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Maria Fernanda Lara-Diaz,
National University of Colombia, Colombia
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Peter T. Cahill
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PUBLISHED 19 January 2024
CITATION
Cahill PT, Ng S, Turkstra LS, Ferro MA and
Campbell WN (2024) Exploring the valued
outcomes of school-based speech-language
therapy services: a sequential iterative design.
Front. Rehabil. Sci. 5:1290800.
doi: 10.3389/fresc.2024.1290800
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which does not comply with these terms.
Exploring the valued outcomes of
school-based speech-language
therapy services: a sequential
iterative design
Peter T. Cahill1*, Stella Ng2,3, Lyn S. Turkstra1, Mark A. Ferro4,5
and Wenonah N. Campbell1,5
1
School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada,
2
Department of
Speech-Language Pathology, University of Toronto, Toronto, ON, Canada,
3
Centre for
Interprofessional Education, University of Toronto, Toronto, ON, Canada,
4
School of Public Health
Sciences, University of Waterloo, Waterloo, ON, Canada,
5
CanChild Centre for Childhood Disability
Research, Hamilton, ON, Canada
Background: Achieving outcomes that community members value is essential to
high-quality, family-centred care. These valued outcomes should inform the
production and interpretation of research evidence. To date, outcomes
included in studies of service delivery models for speech-language services in
schools have been narrowly defined, and do not match the outcomes
suggested as important by families, teachers, and children. The most
important outcomes of school-based, speech-languages services have not
been directly and systematically investigated. We aimed to address this gap by
asking school community members what outcomes were most relevant to
evaluating and improving the delivery of speech-language services in schools.
Methods: A sequential, iterative mixed-method study was conducted using
interviews with 14 family members, educators, and speech-language therapists
that asked what outcomes or impacts of school-based services they
considered most important or valuable. Summative content analysis was used
to analyse the data. Structural topic modelling between rounds of qualitative
analysis was used to describe both the quality and the quantity of the
interview content. School community members’perspectives were compared
through estimation of topic proportions within interviews from each member
group and through qualitative comparison.
Results: Structural topic modelling diagnostics and qualitative interpretation of
topic output suggested a six-topic solution. This solution was estimated
successfully and yielded the following topics: (1) meeting all needs
appropriately, (2) teamwork and collaboration, (3) building capacities, (4)
supporting individual student needs in context, (5) coordinating care, and
finally (6) supporting core educational goals. Families focused on school-
based services meeting all needs appropriately and coordinating care, while
educators highlighted supporting individual student needs in context. By
contrast, speech-language therapists emphasized building capacities and
supporting core educational goals. All school community members agreed
that current assessment tools and outcome measures were inadequate to
capture the most important impacts of school-based services.
Abbreviations
S-LP, speech-language pathologist; S-LPs, speech-language pathologists; SLT, speech-language therapy; S-LT,
speech-language therapist; S-LTs, speech-language therapists; STM, structural topic modeling.
TYPE Original Research
PUBLISHED 19 January 2024
|
DOI 10.3389/fresc.2024.1290800
Frontiers in Rehabilitation Sciences 01 frontiersin.org
Conclusions: Outcomes identified by school community members as important
or valuable were broad, and included individual student outcomes, interpersonal
outcomes, and systems-level outcomes. Although these outcomes were
discussed by all member groups, each group focused on different outcomes in
the interviews, suggesting differences in the prioritization of outcomes. We
recommend building consensus regarding the most important outcomes for
school-based speech-language services, as well as the prioritization of
outcomes for measure development.
KEYWORDS
outcomes, speech-language therapy, speech-language pathology, service delivery model,
content analysis, mixed methods, structural topic modelling
1 Introduction
Healthcare providers can improve family-centered care for
children if they carefully and thoughtfully track and interpret
meaningful outcomes (1–3). These outcomes include the results
of care, the experiences that families have with their care and
their satisfaction with the same, as well as the reduction or
elimination of adverse events (3). A fundamental principal of
family-centred care is the collaborative identification of desired
service outcomes (4). Although clinicians offer important
perspectives and knowledge, research indicates that there are
important differences in values between practitioners and
patients (5–7), with each contributing to shared, evidence-based
decision making (8). Therefore, it is important to select core
outcomes used to evaluate and improve health care through
dialogue among all relevant parties.
Within paediatric speech language therapy (SLT), systematic
reviews have highlighted important gaps in documented
outcomes, including a paucity of participation-level outcomes
(9,10), as well as a lack of long-term outcomes and measures
regarding family experiences with SLT services (10). Findings
from qualitative research offer guidance regarding the kinds of
outcomes that children and families might value. For example,
Markham and colleagues (11) interviewed school-aged children
with diverse speech, language, and communication needs
regarding their quality of life. Qualitative analysis of these data
suggested that children wanted positive social relationships, a
sense of inclusion with family and peers, and a feeling of
achievement and independence (11). Participants stated that they
wanted to avoid being bullied, as well as feeling isolated or
excluded (11). Lyons and Roulstone (12) also interviewed school-
age children, this time with primary speech and language
impairments, regarding their experiences in schools. These
participants expressed their agency and independence, wanting to
be recognized and included in their school environments, and
resisted attempts of labelling, removal from the classroom, and
separation from their peers (12). Similarly, these children
identified difficulties with social relationships and challenges with
academics as threats to their wellbeing, whereas agency and
positive social relationships were supportive and protective of
their health and happiness (13). Focus groups with parents from
underserved areas of England (including parents of children
receiving school-based services) also provided several suggestions
regarding the improvement of services, including reduced wait
times and increased time dedicated to clinician-family
communication and rapport-building (14). Ethnographic research
in schools has also suggested that parents want greater
communication and care coordination to support their children
with disabilities, including between health professionals working
in schools and their children’s educators (15). In summary,
qualitative research suggests that children and families focus more
on broader outcomes such as inclusion, wellbeing, and service
quality than they do on children’s specific skills and abilities.
