JCPSLP Vol 19 No 2 2017

Journal of Clinical Practice in Speech-Language Pathology Journal of Clinical ractic i Spe ch-L l

Volume 13 , Number 1 2011 Volume 19 , Number 2 2017

Shaping innovative services: Reflecting on current and future practice

In this issue: Speech-language pathologists and food services Language sample analysis in the school setting Saturday service provision in paediatric speech-language pathology Rolling-group delivery of the Lidcombe Program in community health settings The importance of clinical supervision Expanding volume and quality of clinical placements in speech-language pathology

Print Post Approved PP352524/00383 ISSN 2200-0259

Speech Pathology Australia

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JCPSLP Editor Leigha Dark c/- Speech Pathology Australia Editorial Committee Chris Brebner Erin Godecke Laurelie Wall Samantha Siyambalapitiya Cori Williams Copy edited by Carla Taines Designed by Bruce Godden, Wildfire Graphics Pty Ltd

Contribution deadlines Number 1, 2018 1 August 2017 Number 2, 2018 1 December 2017 Number 3, 2018 13 April 2018

Advertising Booking deadlines Number 3, 2017 17 August 2017 Number 1, 2018

1 December 2017

Number 2, 2018 6 April 2018

Shaping innovative services: Reflecting on current and future practice

From the editor Leigha Dark

Contents

W elcome to this issue of JCPSLP in which we explore the topical theme of Shaping innovative services: Reflecting on current and future practice . In the recent Speech Pathology 2030 – making futures happen report (Speech Pathology Australia, 2016), a vision for the profession was shared in which speech pathologists will be aware, responsive and innovative in the face of the opportunities and challenges facing the profession, now and in the future. Specifically, it was identified that speech pathologists “…will be known for our forward-thinking, innovative outlook. We will seek out, contribute to and become thought leaders

57 From the editor 58 The role of speech-language

pathologists in food services: A survey – Katina Swan, Rachel Wenke, Marie Hopper, and Melissa Lawrie 66 Language sample analysis: A powerful tool in the school setting – Samuel Calder, Cindy Stirling, Laura Glisson, Alannah Goerke, Tina Kilpatrick, Lauren Koch, Anna Taylor, Robert Wells and Mary Claessen language pathology service – Emily Davis, Jessica Bauer and Katrina Rohr 76 Rolling-group Lidcombe Program delivery: A prospective cohort study in community health settings – Nicole Rappell, David Schmidt, and Margaret Rolfe 82 Rolling-group Lidcombe Program: Perspectives from participant clinicians in a community-based cohort study – Nicole Rappell and David Schmidt 88 Supervision: Vital for speech- language pathology – Abigail Lewis and Joanne MacDonald 93 Expanding volume and quality of clinical placements: The Capacity Development Facilitation framework in speech-language pathology – Robyn Johnson, Elizabeth Bourne, Lyndal Sheepway, and Lindy McAllister 100 What’s the evidence? Computer- based therapy: How does it compare to clinician-delivered treatment in aphasia? – Rachel Wenke and Melissa Lawrie 105 Ethical conversations: Ethics in clinical practice: An interview with Dr Brenda Carey, clinician researcher – Susan Block 107 Webwords 58: Internet resources – Caroline Bowen 111 Around the journals 112 Resource review 113 Top 10 resources: Supporting patients with behaviours of concern (BOC) in an acquired brain injury unit setting – Delwyne Stephens 72 Saturday paediatric speech-

in the development of new knowledge and technologies with the potential to improve outcomes in communication, eating, and drinking.” (Speech Pathology Australia, 2016, p. 5). An innovative approach will be integral to advancing each of the eight aspirations that underpin the 2030 vision: (1) Communication accessible communities; (2) Access for all; (3) Timely services across the lifespan; (4) Clients and communities driving service provision; (5) Skilled and confident families and carers; (6) Collaborative professional partnerships; (7) Quality services, innovation and continual pursuit of knowledge; and (8) Diverse and dynamic workforce. In this issue, we have the opportunity to highlight the ways in which speech pathologists are addressing aspiration 7 – quality services, innovation and continual pursuit of knowledge – within clinical, research and education contexts. According to the Oxford online dictionary, “to innovate” means to “ introduce new things, ideas or ways of doing something ” and it is this understanding that has shaped the collation of submissions herein. The issue opens with Katina Swan, Rachel Wenke, Marie Hopper and Melissa Lawrie exploring the expanding role of speech-language pathologists in food services and how efficiencies may be enhanced through inter-professional engagement and collaboration. In their article, Samuel Calder and team, consider the practice of language sampling and reflect on innovative ways to apply established methods within the school setting in order to enhance intervention planning and outcome measurement. In an effort to broaden service options for clients and their families, Emily Davis, Jessica Bauer and Katrina Rohr discuss the ways in which a “Saturday service” practice model may be applied within a paediatric community health setting. They share insights and considerations helpful for other speech pathologists looking to expand their service models. In a series of two articles, Nicole Rappell and colleagues share the outcomes of a mixed methods study looking at the effectiveness and acceptability of the rolling-group delivery model for the Lidcombe Program treatment of early years stuttering, within a community health setting. They demonstrate that a group model of service delivery can be an effective, time saving and viable alternative to individual treatment in this setting, and outline valuable clinician perspectives that may assist others to implement similar practice change. In their article, Abigail Lewis and Joanne MacDonald make a strong case for the need for all practising speech pathologists to receive regular clinical supervision, particularly in light of the rapidly changing health landscape. They highlight the need for a best practice approach to supervision to ensure that speech pathologists remain able to provide high-quality care in the face of new and emerging practice environments. In the final article, Robyn Johnson and colleagues present the Capacity Development Facilitation (CDF) framework as a way of enhancing the volume and quality of speech-language pathology student clinical placements, implemented through collaborative partnerships between universities and workplaces. Each author showcases ways in which they have attempted to improve service outcomes for individuals with communication and or eating and drinking problems across a range of practice areas and service contexts, through application of a new idea, practice or collaboration. Also clearly evident in each process is an element of reflection; thinking carefully and critically about what has come before and what is needed to ensure that speech pathology services continue to address the current and future needs of clients, their families and communities. The submissions in this issue, therefore demonstrate that it is through the nexus of reflective and innovative practice that service change may be enacted to ensure that all Australians have the right and access to connection, belonging, participation and self-determination in their daily lives. References Speech Pathology Australia. (2016). Speech Pathology 2030 – making futures happen . Melbourne: Speech Pathology Australia. ISBN-10 1-876705-14-0

