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Background: Treatment fidelity refers to the degree to which an intervention is implemented as intended. Promoting treatment fidelity is important to achieve a valid comparison in intervention research. However, it is often underreported: few studies detail the use and development of fidelity measures. This study aims to promote the treatment fidelity of a modified version of the Derbyshire Language Scheme (M‐DLS), a manualised intervention for children with language difficulties, by exploring participants' opinions on training and intervention delivery. Results inform development of a checklist and scoring system to monitor and promote treatment fidelity in a comparison trial. Method: Ten student speech and language therapists (SLTs) and two research assistants (RAs) participated in the study. All received training on the M‐DLS, and 10 were video‐recorded completing role‐plays of an M‐DLS session in small groups. Feedback was gathered after training and role‐plays in focus groups and interviews. Feedback was interpreted using the constructs of the Theoretical Domains Framework (TDF). A treatment fidelity checklist was then developed using the feedback. The first author and two RAs rated role‐play videos using the checklist to trial it to inform amendments and to promote interrater reliability. Interrater agreement was calculated using Spearman's test of correlation. Results: Participants discussed the importance of having clear materials and time to practise sessions. They suggested amendments to the materials and training to promote treatment fidelity. The checklist and scoring system accounted for participants' suggestions, with amendments detailed in a log. Spearman's correlation results suggested agreement between the raters was strong. Conclusions: Results emphasise the importance of training quality, practice and reflective opportunities and clear materials to promote treatment fidelity. The construction of the checklist and scoring system was described in detail, informing the development of future checklists. After further trialling, the checklist can be used to ensure the M‐DLS is delivered with high treatment fidelity in the comparison trial. What this paper adds: What is already known on this subject: Treatment fidelity is an essential component of intervention effectiveness and efficacy studies, ensuring the intervention is delivered as intended. It is also an essential component of evidence-based clinical practice. However, few research studies report the treatment fidelity process or publish the checklists used, depriving clinicians of useful information for implementation. What this study adds: This study describes in detail the iterative process of treatment fidelity checklist development, engaging those implementing the intervention in development. This ensured clarity and interrater reliability of the checklist. Furthermore, a novel scoring system was developed so that accuracy of implementation can be easily compared across users and across practice attempts. What are the clinical implications of this work?: The importance of treatment fidelity when implementing effective and efficacious interventions cannot be overstated. The treatment fidelity checklist developed for research can be easily adopted to support accurate implementation in clinical practice through an audit process. [ABSTRACT FROM AUTHOR]

Background: In order to conduct research that is meaningful to speech and language therapy services and their patients, it is often desirable to conduct the research within routine clinical services. This can require considerable time and commitment from speech and language therapists (SLTs). It is therefore important to understand the impact that such participation in research can have. Aims: To explore the impact of research participation in the Big CACTUS study of self‐managed computerized aphasia therapy conducted in 21 UK NHS speech and language therapy departments. Methods & Procedures: An online survey was sent to SLTs who took the lead role for the study at their NHS Trust to evaluate the impact of study participation in three domains: capacity‐building, research development and health services. The questionnaire, based on the VICTOR framework for evaluating research impact, included Likert scale statements and closed and open‐ended questions. The results from open‐ended questions were coded and analysed using framework analysis in NVivo 12 and the data from closed questions were analysed descriptively. Outcomes & Results: A total of 12 SLTs returned the survey. Nine codes were identified from open‐ended questions and 20 predefined from the literature. Analysis of the responses demonstrated the perceived impact including improvements in practices and access to therapy, investments in infrastructure, increased SLT profile, and impact on research culture among SLTs. The usefulness of the intervention during the COVID‐19 pandemic was also highlighted. Conclusions & Implications: The results suggest participation in Big CACTUS has resulted