePortfolios (pp. 398-409). Hershey, PA: IGI Global.
Faulkner, M. Aziz, S., Waye, V., & Smith, E. (2013).
Exploring ways that ePortfolios can support the progressive
development of graduate qualities and professional
competencies. Higher Education Research and
Development, 32(6), 871–887.
Gardner, K., & Aleksejuniene, J. (2008). Quantitative
and qualitative analysis of student feedback on ePortfolio
learning. Journal of Dental Education, 72(11), 1324–1332.
Gordon, J. A., & Campbell, C. M. (2013) The role
of ePortfolios in supporting continuing professional
development in practice. Medical Teacher, 35(4), 287–94.
Hallam, G., & and Creagh, T. (2010). ePortfolio use by
university students in Australia: A review of the Australian
ePortfolio Project. Higher Education Research and
Development, 29(2), 179–193.
Hrisos, S., Illing, J., & Burford, B. (2008). Portfolio
learning for foundation doctors: Early feedback on its use in
the clinical workplace. Medical education, 42(2), 214–223.
Jenson, J. D. & Treuer, P. (2014). Defining the E-Portfolio:
What it is and why it matters. Change: The Magazine of
Higher Learning, 46:2, 50–57.
Klenowski, V., Askew, S., & Carnell, E. (2006). Portfolios
for learning, assessment and professional development
in higher education. Assessment and Evaluation in Higher
Education, 31(3), 267-286.
Leeson, J. & Williams, A. (2009). e-Portfolios beyond
education and training [report]. Dulwich, Australia:
Education.au Limited.
McAllister, S., Lincoln, M., Ferguson, A. & McAllister,
L. (2013). COMPASS®: Competency assessment in
speech pathology assessment resource manual (2nd ed.).
Melbourne: Speech Pathology Australia.
Limitations
There are several limitations to the study. First, it is
important to note that students could choose to complete
the questionnaire so the sample may be biased by students
with strong opinions. Second, respondent numbers were
small and the response rate was less than 50%. Third, the
teaching staff was learning the platform at the same time as
teaching the students, thus impacting the effectiveness of
the training particularly for the third and fourth years. Finally,
the students’ difficulties with the software platform may
have affected their other responses.
Implications
The following recommendations are made, based on the
literature and on SP students’ rating of the statements and
their free text answers:
• The software platform chosen is crucial. It needs to be
(a) appropriate for the task requirements; (b) easy to
use and navigate; (c) able to share with external people
(such as employers); and (d) accessible when the
student leaves the university.
• The learning tasks need to be meaningful with a clear
purpose and expectations to ensure students see the
ePortfolio as a learning tool.
• The complexity and workload of tasks needs to
scaffolded through the course.
• Students may benefit from specific skills teaching (e.g.,
reflection).
• Students require training that is clear, concise, and
ongoing to ensure the technology is not a barrier to
learning.
• The link between the student use of an ePortfolio and
future goals as a speech pathologist needs to be made
explicit often (e.g., with examples and reports from
graduates).
As a result of this study, a new software platform will
be piloted with a more scaffolded implementation of the
ePortfolio and a stronger link with future employment.
Further research into the perceptions of speech
pathologists using an ePortfolio for documenting evidence
for Certified Practicing Speech Pathology status would also
be useful.
Conclusion
This study is the first to investigate speech pathology
students’ perspectives of an ePortfolio embedded across a
SP course. Students generally engaged with the ePortfolio
and saw the value as an organisational tool, and to analyse
skills and set goals, but found the technology difficult and
the ePortfolio tasks unduly time-consuming. They did not
see the link with their future career as a speech pathologist,
perhaps due to the limitations of the software platform
chosen. Despite the limitations of the study, some useful
strategies have been suggested to enable the ePortfolio’s
value as a learning tool to be fully realised to increase the
positive perceptions for future use of ePortfolios in SP
courses. As a learning tool an ePortfolio may also be of use
for documenting evidence of ongoing learning as required
for professional self-regulation.

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 145
Abigail Lewis is clinical coordinator and lecturer for Edith Cowan
University’s speech pathology course. Katrina Strampel is a
learning designer at Edith Cowan University. She has researched
and embedded ePortfolios into staff and student learning
environments for several years.
Correspondence to:
Abigail Lewis
Clinical Coordinator/Lecturer in Speech Pathology
School of Psychology and Social Science
Edith Cowan University
270 Joondalup Drive, Joondalup WA 6027
phone: (08) 6304 5438
mobile: 0414 468 879
email: abigail.lewis@ecu.edu.au
Speech Pathology Australia. (2011). Competency-based
occupational standards for speech pathologists (CBOS),
entry level. Melbourne: Author.
Speech Pathology Australia. (2014). Strategic plan
2014–2016. Melbourne: Author.
Tochel, C., Haig, A., Hesketh, A., Cadzow, A., Beggs,
K., Colthart, I., & Peacock H. (2009). The effectiveness of
portfolios for post-graduate assessment and education:
BEME Guide No 12. Medical Teacher, 31(4), 299–318.
Wagner, M., & Lamoureux, E. (2006). Implementing an
outcome-based assessment ePortfolio. In A. Jafari & C.
Kaufman (Eds.), Handbook of research on ePortfolios (pp.
539–550). Hershey. PA: IGI Global.
Walden, P. (2010). Student perceptions of learning
speech science concepts in a hybrid environment.
Pennsylvania Speech-Language-Hearing Association
(PSHA) Journal, 41, 30–40.
Woodley, C., & Sims, R. (2011). Eportfolios, professional
development and employability: Some student perceptions.
Campus-Wide Information Systems, 28(3), 164–174.
Yorke, M. (2011). Work-engaged learning: towards a
paradigm shift in assessment. Quality in Higher Education,
17(1), 117–130.

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Appendix. Questionnaire
Forced choice questions
1. I am:
• 18–20 years old
• 20–25 years old
• 25–30 years old
• 30–40 years old
• 40 + years old
2. Including this year I have studied at University level for:
• 1 year
• 2 years
• 3 years
• 4 years
• 5 years
• 6 + years
3. When I have to use new technology I am:
• Very comfortable
• Comfortable
• Neutral
• Uncomfortable
• Very uncomfortable
4. When I have to use new technology I feel:
• very confident I can work it out
• confident I can work it out
• neutral
• unconfident I can work it out
• very unconfident I can work it out
5-point Likert questions from strongly disagree (1) to strongly agree (5)
Engagement with the portfolio
• In general, the ePortfolio is of value and a useful experience
• The ePortfolio is a worthwhile investment of my time*^
• I understand how to use the ePortfolio*
• I understand what type of evidence to collect*
• I understand how much evidence to collect*
• The ePortfolio involves excessive work*^
Technology
• The ePortfolio needs too much technological skills to use^
• The ePortfolio is easy to use^
• The template design is easy to navigate and has a logical
structure
• The ePortfolio platform (MyExpo) is easy to use and understand
Support and training
• I am given adequate support from staff to use the ePortfolio
• I know how to get help if I need it with the ePortfolio
• The training I have been given to use the ePortfolio was helpful
and easy to follow
• The support documents in the ePortfolio and on Blackboard are
helpful
• The feedback given on my ePortfolio has been useful and I have
learned from it
The educational value of the portfolio
• The ePortfolio helped me to focus on my training*
• The ePortfolio helped me achieve learning objectives*
My reflections
• Reflection is a difficult concept to understand*
• Reflections on my practicum enables me to develop reflect deeply
about my learning in the clinical practicum^
• The ePortfolio allows me to exemplify increasing depth of
reflectionº
• The reflections helped me identify my strengths and areas for
improvement in the clinical practicum*
My evidence
• The ePortfolio allows me to analyse the competencies I need to
be a graduate entry level Speech Pathologist as detailed in CBOS
and COMPASS®º
• The ePortfolio allows me to construct a repository for the ongoing
selection of evidence towards gaining competencyº
• The ePortfolio allows me to evaluate the evidence I collectº
• The ePortfolio helps me generate specific short-term personal
learning outcomes (goals) relating to the competenciesº
My records
• My records enables me to see how I’m progressing towards
covering all range indicators and units of competency
• The records allow me to record my clinical experiences so future
placements/experiences can be planned to build on these and fill
in any gaps
The future
• I can see how the ePortfolio will be useful when I graduate as a
speech pathologist^
• I can see how I can use the ePortfolio to apply for jobs when I
graduate
• I can see how I can use the ePortfolio in my working life as a
speech pathologist^
Free text
• This has been the most useful thing about the ePortfolio.
• This has been the most difficult thing about the ePortfolio.
• Suggestions for improvement (in training, ePortfolio structure, platform) or any other comments.
* adapted from Hrisos, Illing & Burford, 2008; ^ adapted from Gardner & Aleksejuniene, 2008; º ECU SP student learning outcomes for the ePortfolio