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Shaping innovative services: Reflecting on current and future practice

The role of speech- language pathologists in food services A survey Katina Swan, Rachel Wenke, Marie Hopper, and Melissa Lawrie

Among allied health practitioners, dietitians have historically had the greatest involvement with food services. However, speech- language pathologists (SLPs) may work with food services when managing issues related to texture-modified diets and fluids. To date, the role of SLPs in food services has not been reported in the literature. A total of 116 SLPs from Australia and New Zealand completed an online survey investigating SLPs’ self- reported duties relating to food services, prevalence of dedicated food services SLP roles, and SLP perceptions of such a role. Results indicated that the majority of SLPs absorb food-services-related tasks into infrequently reported (8% of respondents), most SLPs (85%) perceived a dedicated role as having the potential to improve the quality and safety of patient care, enhance the relationship between SLPs and food services, and improve service-wide management of texture-modified diets and fluids. S wallowing difficulty, or dysphagia , is a common condition affecting people across the spectrum of care settings. Prevalence is estimated to be 16% in the general community (Eslick & Talley, 2008) and higher in populations with specific conditions such as stroke, dementia and Parkinson’s disease (Takizawa, Gemmell, Kenworthy, & Speyer, 2016). An Australian study indicated that up to one-quarter of hospital inpatients present with dysphagia on screening (Cichero, Heaton, & Basset, 2009). Dysphagia may result in a number of serious health conditions including malnutrition, dehydration, choking, and aspiration pneumonia (Lancaster, 2015), the latter being an acute lung infection that develops from aspiration of material from the oropharyngeal or upper gastric tracts (DiBardino & Wunderink, 2015). In Australia and New Zealand, dysphagia management is a role of the SLP and often involves prescription of texture modified diet and fluids (Jukes et al., 2012; Speech Pathology Australia, existing SLP clinical roles. Although dedicated roles in food services were

2012). These modified diets and fluids control the rate, or ease the transit of food and fluids through the oral cavity and pharynx in order to reduce the risk of aspiration and choking (Garcia & Chambers, 2010). When patients do not receive, or adhere to, the recommended diet and fluids, there may be severe repercussions. For example, in a retrospective study of 140 patients with dysphagia, Low, Wyles, Wilkinson, and Sainsbury (2001), reported that patients who did not comply with their prescribed diet recommendations had a higher mortality rate. Aspiration pneumonia was a common cause of death. Although no current figures are available on the cost of dysphagia within the Australian health care context, the cost is likely considerable based on international estimates. For example, the yearly cost of dysphagia in the North American acute care setting has been estimated to be US$547 million (Altman, 2010). Aspiration pneumonia is the second most common diagnosis among Medicare patients in North America (DiBardino & Wunderink, 2015). An episode of care for aspiration pneumonia costs US$17,000 (Cichero & Altman, 2012). Given the costs to both individuals and health services, effective management of dysphagia and accurate delivery of texture modified diet and fluids is paramount. Correct provision of diet and fluids to patients within health care settings involves input from several disciplines, including nurses, ward clerks, SLPs, dietitians, fluid preparation staff and personal service staff (Zaga & Sweeney, 2014), making it everyone’s business. Food services, or kitchen staff, in particular have an important role to play in the delivery of correct texture-modified diets and fluids. “Food services” is the term widely used in Australia to refer to the non-clinical ancillary staff involved in producing and delivering meals and fluids to patients (Xia & McCutcheon, 2006). These staff include chefs, cooks, stores officers, menu monitors, kitchen supervisors and managers. Due to the number and diversity of staff involved in the provision of correct diets and fluids in health care settings, there is significant potential for error to occur. Synthesis of the available literature indicates that failure to comply with texture-modifications in health care settings may arise from both accidental errors (i.e., due to systemic or process errors) and intentional non- compliance by staff. For example, a study was undertaken in an English acute hospital in which compliance with SLP diet recommendations for patients with dysphagia was audited (Rosenvinge & Starke, 2005). The authors