Although these studies all provide windows into the
perspectives of school-age children with communication
disorders and their parents, few studies have explicitly and
systematically asked multiple members of school communities
about what they view as the desired outcomes of school-based
SLT services (16). An exception is work by Gallagher and
colleagues (17) that explored meaningful outcomes for children
with developmental language disorder through focus groups with
educators, parents, and clinicians and interviews with children.
Using the qualitative data that emerged from the participation
interactions in the focus groups, these researchers found that
participants endorsed valuing the same broad outcomes,
particularly academic and social participation, as well as self-
management and advocacy (17). Nevertheless, there were
important nuances among participant groups in how these broad
outcomes were interpreted. For example, educators
conceptualized academic participation primarily as the ability of
children with developmental language disorder to participate in
classroom activities and respond to teacher questions (17).
Similarly, speech-language therapists (S-LTs) emphasized
building the ability of children to identify when they were
struggling with classroom language, and to know when to
request assistance from teachers (17). By contrast, children
emphasized being able to contribute meaningfully to classroom
discussions and peer interactions, as well as navigating ethical
dilemmas and complex social challenges with peers (17).
A clear opportunity remains to directly and systematically
bring together diverse perspectives to identify the most valued
outcomes of school-based SLT services. Although the work by
Gallagher and colleagues (17) is a valuable contribution that
directly addressed this issue, their findings were focused on
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children with a specific diagnostic label. In contrast, we wished to
expand upon this previous work by exploring desired outcomes of
school-based services for any child receiving or benefiting from
SLT services in schools, including children without diagnostic
labels. Additionally, we wanted to explore in greater detail
desired outcomes within contemporary service approaches, such
as tiered models that offer services across a continuum from
universal, whole class to highly individualized (18). Prior
research indicates that relevant outcomes in tiered service models
may include student-, parent-, educator-, and systems-level
outcomes, such as earlier identification of student needs,
increased student participation in the classroom, expanded
parent and educator capacities, fewer formal diagnoses, and
reduced long-term burden of disabilities on the school
community (19,20). Interviews with S-LTs working in schools
have confirmed that outcomes at these levels are relevant to
practice and remain an area for professional growth (18).
Consequently, it is timely to consider what outcomes of school-
based SLT services are valued by members of school
communities. Qualitative data provides a particular opportunity
to explore the most valued outcomes of care, pivoting away from
set questionnaires and ideas previously established in the
literature, allowing instead participants with close knowledge of
SLT services to describe their perspectives in their own words.
Our research questions were as follows:
1. What outcomes are identified as valued or meaningful to family
members, educators, and clinicians involved in school-based,
SLT services?
2. What differences in these community members’perspectives
are reflected in the quality or quantity of their discussion of
these outcomes?
2 Methods
In the present study, we explore meaningful outcomes for
school-based services through a mixed-methods summative
content analysis using interview data. Summative content analysis
makes use of both qualitative and quantitative aspects of textual
data to explore the usage and meaning of participants’words
(21). This approach is consistent with mixed methods
assumptions that reject a strict duality between qualitative and
quantitative data, and instead posit that data can be either
qualitative or quantitative depending on how the researcher
approaches the data (22). In this study, we represented the data
both quantitatively (the frequency and co-occurrence of words),
as well as qualitatively (interpretation of meaning via close
reading by the researcher). We used a sequential iterative design
(22), allowing the qualitative and quantitative analyses to
mutually inform and develop the results.
2.1 Ethics
Study methods followed ethical guidelines and regulations. All
materials and procedures for this study were reviewed by the
Hamilton Integrated Regional Ethics Board (Project number
#13906) affiliated with McMaster University, as well as the ethics
committees of all participating school boards. All participants
provided informed consent prior to initiating any study activities.
2.2 Sampling strategy
We used purposeful sampling (23), initially identifying
interested and motivated S-LTs who would likely have rich
perspectives on the research topic. Subsequently, we used
snowball sampling (24), asking recruited participants to identify
educators likely to have relevant knowledge and perspectives. This
combined sampling approach has been recommended when
attempting to elicit perspectives on a complex topic from the
perspective of multiple member groups (25,26). To recruit
parents and caregivers, we reached out through known channels,
harnessing the networks of research and clinical colleagues based
at McMaster University’s CanChild Centre for Childhood
Disability Research. We used the concept of information power
(27) to inform the final sample size, using our prior knowledge to
set an a priori sample size and revising the same based on the
variability of data collected. In this case, we originally planned on
interviewing 20 participants; however, we reduced this number as
the interviews rapidly reinforced the ideas from previous
interviews as well as from prior work in this area [see (18)].
2.3 Participants
We recruited participants belonging to three school
community member groups who we anticipated would have an
interest in outcomes for school-based SLT services: families of
children receiving these services (n= 4), S-LTs (n= 5), and
educators (n= 5). All participants were connected to school
boards (a term for a local educational authority) in Ontario,
Canada, with the professionals employed directly by the school
boards rather than by third party health agencies.
2.4 Materials and procedures
Interviews followed a semi-structured format. A common
prompt was used to open every session, with prompts prepared
for contingent response to the discussion. These prompts were
used to follow up on ideas brought up by participants in
response to the initial common prompt. Prompts were developed
based on previous literature regarding outcomes for SLT services
in schools (19) and school-based tiered services (20). See
Additional file 1 for a copy of the interview guide. One pair of S-
LTs preferred to be interviewed together, and so a simultaneous
interview was conducted for these participants.