in improvements in patient care and SLT research capacity and culture in speech and language therapy departments. What This Paper Adds: What is already known on the subject: Practice‐based research is encouraged to assist with the clinical relevance of the research findings. Participation in research can be seen as an activity that is additional to the core business of patient care and it can be difficult to secure time to participate or conduct research in clinical settings. Impact evaluation initiatives of individual trials facilitate early identification of benefits beyond the trial. What this paper adds to existing knowledge: This study describes specific examples of the impact on services, staff and patients from SLT participation and leadership in the Big CACTUS speech and language therapy trial in clinical settings. What are the potential or actual clinical implications of this study?: Clinical services participating in research may benefit from improved clinical care for patients both during and after the study, an improved professional reputation, and increased research capacity and culture within the clinical settings. [ABSTRACT FROM AUTHOR]

Background: Communication and cognitive impairments are known barriers to shared decision‐making. Most people diagnosed with motor neurone disease (MND) will develop a motor speech impairment over the disease course. Some will develop cognitive, linguistic or behavioural disturbance. Despite this, the impact of communication and cognitive impairment on personal healthcare decision‐making in MND is not well known. Aims: This exploratory, longitudinal study aimed to capture the perspectives of people living with MND (plwMND) and family members on managing their healthcare with, or in anticipation of, a communication impairment. Methods & Procedures: Semi‐structured interviews and functional assessments were conducted with plwMND and family members over one to three time points between December 2017 and January 2020. Participants were recruited from a specialist MND clinic using a maximum variation sampling approach. Interview transcripts were analysed using trajectory data analysis: a matrix‐based approach for thematic analysis of longitudinal data. The study was underpinned by interpretive descriptive methodology. Outcomes & Results: A total of 19 plwMND with a range of MND phenotypes and 15 family members were recruited. Disease progression and participant withdrawal resulted in attrition, however 12 plwMND and seven family members participated at all three time points. Consistent cognitive screening was not feasible, which limited the opportunity to explore the impact of cognitive change. An overarching theme 'Communicating takes effort' was identified and illustrates the efforts required to compensate for, or circumnavigate, impairments to maintain involvement in healthcare. Assistance from family and accommodation from healthcare professionals (HCPs) was needed for ongoing engagement. Where plwMND were dependent on alternative communication devices, this assistance was essential and primarily carried out by family members. Despite these efforts, the quality, quantity and accuracy of communication were sometimes compromised. Participants equated good communication with receiving good healthcare, and some expressed anxiety in the anticipation of being unable to express their needs to healthcare workers. Conclusion & Implications: Communication impairment has a direct impact on healthcare involvement. This study demonstrates the effort required by plwMND and their carers to maintain or maximize ongoing involvement. This effort may not always be visible to HCPs. This information may prompt clinicians to consider the best ways to conduct clinical consultations to accommodate patients' abilities. Compromised communication experiences can be moderated by accommodations and support from HCPs and appropriate adjustments in the health system. Asking patients about their communication preferences and needs, allowing extra time and conducting multidisciplinary sessions are examples of such support. What this paper adds: What is already known on this subject?: Communication and cognitive impairments are known contributors to negative health outcomes and barriers to shared decision‐making generally. The existing literature in decision‐making in MND does not address the specific impact of these impairments on personal healthcare involvement for plwMND and their carers. What this paper adds to existing knowledge?: This paper reports the findings of a research project that interviewed 19 plwMND and 15 carers on one to three occasions over a 26‐month period to obtain their perspectives of the impact of communication on healthcare involvement. Whilst a priori the intention was to look at both communicative and cognitive decline, only the former was achieved. The effort and often 'invisible' activity undertaken to manage or maintain involvement in healthcare is identified. Communication impairment requires support and accommodation, otherwise healthcare involvement can be compromised. Results show participants may associate effective communication with good healthcare. What are the potential or actual clinical implications of the work?: Clinicians may wish to use these insights from plwMND and their carers to guide adjustments to their professional practice to maximize healthcare involvement for their patients. Tailored education for different healthcare groups is needed to improve understanding of MND‐related communication impairments and supportive strategies so that involvement in healthcare is not compromised. [ABSTRACT FROM AUTHOR]