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 147
Clinical insight
KEYWORDS
PROFESSIONAL
ISSUES
SPEECH
LANGUAGE
PATHOLOGY
TELEHEALTH
TELEPRACTICE
THIS ARTICLE
HAS BEEN
PEER-
REVIEWED
Jodie May (top)
and Shane
Erickson
Telehealth: Why not?
Perspectives of speech-language pathologists not
engaging in telehealth
Jodie May and Shane Erickson
professional health services at a distance by linking clinician
to client, or clinician to clinician for assessment, intervention
and/or consultation” (American Speech & Hearing
Association [ASHA], 2005).
In order to realise the potential of telehealth, SLPs will
need to embrace a range of new technologies and develop
new skills. However, evidence regarding clinician attitudes
to telehealth and potential facilitators to increase uptake is
scarce. Several studies have documented the experiences
of SLPs who use telehealth. A recent survey of SLP
telehealth users in Australia found that the most significant
challenges to using telehealth were: lack of appropriate
technology and telecommunication connections, lack
of appropriate and available telehealth assessment and
therapy resources, access, and information communication
technology (ICT) support (Hill & Miller, 2011). A range of
potential telehealth facilitators were also identified including:
training and demonstrations, access to resources, funding
and a SPA position paper.
There may also be a disparity between SLP attitudes
towards telehealth and those of their clients. Dunkley,
Pattie, Wilson, and McAllister (2010) found that client
attitudes to telehealth were more positive than their SLPs
anticipated them to be and the clients reported better
access to telehealth technology than the SLPs had
perceived.
To date, little is known about the perspectives and
experiences of SLPs who do not use telehealth in clinical
practice. This study seeks to explore this knowledge gap
and inform the broader profession about (a) the existing
barriers to telehealth use and (b) potential facilitators to
support its uptake. Identifying these barriers and facilitators
is a significant step towards broadening the availability of
telehealth and increasing the access, efficiency and cost
effectiveness of SLP services.
Method
Ethics approval was received from the La Trobe University
Human Research Ethics Committee (reference FHEC
13/083) and from the SA Health Human Research Ethics
Committee (reference HREC/13/SAH/60). A qualitative
research design was utilised given the exploratory nature of
the study and scarcity of previous related research.
Participants
The participants were 18 practising SLPs who self-identified
as not using telehealth for clinical service provision (Table 1).
Participants for individual interviews were recruited
Telehealth-delivered speech-language
pathology services can be effective and
improve efficiency and accessibility. However,
uptake of telehealth among Australian
speech-language pathologists (SLPs) is low
and little is known about those who do not
use it. This study aimed to explore the
barriers preventing SLPs from using
telehealth and describe strategies to support
its uptake. Eighteen SLPs participated in
interviews or focus groups. Data were
analysed using thematic analysis. Existing
barriers and potential facilitators were
reflected in the following themes:
information, training, clinician attitudes and
perceptions, and organisational and policy
barriers. Findings suggest that further
research, training, and information are
required to support telehealth use across a
wider range of clinical settings.
Despite evidence showing that telehealth-delivered
speech-language pathology services can be
effective, efficient and accessible (Reynolds, Vick
& Haak, 2009; Theodoros, 2012), translation into practice
has been limited (Department of Health & Ageing [DoHA],
2011). A recent DoHA survey indicated that only 13%
of Australian allied health professionals use telehealth
(DoHA, 2011). The National eHealth Strategy states that
“the challenges and issues facing the Australian health
care sector will not be solved by doing more of the same,
particularly given the limited nature of available human and
financial resources” (Deloitte, 2008, p. 15). Strategic and
effective use of communication technology is an important
tool to meet growing demand for healthcare services
(DoHA, 2011; Theodoros, 2012).
Inconsistencies regarding telehealth terminology and
definitions confuse both professionals and consumers
(Brennan et al., 2010). In this paper the term telehealth is
used and is consistent with DoHA and Medicare policy
and documentation (however, Speech Pathology Australia
[SPA] has chosen to use “telepractice” in its forthcoming
position statement). Telehealth is “the application of
telecommunications technology to the delivery of

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 149 148 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
transcribed and coded using the following steps (as per
Liamputtong, 2010):
Step 1: Open coding: initial sorting of keywords and
phrases from each transcription into as many codes as
possible, identifying key points relevant to the research
questions.
Step 2: Focused coding: sorting codes into subthemes
searching for similarities and differences and making sense
of patterns within the subthemes.
Step 3: Axial coding: Reviewing subthemes and
comparing back to original transcripts for accuracy. Codes
and subthemes were re-worked for consistency and
accuracy.
Step 4: Selective coding: Final refining of themes
and subthemes and applying definitions and labels to
overarching core themes.
Credibility
Transcripts were analysed by both researchers
independently to increase the validity of the emerging
nationally via the SPA national e-newsletter (June and July
2013) where an information statement and an invitation to
contact the primary researcher were provided. The chief
allied health advisor from a state government health service
facilitated an invitation to SLP heads of department and
clinical lead SLPs to convene focus groups with the primary
researcher at their locations. The combined use of individual
interviews and focus groups ensured adequate participant
numbers. Previous studies involving SLPs as participants
have reported difficulty with participant recruitment (Dunkley
et al., 2010; Hill & Miller, 2012). Participants could attend
either a focus group or an interview depending on their
availability and location.
Twelve SLPs participated in individual interviews (two
face to face [FTF] and 10 via telephone) and six participated
in one of two focus groups (one with four participants and
one with two participants). Focus groups were conducted
via teleconference as participants were more than 100
kilometres from the researcher.
Data collection
Interviews and focus groups used semi-structured
open-ended questions in order to elicit in-depth
understandings and beliefs about telehealth (Liamputtong,
2010). A topic guide, based on Hill and Miller’s (2012)
questionnaire, was used to explore participant perceptions
of telehealth use in SLP (Table 2). Interviews (average
length, 29 minutes) and focus groups (average length, 47
minutes) occurred over a period of three months. All
interviews and focus groups were recorded with a digital
audio-recording device and telephone microphone and the
researcher kept written notes. Data were fully transcribed
verbatim by the first author.
Data analysis
Thematic analysis using a grounded theory approach was
used to analyse the data (Table 3). Transcription occurred
immediately after each interview and focus group.
Transcribed data informed questions presented in
subsequent interviews and focus groups. All data were fully
Table 1: Demographic Data
Name* Age range Years in profession State Geographic location Clinical context Caseload
Sarah 26–35 5–10 SA RR Acute Hosp/CH Mixed
Sandra 36–45 > 15 SA RR CH Mixed
Alison 36–45 > 15 SA RR CH Mixed
Taylor 26–35 < 5 SA RR Rehab Adult
Melody 36–45 > 15 VIC Outer metro Disability Mixed
Kerry 26–35 5–10 VIC Inner metro Acute Hosp. Adult
Trudy 26–35 11–15 VIC Inner metro Acute Hosp. Adult
Rhonda 36–45 > 15 SA RR Acute/Rehab Adult
Rosa 36–45 > 15 SA Outer metro CH Paediatric
Jacinta 26–35 11–15 QLD RR PP Paediatric
Hayley 36–45 > 15 SA RR CH Mixed
Yvonne 46–55 > 15 SA Outer metro CH/PP Paediatric
Maria 26–35 5–10 VIC Outer metro Disability Paediatric
Leila 26–35 5–10 VIC Inner metro Disability Adult
Lucy 36–45 > 15 SA Inner metro CH Paediatric
Fiona 36–45 > 15 SA Inner metro CH Paediatric
Susan Over 55 > 15 VIC RR Disability Adult
Kelly 36–45 > 15 NSW Inner metro Private rehab Adult
Notes. RR: Rural & remote; CH: Community health; PP: Private practice; NSW: New South Wales; SA: South Australia; QLD: Queensland; VIC: Victoria;
Inner metro: within 20km of a CBD; Outer metro: 21–50km of CBD; Rural & remote (RR): more than 50km from CBD. * The names of the SLPs are
pseudonyms.
Table 2. Topic guide
The areas included in the topic guide were:
1. Introduction
Participant demographics
What do you think of when you hear the term telehealth?
What do think about telehealth in speech pathology for clinical
service provision?
2. Exploring the barriers to using telehealth?
Why don’t you use it?
Any further barriers?
3. Potential facilitators to using telehealth.
What would need to be different for you to use telehealth?
What do you believe would support uptake of telehealth in speech
pathology?

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 149
including telephone, Polycom, Skype, and video-
teleconferencing; however, there was broad confusion
about what constituted telehealth.
I really don’t know much about it … I am still not 100%
sure what telehealth is …. I just don’t know. What I am
thinking, is it similar to Polycom? (Maria)
SLPs were aware that telehealth is used clinically by
GPs, medical specialists and allied health professionals.
The Lidcombe Program for paediatric stuttering (Lewis,
Packman, Onslow, Simpson, & Jones, 2008) was the most
frequently identified SLP intervention able to be delivered via
telehealth. Five participants had learnt about it from journal
articles, conferences or other colleagues. The participants
reported that while learning about telehealth research was
exciting, they did not feel equipped to deliver services in
this way and needed more guidance. Potential facilitators
to improve dissemination of telehealth information included
a SPA position paper, practice guidelines, ICT minimum
requirements and technical instructions, and trouble-
shooting guidelines. Additionally, all participants identified
the need for further evidence, particularly cost-benefit
analyses.
Theme 2: Training
A lack of training was also identified as a major barrier.
None of the participants were aware of current telehealth
education opportunities and none had attended formal
training. A trial-and-error approach and incorporating
information from colleagues were identified as likely learning
strategies for those considering telehealth in the future.
Participants reported that accessing training and education
programs which included demonstrations would be most
beneficial.
Part of the reason I’ve never done it is that I’ve never
seen anybody do it. I would want to see people doing
it. (Jacinta)
Theme 3: Clinician attitudes and
perceptions
Metropolitan SLPs commonly reported that telehealth is a
rural and remote issue. Conversely, SLPs in rural and
remote areas indicated that the successful uptake of
themes. Written notes were compared with the audio-
recordings to ensure accuracy of transcription and to
preserve the context of the dialogue. Discussion occurred
between the researchers throughout the data collection and
analysis phases. Differences in interpretation were
discussed until consensus was reached. During data
collection accuracy was checked with participants by
reviewing major points and clarifying information. Following
transcription participants were offered (via email) the
opportunity to review their transcript to verify accuracy. Four
participants (22%) reviewed their transcripts: three made no
amendments and one requested a minor addition.
Results
The participants demonstrated varied knowledge about
telehealth. Those who demonstrated the greatest insight,
including providing a definition consistent with ASHA’s
definition (2005), clinical anecdotes and research
awareness were in senior SLP roles with more than 15
years’ experience. Participants who reported little
knowledge had largely only heard about telehealth in the
context of services offered by rural and remote GPs and
medical specialists. All participants were aware of the
potential use of ICT for staff meetings or professional
development. Despite not using telehealth for clinical
service delivery, all participants identified a range of
potential benefits including: reduced travel time, efficiency
and improved access for clients. Five participants in the
private or disability sectors stated that they intended to trial
telehealth service delivery in the future due to these
perceived benefits.
Data analysis identified existing barriers and potential
facilitators across four major themes: information, training,
clinician attitudes and perceptions, and organisational and
policy barriers.
Theme 1: Information
Lack of information about the use of telehealth was
reported to be a significant barrier. Knowledge of the
potential use of telehealth for clinical service provision was
highest amongst more experienced SLPs in the disability
and private sectors, and in rural and remote areas.
Participants reported awareness of a range of systems
Table 3. Open codes, subthemes and overarching themes
Examples of open codes Subthemes Overarching themes
I’ve heard very little about it. Awareness Information
I don’t know exactly what it is. Knowledge
Terminology
Evidence
Research
I want to see it being done. Professional development Training
I need practical training. Mentoring
Preference for face to face. Fear of technology Clinician attitudes & perceptions
Clients couldn’t do it. Resistance to change
Wouldn’t suit my caseload. Clinician preference
I don’t have time to set it up. Client issues
What are the benefits? Time
Is it cost effective?
I don’t have access to the equipment. ICT Organisational & policy barriers
Who would fund these sessions? Funding
We can’t use Skype. Access
Confidentiality
Policy & procedures