All sessions were conducted using videoconferencing software
and were recorded with automated transcripts. Following each,
the first author listened to the recording three times and
corrected the transcripts. The transcripts were simultaneously de-
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identified with all names and other identifying references removed
and replaced with non-identifiable placeholders. Corrected and de-
identified transcripts were then uploaded to relevant data analysis
software (see next section).
Finally, we used qualitative surveys subsequent to the
interviews to collect additional data. These surveys provided an
opportunity to further develop and expand on ideas explored in
the original qualitative data collection (28). A link to these
surveys was sent out to participants approximately one week
following the interviews and all data was collected using Research
Electronic Data Capture [REDCap: (29)].
2.5 Data analysis
2.5.1 Data familiarization
We performed a summative content analysis (21) using data
from the interviews. The analysis occurred in three steps. In the
first step, the first author read all transcripts in their entirety to
make sense of the data as a whole (30). Memo writing was used
at this stage, recording initial questions and impressions of the
data, and these initial impressions were discussed within peer
debriefing between the first and last authors.
2.5.2 Structural topic modeling
In the second stage, a quantitative analysis was performed. We
used a topic modelling approach embedded within this summative
content analysis, as computer-aided content categorization and
counting is consistent with the paradigmatic assumptions of
summative content analysis (31). All data were uploaded to R
(32) software. Subsequently, structural topic modeling [STM; (33,
34)] was performed using the stm package (35). STM is a multi-
class membership machine learning algorithm used to analyze
textual data and their metadata (36). This algorithm searches
through text calculating the frequency and co-occurrence of
words to identify latent topics that are present in the data set
(36), and to identify the terms most likely to belong to each topic.
2.5.2.1 Data cleaning
We first cleaned the data for analysis. This process removes words
and morphemes that provide little content information (37), such
as articles (e.g., “the,”“a”) and most inflectional and some
derivational morphology (e.g., “assessments”is reduced to
“assess-”with “-ment-”and “-s”removed). This approach
reduces the number of comparisons required by the algorithm
and avoids cluttering the results with function words that
provide little semantic information (37). To do so, we used the
built-in lists with the stm package, and added additional
conversational words, as the built-in lists were developed for use
with formal written texts, as well as words unique to specific
participants contexts (e.g., terms only used by their local
educational authority).
2.5.2.2 Model selection
We then applied STM to the data and used our understanding of
the data from the original qualitative exploration of the data, as
well as relevant previous literature, to interpret topics and inform
the final selection of the number of topics to be retained in the
model. We used goodness of fit statistics to guide the range of
ideal topic numbers; however, we retained the primacy of the
qualitative interpretation to select the final algorithm solution.
We focused on the fit statistics of semantic coherence and
exclusivity. These fit statistics are compared in relative terms to
other topic number solutions for the same data set, rather than
by reference to absolute cut-offs or reference values. Semantic
coherence provides an estimate of how frequently words within
the topic co-occur (35,36), and is strongly associated with
human judgement of topic coherence (38). Exclusivity opposes
semantic coherence, and prefers topics structures where words
are not shared among multiple topics (35,36). Better fitting
models can be identified through model solutions that optimize
the values of these two opposing fit statistics (35,36). The topics
were then named based on qualitative interpretation of the top
terms within each topic.
2.5.2.3 Use of metadata
An advantage of STM for this project is that it does not suppose
independence of the data and the data generating mechanism
(36,39). Consequently, the method allows a description of the
differences in topic proportions across documents (36,37). We
postulated that different school community members may discuss
different topics. This metadata would allow exploration of topic
distribution among member groups. For each topic, we estimated
the topic proportion differences across member groups to
compare the quantity of data dedicated to each outcome.
2.5.3 Qualitative interpretation and categorization
In the third step, topics from the final STM model were
interpreted qualitatively by the research team using notes and
memos from step 1 to help interpret the topics. The first author
named the topics drawing on both the results of the quantitative
model and qualitative familiarity with the data. The first author
then reviewed the transcripts again with the topic solution in
mind and selected emblematic quotes for each topic that
illustrated the meaning and nuance of community members’
discussion of each outcome topic. Finally, the quality and
quantity of the data were interpreted in light of both quantitative
and qualitative results, as well as previous literature in this
research domain. Peer debriefing between the first and last
author was used throughout this step.
2.6 Legitimizing inferences
In mixed methods studies, researchers must develop and
bolster high quality inferences (40). Inferences are the
conclusions and interpretations of the research results (40).
Achieving high quality inferences is a process that occurs
throughout the entire research process, and is central to rigorous
mixed methods research design (40,41). This process has been
referred to as legitimation (41), and can be considered analogous
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to validity and creditability in quantitative and qualitative
paradigms, respectively (40).
To legitimize our inferences, we used several strategies. In
keeping with recommendations for content analysis (30), we used
peer debriefing regularly throughout the project, including
between each phase of the analysis. This was necessary to explore
perceptions and interpretations of the data up to that point,
allowing the analysis to benefit and develop from multiple
perspectives throughout the analytic process. Memo writing also
was used regularly to document and enhance the analysis.
Critical to this analysis, we used data analysis triangulation, using
both qualitative and quantitative analysis techniques to generate
and mutually inform the results. We used this data analysis
triangulation as a form of weakness minimization (41), relying
on qualitative reading and coding of the data to bolster
inferences about the quality of the content, while using STM to
bolster inferences about the relative quantity of topics and their
distribution across the data set. Finally, we used both a close,
human reading of topic content supplemented by a machine
reading of topic quantity to make inferences from our text data
(39). This approach maximized the amount of information
available to the research team when generating inferences from
the data.