KEYWORDS DYSPHAGIA FOOD SERVICES ROLE SPEECH-

LANGUAGE PATHOLOGY

TEXTURE MODIFIED

THIS ARTICLE HAS BEEN PEER- REVIEWED

Katina Swan (top) and Rachel Wenke

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found that inappropriate food being brought from the kitchen accounted for 54% of non-compliance incidents. In Australia, SLPs working in non-metropolitan health care settings also reported the actions of other staff, such as kitchen and ancillary staff, impacted compliance with SLP recommendations (Smith-Tamaray, Wilson, & McAllister, 2011). In addition to accidental or systemic errors, lapses may occur as a result of the attitudes and proficiency of staff. For instance, food services staff have been reported to lack knowledge of patient-specific needs, and/or hold untrue beliefs about dysphagia (Broz, 2009). A survey of food preparers and food deliverers at a large North American health care facility found 88% did not see the potential for pneumonia as a primary concern when patients aspirated liquids (Broz, 2009). Within Australia, food services personnel in some government health services complete an in-house mandatory food safety program which includes topics such as safe food handling, storage and transport, and health and hygiene of food handlers. However, the program does not routinely include information about dysphagia and texture modified diets or fluids. Such evidence reveals the need for SLPs not only to communicate and collaborate with food services staff, but to support development of knowledge about dysphagia within food services. Walton (2012), in an article reviewing opportunities for food services to improve practices in hospitals and residential aged care facilities, likewise suggested that health professionals need to build their knowledge of food services and challenge their perceptions of Food Services as “‘non-clinical”‘. Indeed, the perception of food services as a non-clinical service may have contributed to Ross, Mudge, Young, and Banks’ (2011) finding of a lack of clear “‘ownership”‘ regarding the nutritional intake of older hospitalised patients, ultimately impacting health and well-being outcomes. In the study by Ross et al. (2011), health care professionals working in a large tertiary hospital were interviewed regarding their perceptions of barriers to feeding and nutrition of hospitalised older adults. The findings included barriers such as poor communication between disciplines, lack of a sense of shared responsibility or a coordinated approach, competing priorities, and inadequate practical knowledge of nutrition care processes. Currently, the clinical staff who most commonly engage with food services are dietitians. However, a recent review of the role of dietitians in food services (Walton, 2012) advocated for more health care professionals to work with food services, noting that “it is imperative the health care professionals of today and tomorrow have more than a common interest in food and mealtimes” (p. 224). Although SLPs have a vested interest in correct provision of texture modified meals and fluids, and have been mentioned as “champions” advocating within their organisations for uptake of Australian national standards pertaining to texture modified foods and fluids (Jukes et al., 2012), there is a dearth of literature regarding the role of the SLP in food services. Although not specifically related to SLPs’ role in food services, the literature describes the need for coordinated multidisciplinary input at the individual patient level and at a food services level, to address issues of dysphagia (Bourdel-Marchasson, 2010; Ross et al., 2011; Zaga & Sweeney, 2014) and maximise patient safety. Zaga and Sweeney (2014) reported an example of the effect of SLPs collaborating with food services. In their project to reduce

the frequency of delivery of incorrect texture-modified diet and fluids, an intervention was designed to increase efficiency of services and communication and engagement between staff. The team that designed the intervention was multidisciplinary, comprising SLPs, nurse unit managers and the food services coordinator. This multidisciplinary collaboration resulted in a decrease in the number of meals of incorrect textures being delivered to patients. Anecdotally, SLPs are often involved with food services in Australia and New Zealand, including being part of working groups, advocating dietary recommendations and providing education. For example, in Queensland, Australia, the Queensland Health Speech Pathology Food Services Network includes a working group of SLPs with an interest in food services who are involved in both site- and state-level quality improvement tasks. This includes auditing items from the state-wide menu to assess compliance with national standards for texture modification, and collaborating on projects such as testing recipes for thickening fluids. However, these projects are often undertaken within existing, time-poor clinical roles. Despite anecdotal evidence that highlights the range of different tasks undertaken by SLPs in food services, there is a lack of published literature which describes the current practices of SLPs with regards to food services in the health care context. In light of this, the aim of this study was to explore the following within Australian and New Zealand health care settings: • the prevalence and practices of SLPs working in “dedicated” food services roles; • the nature of food services tasks undertaken by SLPs within existing general clinical roles; and • SLP’s perceptions of an existing or hypothetical dedicated SLP role in food services. Authors used the term “dedicated” to indicate SLPs that had funding for, or time exclusively allocated to, working on activities related to food services. Methods A pilot, prospective, cross-sectional survey was undertaken with a sample of SLPs within Australia and New Zealand. Ethics review was waived by the local Hospital and Health Service Human Research Ethics Committee (reference HREC/16/QGC/46) as the activity was deemed a Quality Activity. Participants A total of 1683 SLPs were invited to participate in an online survey. The survey is available upon request from the corresponding author. The survey was distributed to SLPs in Australia and New Zealand via Speech Pathology Email Chats (SPECS) and the Queensland Leaders in Speech Pathology (LISP) group now called the Queensland Health Speech Pathology Advisory Committee (QHSPAC). Emails containing the link were also sent directly to 26 speech- language pathology departments of tertiary health services identified within the Health Round Table data (The Health Round Table, 2015). A total of 116 SLPs completed the survey, most (80%) were from metropolitan health services. Approximately 9% were based in rural health services and the remaining 11% were non-specific in reporting their workplace settings. It was noted that 33 participants (28%) were from the same facility and an additional 26 (22%) worked within the same health services.