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 151 150 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
participants indicated that these barriers could be
overcome with the provision of appropriate equipment and
ongoing ICT support.
I know we have them [video-teleconferencing facilities]
here, I wouldn’t know where they are though and I
wouldn’t know whether we could use them. (Trudy)
Three participants highlighted environmental workplace
barriers, such as a lack of confidentiality in open-plan
offices and shared work stations. Allocation of telehealth-
specific therapy rooms was identified as a facilitator to
overcome this. Participants from the private sector felt
that SPA must lobby Medicare and private health insurers
to promote the need to fund SLP services via telehealth.
There was also confusion about whether new initiatives
such as the National Disability Insurance Scheme would
fund telehealth services. Participants also indicated that
workplace policy documents to support the implementation
of telehealth are needed.
Discussion
This study was designed to explore the existing barriers
and potential facilitators to telehealth use identified by SLPs
not using this service delivery method. Coding of data
generated the following themes: information, training,
clinician attitudes and perceptions, and organisational and
policy barriers. Given the paucity of research investigating
this population, it is important to compare and contrast
these findings with what is known about SLPs who use
telehealth. Identification of common barriers and facilitators
may lead to an important increase in the uptake of
telehealth. Many participants recognised the broad appeal
of telehealth including five participants who indicated a
desire to utilise it in the future.
Two significant factors differentiate telehealth users (Hill &
Miller, 2012) from non-users: attitudes and perceptions, and
organisational and policy barriers. The participants in this study
hold some perceptions that contradict recent research
including that clients have limited capacity for telehealth
(Dunkley et al., 2010; Sharma, Ward, Burns, Theodoros &
Russell, 2013) and that telehealth is limited to research
settings and rural and remote areas (Mashima & Doarn,
2008). Clearly there is a need for further dissemination and
promotion of evidence that has highlighted the use of
telehealth across diverse settings and locations (i.e.,
Mashima & Doarn, 2008; Reynolds et al., 2009).
Access to appropriate technology is problematic.
Organisational policy preventing the use of Skype appears
common despite its recent use in SLP literature (e.g.
Boisvert, Hall, Andrianopolous & Chaclas 2012; Erickson,
2012). However, the DoHA Telehealth Technical Standards
Position Paper (2012) supports such policy by highlighting
that “consumer-centric” options like Skype have lower
security and poorer quality compared to business grade
options (e.g. Polycom, Redback). Despite the accessibility
of the telephone, its potential use to deliver clinical services
is not being realised, even with supporting evidence (e.g.,
Carey, O’Brian, Onslow, Block, Jones, & Packman, 2010)
and reduced confidentiality concerns. Overall, the SLPs
without access to appropriate technology viewed telehealth
more negatively which highlights the importance of funding
appropriate infrastructure and recognising potential use of
existing resources.
As in previous studies (Hill & Miller, 2012; Mashima
& Doarn, 2008), the need for cost-benefit analyses
was emphasised in this research. Many participants
were not convinced that telehealth would improve cost
telehealth would require a partnership between all SLPs.
Most participants believed that telehealth was limited to
specialised research and university settings. Several
questioned the relevance of the current evidence given that
highly controlled research conditions do not reflect their
clinical settings.
The majority of participants thought telehealth intervention
would be more time consuming than the equivalent
intervention delivered FTF due to the required preparation
and technical problem-solving. Participants also reported
that a fear of technology posed a significant barrier.
People are a bit reluctant to take things on, you know
… “I don’t know how to make this work” so it’s kind of
a technological fear. (Rhonda)
A number of participants questioned the appropriateness
of telehealth for clients from culturally and linguistically
diverse backgrounds and those with complex
communication needs. In addition, most participants said
that they would not assess dysphagic clients via telehealth
due to safety concerns.
The participants largely reported that clients have little or
no access to the required technology and limited capacity
and willingness to accept telehealth. Most also reported
that clients prefer FTF services. Conversely, two remote
SLPs felt their clients would welcome telehealth because of
improved access and reduced travel time.
Several participants were unwavering in believing that their
service must be delivered FTF to be effective. They were
concerned that telehealth could negatively affect rapport
building and client relationships. Additionally, they feared
missing crucial incidental information only available when in
the same room as the client. Paediatric SLPs thought
therapeutic processes such as modelling, behaviour
management and managing sensory needs could be
difficult via telehealth. They were also concerned that parents
would not be engaged as they would need to manage the
session and their child independently without a SLP in the
room. Conversely, one paediatric clinician thought telehealth
could provide a useful insight into a child’s home
environment and an opportunity for better treatment
generalisation. Overall the majority of paediatric SLPs felt
strongly that the relationship-based approach frequently
used with parents would not be compatible with telehealth.
The five SLPs who intended to use telehealth in the
future recognised the need to allow sufficient time to
develop and trial methods and resources. In addition, one
SLP emphasised the need to gain their client’s perspective
before commencing. Participants broadly believed that
telehealth should not replace FTF delivery but many
recognised that telehealth could be an appropriate adjunct
delivery option.
Theme 4: Organisational and policy
barriers
Limited or no access to telehealth technology in the
workplace is a significant barrier, particularly within the
government sector. Three participants indicated that they
had no access to necessary equipment while 13 indicated
that although the equipment was available, medical and
mental health staff had priority access. Conversely, SLPs in
the private sector did not report access to equipment as
being a significant barrier. Eight participants identified that
using Skype to deliver services was problematic, primarily
because it was against organisational policy (in a range of
settings). This policy was reported to be in place because
of concerns about reliability, security and confidentiality. The

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 151
Carey, B., O’Brian, S., Onslow, M., Block, S., Jones,
M., & Packman, A. (2010). Randomized controlled non-
inferiority trial of a telehealth treatment for chronic stuttering:
The Camperdown program. International Journal of
Language and Communication Disorders, 45(1), 108–120.
Deloitte Touche Tohmatsu (Deloitte) (2008). National
e-health strategy: National E-Health & Information Principal
Committee. Deloitte, Australia.
Department of Health and Aging (DoHA). (2011). The
ehealth readiness of Australia’s allied health sector.
Retrieved from: http://www.health.gov.au/internet/
publications/publishing.nsf/Content/ehealth-readiness-
allied-toc-app-3-Speech+pathologists
Department of Health and Aging (DoHA). (2012).
Telehealth technical standards position paper. Retrieved
from http://www.mbsonline.gov.au/internet/mbsonline/
publishing.nsf/Content/5832E4E7E50D568BCA25790600
0BCDD0/$File/Telehealth%20Technical%20Standards%20
Position%20Paper.pdf
Dunkley, C., Pattie L., Wilson, L., & McAllister, L. (2010).
A comparison of rural speech-language pathologists’ and
residents’ access to and attitudes towards the use of
technology for speech-language pathology service delivery.
International Journal of Speech-Language Pathology, 12(4),
333–343.
Erickson, S. (2012). No boundaries: Perspectives of
international Skype delivery of the Lidcombe Program.
Journal of Clinical Practice in Speech-Language Pathology,
14(3), 146–148.
Hill, A. J., & Miller, L. E. (2012). A survey of the clinical
use of telehealth in speech-language pathology across
Australia. Journal of Clinical Practice in Speech-Language
Pathology, 14(3), 110–117.
Lewis, C., Packman, A., Onslow, M., Simpson, J., &
Jones, M. (2008). A phase II trial of telehealth delivery of the
Lidcombe Program of Early Stuttering Intervention.
American Journal of Speech Language Pathology, 17(2),
139–149.
Liamputtong, P. (2010). Research methods in health:
foundations for evidence based practice. Oxford University
Press, Australia.
Mashima, P.A., & Doarn, C. R. (2008). Overview of
telehealth activities in speech-language pathology.
Telemedicine and e-health, 14(10), 1101–1117.
Reynolds, A. L., Vick, J. L., & Haak, N. J. (2009).
Telehealth applications in speech-language pathology:
a modified narrative review. Journal of Telemedicine and
Telecare, 15(6), 310–316.
Sharma, S., Ward, E. C., Burns, C., Theodoros, D., &
Russell, T. (2013). Assessing dysphagia via telerehabilitation:
Patient perceptions and satisfaction. International Journal of
Speech-Language Pathology, 15(2), 176–183.
Theodoros, D. G. (2012). A new era in speech-language
pathology practice: Innovation and diversification. International
Journal of Speech-Language Pathology, 14(3), 189–199.
effectiveness or efficiency because of the additional time
required for planning, set up and potential technical issues.
Like the Hill and Miller, this study also confirmed that
insufficient information and training are significant barriers
for both users and non-users of telehealth. To address
this, practising SLPs should be made aware of existing
resources such as the Telehealth Technical Standards
(DoHA, 2012), “A Blueprint for Telerehabilitation Guidelines”
(Brennan et al., 2010) and the upcoming publication of
the SPA Telepractice Position Statement. Additionally,
the curricula of SLP teaching institutions should expose
students to the evidence regarding telehealth-delivered
SLP services and prepare them to deliver such services.
This exposure should occur both in academic subjects and
via clinical placements. The extent to which this already
happens in Australia is yet to be formally established.
Finally, telehealth policy review and development is
urgently needed across all sectors. To date very little
promotion of funding options by private health insurers and
federal government initiatives has occurred. Establishing
and disseminating the policy guidelines for all funding
bodies is essential. Furthermore, the continued lobbying of
Medicare to expand current telehealth rebates to include
allied health services is warranted.
Limitations and future research
This paper reports findings from a small sample of SLPs,
most of whom were from a government health service in
one state. Several states were not represented and no
participants worked in the education sector (perhaps due to
the use of the “health-centric” term telehealth rather than
telepractice). Caution should therefore be exercised in
making generalisations from these findings. Future research
should include a larger, more representative sample. This
could be achieved with a quantitative approach utilising a
questionnaire based on the major themes identified in this
study. Research is also needed to establish the impact of
education, training and policy development on the uptake
of telehealth in the profession.
Conclusion
The findings of this study are clinically relevant given a
disparity between the National eHealth Strategy (Deloitte,
2008) and the willingness of many SLPs to embrace
telehealth (DoHA, 2011; Hill & Miller, 2012). Despite
evidence supporting the benefits of utilising teleheath in
SLP including increased efficiency and improved access
(Mashima & Doarn, 2008; Reynolds et al., 2009), changes
must occur if the true potential is to be realised. Addressing
clinician attitudes and perceptions, providing suitable
education and training and reducing organisational barriers
could result in a greater uptake of telehealth, and
consequently, much needed increases in access, efficiency
and cost effectiveness of SLP services.
References
American Speech-Language-Hearing Association (ASHA).
(2005). Speech-language pathologists providing clinical
services via telepractice: Position statement. Retrieved from
www.asha.org/policy
Boisvert, M., Hall, N., Andrianopolous, M., & Chaclas,
J. (2012). The multifaceted implementation of telepractice
to service individuals with autism. International Journal of
Telerehabilitation, 4(2), 11–24.
Brennan, D., Tindall, L., Theodoros, D., Brown, J.,
Campbell, M., Christiana, D. … Lee, A. (2010). A blueprint
for telerehabilitation guidelines. International Journal of
Telerehabilitation. 2(2), 31–34.
Jodie May is a speech pathologist specialising in early childhood
intervention. Shane Erickson is a speech pathologist, lecturer
and researcher at La Trobe University.
Correspondence to:
Dr Shane Erickson
Department of Human Communication Sciences
La Trobe University, Bundoora, Vic. 3086
phone: (03) 9479 1838
email: s.erickson@latrobe.edu.au