Background: People with post‐stroke dysphagia often require informal care from family to facilitate safe swallowing, modify food/drink or administer tube‐feeds. Previous survey studies have found dysphagia may increase family caregiver burden. However, the experiences of family members in this population have not been fully explored. Aims: To explore family members' experiences of living with a spouse with post‐stroke dysphagia. Methods & Procedures: This exploratory qualitative study used one‐to‐one semi‐structured interviews to explore family members' experiences. They were asked open questions about previous eating routines, dysphagia onset, their role and future hopes. Interviews were audio‐recorded, transcribed and analysed thematically with an inductive approach to determine key features of family members' experiences. Outcomes & Results: Five spouses aged 70–93 years participated. Their relatives' strokes happened 3 months to 3 years before the interview. Five themes were identified: 'I do all of it'; making sense of dysphagia; emotional responses; reflecting on relationships; and redefining lifestyle. Conclusions & Implications: It is important to consider family members' perspectives as they often provide vital care to loved‐ones with dysphagia. In relation to eating and drinking, maintaining elements of previous routines seems important to families. Healthcare professionals should consider these when making recommendations for rehabilitation. Family members have differing perspectives of the comparative impact of dysphagia; patient and family priorities should be explored for healthcare professionals to provide better‐targeted support. What this paper adds: What is already known on the subject: Informal caregivers, often spouses, play a vital role in supporting the health and well‐being of older people with health conditions. The presence of post‐stroke dysphagia may present increased challenges for the informal caregiver. There are limited studies qualitatively exploring the experiences of informal caregivers in this population. What this paper adds to existing knowledge: Current health and social care provision for this population leaves informal caregivers feeling they have been left to manage dysphagia alone. Informal caregivers demonstrate a breadth of knowledge about their spouse's dysphagia, problem‐solving effective solutions. Informal caregivers have a range of interpretations of the nature and cause of dysphagia; leading to miscommunication with health professionals and complex emotional responses. What are the potential or actual clinical implications of this work?: Healthcare professionals might consider ways in which to support dysphagic patients' families later in their care pathway, through scheduling reviews or running dysphagia patient and family groups. Health and social care professionals and policymakers should learn from informal caregivers' expertise to promote better health and quality‐of‐life outcomes for the patient and caregiver. Equal, open conversations between health and social care professionals and patients/families on their understanding of dysphagia may help informal caregivers to better voice their concerns and support mutual understanding. This has implications for adherence to recommendations, psychological well‐being and patient safety. [ABSTRACT FROM AUTHOR]

Background: Communication between people with aphasia and their healthcare professionals (HCPs) can be greatly improved when HCPs are trained in using supportive conversation techniques and tools. Communication partner training (CPT) is an umbrella term that covers a range of interventions that train the conversation partners of people with aphasia. Several CPT interventions for HCPs have been developed and used to support HCPs to interact successfully with people with aphasia. Aims: The objective of this study was to identify the mechanisms of change as a result of a Dutch CPT intervention, named CommuniCare, in order to evaluate and optimise the intervention. Methods & procedures: A total of 254 HCPs from five different healthcare centres received CommuniCare. An explorative qualitative research design was chosen. Two interviews were conducted with 24 HCPs directly after and 4 months after receiving the training that was part of CommuniCare. Two conceptual frameworks were used to deductively code the interviews. HCPs' perspectives were coded into a four‐part sequence following CIMO logic: the self‐reported use of supportive conversation techniques or tools