3 Results
3.1 Step 1. Data familiarization
Initial qualitative impressions indicated that participants
frequently focused on processes related to key outcomes (e.g., I
must collaborate with the teacher in order to achieve student
progress). Additionally, all participants appeared to generally
agree that all outcomes were important, although the
prioritization of each outcome may have differed among the
member groups, as families particularly appeared to focus more
on access to services and the provision of all appropriate services
to students, whereas S-LTs and teachers focused more on
collaboration and implementation in the classroom. Participants
also appeared to discuss student-level, interpersonal, and
systems-level outcomes as important and interrelated.
3.2 Step 2. Structural topic modeling
We fit topic models to the transcript data. Only three follow
up surveys were completed with very brief responses that
reiterated discussion points in the interviews. As topic
modelling can perform poorly on short text excerpts (42), we
choose to exclude this data from the analysis. We started with a
five-topic solution and proceeding until a 20-topic solution and
then evaluated diagnostics, focusing on estimates of semantic
coherence and exclusivity for each model. See Figure 1 for a
visual diagram of the diagnostic results. A good topic solution
should optimally maximize both exclusivity and semantic
coherence, which are in tension with each other. Potential topic
solutions can be identified by point values relatively closer to
the top left corner of the figure. (To illustrate, in the included
figure a seven-topic model unequivocally outperforms a five-
topic model.) The diagnostic results suggested four potential
solutions (6, 7, 10, and 14 topics) as outperforming the
remainder. We estimated each of these topic-number models
and analysed the resulting topics qualitatively and eliminated
the 10 and 14 topic solutions for poor interpretability. We
compared the six- and seven-topic solutions more fulsomely,
and eventually eliminated the seven-topic solution in favour of
FIGURE 1
Semantic coherence and exclusivity per topic model.
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the more qualitatively meaningful six-topic model. Consequently,
we proceeded with the six-topic solution.
The highest probability terms for each of the six topics are
listed in Table 1, using four metrics for topic membership.
According to the model, these words have the highest probability
of belonging to the topic when they appear within the text.
Additional information on the nature and calculation of each is
beyond the scope of this manuscript and we refer readers to the
technical literature [see (36)]. To summarize, Highest refers to
the words with the highest probability of belonging to the topic
(43). FREX and Lift reduce the probability for words that are
shared amongst multiple topics, identifying the words with
greater exclusivity to the topic (43). Score adjusts for overall
word frequency, pinpointing less commonly used terms (43). We
include all metrics here for thoroughness and transparency.
We then estimated the prevalence of each topic within text
from each participant group. As this work is situated within the
disciplinary perspective of speech and language therapy, we used
the S-LTs as the reference group for comparison. In this way, we
would be able to identify topics that teachers and families
discussed significantly more or less when compared to S-LTs,
suggesting potential divergences in group members’perspectives.
Figures 2,3present the point estimates and 95% confidence
intervals for topic proportions across participant groups. In both
cases, positive values indicate that S-LTs discussed the topic
more, whereas negative values indicate that the comparison
group (educators and families) discussed the topic more. Zero
(indicated in the figures with the dotted vertical line) signals that
the data are consistent with no differences in topic proportions
between groups. Compared to teachers, S-LTs discussed topic 3
more and topic 4 less. S-LTs may have also dedicated more
attention to topic 6, although the data are also consistent with
no difference. Topics 1, 2, and 5 did not vary in proportions
between S-LTs and teachers.
Compared to families, S-LTs discussed topics 3 and 6
more,and1and5less.Thedatawereconsistentwithno
differences in prevalence for topics 2 and 4. Specificvaluesfor
coefficients, standard errors, t-andp-values can be found in
the Additional file 2.
3.3 Step 3. Qualitative interpretation and
categorization
After completing data familiarization and structural topic
modelling, we then qualitatively interpreted both previous steps.
Greater detail regarding the quality of what was said relevant to
each topic is provided below, along with emblematic quotes.
3.4 Topic 1—appropriately meeting all
needs
The content within the topic focused on meeting all needs
within the school. Family members discussed this topic more
than S-LTs and indicated that sufficient supports were not
available within the school system to adequately need the needs
of all students. For example, one parent stated:
TABLE 1 Associated words per topic for six-topic model.
Topic number Words with highest probability of belonging to topic Initial interpretation by data analyst
1 Highest: need, servic, disabl, child, privat, peopl, involv Appropriately meeting all needs
FREX: disabl, privat, public, therapi, etc, evalu, spectrum
Lift: cost, defin, embodi, govern, harm, ignor, injustic
Score: disabl, etc, evalu, harm, injustic, righteous, midst
2 Highest: feel, week, languag, teacher, communic, team, need Teamwork, collaboration, and partnership within the school
FREX: week, feel, part, sens, team, target, growth
Lift: partner, valuabl, accomplish, faster, husband, incorpor, most
Score: accomplish, week, incorpor, member, real, partner, connect
3 Highest: tier, student, teacher, educ, program, strategi, classroom Developing capacities within the classroom
FREX: tier, strategi, referr, feedback, may, two, play
Lift: check-in, guest, essenti, grammat, potenti, prior, specialti
Score: tier, narrat, feedback, student, indic, strategi, potenti
4 Highest: student, languag, speech, need, classroom, servic, back Supporting individual student needs within the classroom
FREX: languag, pathologist, back, slps, speech, student, build
Lift: graduat, path, pronoun, advic, anxieti, bodi, built
Score: student, stutter, languag, impact, intervent, cdas, confid
5 Highest: communic, child, slp, speech, need, support, children Coordinating services and supports for children with
greater needs
FREX: child, devic, train, name, attend, region, slp
Lift: anxious, design, dress, fact, fulli, googl, offici
Score: child, arrang, statist, pec, surpris, devic, except
6 Highest: teacher, student, read, impact, want, decod, support Supporting core educational skills and goals
FREX: decod, phonem, read, level, term, awar, instruct
Lift: equip, instanc, product, advanc, bang, buck, checklist
Score: decod, phonem, impact, benchmark, reader, instruct, three
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FIGURE 3
S-LT topic proportion differences compared to families with point estimates and 95% confidence intervals.