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 153 152 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
Clinical insight
Charissa Zaga
(top) and Joanne
Sweeney
THIS ARTICLE
HAS BEEN
PEER-
REVIEWED
KEYWORDS
ADVERSE EVENT
AUDIT
MEAL PROVISION
PATIENT SAFETY
TEXTURE
MODIFIED DIET
Reducing error in a
complex system
Texture modified diet and fluid provision
Charissa Zaga and Joanne Sweeney
of dysphagia can lead to significant poor health outcomes
including aspiration, pneumonia, malnutrition, asphyxiation
and death (Langmore et al, 1998; Cichero, 2006). A
common method of management for dysphagia by speech
pathologists is the provision of texture modified diet and
fluids (Garcia, Chambers & Molander, 2005). Cichero (2006)
reports that thickened fluids or altered texture provide
additional cohesion to the bolus, slow oral and pharyngeal
transit and provide greater oropharyngeal control of the
bolus.
Austin Health is a major provider of tertiary health
services and health professional education and research in
the northeast of Melbourne comprising 980 beds across
three sites. At Austin Health, the meal provision system
is complex. Meals are transported across the three sites,
multiple disciplines are involved from the prescription of
diet and fluids to delivery at the patient’s bedside. All meals
are prepared at the Heidelberg Repatriation Hospital (HRH)
in a large food production kitchen. Meals for the Austin
Hospital and HRH are transported to the Austin Hospital
for plating and heating in re-therm trolleys. Meals for Royal
Talbot Rehabilitation Centre (RTRC) are transported directly
to RTRC for heating and serving. Meals for patients at the
Austin Hospital are taken to the ward in the re-therm trolley
and delivered. Meals for HRH are placed in the re-therm
trolley at the Austin Hospital, then loaded onto a truck and
transported back to HRH where the re-therm trolley is
unloaded, taken to the ward and the meals are delivered.
There are two electronic meal-ordering systems: TrakCare
and ChefMax. All ward staff including nurses, dietitians and
speech pathologists order meals via TrakCare. Following
this, menu monitors enter the TrakCare diet code into
ChefMax with the patient’s relevant menu preferences.
ChefMax generates a meal tray slip that is printed for each
patient and placed on the tray where the meal is plated.
There are set meal ordering cut-off times on TrakCare
whereby any diet/fluid changes entered after the cut-off
time will not come into effect. This reflects the timeframe of
the process from when the meal reports and meal tray slips
are printed, plating begins and all plated meals are placed
in the re-therm trolley. At the Austin Hospital, this timeframe
is approximately two hours; however, at HRH this timeframe
is between 5 and 11 hours. Speech pathologists must
communicate all diet/fluid changes verbally to the menu
monitors in cases where delivery of the new diet/fluid would
result in risk to the patient (e.g., patient with worsened
dysphagia requires a more modified diet). This process
aims to ensure the meal that is plated and delivered is safe
as the meal report for plating has already been printed. In
This paper describes how a complex meal
provision system in an acute hospital setting
supports clinical decision-making in
dysphagia management at the ward level.
The aim was to reduce the number of
incorrect texture modified diet and/or fluids
delivered to patients with dysphagia. A
process map of the meal provision system at
The Austin Hospital was revised and an
auditing tool created for the purposes of this
study. This auditing tool comprised nine key
parameters in the meal provision process for
texture modified diet/fluids. An audit was
conducted across eleven acute wards over
three breakfast, lunch and dinner meals over
four non-consecutive days. Following
analysis of the audit, focus groups were held
with seven speech pathologists, four nurse
unit managers and the food services
coordinators. Audit results, barriers to
achieving higher accuracy across auditing
parameters and areas for intervention were
discussed in these groups. Intervention was
three-fold: targeting safe swallowing bed-
signs, and supervision of the plating line and
in the re-therm trolley room. Three and a half
months after the first audit and
implementation of the interventions, a
subsequent audit was conducted on six acute
wards over two breakfast and lunch meals on
two consecutive days. Overall reductions in
the number of delivered meals of incorrect
texture were noted between the initial audit
and the subsequent audit results.
Dysphagia is associated with many different etiologies
across the lifespan, including but not limited
to neurological conditions, trauma, respiratory
disorders, psychiatric conditions and effects from
polypharmacy (Cichero, 2006). The estimated prevalence
of dysphagia varies depending on the classification of the
medical condition. Consequences of unmanaged cases

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 153
groups were conducted with stakeholders to inform the
areas for intervention. Seven speech pathologists, four
nurse unit managers and the food services coordinator
analysed qualitative data regarding barriers to acheiving
higher accuracy across auditing parameters and identified
areas for intervention. Following this process a three-fold
intervention was implemented: 1) targeting safe swallowing
bed-signs; 2) improving the level of supervision on the
plating line; and 3) improving the level of supervision in the
re-therm trolley room in the kitchen.
Results
First audit
The first audit results (see Table 1) identified some
inaccurate diet/fluid code matching across the EMOS,
patient’s medical file and bed-sign. Poor use of the safe
swallowing bed-sign was evident. These results prompted
analysis and intervention to increase the presence of the
safe swallowing bed-signs, increase accuracy of diet/fluid
code matching across the parameters, and reduce the
number of patients receiving incorrect meals.
Intervention based results of the audit
Safe swallowing bed-signs
The safe swallowing bed-sign acts as a key communication
tool between the speech pathologist, nurse and food
services staff in identifying diet/fluid requirements at the
point of diet/fluid delivery at the bedside. It is the
responsibility of the speech pathologist to place a safe
swallowing bed-sign above the bed of patients with
dysphagia. The food services staff use this sign to
cross-check the patient’s name and meal requirements
against the plated meal before delivery. This is the final
cross-checking point in the complex meal delivery system
(see Figure 1) and is essential to minimise incorrect meal
delivery. Poor compliance with the presence of safe
swallowing bed-signage prevents this cross-checking to
occur and was at least one of the causes of incorrect meal
provision during the audit.
Speech pathologists identified several barriers during the
focus group:
1. Lack of bed-signs available in the department
2. Lack of bed-signs available while on the ward
3. Forgetting to place a bed-sign
4. Bed-signs falling down and not being replaced at bed-
side by nursing staff
5. Bed-signs being placed initially but not moved with
patient who is transferred to another bed or ward.
instances where there is no risk for the patient to receive
the older meal order, the new diet/fluid change will take
effect from the next mealtime. Staff from seven disciplines
– nurses, ward clerks, speech pathologists, dietitians,
menu monitors, fluid preparation staff and personal service
assistants (PSA) – are involved in meal provision.
Of the average 15,400 meals produced per week, the
food services department estimates 10% (~1,540 meals) of
these to be texture modified meals and/or fluids (TMD/F).
Given the complexity of the meal provision system and
the potential for error and adverse events, the aim of this
project was to reduce the number of incorrect texture
modified diet/fluids delivered to patients with dysphagia at
the Austin Hospital.
Method
The existing TMD/F provision process map (see Figure 1)
was revised following consultation with multiple
stakeholders including nurse unit managers (n = 10), deputy
manager of dietetics and food services coordinator. This
review enabled documentation of current procedures within
each relevant department at the ward and kitchen levels.
The parameters in the process map informed the
generation of an auditing tool developed for the purposes
of this study.
The auditing parameters were:
1. Presence of a safe swallowing bed-sign.
2. Presence of a meal tray slip.
3. Matched safe swallowing bed-sign to meal tray slip.
4. Matched meal tray slip to diet/fluid code on electronic
meal ordering system (EMOS).
5. Matched meal tray slip to plated meal.
6. Matched plated meal to diet/fluid code on EMOS.
7. Matched plated meal to documented diet/fluid code in
patient’s medical file.
8. Matched diet/fluid code documented in patient’s
medical file to diet/fluid code on EMOS.
9. Presence of correct meal delivered.
An initial audit was conducted across eleven acute adult
wards in the Austin Hospital over three breakfast, lunch
and dinner meals over four non-consecutive days. Over the
auditing period 82 patients were on texture modified diet/
fluids recommended by speech pathology; however, 6 (7%)
of these were not delivered resulting in a sample size of
76 meals. Reasons for meals not being delivered included
patients fasting for procedures or being too drowsy for oral
intake.
Following the initial audit and analysis of the results,
a review of the process map was undertaken and focus
Table 1. Summary of audit results
Audit 1 Audit 2
Number of TMD/F meals delivered 76 35
Presence of safe swallowing bed-sign 61% 74%
Presence of meal tray slip 99% 100%
Matched bed-sign to meal tray slip 89% 85%
Matched meal tray slip to diet/fluid code on EMOS 93% 94%
Matched meal tray slip to plated meal 97% 94%
Matched plated meal to diet/fluid code on EMOS 92% 94%
Matched plated meal to documented diet/fluid code in patient’s medical file 95% 94%
Matched diet/fluid code documented in patient’s medical file to diet/fluid code on EMOS 95% 97%
Presence of incorrect meal delivered 3% 0%

