Technical processes of ethics, data collection and data management
The study was approved by Stirling University’s School of Health Sciences Ethics Committee on 19th November 2014. R&D Management Approval was received from all three participating NHS services by 31st March 2015, and Letters of Access issued.
AN approached speech and language therapy managers of the three services. They agreed to an initial discussion followed by staff meetings to talk about the study and seek permission to contact by email without obligation. All processes were designed to maintain confidentiality, e.g. AN did not discuss with managers or participants who had declined, consented or taken part, and offered participants any place, time, or mode of contact.
An estimated 88 NHS therapists were eligible, of whom 81 gave permission to contact. Eight did not respond, 15 declined, and six did not return consent forms, leaving 52 potential NHS participants. An estimated 21 private practitioners could have volunteered of whom four completed the consent process. At interview, 9/42 participants were based in Clootshire, 11/42 in Staneshire, 19/42 in Blaeshire, and 3/42 were private practitioners. Most elected to have an individual interview (n = 28), including one by telephone, while four chose to have paired interviews (n = 2) and 10 to participate as small-team focus groups (n = 3).
AN conducted all interviews and focus groups. All encounters were audio recorded, with time averaging 78 minutes (range 48 to 112 minutes). Some participants provided artefacts, including two protocols developed for parent groups.
Electronic data was held on a secure, password-protected university computer, and paper data stored securely. File labelling did not compromise confidentiality. Digital voice recordings were transferred to the computer as soon as possible, and the recording deleted from the portable device. Electronic data was managed within NVivo 10, Excel and Word.
Data analysis
In transcribing all encounters, AN paid attention to accuracy and turn-taking, noting emphasis, hesitation and humour to aid analysis. She used the process of anonymising data to deepen her awareness of how context may have shaped and constrained therapists’ actions. This included: giving pseudonyms to participants, services and any non-participants named in interviews; coding the structure of each service; and banding demographic data such as year of qualification and whole-time equivalence.
We used a realist approach to qualitative analysis to make sense of the diversity of practice change (16). Our analysis focused on describing child speech intervention according to therapists’ reports of how their intervention had – and had not – changed over time.
AN identified, organised and categorised the numerous practice changes raised by therapists in an iterative process. This led to analytical separation of ‘intervention’ from three other aspects of practice change: the service; caseloads; and candidacy. Candidacy (17) refers to who is considered eligible for starting, continuing with and ending therapy. These aspects will be reported elsewhere.
We compared data and ideas using connecting and categorising activities (16). These included indexes, maps, tables, summaries, ethnographic monologues and a contribution matrix. Two transcripts were intensity sampled for detailed coding because these interviews were nuanced explorations of practice change in relation to complex interventions; the importance of the NPT differentiation component was identified in the process of coding the first, with “the same yet very different” a preliminary mechanism. Two documents (group plans) were also compared. Counterfactual thinking (18) took account of absence as well as presence, for example asking “What is it about particular interventions that makes them possible (or not) to consider and use?”
AN explored the tension between intervention(s) as parts and a whole (19) through writing around interviewees’ experiences of adaptation. These included the concept of fidelity, reasons to adapt, using parts, combining parts of interventions, shifting the weight of routine intervention, and de-implementation. She arrived at the coherence framework through progressive casing (12).
Coherence work in child speech intervention
Here, we illustrate how context impacted on coherence work when a new intervention was introduced to existing routine practice. Examples of how the four NPT coherence constructs help explain what was happening are highlighted as [Differentiation], [Communal specification], [Individual specification] and [Internalisation].
Coherence work: non-traditional theory
Participants consistently referred to ‘traditional’ intervention. There was consensus over what it was, and it appeared entrenched. Theories underpinning traditional intervention included attending to how speech sounds are produced (articulation), contrasted (phonology) and manipulated (phonological awareness), as well as to where the speech chain is breaking down (psycholinguistic models).
Non-traditional interventions were a heterogeneous group recognised as ‘new’ to clinical practice within the last six years but not to the literature. They challenged traditional linguistic assumptions [Differentiation], meaning therapists had to work harder to make sense of and feel comfortable with them. Some reported benefits such as more targeted therapy and faster progress [Internalisation].
Therapists who had tried non-traditional interventions expressed surprise and often embarrassment that they had not known about them. On moving to a new service, Erin remembered, “It was really eye-opening coming here actually. Cos I just had no…I had no clue and I just thought I can’t believe, you know, that I didn’t know about this.” Wendy returned from maternity leave and noticed “a huge, kind of vast change in where everybody’s thinking was now.”