FIGURE 2
S-LT topic proportion differences compared to teachers with point estimates and 95% confidence intervals.
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“When you have these two people servicing a few individuals
who need it, it shows you need so much more in order to
service all these other kids that really do not need as much
care and attention…But right now, it seems like it’sjust,
this is what we are picking [the children receiving intensive
services]. This is what all we have and that’swhogetsitand
that’sit.So,whatabouteverybodyelse?”Family member 7
Family members indicated that those families who could
frequently turned to private speech-language services outside of
the schools to meet the needs of their children, while recognizing
that this was problematic and inequitable to many families. One
family member reported frustration with consistently needing to
access resources outside of the school, and the negative impacts
the family was suffering as a result.
“I had to go through other side channels and try to get either
information or like any kind of like, you know, to push things
forward. Like I said, even [child’s name] being transferred to
a completely different platform, educational platform, has
never been offered to me, or presented as an option to me by
the school…She will be starting grade one, and she’s not
going to be on the educational plan for grade one, which is a
complete disaster.”Family member 3
S-LTs and educators also expressed concern regarding meeting
all needs within the school and noted the substantial staffing and
resource challenges within their workplaces, albeit less frequently
and forcefully compared to the family members. One S-LT
suggested that there was great uncertainty in how to best allocate
resources to meet needs, and that this was a major barrier to
offering impactful services in schools.
“I think that having more information about the things that are
impactful would be beneficial in terms of prioritizing the
caseload and managing the caseload. Absolutely. You know,
there, there are times when you spend a lot of time with it
with a student, and the educators, and the assistants, and the
parents, but in the end, you really do not know the impact
that you are having. You just feel that well this is what I
should be doing this is how I think it would help.”S-LT 13
3.5 Topic 2—teamwork, collaboration, and
partnership within the school
The content of this topic focused on the importance of
teamwork, collaboration, and partnership within the school. All
participants discussed this topic at length. S-LTs and educators
frequently emphasized the critical role that collaboration held
within school-based practice. For example, one teacher stated:
“That is the most integral part of educating the student. And so,
when we are just with me and my educational partners
my teaching partners, it is the co-teaching, co-assessing.
But then, with all of our outside support services like S-LP
[S-LT], and the community services. You have to have the
mindset that nobody knows more than the other but that it
is like a symbiotic relationship where I am going to learn
from you, and you are going to learn from me. And we kind
of have that time and space to work together. It has been
impactful and in my experience. I have always been open to
anybody who is going to help me bring my students
forward.”Educator 1
Family members discussed wanting to be more involved with
the school team, and for more open and consistent
communication with the S-LTs and educators. A desire for a
more proactive and engaging approach from the school was also
reported by family members. For example, one participant stated
the following.
“It should not be me to be the expert. Even though I am not, I
felt like I became one. It is supposed to be them who will be
teaching and guiding me instead of me trying to figure out
how to arrange a training for certain number of people, so
that they will know how to support my child’s needs while
she is there, and I told them that I really want us to work as
a team. I do not want the burden to be on you only but at
the same time you have to do something from your side.”
Family member 3
3.6 Topic 3—developing capacities within
the classroom
The content of this topic was focused on how S-LTs could
support teachers, educational assistants, and other professionals
working in the classroom, building their capacities to support
their students’needs. S-LTs discussed this topic more when
compared to both educators and families and building staff
capacity seemed to be considered a core aspect of achieving
desired outcomes within school-based practice.
“For me it truly feels that when I’m able to educate the teacher
around what they can do in the-every-day. I am only there once
a week, most of the time. So once, once they start implementing
the strategies that I give every single day, they know. They notice
a difference. They notice an impact.”S-LT 5
Building staff capacity included both the skills and knowledge
of teachers and other school personnel, as well as their confidence
and positive attitude towards supporting children with
communication difficulties within the classroom.
“There are many people who feel like, if they have a student, that
they are struggling with. When I say struggling with, I mean
feeling like they are not making a strong effect on and not
being able to teach them and move them along. Then the
feeling is, they want someone else to come in and help them.
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And what we really want to do is we really, really, really want to
provide teachers, educators with the feeling that they have the
skills.”S-LT 12
When family members discussed this topic, they included
everyone within the school as benefiting from capacity and
knowledge development. For example, one parent suggested that
the S-LT spend time in the classroom educating peers about
communication disorders and inclusive practices.
“To me, the important thing is trying to make it inclusive for the
child. So, if the S-LP [S-LT] is going to come into the class, then I
think it would be a great idea for them to say hey guys you know
I am the speech therapist. And this is to the whole class not to
my child only, to say I am a speech therapist and there is
some children who sometimes have difficulty with language,
with communication, with all these different things, and I am
here to help. And these are some of the things that we can
do.”Family member 9
3.7 Topic 4—meeting specific student needs
within the classroom
The content of the fourth topic focused on how to support
specific students within the classroom. Educators discussed the
topic more than did S-LTs. Teachers emphasized the need for
supports, strategies, and suggestions to make sense within the
educational context. One educator emphasized how having
school-based S-LTs as opposed to external professionals helped
ensure impactful recommendations to support children within
their educational context.