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 155 154 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
Processes in the kitchen
Meetings were held with food services department staff to
discuss the initial audit results and their perceived “high-
risk” areas within the kitchen, plating line, and meal delivery
process. Three key areas were identified as requiring
attention: (1) the lack of cross-checking processes, (2) the
level of level of supervision on the plating line, and (3) the
absence of supervision in the re-therm trolley room.
Changes implemented as a result of these meetings include
an additional food services supervisor was directed to work
on the plating line, enabling further cross-checking of plated
meals and diet/fluid code changes.
New allocation of a food services supervisor who was
directed to work in the re-therm trolley room enabling
cross-checking and system controls to streamline diet/fluid
code changes prior to plated meals being transferred to the
ward. A whiteboard was introduced for all new diet slips to
be affixed to.
Individual meetings were also held with nurse unit
managers (n = 4) to discuss the first audit results. The
discussion included the presence of safe swallowing
bed-signage and the importance of bed-signs moving
with patients who are transferred to other beds or wards.
Education was provided regarding the role of the safe
swallowing bed-sign in the TMD/F provision system.
Actions and implemented changes as a result of this
meeting included:
• Speech pathologists
1. Adequate copies of bed-signs made available in each
department/ward
2. Verbal and email reminders provided to speech
pathologists quarterly regarding placement of safe
swallowing bed-sign when clinically indicated
• Nurse unit managers
1. Review bed-transfer processes with staff with
reminders to move bed-sign when patient
transferring to another bed or ward.
Identify special
dietary needs
Recommend
texture
modified
diet/fluid
(TMD/F)
Notify
ANUM/RN
of TMD/F
required
Document
TMD/F
recommendation
in patient’s
medical file
Send DT
referral with
detailed
comments incl.
diet code,
prognosis, d/ch
plan if known
Place
bed-sign
outlining
TMD/F
required
Initiate SP and/or DT Cerner referral if indicated
Instruct ward clerk to
order specified diet
Is it a
complex diet/
fluid code entry on
TrakCare?
No
Yes
Request via
Lanpage that DT
make TMD/F
code entry on
TrakCare
Enter
required
TMD/F
code on
TrakCare
Is the
change a
downgraded
TMD/F code and is
it outside cut-off
time for
next meal?
Yes
No
Notify
MM of
TMD/F
code
order or
change
Conduct interview
with pt. Enter
diet code data
into Chefmax
according to
dietary
requirements
Authorise
& finalise
diet codes
in Chefmax
Crosscheck
diet/fluid
code changes
via TrakCare
prior to
cut-off time
Print TrakCare
report &
give to FP.
Print meal
tray slip &
give to FSA
Verbally notify FP
of TMD/F order
or change
if applicable
Complete new meal
tray slip and give to FSA
TrakCare reports
received from MM
Plate meal for
next service
meal as per
meal tray slip
received No Yes
Prepare mid
meal fluids
& supps
according
to TrakCare
Has
original meal
been plated? Has
re-therm trolley
with meal left
the kitchen?
Yes
No
Place MT/AF/supper fluids
and supplements on trolley
for delivery to ward
Can
the kitchen
produce the meal by
required time?
Yes
No Plate new meal
Take plated
meal to
re-therm
trolley
Place meal
on late trolley
from kitchen
to ward
Take re-therm
trolley from
kitchen to
ward
Deliver
meal +/or
fluids +/or
supplements
to patient’s
bedside
Does
the meal
+/or fluid +/or
supplements on
tray match the
meal tray slip
and signage
above pt’s
bed?
Yes
No
Do not deliver to pt.
Check with ANUM
&/or RN. Request
ANUM to follow up
Deliver meal
+/or fluids +/or
supplements
to patient
Is there
a discrepancy
between the SP/DT/medical
entry in pt’s file +/or bed sign
+/or diet code in
TrakCare?
Yes
No
RN to contact SP/DT
to clarify
recommendations
Call MM to rectify
Nurse
(ANUM/RN)
Ward clerk
(WC)
Speech
pathologist
(SP)
Discipline Prescribing Ordering
Preparing Dispensing
Dietitian
(DT)
Menu
monitor
(MM)
Food service
assistant
(FSA)
Fluid prep
staff
(FP)
Personal
service
assistant
(PSA)
Deliver tea and coffee to patients
on the ward at patient request
Figure 1. Process map of texture modified diet and fluid provision at Austin Health – Austin Tower and ONJ Wards

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 155
audit results. Additionally, no incorrectly delivered meals
were identified in the second audit compared with the first.
Discussion
It is unclear which intervention directly related to improved
accuracy of the diet/fluid code matching across the two
electronic meal ordering systems, documentation in the
medical file and bed-signage. This is thought to be due to
the large number of steps in the process, the number of
disciplines involved and the interventions only targeting
parts of the meal provision process. No significant changes
were made to the process map during the course of the
audits or the focus groups as all stakeholders agreed that
the process map reflected the meal provision system.
Through the focus groups, increased engagement and
buy-in from the speech pathologists and nurse unit
managers was reported. Additionally, increased awareness
of the complexity of the meal provision system at Austin
Implementation of both interventions (i.e., the safe
swallow bed-signs and improved kitchen processes)
occurred three months following the first audit. Two weeks
after the interventions were implemented, the second audit
was conducted on six acute adult wards in the Austin
Hospital over two breakfast and lunch meals on two
consecutive days. Over the auditing period, 36 patients
were recommended to have texture modified diet/fluids.
However, one of these meals was not delivered due to
reduced patient alertness as directed by the nurse. The six
acute adult wards involved in the second audit were
selected on the basis of higher proportions of patients
requiring TMD/F.
Second audit
The second audit results (see Table 1) identified improved
accuracy of diet/fluid code matching across the EMOS,
patient’s medical file and bed-signs, with the bed-sign use
being the most significant change compared with the first
Identify special
dietary needs
Recommend
texture
modified
diet/fluid
(TMD/F)
Notify
ANUM/RN
of TMD/F
required
Document
TMD/F
recommendation
in patient’s
medical file
Send DT
referral with
detailed
comments incl.
diet code,
prognosis, d/ch
plan if known
Place
bed-sign
outlining
TMD/F
required
Initiate SP and/or DT Cerner referral if indicated
Instruct ward clerk to
order specified diet
Is it a
complex diet/
fluid code entry on
TrakCare?
No
Yes
Request via
Lanpage that DT
make TMD/F
code entry on
TrakCare
Enter
required
TMD/F
code on
TrakCare
Is the
change a
downgraded
TMD/F code and is
it outside cut-off
time for
next meal?
Yes
No
Notify
MM of
TMD/F
code
order or
change
Conduct interview
with pt. Enter
diet code data
into Chefmax
according to
dietary
requirements
Authorise
& finalise
diet codes
in Chefmax
Crosscheck
diet/fluid
code changes
via TrakCare
prior to
cut-off time
Print TrakCare
report &
give to FP.
Print meal
tray slip &
give to FSA
Verbally notify FP
of TMD/F order
or change
if applicable
Complete new meal
tray slip and give to FSA
TrakCare reports
received from MM
Plate meal for
next service
meal as per
meal tray slip
received No Yes
Prepare mid
meal fluids
& supps
according
to TrakCare
Has
original meal
been plated? Has
re-therm trolley
with meal left
the kitchen?
Yes
No
Place MT/AF/supper fluids
and supplements on trolley
for delivery to ward
Can
the kitchen
produce the meal by
required time?
Yes
No Plate new meal
Take plated
meal to
re-therm
trolley
Place meal
on late trolley
from kitchen
to ward
Take re-therm
trolley from
kitchen to
ward
Deliver
meal +/or
fluids +/or
supplements
to patient’s
bedside
Does
the meal
+/or fluid +/or
supplements on
tray match the
meal tray slip
and signage
above pt’s
bed?
Yes
No
Do not deliver to pt.
Check with ANUM
&/or RN. Request
ANUM to follow up
Deliver meal
+/or fluids +/or
supplements
to patient
Is there
a discrepancy
between the SP/DT/medical
entry in pt’s file +/or bed sign
+/or diet code in
TrakCare?
Yes
No
RN to contact SP/DT
to clarify
recommendations
Call MM to rectify
Nurse
(ANUM/RN)
Ward clerk
(WC)
Speech
pathologist
(SP)
Discipline Prescribing Ordering
Preparing Dispensing
Dietitian
(DT)
Menu
monitor
(MM)
Food service
assistant
(FSA)
Fluid prep
staff
(FP)
Personal
service
assistant
(PSA)
Deliver tea and coffee to patients
on the ward at patient request
Figure 1. Process map of texture modified diet and fluid provision at Austin Health – Austin Tower and ONJ Wards