Marie Hopper (top) and Melissa Lawrie

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Table 1. Respondents’ location Percentage of Respondents State/country

Percentage of Respondents

Location of respondent’s facility or health service

44%

Queensland

80%

Metropolitan

25%

New South Wales

9%

Rural

7%

Victoria

11%

Unspecified

3%

New Zealand

4%

Tasmania

3%

South Australia

1%

Western Australia

1%

Australian Capital Territory

12%

Unknown (not disclosed)

Table 2. Respondents from within same facility or health district

Key: Zone

Same facility QLD, M1: n = 5 QLD, M1: n = 4 QLD, M1: n = 3 QLD, M2: n = 2 QLD, M2: n = 3 QLD, R1: n = 2 QLD, R2: n = 2 NSW, M2: n = 3 S.A., M1: n = 2

Same district QLD, M1: n = 2 QLD, M1: n = 2 QLD, M2: n = 5 QLD, M2: n= 3 QLD, M2: n = 2 QLD, M2: n = 3 QLD, R2: n = 2 VIC, M1: n = 2 VIC, M2: n = 2 NSW, M2: n = 6 TAS, M1: n = 4 Total: 33

Category

Metropolitan zone

M1 Capital cities M2 Other metropolitan centres (urban centre population > 100,000) R1 Large rural centres (urban centre population 25,000–99,999) R2 Small rural centres (urban centre population 10,000–24,999)

Rural zone

Total: 26

Source: Australian Government Department of Health (1994).

Procedure SurveyMonkey™ online survey software was used to deliver an 18-item questionnaire which remained “live” for two weeks. Due to the lack of prior research in this area, the authors developed questions based on anecdotal knowledge and local information. Questions investigated several areas including: a) demographics of the respondent, b) prevalence, scope and tasks of SLPs in dedicated food services positions within their organisation, c) SLP participation in food services meetings, d) food service tasks undertaken by SLPs within non-food service dedicated clinical roles, and e) overall perceptions of a hypothetical dedicated SLP role in food services. The survey included both multiple choice questions and open-ended questions. Skip logic was used to change the questions presented to the participants based on their previous responses. This maximised efficiency for participants and restricted presentation of irrelevant questions (e.g., if participants indicated they did not attend food services meetings, no further questions on this topic were presented). As not all participants were eligible for all questions, approximately 5% of respondents completed all questions. A total of 86% (n = 100) participants who commenced the survey, finished it. Data analyses Descriptive statistics were applied to quantitative survey data, with responses collated and percentages for each item calculated. To expand on the quantitative data, a

complementary descriptive approach to examining qualitative data was employed. Responses to the open- ended survey questions were analysed informally, with content categorised by the first author (KS) using keywords. These responses were grouped into broad themes, after which the themes were discussed with the second author (RW) and then finalised through consensus. The number of responses aligned with each theme were quantified. Results Speech-language pathologists in a dedicated food services role A total of nine respondents (8% of whole group) indicated that their facility/health service utilised a SLP in a dedicated food services role. Three of these nine respondents did not provide any further details regarding the role, while the remaining six (participants 14, 71, 78, 88, 89 and 108) answered a series of related questions about the amount of time spent in the role, origins of the role, seniority level and duties of the position. Two positions were reported to be part-time and four were “consulting or casual” (defined within the survey as providing advice or support to food services on an ad hoc basis, one day or less per month). In response to the question, “How long has this position existed?”, the position had existed for more than five years in five instances, and for 2–5 years in one. Four of the positions were filled by senior level SLPs. One respondent reported the role was graded as a base or entry level

