JCPSLP Vol 17 No 3 2015

Fresh science and pioneering practice

What supports speech- language pathologists to implement treatments with fidelity? Maryanne O’Hare and Elizabeth Doell

One of the challenges for speech-language pathologists implementing evidence-based interventions is the need to consider treatment fidelity. This paper reviews the treatment fidelity guidance provided in three evidence-based interventions utilised in Australia and New Zealand practice for children with communication difficulties. The challenges in measuring and monitoring treatment fidelity within real-world practice contexts are identified along with recommendations for ways of supporting speech-language pathologists (SLPs) to develop and monitor treatment fidelity procedures. The paper proposes an organisational perspective for supporting speech-language pathologists to implement evidence-based interventions for children with communication difficulties. E vidence-based practice is the combination of three equally important components: high-quality published research, clinician skills and knowledge, and client preferences and values (Reilly, 2004). Although speech-language pathologists (SLPs) understand the value of evidence-based practice and have an ethical requirement to provide clients with best practice (SPA, 2010), they experience difficulties applying evidence to their everyday practice contexts (Hoffman, Ireland, Hall-Mills & Flynn, 2013; Roulstone, 2015). Accessing and translating evidence into practice is a complex task requiring skills in reading and analysing research combined with clinical expertise and the ability to access and integrate clients’ and caregivers’ values and preferences. Kenny and Block (2014) discussed ethical challenges related to translating research knowledge to practice and the need to adapt knowledge to the “culture and worldview of consumers so they may benefit from new approaches” (p. 38). Clinicians may be faced with a dilemma when considering how to make program adaptations in response to stakeholder preferences that do not compromise the requirements for maintaining treatment fidelity. An organisational priority is the need to ensure that allocated resources result in optimal outcomes, with

concomitant requirements for clinicians to demonstrate that their implementation of evidence-based interventions is effective and efficient. Speech-language pathologists have been encouraged to consider the treatment fidelity of their implementation of evidence-based programs as this has a significant impact on effectiveness of the intervention and subsequent outcomes (Kaderavek & Justice, 2010). What is treatment fidelity? In this article, treatment fidelity refers to the extent to which an intervention relates to the prototype intervention or the effectiveness research carried out on the intervention (Hulleman & Cordray, 2009; Kaderavek & Justice, 2010). Treatment fidelity is reported in published studies to establish the consistency and integrity of the application of the intervention, to strengthen the internal validity of the study. Just as demonstrating fidelity assists researchers to establish underlying reasons for the success of an intervention in research, it is highly likely that the degree of fidelity in the implementation of clinical interventions will impact client outcomes (Kaderavek & Justice, 2010). Implementing a range of treatment fidelity measures as part of service delivery is important for monitoring the outcomes of an intervention. As more validated interventions are developed, monitoring treatment fidelity will become more important for implementing successful interventions for clients (Kaderavek & Justice, 2010). When there is low fidelity to the original intervention, clinical decision-making regarding the success of an intervention can be difficult because it is unclear if a treatment is effective (or not) due to the actual intervention or factors related to how the intervention was delivered. Implementing interventions with high treatment fidelity requires integration of two of the evidence-based practice components: the findings from published research and the clinician’s skills and knowledge. It is important that SLPs apply treatment fidelity measures both in their own clinical practice and at the service delivery level. Treatment fidelity measures There is a range of suggested treatment fidelity measures. Distinctions are made between context, compliance, and competence measures (Fixsen, Naoom, Blase Friedman, & Wallace, 2005). Context measures refer to the prerequisite required supports for an intervention, from the completion of training to the clinician’s caseload capacity to deliver the intervention. Compliance measures are utilised to monitor a clinician’s application of the intervention process and

KEYWORDS COACHING EVIDENCE- BASED PRACTICE SUPERVISION TREATMENT FIDELITY

THIS ARTICLE HAS BEEN PEER- REVIEWED

Maryanne O’Hare (top) and Elizabeth Doell

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JCPSLP Volume 17, Number 3 2015

Journal of Clinical Practice in Speech-Language Pathology