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 157 156 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
Charissa Zaga is a speech pathologist working within the acute
care setting. Charissa has a keen interest in quality and safety in
healthcare, specifically, the efficiency of the systems and
processes that underpin clinical management. She is currently
undertaking a Master of Public Health. Joanne Sweeney is the
manager of speech pathology at Austin Health. Joanne has a
longstanding interest in safety, quality and risk and concepts of
clinical governance as they apply to the speech pathology
profession.
Correspondence to:
Charissa Zaga
The Austin Hospital, Austin Health
145 Studley Rd, Heidelberg, Melbourne VIC 3084
phone: +61 (0)3 9496 5000
Health was reinforced to stakeholders along with the
potential associated risks for patients with incorrect meal
provision. This increased knowledge engendered improved
compliance with the steps in the process map and
highlighted the importance of accurate communication and
diet/fluid code matching.
Significant differences in the number of meals delivered
between audit 1 and audit 2 means the results of this study
need to be viewed with caution. It is unknown whether the
two interventions applied were directly effective in increasing
the overall accuracy of the meal provision system and
ultimately minimising the number of incorrect meals delivered.
A further larger audit is required to explore this further
regarding the local texture modified meal provision at HRH
and RTRC sites.
Intuitively, an additional supervisor on the plating line and
the new allocation of a supervisor to streamline meal tray
switching in the re-therm trolley following diet/fluid code
changes may increase the accuracy of meal provision.
Anecdotal feedback from food services department
staff has reported this change was positive as it enabled
increased consistency in the process and confidence that
the staff were delivering the right meal to the right patient.
In future it would also be valuable to continue to embed
elements of the National Safety and Quality Health Service
Standards (Australian Commission on Safety and Quality
in Healthcare, 2012), such as patient identification and
procedure matching, clinical governance, partnering with
consumers and clinical handover to maximise patient
safety, experience of care and minimisation of risk relating
to meal provision.
Conclusion
The meal provision system at the Austin Hospital is
complex and relies on up to seven stakeholders’ timely and
clear roles within the process to ensure accuracy and
safety. With all complex systems, stakeholder engagement
and multiple small projects targeting different aspects of the
system are necessary to effect meaningful change and
improve outcomes. Limited funding availability for large-
scale change in this area (e.g., technology software
changes, and use of online menu reporting, etc.) results in
reliance upon education and engagement with relevant staff
and increasing efficiency and accuracy within existing
resources. Reduction in the number of incorrect meals
delivered following intervention was observed. The risk of
patients receiving the incorrect meal remains at each meal
service however, making continued efforts to minimise the
risk is essential.
References
Australian Commission on Safety and Quality in Healthcare.
(2012). National safety and quality health standards.
Canberra, Australia: Author.
Cichero, J. (2006). Conditions commonly associated with
dysphagia. In J. Cichero & B. Murdoch (Eds.), Dysphagia:
Foundation, theory and practice (pp. 237–298). Chichester,
UK: John Wiley and Sons.
Garcia, J. M., Chambers, E., & Molander, M. (2005).
Thickened liquids: Practice patterns of speech-language
pathologists. American Journal of Speech-Language
Pathology, 14(1), 4–13.
Langmore, S. E., Terpenning, M. S., Schork, A., Chen, Y.,
Murray, J. T., Lopatin, D., & Loesche, W. J. (1998).
Predictors of aspiration pneumonia: How important is
dysphagia? Journal of Dysphagia, 13, 69–81.

Research
www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 157
academics who link up with clinicians, and vice versa, are a
rare breed, with both bemoaning lost opportunities,
stubbornly lodged in the research–practice gap. But are
SLP/SLT clinicians and researchers really worlds apart?
Academics talk of the doubtful pleasures of grappling
with administrative responsibilities, teaching loads, budget
cuts, disruptive “restructures”, exam marking and grant
proposals that can impinge unhelpfully on their own
research projects, and time pressures that won’t go away.
Clinicians, meanwhile, speak of handling the challenges
of waiting lists, unwieldy caseloads, unsympathetic
bureaucracies, complex clienteles and of course, those
ever-present time pressures too. Neither party tends to
use these circumstances to excuse the undeniably low
prevalence of clinician-researcher collaboration. So, one
has to wonder if that common factor – time – is the most
active ingredient in maintaining the status quo, and whether
concentrated information literacy homework2, planning
and time management3 on both sides might be a good
part of the solution.
Information literacy and time
management
Information literacy is an intellectual framework for
recognising the need for, understanding, finding,
evaluating, and using information. These are activities
which may be supported in part by fluency with
information technology, in part by sound investigative
methods, but most importantly through critical
discernment and reasoning. (Bundy, 2004, p. 4)
Ratcliff, Swartz and Ivanitskaya (2013, p. 38) found
significant differences in information literacy between
students, across introductory, mid-level and advanced
academic levels. They concluded that students at all levels
might benefit from further training in information literacy
skills, noting that “institutions of higher education are well
positioned to be leaders in developing better competencies
in information literacy in consumers of information”. It
probably holds true that for the majority of practising
clinicians interested in taking the researcher path the said
“further training” is in order. In the endlessly helpful Clinical
Research Methods in Speech-Language Pathology and
Audiology, Irwin, Pannbacker and Lass (2013) emphasise
information literacy, suggest the use of research
databases and other online tools4 including social
networking, take into account qualitative research and
evidence-based practice, provide a detailed discussion of
research ethics, and explain how to frame questions using
the PICO5 framework to formulate answerable questions.
Researchers, and new or intending clinician-researchers,
have much to gain from the concise and positively reviewed
Dobson and Wren (2013) book on creating practice-
based evidence, the insightful McComas (2014) on how
women become researchers in communication sciences
and disorders, and from reading, or re-reading McGinty
Wont to test the water in Twitter when broaching
JCPSLP topics, @speech_woman spared a sun-
drenched winter moment, poolside in Durban for
six Tweets.
1) @WeSpeechies who want to collaborate with
researchers in clinical research: What would you like
researchers to tell you first up?
2) Researchers who want to collaborate with
@WeSpeechies in clinical research: What would
you like clinicians to tell you first up?
3) @wespeechies tell me the keys to clinician-
academic collaboration in forming research
partnerships.
4) @WeSpeechies #SLPeeps #SLP2B Can you please
recommend books, articles with guidelines to
getting started in SLP/SLT clinical research?
The response was immediate and international.
A doctoral scholar in Sydney said, “This is such an
important issue to unlock! Making research accessible to
busy clinicians is key!” and “I would love to see clinician
participation in research”. A Pennsylvanian student
blogger asked, “Would ASHA’s CLARC1 program have
info on that? Or does it just link clinicians and researchers
together?” A globetrotting Manchester SLT practitioner,
lecturer and researcher wrote, “See this brilliantly accessible
book: Creating Practice Based Evidence” (Dobson &
Wren, 2013). A researcher in Montreal said, “The clinic
community could invite research students and researchers
into their sites to evaluate outcomes more often” and “The
clinical community needs to facilitate clinical research by
collaborating with the academic community”. And a school-
based clinician in Ellendale ND Tweeted, “Great question.
Guidelines in how to get started would be helpful”. The
getting started guidelines Tweet aroused curiosity, so
@speech_woman Tweeted on.
5) Do @ASHAweb, @IASLT, @NZSTA, @RCSLT,
@SAC_OAC or @SpeechPathAus publish general
guidelines to getting started in clinical research?
6) @WeSpeechies #SLPeeps #SLP2B Point me to
university sites with general guidelines to getting
started in SLP/SLT clinical research.
The last two questions drew no response.
Worlds apart
Regular professional association conference attendees in
Australia or abroad know that there is a continual call from
the academic world, alongside offers of help with the
practicalities, for speech-language practitioners to conduct
clinical research. Presenters of continuing professional
development events, nationally and internationally, hear an
equally insistent call from the clinical world from therapists
seeking the wherewithal to gain and implement research
skills. But, despite goodwill and enthusiasm on either side,
Webwords 50
Clinical research: A meeting of minds in SLP/SLT
Caroline Bowen