Even where therapists were aware of non-traditional approaches, there was a consistent mismatch with what they saw in practice [Communal specification]. This was most evident from more recently qualified participants.
Megan: I remember at university, actually, they talked about doing the complex sounds first? And then that the others would fall into place. It’s one thing I’ve never tried.
Interviewer: And presumably never seen anybody else-
Megan: No… and never really heard anyone else speak about doing it. I just remember it being a suggestion in one of the textbooks.
Traditional elements made theoretical sense to therapists, while non-traditional elements were unsettling [Individual specification]. Isla was initially nervous when using an evidence-based intervention where targets are chosen by the child. A 4-year old wanted to say words like ‘waterslide’, ‘karate’ and ‘Cinderella’, “things that you would think from a therapist’s point of view ((puts on fed-up voice)) ‘oh! That’s going to be really hard! She’s not going to manage that’”. Diane repeatedly used the word “strange” to describe a demonstration video of an evidence-based intervention where the therapist did not help the child correct their speech:
Jackie: I find that really hard sitting there
Diane: I thought that was strange
Jackie: Listening to a child.. not achieving for.. for.. (overlapping) a long time
Diane: And you’re saying ‘oh good try’ [[yeah]].. but you’re not really..
Nicole: And if THEY know (laughs), if they know that they’re not achieving, that’s really hard
The entrenchment of traditional intervention in the profession was also confirmed by what happened when it was questioned [Internalisation]. Carolyn asked for training in non-traditional approaches, and “it was sort of a bit, as I was told, ‘well that’s your bread and butter’, it’s sort of an assumption that kind of somehow you know everything there is to know”. When Emily was on student placements, “you’re like, ‘so which approach are you using?’, they go ‘oh well I use a combination’ (pause) em, so that was sort of my learning of oh you don’t have to use just one or the other religiously”. Elizabeth interjected phrases such as “I feel like I’m a heathen now” and “it’s a bit illegal to say that” when she wondered whether the tasks that children are traditionally expected to do before they can move on to other ones actually do predict improvement.
The coherence of traditional theories of intervention - and the struggle to find coherence with non-traditional theories - suggests that, as a profession, systematic support is needed for the theoretical work of implementing non-traditional interventions. As discussed in the next section, coherence of logistical work was more dependent on local convention.
Coherence work: unconventional logistics
Logistical elements of intervention were where the client was seen (clinic; nursery or school; home), the format (e.g. a group or one-to-one; whether and how parents were involved) and dosage (e.g. number of sessions in a week over what duration). Services introduced unconventional logistics to meet priorities such as reducing waiting lists or shifting resources from specialist to universal provision. However, therapists had little agency to vary where, how and when they saw clients, with implications for coherence of non-traditional interventions.
Therapists often had to experience a change from a conventional to a non-conventional place before they realised the impact it had on other intervention elements [Internalisation]. For example, Kate missed the “more calming environment” of a clinic because the busyness, noise and lack of opportunity to involve parents at education premises constrained what intervention was possible. Moving from NHS to private practice gave rise to unexpected benefits when therapists worked in clients’ homes. Isobel noticed “I think about the child in the whole, way more than I did before”. She also found it easier to involve parents because “when they are in the situation, you make them think about ‘how can you implement?’”
Where schools had been the conventional place, without parents present, the consequences of a shift to clinics were surprising. Maureen found it helped make the tasks and responsibilities of non-traditional interventions apparent [Individual specification]:
With a parent sitting in front of you as well, when you’re asking them to commit to therapy with their child, it almost felt like you wanted to have more of a rationale for what you were doing…
This opportunity to build a shared understanding [Communal specification] meant she felt more confident negotiating intensive dosage (“‘the evidence for this is this amount of intervention will bring about successes’”). Dosage was, however, the logistical convention therapists felt least able to address as shown by observations such as “that is how (pause) we’re sort of programmed to be”. Vivienne had experimented with an evidence-based non-traditional intervention, but its required dosage was unconventional for her service [Differentiation]:
…it’s meant to have at least 60 minutes a week, and I’m not seeing anybody more than once a week. Most of them are lucky to be seen once a week.
Instead, therapists varied intervention dosage through shortening recommended length, number or frequency of sessions to the local convention, and asking parents to do more.
Although participants used parent groups for other client groups, they were unconventional for child speech [Differentiation]. Jenna and colleagues now started with two parent group sessions, so parents would see themselves as capable of doing speech work [Communal specification]:
…demonstrating all the time how you would carry out these activities with your child. And we have another booklet – we’ve got booklets for everything – that they can go back through and read up on. ‘This is the steps, this is how you do it.’ So we’re trying to be as supportive as possible.