“And I think by having speech and language in the buildings, it is
helping to close that gap significantly. Because especially with
special education, a lot of times we have outside providers that
will come in, and in the past this has been speech and language,
that will make recommendations and say, you know what you
can just do this, and you can do this, and you can do this, which
is all great in theory and in a supervised setting or a one-on-one
setting or a nice, quiet environment, it is ideal. But when you
bring that into the regular chaos of the classroom, and all the
other needs that are in there, it is not always applicable. And I
think by having speech and language in the building, they are
seeing now more what is happening in the classroom
environment, and then they are adapting the programming and
the services to meet to better meet those needs. And I think that
has helped immensely as well.”Educator 10
Educators also reported an appreciation for the speciality skills
brought into the classroom by S-LTs, and how these skills could be
leveraged into specific daily practices.
“They [S-LTs] are often the ones that are able to pinpoint the
specific need that a child has. So, when I’m working with a
student and I know that there is gaps in their language, or
their speech, I might be able to take a guess at what areas
they need to develop…But because I do not have that trained
ear that you guys have when you are doing an assessment, I
am really just guessing. I am guessing at what sounds are
missing. And oftentimes the speech language pathologist [S-
LT], they will come back, and they will be very specific and
say, oh, you know what, in language, it is actually their word
retrieval, or it is their sounds that they make with “tr”or
something that. So, they are very specific. And then when they
work with the children, they are able to give me specificways
that I can help the child improve with their language and
their speech on a daily basis.”Educator 11
3.8 Topic 5—coordinating services and
supports for children with greater needs
The content of this topic concentrated on care coordination to
support individual student needs and was a major focus for family
members. Families expressed a strong preference for care
coordination within schools and reported negative feelings about
the effort required to advocate for care coordination for their
children. For example, one parent stated:
“I am expecting that that support and that implementation will
be in place before even I reach out. Not once I put foot in that
school and then, they are going to start to search. Okay, whom
do we need? Like you cannot gather a team or try to figure out,
okay, what do we need to support this child? So, you should have
some sort of a process and people in place already available so
that a child like mine comes in, they will know what to do
from day one.”Family member 6
S-LTs being responsive to children’s holistic needs also was
mentioned frequently. Educators noted that S-LTs were frequently
the point of entry for other referrals, such as to formal assessment
for social communication challenges. Parents reported valuing S-
LTs proactively coordinating or initiating interprofessional
collaboration to support the child as a whole person.
“And then the other thing is just having that view of the child
that I am going to look at a child was a whole person. And
okay I am supposed to focus on his speech, but is there
anything else that might be hindering him from being
successful? So, if you know if you can see that my child you
know cannot regulate himself or their sensory needs, you
know, then you know to me the S-LP [S-LT] then should
within their school team say, you know what, in my, in my
sessions I am finding that you know he cannot really
concentrate. He sort of looks like he needs to have a lot of
movement. Or I see that he is struggling a lot with fine motor.
So can we refer him for OT [occupational therapy] services,
you know, so to me that is looking at the whole child or, you
know, her saying, you know mom is coming to me and saying,
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you know, he cannot even toilet himself. So do we have supports
in place for that?”Family member 9
Compared to family members, educators reported most
positively about care coordination within schools and
emphasized how S-LTs had impacted the ability of the system to
respond rapidly to referrals. Teachers also emphasized that this
care coordination is effective when conducted within the school,
and that they would not expect the same outcomes from S-LTs
sent from external agencies.
“Really the biggest change for any support for any kid anywhere
is waitlist. I think we do a pretty good job in our [school] board
though with, like, I have to say our speech and language team
has been right on top of everything this year and getting in
and assessing kids. We are able to start to put programming
in place pretty quickly. Outside supports, there is, you know, if
we have to send a kid to school-based support [provided by an
external agency], then that is like a yearlong waitlist and then
they only come in a few times, maybe 10 times a year, to see
the student.”Educator 6
3.9 Topic 6—supporting core educational
skills and goals
The content of the final topic focused on how S-LTs could
support core educational skills and goals, with a particular focus
on literacy instruction. S-LTs discussed how they felt that they
could support teachers in evidence-based practices relevant to
core educational skills, and provide material resources, training,
and other supports to improve educational practices. For
example, one S-LT reported highly valuing this outcome.
“I just really want to have more of an impact in supporting
literacy development within the schools because it is a little bit
disorganized right now within our school system. There is very
inconsistent access to literacy supports from one school to the
next, and I find that that’s where a lot of the educators are
coming to me for support, and we do not have the time to
give as much support as I would like to. So, my biggest impact
that I want to make is continuing to empower and enable
educators to enhance their literacy skills and their literacy
support for students.”S-LT 5
Supporting children’s educational journeys was also reported to
be a core aspect of speech-language practice in schools according to
the S-LTs, and that this aspect of practice was unique to working
within a school-based context. One S-LT highlighted how they
considered students’educational success as the most distal
outcome of services in schools, and how practice must be
oriented towards achieving this success.
“Ultimately, like I said, the goal is having them in the classroom
and supporting them in the classroom. So, in terms of how
successful they are in the classroom that is then, I believe,
kind of an indirect reflection of how successful they are with
those strategies and supports that we have recommended, and
those strategies and supports are then helping them to access
curriculum and to be successful in the classroom, which is our
ultimate goal.”S-LT 4
Educators also discussed the importance of keeping the child in
the classroom accessing core educational activities, and that S-LTs
providing these supports could help educators achieve their desired
educational outcomes more effectively and efficiently.