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position. The remaining participant reported that the role involved one full-time grade 1 (entry level clinician) and one part-time grade 2 clinician (> 1 year of experience, but not senior level). Participants 14, 71, 78, 88, 89 and 108 also answered the question “Why was the position created?” Responses ranged from developing and maintaining good working relationships with food services, addressing issues pertaining to texture-modified foods and fluids, to providing ongoing representation at food services meetings. All respondents (n = 6) reported that a range of duties were undertaken within this dedicated position. These duties included: auditing compliance of texture-modified diets with national standards, research/quality improvement in texture- modified diet/fluids management, resolving joint SLP and food services issues, and creating links between food services and SLP. In addition, one respondent described working with food services to develop a new patient menu. No respondents reported that their organisation had evaluated the impact of a dedicated SLP role in food services. Speech-language pathologists completing food services tasks within existing clinical roles A total of 85% of respondents (n = 99) answered the question “Do any speech pathologists from your department perform the following food services related tasks within their existing clinical roles?” A large proportion of these respondents (n = 88) reported that SLPs in their department provided education and training to food services staff and worked to resolve clinical issues related to texture-modified diets/thickened fluids (n = 87), such as items of inappropriate texture being provided to patients. They also reported performing audits on texture-modified diets (n = 71) and thickened fluids (n = 87). Of these 99 participants, almost 60% indicated someone within their department attended food services meetings and 64% (n = 64) resolved requests from food services (e.g., issues with texture-modified diets) at a departmental or service level, while 65% (n = 65) indicated that they or someone within their department provided input into development and/or selection of new meals. Twenty-eight per cent of respondents (n = 28) reported participating in state-wide food services networks. Two of the 99 respondents indicated they did not perform any of the aforementioned duties within their department or any other food services tasks. Figure 1 depicts how many hours per fortnight SLPs within their departments reportedly spent on food services tasks, with the most common response (58%) being between 1 and 4 hours per fortnight. However, 15% of respondents (n = 15) indicated that they or someone in their department spent up to 32 hours per fortnight performing these tasks.

8-16hours, (3), 3%

16-32 hours, (0), 0%

0 hours, (6), 6%

>32 hours, (15),15%

4-8 hours, (18),18%

1-4 hours, (57), 58%

Food services meetings As shown in Table 3, the majority of respondents (n = 71) reported their facility or health service had regular food services meetings which mostly occurred on a monthly basis (49%). Figure 2 depicts which members of the team reportedly attended these meetings, with the majority having dietitians, food services managers and SLPs in attendance. One quarter of respondents reported “others” attended food services meetings; these included nutrition assistants, chefs, food service coordinators, kitchen manager, food service assistants and menu monitors. Perceptions of a dedicated speech- language pathology role in food services A total of 77 participants responded to the open-ended question “What are your thoughts on a dedicated Speech Pathology role in food services?” Two major themes were identified: (a) potential benefits of the position and (b) service considerations of such a position. Subthemes within each of these categories are shown in Table 4. Perceived benefits Nine respondents (12%) commented that a dedicated speech pathology role within food services could have possible benefits to patients in terms of safety and quality of meals. For example, participant 51 noted: Figure 1. Hours per fortnight department spends on food- services-related tasks within existing clinical roles Note: differences in sizes between departments unknown; data may be impacted by number of staff within a facility.

Table 3. Food services meetings

Questions

Responses

Yes 71% (n = 71)

No 7% (n = 7)

Unsure 22% (n = 22) Quarterly 18% (n = 12)

Does your health service have regular food service meetings?

Weekly 4% (n = 3)

Monthly 49% (n = 33)

How often do they meet?

Other: 28% (n = 19)

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100

n Dietitians

90

n Food Services Managers

n SLPs

80

n Nursing Staff

70

n Others

60

n Quality & Safety Staff

50

n Food services/Nutritian Researchers

40 Percent

n Environmental Services

30

n Consumer Representatives

20

n Medical Officers

10

n Nutritian Clinical Nurse Consultants

n Public Health Representatives

0

Respondents

Figure 2. Who is involved in food services meetings?

The role was also perceived by nine respondents to have generic value-adding potential (12%), with one commenting: Currently at the [facility name here] SLPs spend a significant number of hours attending [food services] meetings, conducting meal audits, contributing to chef education on modified diets etc. [These SLPs] are also expected to maintain their clinical caseload – given no specific funding for food services. A dedicated role in food services would ensure SLPs were involved in discussions about modified diets… a consistent face would improve lines of communication, allow for a more coordinated approach to the service. (Participant 40) Considerations about the position A proportion of respondents (n = 28, 36%) were in favour of the position but had specific comments about how it should be funded or utilised. Four participants (5%) commented on the need for funding to support such a role, as well as a need for protected non-patient contact time: Would be a wonderful idea if there was funding to support such a role… (Participant 49) I believe it would be beneficial, as currently we are retrospectively managing the issues rather than being proactive… it consumes a significant amount of clinical time… (Participant 58)

I think it’s a wonderful role that can make a huge difference for patient satisfaction as well as safety at meal times… this [role] would hopefully result in audits completed sooner [and] reduced risk, as issues could be worked through quickly…. A further six respondents (8%) commented on the potential of the role to enhance the relationship between SLPs and food services. Participant 18 explained: The feedback we get from food services is the lack of understanding for reasons for dysphagia related diets, and from the SLPs is about the lack of food services insight into potential hazards. Having someone to bridge the gap would be invaluable. Five respondents also commented that the role would have potential to promote education of food services staff in hospitals and community organisations: SLPs play a huge role in the education of food services staff, and to ensure texture-modified diets and thickened fluids meet the requirements for patient safety. (Participant 93) I think it [food services position] is beneficial in hospitals and nursing homes and in organisations such as Meals on Wheels or those providing a Food Service to people with dysphagia. Education, compliancy and quality are areas SLPs can contribute to… (Participant 101) .

