JCPSLP
Volume 16, Number 1 2014
11
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
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).