The other child speech parent group also had two sessions but had been introduced to increase throughput, was poorly attended, and therapists saw it as ineffective. Melanie reflected on what was invested in this “massive” service change [Internalisation]:
we wanted to try it on a small scale, and maybe try and test that to see if it was effective…but I think there was just high demands from ‘we just need to do this’ and get it rolled out across. So it’s always trying to balance that out and, you know, are we being effective against ‘oh we just need to see these people and get them off the waiting list’
Non-traditional interventions were not used either in a parent group, or when intervention was delegated to parents or education staff. The next section helps explain why they may have been unsuitable for these formats.
Coherence work: relating non-traditional interventions to clients
Speech and language therapists manage cases (children and their parents) and caseloads. Non-traditional interventions challenged the coherence of this relational work.
Therapy for child speech necessarily involves meta-language (talking about talking). It became clear that this applied both to talking about the child’s speech problem and talking about a particular intervention in ways that made sense to people who don’t have specialist linguistic knowledge [Communal specification]. Louise drew attention to this problem with non-traditional interventions:
How are you gonna pass that on to parents? (laughs) How are you gonna explain? ‘Cos I think some of these concepts… these approaches are very complicated. (pause) REALLY complicated… So it’s ultimately down to the, you know, it’s down to your skills in terms of how you’re able to present that…
Although many participants had spent time learning about non-traditional interventions, the meta-linguistic demands were not addressed in intervention descriptions. How non-traditional interventions impacted on routine session plans also appeared relatively invisible from the literature. Implementing such interventions made Erin “realise how set in your ways you get” and how traditional intervention had “this same same same same session plan that you go along with”. She wondered how it was possible that she was still doing similar activities for non-traditional intervention yet “every session for every child is totally different?” [Differentiation].
The need to individualise non-traditional interventions also extended to therapy materials [Individual specification]. Traditional intervention lent itself to pre-prepared generic sets of materials sorted into folders and boxes for easy transport and adaptable use. As Fran said, “I could just grab that” whereas preparing materials for non-traditional approaches was “very very time-consuming” and “there’s no way that you just would grab – d’you know?” However, it helped that a favourite source of child speech materials (Black Sheep Press) has resources which can support implementation of non-traditional intervention targets. On placing a recent order, Jess was amused when confronted with the previous pattern: “you can totally see how your thinking’s changed!”
The clearest relational challenge to coherence of non-traditional interventions came from the impact on support and feedback strategies therapists used to guide the child through therapy. Therapists talked about routinely shifting the power of the relationship to give the child control and being facilitative and non-directive. However, non-traditional interventions often called for directive techniques such as repetitive practice (drilling). Because it was important to make therapy fun and interesting – possibly for themselves as well as clients – therapists were conflicted by the idea of drilling [Internalisation]. Beverly acknowledged, “it is drills, it is repetitive, it’s not the most exciting therapy work”. Not only was it unexciting in itself, but implementing it reduced the kind of rewards that could be used; as Heather observed, “it’s hard because the more exciting you make it the longer it becomes!” Elizabeth had made a conscious decision to use drilling as part of implementing non-traditional interventions but noted it “seems more acceptable to drill in American texts than it is here”, adding:
I don’t know, it’s funny isn’t it? It’s maybe a feeling that you’re doing something to the child and…it’s like making the child into some passive recipient…
Where there is a strong rationale for drilling, this cultural barrier may need to be explicitly addressed.
Framing coherence in child speech intervention
To make the coherence work described by therapists more visible, we configured an explanatory framework. It is based on what participating therapists had changed or held constant, taking account of how this was shaped and constrained by context. The framework has three inter-related parts (Table 2):
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Ten changeable elements of child speech intervention
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Binary contextual characteristics that made coherence work more or less challenging
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The main types of work therapists had to do to deliver or change these elements: theoretical (intellectual), logistical (organisational) and relational (people) work
In summary, theoretical coherence work was increased if elements of intervention were non-traditional for the speech and language therapy profession. Logistical coherence work was increased if elements of intervention were unconventional for the local service. Relational coherence work was increased if therapists had to do more tailoring of intervention elements. Overall, the framework shows that a new intervention demands the most coherence work when it needs a non-traditional approach, target and focus, an unconventional place, format and dosage, and comes with an unspecified meta-language, an incongruent scaffold, a non-routine session plan and the need for individualised materials.