Table 4: Perceptions of respondents from open ended questions

Broad theme Benefits of a dedicated SLP position in food services

Considerations for a dedicated SLP position in food services

• A part-time role may be more suitable than a full-time one • A temporary/ project related role may be more suitable than a part- time or full time position • There is a need for protected non-clinical time and funding for food services tasks • The local context should be considered if health services choose to create such a role; for example, it may not be a priority in rural areas

Subthemes

• Patient benefits: safety and quality of meals • Enhances relationships between SLP and food services • Promotes education of staff • A range of value-adding potential, such as joint speech-language pathology/nutrition research, development of resources and procedures

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Seventeen respondents (22%) commented that a dedicated position should be part-time: I’m not sure if a position would be needed for full- time basis, unless the SLP was also offering recipes, creating menus for each diet consistency, assisting with ordering products, and other tasks that are currently being completed by food services [staff]. (Participant 109) Another stated, “It is essential to have representation at these meetings, the [full-time equivalent needed] is probably dependent on the size of the network …” (Participant 87). Four participants (5%) suggested that a dedicated role should be temporary, such as for projects or research. For example, Participant 68 commented: “Excellent idea! Even just as a project/temporary role with goals around minimisation of risk/waste etc. and establishing solid procedures/ policies” . Another four participations (5%) did not feel the role would be appropriate to their setting, but commented the role would still have merit perhaps in different settings or contexts. “This work is the last job on the to-do list of a regional, rural or remote speech path, but would make a big difference to patient care” (Participant 7). One of these participants suggested a state-wide position: “I would encourage this as a state-wide position due to consistent and similar issues being tackled locally across the state” (Participant 110). Three respondents (4%) commented that they did not believe a dedicated SLP in food services role would be beneficial. Concerns focused around the role being limited and the potential disadvantage of splitting food services skills from general clinical duties, as one respondent commented: I think it is important to be affiliated with food services and work closely with them so that issues can be easily resolved however I don’t think there needs to be a SLP that is dedicated to this department. (Participant 114) A final open-ended question provided the respondents with an opportunity to add any other comments. A total of 20 respondents provided additional comments. Resultant themes were similar to the previous question. Almost half of the respondents (n = 8, 40%) provided general comments about the nature of the relationship between food services and speech-language pathology departments within respondents’ facilities, or expressed interest in results of the survey: “It is an area which does not always get recognised as a speech-language pathology role by management…” (Participant 74). Six respondents (30%) made comments about the potential benefits of a SLP in food services to the organisation and patient safety. For example, one respondent shared information about the complexity of their health service and the possibilities of a dedicated role in food services: I find that food service in aged care is even more complex than acute services as in order to provide person-centred care, we need to be able to be flexible for those long-term residents. It is limiting for residents if we stick strictly to the national guidelines for meals, and I find in order to provide quality of life in aged care, we are often making exceptions for individuals… This is another example of the complexity of Food Service and how our facilities within each hospital and health

service would benefit from a dedicated food service SLP. (Participant 17) Three respondents noted potential barriers to such a role, with attitudes and competing clinical priorities being of primary concern: “Residential facilities are VERY resistant to anyone other than food service staff making suggestions, particularly dietitians and SLPs. When suggestions are accepted (grudgingly) there is always the complaint that it makes more work for them” (Participant 49). Discussion The present project aimed to explore the prevalence, practices and roles of SLPs working within food services. It also examined the type of tasks related to food services that SLPs take on within their clinical roles, and SLPs’ perspectives on a hypothetical dedicated SLP position in food services. The survey revealed that currently only a small number of SLPs surveyed (less than 8%) have a dedicated SLP role in food services within their organisation, despite the majority of respondents (86%) indicating that a dedicated role would be of benefit. Of the dedicated positions reported, most were described as informal liaison/consultation roles, rather than dedicated roles funded to work a regular, set number of hours in food services. The low prevalence of dedicated SLPs in food services roles is consistent with the paucity of literature about this role. Interestingly, the positive response to a possible food service role in this survey, as well as the existence of groups such as the Queensland Health Speech Pathology Food Services Network, indicates this is a growing but under-researched area of SLP practice. Based on the survey results, responsibilities of dedicated SLP roles in food services included: (a) auditing texture- modified diets and fluids compared to national standards; (b) research and quality improvement activities related to texture-modified foods/fluids; and (c) creating and maintaining links between the SLP and food services departments and resolving any issues affecting both services. This diverse range of tasks represents the broad scope of SLP work in food services, which includes education, research, system-wide improvements, liaison with key stakeholders and working on issues of clinical care. These varied SLP activities are similar to the scope of tasks undertaken by dietitians working within food services in Australia (DAA, 2015). It is also interesting to note that, although the greatest proportion of participants reported working within Queensland (44%), only one of the nine dedicated SLP food services positions were based in Queensland. By comparison, dietitians in Queensland Health often have dedicated roles within food services. Dedicated food services SLP positions as reported by respondents were most often senior or higher grade level, or a mix of senior and base grade. This may be an indication of the complexity of tasks within food services and the knowledge of the organisation required to undertake these duties. Zaga and Sweeney’s (2014) systems-level intervention for improving frequency of provision of correct diet/fluids to patients with dysphagia required significant and timely stakeholder engagement across seven disciplines, and modification of several phases of the meal process (prescribing, preparing, ordering and dispensing). This would reflect the need for a more experienced SLP. The majority (98%) of SLPs without dedicated positions in their department or health service reported undertaking food services tasks within existing clinical roles, with work being absorbed within clinical time.