“Tier one is how the S-LP [S-LT]…is supporting the classroom
teacher. So how are you supporting them so that they can deliver
better material and better lessons and so on. So you are guiding
their practice, as opposed to being the one to kind of directly do
it…they could talk about those strategies about what we do and
why we do it how it is helpful and how those spelling tests you
have done every week, you know, they did have a purpose but
now we can focus on this because we want to get more bang
for our buck. We want to make sure that the time we are
spending on these areas with kids is actually more effective.”
Educator 2
Parents discussed this topic less frequently compared to S-LTs
yet indicated sentiments consistent with the outcomes the S-LTs
reported as valuing, such as maintaining students within an
inclusive classroom with their peers, learning with and from their
classmates. However, family members connected this outcome to
topic 5 (care coordination), rather than the supports to core
educational skills and goals, which was highlighted by S-LTs.
3.10 Overarching issues related to
outcomes
Some participants proffered perspectives on the use of
outcomes in school-based practice. Multiple participants pointed
out inconsistencies or challenges with indicators (specific
measures for an outcome). For example, one educator reported
that what was measurable was not what mattered, and that
important outcomes required qualitative assessment rather than
measurement.
“I need to see you know benefits in their day-to-day life that
maybe are not the most measurable things but are more
important. It is interesting to see like if they are collecting
data in like certain ways. But I do not think everything that is
always the most important thing that we, as teachers, or as
parents, are looking for are always the most measurable
things. They are maybe something that can be reflected on
more anecdotally.”Educator 11
In contrast, a parent reported similar dissatisfaction with
current measurement techniques, yet emphasized the need for a
quantitative approach.
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“We want to see growth, right? But how do we measure that
growth? I think that is key. Like if there was some sort of
assessment, or where it is streamlined, so that everyone is
using it and that information is shared. Like it is hard to see
growth unless it is, I don’t know, numbers based, or if it is
quantitative data, I guess you would say. Data that is actually
real.”Family member 8
S-LTs also reported frustration with their current ability to
assess and make judgements about the outcomes of their
services, and that further work in this area was important for the
development of the profession.
“I guess just in general I mean I think we have a lot of impact in
the schools, but they are just not just really not recognized, I
think. We really do not. There is not a really objective way for
us to know what the impacts are.”S-LT 13
All participant groups reported that the measurement or
qualitative assessment of important outcomes would contribute
to improving school-based services, and there was general
agreement that current measurement techniques are not
sufficiently developed to provide robust, meaningful information
about the impact of practice within schools.
4 Discussion
In this study, we interviewed S-LTs, educators, and family
members about their perceptions of meaningful outcomes for
school-based speech-language therapy services. After initial
qualitative reading of all data, structural topic modelling was
used to identify six latent topics within the interview data, and
the quality of the content within each topic was explored
through further qualitative analysis. The results are broadly
consistent with previous literature, confirming important areas
for further work on outcomes in the discipline. However, they
provide additional nuance and detail.
Consistent with previous literature (18,20,33), the participants
in this study considered multiple outcomes beyond individual
student clinical outcomes to be important, including outcomes
related to partnership and collaboration as well as system-
functioning. Additionally, it was evident that these partnership
and systems outcomes were valued across participant groups,
with S-LTs emphasizing collaboration and capacity building with
the school team for example, and family members discussing the
importance of coordinated care that was responsive to all needs.
Such outcomes have been noted to be infrequently included in
SLT research to date (10), and the implementation of new
outcomes in research and practice remains an important area for
future growth within the profession. These results reinforce calls
from the limited previous literature (18,20,33) on this topic for
research in the profession to expand dramatically beyond its
traditional clinical outcomes, considering a broader scope of
outcomes more consistent with a biopsychosocial approach to
health. Without considering these partnership and collaboration
outcomes, research in the area will be unable to provide
evidence-based guidance to inform the most meaningful
decisions for these important services.
Similar to the work done by Gallagher and colleagues in
Ireland (17), we spoke with family members, educators, and S-
LTs, with similar topics present in our discussions with
participants. For example, the participants in our study also
spoke to the value of children participating meaningfully in the
academic and social life of schools, as well as understanding
how to engage with learning activities and their peers.
Participants also mentioned children implementing new skills to
be more independent and successful in the classroom as an
important outcome. These sentiments all closely reflect the
previous findings (17). Maximizing the time students spend in
the classroom with learning and interacting with their peers
also was endorsed by all participant groups in this study,
reflecting the previously reported desire of children with
communication to remain in inclusive environments and not to
be labelled and separated from their classmates (11–13).
Therefore, an increase in the time the children spend within the
classroom or a reduction in the time spent withdrawing the
student for supports may be an important outcome of service
delivery in schools. Our results also are consistent with previous
work suggesting that proactive communication and care
coordination with families was an important desired outcome of
rehabilitation services in schools (15). Ng et al.’s(15)
ethnographic study was conducted in the same province where
our study was completed, suggesting that care coordination may
be an important outcome in this particular context. Finally, our
results are consistent with the observation by Murphy (34)that
the outcomes valued most by school community members are
not frequently included in research. The outcomes measured in
studies of school-based service delivery to date [see (44,45)]
have been narrowly defined clinical outcomes, such as
standardized test scores and specific trained skill and
generalization probes. These types of outcomes, although
important, do not reflect all relevant aspects of service impact
and care quality. The continued exclusion from research studies
of outcomes that families, educators, and S-LTs deem
meaningful will likely reduce the relevance of the evidence base
for informing practice. Based on previous studies, S-LTs
working in schools have innovated around this limitation in the
research, finding new ways to measure and evaluate the impact
of their services (46), although they report the need for
additional support to continue to develop and innovate. An
expanded and improved research base may be of great utility in
fostering further innovation in practice.
