JCPSLP Vol 16 Issue 1 2014

cognitive-communication deficits, severe motor speech disorders, or high level cognitive-communication deficits). Where guidelines exist, they tend to be generalised, for example, a recommendation of one SLP session per day, with a frequency from one to five days per week (CDLE, 2005). Prioritisation methods Within the BIRUs surveyed, SLPs utilised two main factors to determine intervention intensity: diagnosis/presentation and clinical reasoning. Unsurprisingly, these two methods are congruent, and are often utilised together within a clinical setting. Intensive therapy services were identified for patients with severe communication impairments and dysphagia, which aligns with patient presentation and need. Additional features contributing to higher intensity services included ability to participate and patient goals. Patients identified as receiving lower (individual) treatment intensity were those with high level cognitive-language/cognitive-communication deficits, with additional service delivery options utilised for this group including independent directed activities and group therapy. Given that ABI and TBI can result in an extensive range and degree of communication deficits (RCSLT, 2006), identification of different treatment schedules is not surprising. Clinical interventions A range of interventions were identified as being provided by BIRU SLPs, including 1:1 services, groups, community- based activities and joint therapy interventions. Group therapy was a common mode of service delivery, with SLP groups expanding outside traditional “communication” interventions (e.g., memory and orientation groups). This reflects the growing role of SLPs with cognition, meta- cognition and executive functioning (ASHA, n.d.a; MacDonald & Wiseman-Hakes, 2010) within this population, and in targeting cognitive-communication disorders. BIRU SLPs provide both impairment/skill-based and functional/participatory groups. While groups have been categorised by the investigators for reporting, clinicians may dispute this delineation of group type. In reality, many groups are likely to have aspects belonging to both categories, or may target both areas simultaneously (e.g., a “news group” working on specific communication or cognitive skills). This survey has demonstrated that a range of service types are utilised, and likely necessary to meet the wide range of client goals and requirements, and that there is not a “one-treatment-fits-all” approach to providing optimal intervention for this complex client group. When compared against available international practice guidelines, Australian SLP BIRU services are found to be congruent. This includes the delivery of specialist services as part of a coordinated team, supporting communication goals within the community, and utilising interventions that support a range of goals including recreation and social goals (RCSLT, 2006); delivering rehabilitation to accomplish objectives and goals, and to enhance activity and participation (ASHA, 2004); utilising a combination of approaches (ASHA, n.d.b) and delivering services that are functional and within a contextual paradigm (Ylvisaker et al., 2003).

While it is evident that our services meet these broad aspects of service delivery, even with significant under- staffing, the authors cannot comment on other aspects of SLP BIRU services, including intensity of therapy, types of interventions and prioritisation methods, as guidelines do not currently exist to govern these practices. In reality, SLPs continue to rely upon clinical knowledge, experience and internal (e.g., hospital/unit specific) guidelines for other aspects of practice. Limitations This survey has attempted to provide a snapshot of SLP inpatient brain injury services in Australia; however, not all aspects of clinical practice have been investigated (e.g., SLP assessment). While not all BIRUs participated in data collection (with eight of ten identified units participating), the responses represent the majority of BIRU SLP teams, and can be seen as providing a representative sample of current practice. Additionally, there may have been varying levels of collaboration within the SLP teams with respect to responses provided, and responses may not reflect the opinions of all staff in the unit. Statistically, the small number of participants is a limitation (given the low number of BIRUs within Australia), but is the situational reality. External changes to service delivery (e.g., maternity leave, funding, bed pressures, changing models of care) may also impact the information reported, with some participants reporting the influence of internal and budgetary changes on current levels of staffing impacting clinical service delivery (e.g., positions not being backfilled). This survey thus provides a snapshot of SLP BIRU services which is likely to change over time, with potential changes to funding, staffing and state health service priorities impacting the level and types of SLP BIRU service provision in the future. Conclusion This paper has begun to identify the practice patterns and service provision of SLPs working within specialised inpatient brain injury rehabilitation centres in Australia. BIRU SLP services are provided in line with international guidelines, and are congruent in many areas of service delivery and therapy provision, with patterns seen in therapy prioritisation and scheduling. Differences in service delivery arise between services in therapy intensity, and large differences exist in staffing levels and patient to clinician ratios, which impact service delivery and the ability to meet best practice guidelines. While BIRUs are congruent in location (based in metropolitan areas) and scope of service (providing statewide services), differences in funding and health priorities affect the level and extent of service provided. While international guidelines govern broad aspects of clinical practice, there has been minimal research into the efficacy of specific SLP interventions and treatment schedules within this population, which has consequences for the development and availability of clinical guidelines and evidence based interventions. Beginning to gather evidence on current clinical practice within this setting will help to build a foundation for future research into this area. This study has provided an initial overview of BIRU SLP services and identified a range of similarities and

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JCPSLP Volume 16, Number 1 2014

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