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to New Zealand. The lack of prior research in the area further impacted the questions generated for the survey, as they were based on local and anecdotal knowledge as opposed to previous, substantive research in the area. The use of a survey as the only data collection medium was also a limitation, as interviewing the participants to clarify questions and explore themes further was not undertaken, and may have yielded greater contextual clarity and understanding of the nexus between speech-language The present findings warrant further research into the current practices and duties of SLPs in relation to food services. Specifically, examination of SLP time spent on food services tasks within existing clinical roles and investigation of the impact of SLP input into food services in terms of patient satisfaction and safety would be warranted. Barriers and facilitators to SLP work within food services should also be investigated, from the perspectives of both SLPs and food services workers. Based on the current findings, SLP services and managers may also wish to consider evaluating the time that clinicians spend in food services tasks and potentially trial a dedicated SLP role in food services, or the allocation of dedicated time for SLP involvement in food services tasks. Exploration of the impact of SLP input into food services with regards to patient outcomes, quality of services and budgetary concerns should also be considered. Conclusion The survey, though preliminary, provides insight into the current practices of SLPs in food services and potential areas for further more formalised research in this area. Although the majority of SLPs undertake food services related tasks within existing clinical roles, few organisations have dedicated food services SLP roles. The majority of SLPs see a dedicated food services SLP role as a potentially useful position which may have a positive effect on communication and understanding between SLP and food services and, ultimately, patient safety. However, empirical investigation of the SLP role in food services is needed before any conclusions regarding their impact can be made. Declarations of conflicting interests The authors declare that they have no conflict of interest. References Altman, K. W., Yu, G. P., & Schaefer, S. D. (2010). Consequence of dysphagia in the hospitalized patient: impact on prognosis and hospital resources. Archives of Otolaryngology-Head & Neck Surgery , 136 (8), 784–789. Australian Government Department of Health. (1994). Rural, remote and metropolitan areas (RRMA) classification. Retrieved from Australian Institute of Health and Welfare, http://www.aihw.gov.au Bethlehem, J., & Biffignandi, S. (2011). Handbook of web surveys (Vol. 567). Hoboken, NJ: John Wiley & Sons. Bourdel-Marchasson, I. (2010). How to improve nutritional support in geriatric institutions. Journal of the American Medical Directors Association , 11 (1), 13–20. Broz, C. C. (2009). Healthcare foodservice workers’ knowledge of dysphagia and development of a sensory descriptor lexicon and benchmarking instrument in pathology and food services. Recommendations

Several respondents made comments about the competing priorities of food services work, patient contact and other responsibilities. While the majority of SLPs perceive work in food services as valuable, absorbing these extra food services duties into existing clinical roles may place additional pressure on systems which are often already at capacity. Heavy, underresourced workloads are reported by SLPs in the literature (McLaughlin, Lincoln & Adamson, 2008) and time constraints were identified in this survey as a barrier to undertaking food services tasks. These issues may account, in part, for the lack of formal SLP roles in food services to date. Generally, most respondents were in favour of dedicated food services SLP positions and believed there would be benefits to patient safety and quality of care. This is consistent with previous research of SLPs collaborating with food services and the multidisciplinary team, resulting in a reduction of incorrect dietary items being delivered to patients (Zaga & Sweeney, 2014). The impact of SLP work in food services has not been evaluated thus far; however, dietitians working as food services managers have reported that their allied health training supports the integration of food services with the clinical management of patients (Kuhn, 2014). Although few facilities within this survey had dedicated food services SLPs, participants reported food services meetings primarily included dietitians, food services managers and SLPs. SLP presence at food services meetings indicates that engagement and collaboration between SLPs and food services occurs, even in the absence of a dedicated food services SLP position. This may indicate the importance of SLP involvement in food services processes, and SLPs’ interest in food services. Indeed, SLPs have been mentioned as “champions” for effective change in food services practices A significant limitation of this study was the lack of clear definition of the term “dedicated”. Authors used the term to indicate a speech pathology role with time or funding specifically allocated to food services; however, this was not made explicit in the survey. From subsequent comments and responses to open-ended questions, it was apparent most respondents interpreted the term “dedicated” accurately. Inclusion of a “pop-up” definition for key terms would address this issue in future surveys. Another limitation of this study was the relatively low response rate, which was perhaps related to the medium of distribution (email). Although online surveys are fast, simple and cost-effective (Bethlehem, & Biffignandi, 2011), an inherent issue is the response rate, which is often low (Sheehan, 2001). The addition of a follow-up contact may have improved the response rate as would perhaps increasing the length of time the survey was “live”. Although the response rate was low, the spread of respondents over six states and one territory in Australia permitted a sample of the current state of SLP views and practices related to SLP food services roles to be considered. However, results should be interpreted with caution as the majority of responses were from one state (Queensland) and most participants were located in metropolitan settings. There were also multiple respondents from the same facility or health service, which may have influenced the findings for some questions. Although a number of facilities were invited to participate in New Zealand, the response rate was very low (3%), limiting the applicability of these findings (Jukes et al., 2012). Limitations