pre‐intervention (Context), the intervention elements (Intervention) that evoked certain mechanisms (Mechanisms), resulting in the self‐reported use of supportive conversation techniques and tools post‐intervention (Outcomes). The Capabilities Opportunities Motivation–Behaviour (COM‐B) model was used to fill in the Mechanisms component. Outcomes & results: Three themes were identified to describe the mechanisms of change that led to an increase in the use of supportive conversation techniques and tools. According to HCPs, (i) information, videos, e‐learning modules, role‐play, feedback during training and coaching on the job increased their psychological capabilities; (ii) information and role‐play increased their automatic motivations; and (iii) information, videos and role‐play increased their reflective motivations. Remaining findings show HCPs' perspectives on various barriers to use supportive conversation techniques and tools. Conclusions & implications: HCPs in this study identified elements in our CPT intervention that positively influenced their behaviour change. Of these, role‐play and coaching on the job were particularly important. HCPs suggested this last element should be better implemented. Therefore, healthcare settings wishing to enhance HCPs' communication skills should first consider enhancing HCPs' opportunities for experiential learning. Second, healthcare settings should determine which HCPs are suitable to have a role as implementation support practitioners, to support their colleagues in the use of supportive conversation techniques and tools. What this paper adds: What is already known on this subject?: Several communication partner training (CPT) interventions for healthcare professionals (HCPs) have been developed and used to support HCPs to interact successfully with people with aphasia. To date, there is limited evidence of the mechanisms of change that explain exactly what changes in HCPs' behaviour after CPT and why these changes take place. What this paper adds to existing knowledge: Evaluating our CPT intervention by identifying mechanisms of change from the perspectives of HCPs provided us with: (i) a better understanding of the elements that should be included in CPT interventions in different contexts; and (ii) an understanding of the important remaining barriers identified by HCPs to use supportive conversation techniques, even after CPT is implemented. What are the potential or actual clinical implications of this work?: This study shows the different intervention elements in our CPT intervention that improve HCPs' capabilities, motivations or opportunities to use supportive conversation techniques and tools. Essential ingredients of CPT according to HCPs in this study were role‐play and coaching on the job by an expert and were linked to an increase in HCPs' motivations or beliefs about self‐competency. Healthcare settings wishing to enhance HCPs' communication skills should therefore consider appointing implementation support practitioners to coach and support HCPs, and facilitate these practitioners to fulfil this role. [ABSTRACT FROM AUTHOR]

Background: A clinical swallow examination (CSE) provides integral information that informs the diagnostic decision‐making process within dysphagia management. However, multiple studies have highlighted a high degree of reported variability within the CSE process. It has been hypothesized that such variability may be the result of the clinical reasoning process rather than poor practices. Aims: To elucidate the nature of expert, speech–language therapists' (SLTs) clinical reasoning during an initial bedside assessment of patients referred for suspected dysphagia in the acute care environment. Methods & Procedures: An exploratory 'observation of practice' qualitative methodology was used to achieve the aim. Four expert SLTs, from two clinical services, completed CSEs with 10 new referrals for suspected dysphagia. All assessments were video‐recorded, and within 30 min of completing the CSE, a video‐stimulated 'think aloud' semi‐structured interview was conducted in which the SLT was prompted to articulate their clinical reasoning at each stage of the CSE. Three types of concept maps were generated based on this video and interview content: a descriptive concept map, a reasoning map and a hypothesis map. Patterns that consistently characterized the assessment process were identified, including the overall structure; types of reasoning (inductive versus deductive), facts (i.e., clinical information) drawn upon; and outcomes of the process (diagnosis and recommendations). Interview content was examined to identify types of expert reasoning strategies using during the CSE. Outcomes & Results: SLTs' approach to clinical assessment followed a consistent structure, with data gathered pre‐bedside, during the patient interview and direct assessment before a management recommendation was made. Within this structure, SLTs engaged in an iterative approach with inductive hypothesis‐generating and deductive hypothesis‐testing, with each decision‐making