www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 159 158 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
Irwin, D. L., Pannbacker, M., & Lass, N. J. (2013). Clinical
research methods in speech-language pathology and
audiology (2nd ed.). San Diego, CA: Plural Publishing.
McComas, K. L. (2014). Dig your heels in and fight! How
women become researchers in communication sciences
and disorders. Guildford, UK: J&R Press.
McGinty, A. S. (2012, October). A programmatic
approach to clinical practice research. Access Academics
and Research. Rockville, MD: ASHA. Available from: http://
www.asha.org/Academic/questions/A-Programmatic-
Approach-to-Clinical-Practice-Research/
Mullins, G., & Kiley, M. (2002). It’s a PhD, not a Nobel
Prize: How experienced examiners assess research theses.
Studies in Higher Education, 27(4), 369–386.
Ratcliff, A., Swartz, B., & Ivanitskaya, L. (2013).
Information literacy skills in speech-language pathology
students: skill differences across academic levels,
Contemporary Issues in Communication Sciences and
Disorders, 40(1), 31–39.
Robey, R. R. (2004). A five-phase model for clinical-
outcome research. Journal of Communication Disorders,
37, 401–411.
Tracy, S. J. (2010). Qualitative quality: Eight “big-tent”
criteria for excellent qualitative research, Qualitative Inquiry,
16(10), 837–851.
Links
1. http://www.asha.org/academic/CLARC/
2. http://www.ala.org/acrl/issues/infolit/overview/intro
3. http://www.timeshighereducation.co.uk/features/
feature-work-less-do-more-live-better/2014929.article
4. http://www.asha.org/research/researcher-tools/
databases/
5. http://learntech.physiol.ox.ac.uk/cochrane_tutorial/
cochlibd0e84.php
6. http://thesiswhisperer.com/
7. https://medium.com/@Write4Research
8. http://airs.library.qut.edu.au/1/
9. http://courses.mq.edu.au/postgraduate/research/
bachelor-of-philosophy-master-of-research
10. http://matt.might.net/articles/productivity-tips-hints-
hacks-tricks-for-grad-students-academics/
11. http://blogfiles.wfmu.org/KF/2011/08/24/mindmap-for-
web.jpg
12. http://www.scribendi.com/advice/finding_time_to_write.
en.html
Webwords 50 is at www.speech-language-therapy.com
with live links to featured and additional resources.
(2012), Robey (2004) and Tracy (2010). Those considering
a research degree at Masters or doctoral level will unearth
Google gold among the dross by searching “encouraging
clinical researchers in speech-language pathology”, and
have a rewardingly drossless experience at The Thesis
Whisperer6 and Writing for Research7 websites.
Speechwoman had golden moments when she found
Queensland University of Technology’s Advanced
Information Research Skills8 issued under a Creative
Commons License, and Macquarie University’s Bachelor
of Philosophy/Master of Research9, designed to smooth
the transition from, well, wherever you’re “at” now, and
into the doctoral journey. There is good time management
advice available from Matt Might10, Learning
Fundamentals11, a few related thoughts at Finding Time
to Write12 and good advice generally in an old favourite:
Mullins and Kiley (2002).
Working together
When Tracy (2010) wrote her article, she aimed to present
and explore key markers of quality in qualitative research.
The markers, which left room, as she said, for dialogue,
imagination, growth, and improvisation, make a good
starting point for clinicians and academics approaching
research partnerships. They included: (a) worthy topic, (b)
rich rigor, (c) sincerity, (d) credibility, (e) resonance, (f)
significant contribution, (g) ethics, and (h) meaningful
coherence.
Among the challenges and joys of both clinical practice
and working in academic, research environments
are the lasting personal friendships, collegial working
relationships, life-long learning opportunities, and sense
of shared discovery and endeavour. Those who venture
to-and-fro from clinic to research lab, or from lab to clinic
can enjoy the best of both worlds and stand a strong
chance of enriching their professional lives, contributing
to the evidence base, and adding small incremental
enhancements to client care. For this to happen, clinicians,
clinician-researchers, and researchers must work together,
learning from each other, and finding mutuality of respect
for each other’s expertise.
References
Bundy, A. (2004). Australian and New Zealand information
literacy framework: Principles, standards and practice (2nd
ed.). Adelaide, Australia: Australian and New Zealand
Institute for Information Literacy (ANZIIL) and Council of
Australian University Librarians (CAUL).
Dobson, C., & Wren, Y. (2013). Creating practice based
evidence: A guide for SLTs. Guildford, UK: J&R Press.
Would you like to contact more
than 6,000 speech pathologists?
Advertising in JCPSLP and Speak Out is a great way to spread your message to speech
pathologists in Australia and overseas. We have different size advertising space available.
If you book in every issue for the whole year you’ll receive a discount.
See www.speechpathologyaustralia.org.au for further information about advertising.

Research
www.speechpathologyaustralia.org.au JCPSLP Volume 16, Number 3 2014 159
Top ten resources in an intensive,
group-based intervention setting
for young children with autism
spectrum disorder
Katherine Pye
alternative visual supports include high- and low-tech
communication devices and visual timetables.
3 Research
We are very lucky to have a full-time researcher, Dr
Giacomo Vivanti, working in the centre, and he often alerts
us to new findings and articles that are relevant to our
practice. Members of our team also attend local and
international conferences, use the university library and
benefit from regular updates from Informa Healthcare
(http://informahealthcare.com) – it’s a great time-saver to
receive articles relevant to your needs, straight to your
inbox! The centre was established following international
findings that early, intensive, behavioural intervention is the
most effective (Granpeesheh, Dixon, Tarbox, Kaplan, &
Wilke, 2009; Odom, Boyd, Hall, & Hume, 2014; Peters-
Scheffer, Didden, Korzilius, & Matson, 2012; Rogers, 2013),
and more recent research has supported the efficacy and
long-term cost-benefits of approaches including the ESDM.
We continue to be guided by current research.
4 The transdisciplinary team
The transdisciplinary team is based on shared skills, open
communication and thorough organisation. We meet twice
weekly and use email, cheat sheets, joint working and
frequent face-to-face updates to keep each other up to
speed with children’s needs and our own workloads. In a
busy group setting, timetabling is crucial: groups,
transitions, inclusion visits, therapy space, staffing, meals
and the children’s toileting are all tightly scheduled to keep
things running as smoothly as possible, providing children
with learning and care throughout the day. The therapists in
the room have clear roles and expectations at all times.
Families are central to the team around each child. As we
are a childcare setting, parents are not present in the
therapy provided on a daily basis, but regular meetings
ensure their concerns are addressed and consistency
between home and the centre is increased. Parents are
offered training in ESDM techniques and they take part in
goal-setting with their child’s key workers. Seeing parents
every morning and afternoon helps us to build a strong
relationship through regular communication – we learn a lot
from each other.
5 Standardised tests
Standardised tests are used to track children’s progress
through the program, enabling comparison with alternative
intervention models, such as Applied Behaviour Analysis
(ABA). Our research psychologist carries out this work,
which evaluates the effectiveness of the ESDM in a group
The Victorian Autism Specific Early Learning and
Care Centre (Vic ASELCC) is a federally funded
service that is governed by La Trobe University.
The service is part of the Community Children’s Centre
and has a research partnership with the Olga Tennison
Autism Research Centre (OTARC). We provide intensive
intervention for young children with autism spectrum
disorder (ASD) in a naturalistic (childcare) setting, using the
transdisciplinary Early Start Denver Model (ESDM). Currently
our children are aged 2–6 years and on average they attend
for four days each week. Most intervention happens in the
playrooms during 1:1 interactions, facilitated play with peers
and small/large group activities. Children needing additional
input (e.g., to target motor speech [Rogers et al., 2006]) are
withdrawn for individual therapy sessions.
1 ESDM resources for young children
with autism
The Vic ASELCC is a transdisciplinary setting where
teaching staff and allied health (speech pathologists,
occupational therapists and psychologists) are all ESDM
trained. Reaching “fidelity” as an ESDM therapist involves
formal training and submission of videos that demonstrate
effective use of the technique in 1:1 interactions. The ESDM
manual (Rogers & Dawson, 2010a) is vital during this
process, particularly for the “Teaching fidelity rating system”,
which is used by trainers to assess prospective ESDM
therapists. Children are assessed on arrival and every three
months using the ESDM curriculum checklist (Rogers &
Dawson, 2010b). This in turn guides goal writing to target
the nine developmental areas supported by the ESDM.
2 Data collection system
Once a child’s sixteen (or more) SMART goals are written
and broken down into 5–6 steps, their data sheets are kept
in the playroom so the team can target goals and record
data throughout the day. The data is reviewed weekly and
children are moved up their steps toward achieving their
goals. We are in the process of moving from paper data
sheets to a more efficient electronic (tablet-based) system
of data collection and analysis. The ESDM is focused on
teaching children with ASD to learn in their natural
environments and it is not assumed that all children need
the same type or level of support. When children do not
progress as expected, a decision tree is used to plan an
alternative teaching structure, reinforcement and supports
to help the child achieve their goals. For example, if a child
does not respond and learn from clear verbal, gestural,
object and tactile prompts, aided language displays (ALDs)
may be used to support their communication. Other