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Katina Swan is a speech pathologist at Gold Coast Health. Dr Rachel Wenke is a principle research fellow (Allied Health) and Senior Speech Pathologist at Gold Coast Health. Marie Hopper is the assistant director of speech pathology for Robina Hospital and Community Programs and is an active member of the Queensland Health Speech Pathology and Food Services Network. Melissa Lawrie is director of speech pathology at Gold Coast Health. Rosenvinge, S. K., & Starke, I. D. (2005). Improving care for patients with dysphagia. Age and ageing , 34 (6), 587–593. Ross, L. J., Mudge, A. M., Young, A. M., & Banks, M. (2011). Everyone’s problem but nobody’s job: Staff perceptions and explanations for poor nutritional intake in older medical patients. Nutrition & Dietetics , 68 (1), 41–46. Sheehan, K. B. (2001). E-mail survey response rates: A review. Journal of Computer-Mediated Communication , 6 (2), 0. doi: 10.1111/j.1083-6101.2001.tb00117.x Smith-Tamaray, M., Wilson, L., & McAllister, L. (2011). Factors affecting dysphagia management and compliance with recommendations in non-metropolitan healthcare settings. International Journal of Speech-Language Pathology , 13 (3), 268–279. Speech Pathology Australia. (2012). Clinical guideline: Dysphagia. Retrieved Aug. 2016 from http://www. speechpathologyaustralia.org.au. Takizawa, C., Gemmell, E., Kenworthy, J., & Speyer, R. (2016). A systematic review of the prevalence of oropharyngeal dysphagia in stroke, Parkinson’s disease, Alzheimer’s disease, head injury, and pneumonia. Dysphagia , 31 (3), 434–441. Walton, K. (2012). Improving opportunities for food service and dietetics practice in hospitals and residential aged care facilities. Nutrition & Dietetics , 69 , 222–225. Xia, C., & McCutcheon, H. (2006). Mealtimes in hospital: Who does what? Journal of Clinical Nursing , 15 (10), 1221–1227. Zaga, C., & Sweeney, J. (2014). Reducing error in a complex system: Texture modified diet and fluid provision. Journal of Clinical Practice in Speech-language Pathology , 16 (3), 152–156.

formulation testing . (Unpublished doctoral dissertation). Texas Tech University, Lubbock, TX. Cichero, J. A., & Altman, K. W. (2012). Definition, prevalence and burden of oropharyngeal dysphagia: A serious problem among older adults worldwide and the impact on prognosis and hospital resources. In J. Cichero & P. Clave (Eds.), Stepping stones to living well with dysphagia (Vol. 72, pp. 1–11). Barcelona, Spain: Karger Publishers. Cichero, J., Heaton, S. & Bassett, L. (2009). Triaging dysphagia: Nurse screening for dysphagia in an acute hospital. Journal of Clinical Nursing , 18 (11), 1649–1659. DiBardino, D. M., & Wunderink, R. G. (2015). Aspiration pneumonia: A review of modern trends. Journal of Critical Care , 30 (1), 40–48. Dietitians Association of Australia (DAA) Food Service Interest Group. (2015). Role statement for accredited practising dietitians practising in the area of food service management. Retrieved 16 Aug. 2016 from http://daa.asn.au Eslick, G. D., & Talley, N. (2008). Dysphagia: Epidemiology, risk factors and impact on quality of life – a population-based study. Alimentary Pharmacology & Therapeutics , 27 (10), 971–979. Garcia, J., & Chambers E. (2010). Managing dysphagia through diet modifications. The American Journal of Nursing , 110 (11), 26–33. The Health Round Table. (2015). Allied health R12: Inpatient speech discipline report, all episodes – Demeter. Retrieved from https://www.healthroundtable.org/ Jukes, S., Cichero, J., Haines, T., Wilson, C., Paul, K., & O’Rourke, M. (2012). Evaluation of the uptake of the Australian standardized terminology and definitions for texture modified foods and fluids. International Journal of Speech-Language Pathology , 14 (3), 214–225. Kuhn, L. A. (2014). The perspectives of advanced practice dietitians in foodservice director roles: An exploratory investigation (Unpublished doctoral dissertation). Ohio State University, Columbus, OH. Lancaster, J. (2015). Dysphagia: Its nature, assessment and management. British Journal of Community Nursing , 20(S7), S28 . Low, J., Wyles, C., Wilkinson, T., & Sainsbury, R. (2001). The effect of compliance on clinical outcomes for patients with dysphagia on videofluoroscopy. Dysphagia , 16 (2), 123–127. McLaughlin, E., Lincoln, M., & Adamson, B. (2008). Speech-language pathologists’ views on attrition from the profession. International Journal of Speech-Language Pathology , 10 (3), 156–168.

Correspondence to: Dr Rachel Wenke Gold Coast Health phone: (07) 5687 3041 email: Rachel.Wenke@health.qld.gov.au

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