pathway individually tailored and informed by patient‐specific facts collected during the assessment. Clinical assessment was primarily geared towards management of an initial acute presentation with less focus on formulating a diagnostic statement. Conclusions & Implications: Variability in reported dysphagia practice is likely the result of a patient‐centred assessment process characterized by iterative cycles of fact‐gathering in order to generate and test clinical hypotheses. This has implications for the development of novel assessment tools, as well as professional development and education of novice SLTs. What this paper addsWhat is already known on the subjectCSE practices are reportedly variable, which has led to calls for more stringent, standardized assessment tools. Emerging evidence suggests that this variation is non‐random, but may arise from clinical reasoning processes.What this paper adds to existing knowledgeWe directly observed expert SLTs conducting CSEs and identified patterns in practice that were consistent across all CSEs evaluated. These patterns were consistent in structure, whereas the content of the assessment items varied and was tailored to individual patient presentation. Overall, expert SLTs engaged in balanced cycles of inductive hypothesis generation and deductive hypothesis‐testing, a hallmark of good clinical assessment and practice.What are the potential or actual clinical implications of this work?Ensuring quality CSE requires a more nuanced approach that considers the role of clinical reasoning in SLTs' decision‐making and the potential unintended negative consequences of standardized assessment tools. [ABSTRACT FROM AUTHOR]

Background: Several studies have suggested that practitioners hold speech and language therapy (SLT) practice as tacit and consequently it is difficult for the therapist to describe. The current study uses a range of knowledge elicitation (KE) approaches, a technique not used before in SLT, as a way of accessing this tacit knowledge. There is currently no agreed framework that establishes key factors underpinning practice for preschool children with speech and language disorders. This paper attempts to address that gap. Aims: To develop a framework of SLTs' practice when working with preschool children with developmental speech and language disorders (DS&LD). Methods & Procedures: A mixed‐methods approach was adopted for this study. Data were collected iteratively, from 245 SLTs with experience of working with preschool children with DS&LD across sites in England, by means of focus groups and national events. There were three stages of data collection: local sites, specific‐interest groups and two national events. KE techniques were used to gather data, with initial data being collected in local site focus groups. Findings from groups were taken to subsequent larger groups where a combination of concept mapping, teach‐back and sorting exercises generated a more detailed description of practice, using discussion of consensus and disagreement to stimulate further exploration and definition and provide validatory evidence. Outcomes & Results: This paper provides a high‐level framework of therapy for preschool children with DS&LD that makes practice explicit in this area. The framework proposes that therapists' aims for this group of children fall into three categories: addressing children's areas of impairment and skills; achieving functionally meaningful skills and carryover; and supporting adults to provide a supportive communication environment. The exact configuration is shaped by the child's context and needs. Conclusions & Implications: The framework highlights themes that are well researched in the literature (e.g., speech) and others that have been little studied (e.g., adult understanding), indicating a disconnect between research evidence and practice. The research also highlights the complex nature of interventions for preschool children with DS&LD and the importance therapists attribute to tailoring therapy to individual needs. The framework provides a scaffold upon which SLTs can focus their clinical practice and encourages the profession to understand and explore better the gaps between research evidence and clinical practice for preschool children with DS&LD. [ABSTRACT FROM AUTHOR]

Background: Subjective well‐being (SWB) and quality of life (QOL) are intricately related constructs. Recent research shows both constructs share some facets, but are distinct entities. It is unclear, both internationally and in the Netherlands, if and how SLTs address SWB in clinical practice. The current study was set up to explore Dutch SLTs' perceptions of SWB in relation to the management of people with aphasia. Aims: To describe how Dutch SLTs, working with people with aphasia in a private practice or a healthcare setting, address patient's SWB during diagnosis and treatment, and to identify barriers and facilitators they experience when addressing SWB. Methods & Procedures: A qualitative research design with a phenomenological approach was used. SLTs