Inconsistent with previous work, we did not observe a
substantive focus on the children’s voice directing or informing
the supports they receive in schools, something which has been
found in other studies (17,47). This is likely because we did not
speak directly with children with disabilities, something that was
a focus of these previous studies (17,47). The content of topic
one was unexpected, as family members discussed the
importance of providing sufficient supports to all children in
schools as a public good, and that families turning to the private
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sector for services was considered an indicator of unsuccessful
service delivery models within schools. It is unclear if this
finding primarily reflects the context in which our research was
conducted. Finally, we note that previous work (18) in this locale
has identified accountability to systems as an outcome that drives
decision-making, where demonstrating to managers, regulatory
bodies, or funders that certain types or frequencies of services are
being provided, or that certain standards are being met are an
important part of determining the outcomes of services in
schools. In that study, we asked experienced clinicians and
clinical managers to describe what outcomes were used in their
schools and local education authorities. In the present study, we
asked multiple groups from school communities about the
outcomes that they valued, and accountability to systems was
present in the data, suggesting that such outcomes, although they
may be required in certain organizational contexts, are not
informative regarding whether S-LT services in schools are truly
achieving valued outcomes.
In summary, this study confirmed that multiple types of
outcomes, including those relevant to individual students,
partnership and collaboration in schools, care coordination, and
capacity building (among others) were considered valuable or
important outcomes by family members, educators, and S-LTs.
These topics were present in the data from all participants,
suggesting that they may all be important outcomes of S-LT
services in schools. However, there were difference among
participants regarding the quantity they discussed each. S-LTs
focused more than the other school community members on
capacity building and supporting core educational skills and
goals; family members focused on meeting the needs of all
students and providing responsive and well-coordinated care;
finally, educators focused on problem solving and strategy
implementation to support individual students. These differences
in emphasis by various members of the school community
should be explored further in future work, and a consensus
exercise to identify the most important core outcomes of SLT
services in schools may prove fruitful.
4.1 Limitations
This study has several limitations. First, although we included
multiple groups from the school community who have a vested
interest in school-based services, we did not include one very
critical member group of this community. We did not speak
directly with children. Although children appear to agree with
their parents, teachers, and S-LTs regarding what outcomes
they value, children also bring a nuanced interpretation of the
same (17). We hope to explore what these outcomes mean to
children who receive such services in future work. Additionally,
we recruited participants only from a narrow geographical area.
This design choice potentially limited the diversity of included
perspectives by excluding those who did not reside within a
specific locale, which may suggest additional outcomes as
relevant to tiered, school-based services beyond those which
we identified.
Further, this study has important theoretical limitations. We
approached the issue of outcomes with the assumption that
quantifying outcomes of services is a meaningful method for
evaluating service quality. In previous work (18), clinicians have
questioned this assumption regarding the primacy of outcome
quantification over rich, narrative information on student and
system functioning. Interestingly, some participants who
contributed to the present study also questioned this approach.
Had we grounded our analysis in other paradigmatic
perspectives, we may have arrived at different results about the
roles of outcomes in health service delivery and evaluation. Such
perspectives may be valuable to promote reflexivity and growth
within the profession of speech-language therapy.
5 Conclusion
In this study, we asked family members, educators, and
clinicians about the most important and valued outcomes of
speech-language therapy services delivered in schools. Structural
topic modelling revealed six broad outcome concepts identified
as important by these stakeholder participants. These outcome
concepts included: meeting the needs of all students; teamwork,
collaboration, and partnerships within the school; building
capacities within the classroom to support student needs;
supporting individual student needs within the classroom;
coordinating services and supports for students with greater
needs; and, finally, supporting core educational skills and goals.
Although all outcome concepts were discussed by all participants,
there were several differences among S-LTs relative to educators
and family members regarding the quantity of data dedicated to
each, suggesting differences in how different members of the
school community valued each outcome concept. The outcomes
identified as important were notably neither those included in
research to date, nor were they considered feasibly measured
with current outcome measures and assessment tools. To further
build from this work, we recommend consensus and
prioritization work to identify the core outcomes for school-
based service delivery and the most urgent outcome measure
development and implementation for school-based services.
Data availability statement
The raw data supporting the conclusions of this article will be
made available by the authors, without undue reservation.
Ethics statement
The studies involving humans were approved by Hamilton
Integrated Research Ethics Board. The studies were conducted in
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accordance with the local legislation and institutional
requirements. The participants provided their written informed
consent to participate in this study.
Author contributions
PC: Conceptualization, Data curation, Formal Analysis,
Methodology, Software, Visualization, Writing –original draft,
Writing –review & editing. SN: Conceptualization, Methodology,
Writing –review & editing. LT: Conceptualization, Writing –
review & editing. MF: Conceptualization, Writing –review &
editing. WC: Conceptualization, Funding acquisition,
Methodology, Resources, Supervision, Validation, Writing –
original draft, Writing –review & editing.
Funding
The author(s) declare financial support was received for the
research, authorship, and/or publication of this article.
This study was supported by funding from the John and
Margaret Lillie Chair in Childhood Disability Research (WC).
Acknowledgments
We thank the participants for generously sharing their time
and experience to inform the results of this study.
Conflict of interest
The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed
or endorsed by the publisher.
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