160 JCPSLP Volume 16, Number 3 2014 Journal of Clinical Practice in Speech-Language Pathology
balloons, crash mats, cars, craft, dress-ups, puzzles,
books, drawing and sensory materials, bikes, slides,
figurines and CDs: all the usual things we expect to see in a
well-stocked childcare setting.
References
Granpeesheh, D., Dixon, D., Tarbox, J., Kaplan, A., & Wilke,
A. (2009). The effects of age and treatment intensity on
behavioural outcomes for children with autism spectrum
disorders. Research in Autism Spectrum Disorders, 3,
1014–1022.
Lord, C., Rutter, M., DiLavore, P., Risi, S., Gotham, K.,
& Bishop, S. L. (2012). Autism diagnostic observation
schedule (ADOS-2), Part 1: Modules 1–4 (2nd ed.). Los
Angeles, CA: Western Psychological Services.
Lord, C., Luyster, R. J., Gotham, K., and Guthrie, W.
(2012). Autism diagnostic observation schedule, (ADOS-2),
Part II: Toddler module (2nd ed.). Los Angeles, CA: Western
Psychological Services.
Mullen, E. M. (1995). Mullen scales of early learning: AGS
edition. Circle Pines, MN: American Guidance Service.
Odom, S., Boyd, B., Hall, H., & Hume, K. (2014).
Comprehensive treatment models for children and youth
with autism spectrum disorders. In F. R. Volkmar, R. Paul,
S. J. Rogers, & K. A. Pelphrey (Eds.), Handbook of autism
and pervasive developmental disorders (4th ed., Vol. 2,
770–787). Hoboken, NJ: Wiley.
Perry, A., Flanagan, H. E., Dunn Geier, J., & Freeman,
N. L. (2009). Brief report: The Vineland adaptive behaviour
scales in young children with autism spectrum disorders
at different cognitive levels. Journal of Autism and
Developmental Disorders, 39(7), 1066–1078.
Peters-Scheffer, N., Didden, R., Korzilius, H., & Matson,
J. (2012). Cost comparison of early intensive behavioral
intervention and treatment as usual for children with
autism spectrum disorder in the Netherlands. Research in
Developmental Disabilities, 33, 1763–1772.
Rogers, S. (2013). Early Start Denver Model. In
Encyclopedia of autism spectrum disorders (Vol. 2,
1034–1042). New York, NY: Springer.
Rogers, S. & Dawson, G. (2010a). Early Start Denver Model
for young children with autism. New York: The Guildford Press.
Rogers, S. & Dawson, G. (2010b). Early Start Denver
Model curriculum checklist for young people with autism.
New York, NY: The Guildford Press.
Rogers, S. J., Hayden, D. Hepburn, S., Charlifue-Smith,
R., Hall, T., & Hayes, A. (2006). Teaching young nonverbal
children with autism useful speech: A pilot study of the
Denver Model and PROMPT interventions. Journal of
Autism and Developmental Disorders, 36(8), 1007–1024.
Wiig, E., Secord, W., & Semel, E. (2006). Clinical
evaluation of language fundamentals – Preschool (2nd ed.,
Australian and New Zealand Standardised edition). Sydney,
Australia: Pearson.
setting. Children are assessed using the Autism Diagnostic
Observation Schedule (ADOS; Lord, Rutter et al., 2012;
Lord, Luyster, Gotham, & Guthrie, 2012), the Mullen Scales
of Early Learning (Mullen, 1995) and the Vineland Adaptive
Behaviour Scales (Perry, Flanagan, Geier, & Freeman,
2009). Other, discipline-specific tests are used as needed
(e.g. for funding applications, or to support goal writing for
children with higher verbal skills) including the Clinical
Evaluation of Language Fundamentals – Preschool
(CELF-P2; Wiig, Secord, & Semel, 2006).
All modules of ADOS-2 are available for $2812 at ACER:
https://shop.acer.edu.au/acer-shop/group/ADOS2 . The
Mullen Scales are available for $1683 at Pearson: https://
www.pearsonclinical.com.au/products/view/345. Vineland
starter kits are available from $357 at Pearson: https://
www.pearsonclinical.com.au/products/view/244. And
CELF-P2 is available for $990 at Pearson: https://www.
pearsonclinical.com.au/products/view/84
6 Energy, imagination and a sense of
adventure!
These “tools” are very important when working with young
children and the group setting can be particularly
challenging at times. We often need to work hard to build
rapport with our children and motivate them to learn, and
the ESDM is very big on keeping play exciting and varied.
As an intensive therapy setting, it is crucial that we maintain
effective therapy for the 25 hours per week provided. This
takes energy, imagination and a sense of adventure.
7 Sensory social routines
Sensory social routines (SSRs) are a key component of
ESDM, and similar activities are seen in many other therapy
approaches. SSRs use fun, person-to-person play such as
tickles, swinging in the air or peekaboo, to promote social
attention and interaction. They are often the “way in” when
working with children who are object-focused or socially
avoidant, allowing us to target skills in multiple domains. We
aim to engage children in a variety of SSRs and elaborate
on them to achieve more diverse teaching and encourage
flexibility and generalisation.
8 Peers
Children with ASD have increased difficulty interacting with
their peers. In a group setting, other children provide
endless opportunities for spontaneous and exciting play, as
well as structured practice of social exchanges that are not
available in a 1:1 setting.
9 Video
Whether it is for self-reflection, team communication or
training other professionals, video is a confronting but
extremely powerful resource in any therapeutic setting. We
use handycams and security surveillance cameras to record
our intervention regularly. Video is also useful in detailed
assessment of motor speech, as required in PROMPT
therapy.
10 Toys
Our children love new, exciting toys and our store
cupboards are overflowing with dolls, blocks, bubbles,
Correspondence to:
Katherine Pye
Speech Pathologist
Vic ASELCC, La Trobe University
e-mail: k.pye@latrobe.edu.au
website: http://www.latrobe.edu.au/child/services/aselcc

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Reference
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Disclaimer
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Association makes no warranty or
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Articles should not usually exceed 3500 words (including tables and
references). This is equivalent to approximately 11 double-spaced
pages. Longer articles may be accepted, at the discretion of the
editors. For further information go to
http://www.speechpathologyaustralia.org.au
Format
The article should be submitted electronically via email (as an
attachment). One hard copy and a copy on disk (pre ferably in
Microsoft Word) is required if the article contains symbols (e.g.,
phonetic font).
The title page should contain the title of the article, the author’s
name, profession, employer, contact phone number, and
correspondence address, as well as a maximum of five key words
or phrases for indexing. Please provide brief biographical details
(up to 15 words) for all authors.
The format must be double spaced with 2.5 cm margins, in a
serif face (such as Times or Courier), each page numbered
sequentially.
CDs must be clearly marked with file name, author’s name and
program used, including version number and whether PC or
Macintosh (e.g., MS Word 2007). Each table or figure must be in a
separate file on the disk. Do not incorporate figures or tables within
the text of the article. Formatting must be kept to a minimum. Do
not use tabs, bold, or other highlighting of the text. References
must appear at the end of the article. The first line of each
paragraph should be indented. Do not right justify the text. Use one
space after punctuation, including full stops. Double quotes should
be used.
Peer review
Articles submitted to JCPSLP generally undergo a double-blind
peer-review process. The article will be sent to two expert
reviewers. The authors will be provided with information from the
review process and will be invited to revise and resubmit their work
if this is indicated. The sentence “This article has been peer-
reviewed” will appear after the title for all peer-reviewed articles.
Style
Clear and concise writing is best. Use short sentences and
paragraphs and plain English.
Reproduce any quotations exactly as they appear in the original
and provide the page number(s) for the pages you have quoted
from.
References, which should be kept to a minimum, should follow
the American Psychological Association (APA 6th ed.) style.
The title should be kept as short as possible (maximum 80
characters).
Headings should be short. Within the article a maximum of two
levels of headings should be used. For first level headings use all
capitals, centred with one line space above and one line space
below. For second level headings use a capital letter for the first
letter of the first word only, centred with one line space above and
one line space below.
Tables and figures
If there are to be tables or figures within your article, these should
be in separate files with a clear indication of where they are to
appear in the article. All tables and figures should be numbered.
Figures should be presented as camera-ready art. Do not
incorporate tables or figures within the text of the article. Digital
images should be sent as uncompressed TIF or EPS files.
Abstract
Please include an abstract of approximately 100 words describing
your article.
Photograph
Please include a clear photograph of yourself. This can be a casual
or formal shot. A good quality print or slide is acceptable. These should
be labelled with your name on a sticky label on the back. To avoid
impressions damaging the back of the photo, write on the label
before it is attached to the photo. Digital photos should be JPEG
files (>120kb).
Article submission form
If your article is accepted for publication, it will only be published if
the “Article Submission Form” and “Copy right Warranty and
Assignment” are completed and signed (please contact National
Office for these forms) or go to
http://www.speechpathologyaustralia.org.au/publications/
jcpslp
Send articles marked Attention JCPSLP Editor to:
Speech Pathology Australia
Level 2 / 11–19 Bank Place
Melbourne, Victoria 3000
pubs@speechpathologyaustralia.org.au
Alternatively, send articles to Editor:
David Trembath – jcpslp@speechpathologyaustralia.org.au
The Journal of Clinical Practice in Speech-Language Pathology
(JCPSLP) is a major publication of Speech Pathology Australia and
provides a professional forum for members of the Association.
Material may include articles on research, specific professional topics
and issues of value to the practising clinician, comments and
reports from the President and others, general information on
trends and developments, letters to the Editor, and information on
resources. Each issue of JCPSLP aims to contain a range of material
that appeals to a broad membership base.
JCPSLP is published three times each year, in March, July, and
November.
Issue Copy deadline Copy deadline Theme*
(peer review) (non-peer
review)
Number 2, 1 December 9 February 2015 Aged Care
2015 2014
Number 3, 13 April 2015 29 June 2015 TBA
2015
Number 1, 1 August 2015 14 October 2015 TBA
2016
* articles on other topics are also welcome
ACER Product Update
ACER offers an extensive range
of specialist resources for both
teachers and speech pathologists
ACER and Sounds for Literacy present the
Cued Articulation App
Consonants and Vowels
by Jane Passy, Helen Botham & John Botham
Australian Council for Educational Research
Cued Articulation
iPad App
Key features:
• Addition to the popular Cued
Articulation series
• Interactive consonant, vowel and
diphthong tables
• Videos and audios of each sound
and gesture
• Examples of each sound within
everyday words
https://itunes.apple.com/AU/app/
id873057924?mt=8
School Entry
Alphabetic and
Phonological
Awareness
Readiness Test
(SEAPART)
Key features:
• Measures pre-literacy skills at the
point of school entry
• Precursor to the popular SPAT-R
assessment
• Takes less than fi fteen minutes to
administer and score
• USB includes PDFs, presentation and
video demo
https://shop.acer.edu.au/acer-shop/
product/990SRT
Astronaut Invented Spelling Test-2
(AIST-2)
Key features:
• Measures phonemic awareness via
spelling attempts
• Provides information about emerging
orthographic awareness
• Can be given to whole classes or
individuals in ten minutes
• By the creator of SPAT-R and SEAPART
https://shop.acer.edu.au/acer-shop/
product/990AIS

Journal of Clinical Practice in
Speech-Language Pathology
Volume 13, Number 1 2011
Research
Print Post Approved PP352524/00383 ISSN 2200-0259
In this issue:
Understanding ethnography
The value of honours graduates
Participatory research
Implementation of ePortfolios
Why SLPs don’t engage in telehealth
Clinical research: A meeting of minds
Journal of Clinical Practice in
Speech-Language Pathology
Volume 16, Number 3 2014
JOURNAL OF CLINICAL PRACTICE IN SPEECH-LANGUAGE PATHOLOGY
Volume 16, Number 3 2014