from private practices and healthcare settings were invited to participate in individual interviews and a focus group. The data were analysed thematically using a combination of inductive and deductive methods. Outcomes & Results: Eight SLTs participated in the study. The SLTs' experiences were captured in four themes that emerged from the data: (1) SWB is a multifaceted concept and depends on patient‐specific factors: premorbid factors, life priorities and time post‐stroke; (2) SLTs experience more responsibility for patients' SWB than their profession allows; (3) collaboration between SLTs and patients, patients' network and other healthcare professionals is required to address SWB during diagnosis and treatment; and (4) misinterpretations are inevitable when SLTs or the patients' network address patients' SWB. Conclusions & Implications: The results showed that SLTs feel responsible for addressing SWB in the management of people with aphasia. Their perception of the concept of SWB is similar to the definition used in the literature and is multifaceted. They feel responsible for the part of SWB that is related to communicative functioning, but less so for the more heuristic aspects of SWB. This is related to their experienced limitation of influence on SWB, which for some leaves them feeling out of depth and uncertain about boundaries between professionals. Addressing SWB in a multidisciplinary team is therefore considered important in order to adequately and fully capture someone's SWB and reduce to clinicians' experienced burden and responsibility. What this paper addsWhat is already known on this subjectRecent studies suggest that quality of life measures may lack facets related to subjective well‐being (SWB). Aphasia is likely to impact on SWB of a stroke survivor, but it is unclear if and how SWB is addressed by speech and language therapists in diagnosis, and treatment of Dutch PWA.What this study addsThis study provides insight into the operationalization of SWB in Dutch clinical practice, including barriers SLTs experience when addressing SWB.Clinical implications of this studyMonitoring and influencing SWB of people with aphasia is a complex process, that SLTs consider only possible in multi‐disciplinary teams. Clear guidelines on roles and responsibilities between various disciplines involved are necessary to improve care for people with aphasia. [ABSTRACT FROM AUTHOR]

Background The speech and language therapy/pathology (SLT/SLP) profession is characterized by extreme 'occupational sex segregation', a term used to refer to persistently male- or female-dominated professions. Men make up only 2.5% of all SLTs in the UK, and a similar imbalance is found in other countries. Despite calls to increase diversity in the allied health professions more generally, research into the reasons for occupational sex segregation and gender as a potential key factor remains scarce. Aims This study aims to explore the potential role of gender/gendered discourses in people's decision to pursue a career in SLT/SLP. It seeks to illustrate how gendered assumptions/expectations/discourses continue to construct SLT as a 'gendered' profession, and to make some recommendations in this area for SLT recruitment and practice. Methods & Procedures The study adopted a qualitative design which elicited research participants' views, knowledge and experiences (in their own words) in relation to the research questions. Data collection involved two iterative phases: a preliminary data phase-which involved semi-structured interviews with newly qualified SLT graduates and practising SLTs, and the completion of questionnaires by undergraduate SLTs-and a main/focus group phase. In the focus group phase reported in this paper, six focus groups in total were held with SLTs, teachers of SLT, and careers advisors in London, UK. The data were analysed qualitatively using grounded theory principles, thematic analysis and discourse analysis. Outcomes & Results The findings extend our knowledge and understanding of gender as a parameter of people's motivations and perceptions, which can influence their choice of career (e.g. as regards pay and flexibility). The findings also show that discourses around women as carers, nurturers and communicators constitute key ways through which the SLT profession continues to be constructed as 'women's work'. The topic of structural gender inequalities in the profession was also discussed in the data. Some recommendations for change, with implications for SLT recruitment and practice, were made by the participants themselves. Conclusions & Implications Gender imbalance in SLT needs to be researched further in order to help address inequalities, re-evaluate professional practices and develop service delivery in the profession. This area also needs to be researched via analysis that goes beyond gender distribution in numerical terms to consider the complex perceptions or discourses around gender and work. Cross-disciplinary and comparative perspectives in future research would also be fruitful. [ABSTRACT FROM AUTHOR]