Service delivery

Getting off to a flying start

The transition from student to newly qualified therapist can be frustrating when there are barriers to putting ideals into practice. With support from her colleagues and manager, as well as the Scottish Governments Flying Start programme, Esther Black finds that the biggest challenges in this case collaborative working with early childhood educators - can inspire the most radical changes and opportunities for professional development.
READ THIS IF YOU ARE INTERESTED IN ENVISIONING THE BEST SERVICE EVER CHANGING THINKING AND BEHAVIOUR TRANS DISCIPLINARY WORKING

s a new graduate I was looking forward to the challenge of working in an environmentally deprived area and to collaborating with early childhood educators (nursery teachers, early years officers and auxiliaries) to improve the communication skills of local children. My service provision involved working with individual children in the nursery, working with staff, joint sessions with staff and occasional short training sessions for staff. In the event, service delivery in the nurseries was particularly demanding. This was due to multiple factors including: the lack of language stimulation that can exist in some families, particularly in environmentally deprived areas high non-attendance rates at appointments

a varying degree of commitment from parents and early childhood educators to supporting my recommendations a lack of shared agreement with some nursery staff about my role and about their role within speech and language therapy aims. The aims for episodes of care for children on my caseload (Malcomess, 2001) were therefore not always met, and I experienced growing frustration.

Build capacity

Partly as a result of this, my manager set up a departmental working party to consider service provision to environmentally deprived areas, which I was invited to join. A further consideration was the potential health promotion role of speech and language therapists (RCSLT, 2006), in particular

when working in environmentally deprived areas. The other driver for change was ongoing discussion within the department regarding a model of service delivery which would build capacity in schools in line with legislation (Scottish Government, 2008) and good practice in education (Learning & Teaching Scotland, 2008). We hoped to build the capacity of early childhood educators in their interaction with children particularly those with language delay which may or may not be the result of a lack of stimulation. We reasoned that this would have an effect on the ability of staff to support children with additional support needs, facilitate their contribution to speech and language therapy goals, and help children develop towards being successful learners, confident individuals, responsible citizens and effective contributors (Learning and Teaching Scotland, 2008). As part of the working party, I was involved in carrying out a literature search into training that is effective and changes thinking and behaviour. Hulme (2005) outlines a pilot scheme offering training for childcare staff using a simple self-rating tool to analyse staff-child interaction. This involved a one-day in-service plus four weekly small group tutorial sessions. Staff members were asked to identify one target for developing their interaction. This method led to staff reducing their use of questions and directions, allowing the children more time to initiate. Staff feedback was positive. Sutton & Sedgemore (2005) describe their strategic, coordinated response to the increase of nursery aged children with a speech and language delay. This involved identifying a key
Figure 2 The best nursery ever Appropriate accommodation and resources A genuinely collaborative approach based on shared understanding, knowledge, skills, roles, enthusiasm, training An enabling environment eg. visual timetables, symbolised environment.

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

Service delivery
Figure 3 Domainal map of change in service delivery to nurseries

worker from each nursery to attend a weekly one-day training session. The key worker then cascaded the information to other members of staff. This approach intended to address the communication needs of all the children in the nursery, not just those on the speech and language therapy caseload. As figure 1 shows, we took these articles into account when planning training. Our working party then considered the potential features of providing a speech and language therapy service in the best nursery ever (activity adapted from Duffy & Griffin, 2000). Our ideals are in figure 2. We discussed as a group how this could be facilitated and agreed that a change in service delivery was required. We then used a domainal map (a visual tool devised by Spiegal et al., 1992). This enables judgement of whether a change is feasible by examining the costs, benefits, implications and potential problems for those involved (figure 3).

A positive experience

With the support of the head teacher and educational psychologist, I took forward some of these principles in my service provision to a nursery in an environmentally deprived area. This was facilitated by the head teacher, who approached me to set up a joint initiative for building on staff-child interaction. I had several meetings with the head teacher to discuss offering intensive workshops on

staff-child interaction to all the nursery staff. The head spoke with the nursery staff and identified what they hoped to gain from the training. They were keen to build on the skills they already had, and make their interactions with children more positive rather than repeatedly asking them questions such as What colour is that? They were also looking for the training to be a positive experience to boost their own confidence. I met with a more experienced speech and language therapy colleague to plan and implement training. We then gave the nursery staff a whole day inservice on staff-child interaction and a series of three follow-up workshops. We also offered members of staff the opportunity to have a video made of their staff-child interaction and to receive individual and group feedback on this. Our workshop presentations were influenced by the Hanen Centres Four P Cycle (Prepare, Present, Practise, Personalise) for facilitating learning (Pepper et al., 2004). We included: educator and child styles, balancing questions with comments, listening, waiting and observing during interaction, adding routines to interaction, and interaction with groups of children. Service delivery also changed in that I spent increased amounts of time with individual members of staff discussing their views on the training. I also spent more time with one member of staff who was the key worker for a child on my caseload, modelling strategies and enabling her to evaluate her performance.

Not all members of staff agreed to be videoed and initially none, including the head teacher, were keen on the idea (although they have since purchased their own video camera). Following the whole day training we videoed eight early childhood educators with groups of children. Three agreed to be videoed on a further occasion, this time on a one-to-one with different children. One agreed to do a third video. We analysed the videos of staff who did more than one in terms of how many questions and comments were made by the adult, and the balance of turns (verbal / gesture / vocalisation) in conversation between the adult and the child. As we didnt have a baseline or look at the same adult-child dyads over time the quantitative results provide limited information but, overall, the videos showed us a positive difference in the interaction styles of the adults following the training and feedback. This led to children being able to take more turns in the conversation and thus having increased opportunity to develop their language and communication skills.

Dramatic effect

We measured one childs responses, initiations and use of language in a video made by one member of staff. The child, who was on my caseload, was aged three and had a very limited vocabulary of two or three words. Although her understanding of language was also delayed, it was significantly better than her use of language, but she was often 5

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008

Service delivery unable to express even her basic needs and wants. I modelled strategies for the early childhood educator, including the use of signing and symbols. During the video, the educator significantly reduced the complexity of her language, waited for longer periods of time than before, imitated what the child was saying and mainly used three different key words throughout the interaction. I heard the child imitate and spontaneously use two of these words on many occasions as well as the Signalong sign for the word MORE. The educators use of new strategies appeared to have a dramatic effect on the childs communicative abilities. We got formal feedback from staff who attended the training using a questionnaire at the end of each session and a more detailed Final Reflections one at the end of the final session. We based the questionnaire content on material produced by The Hanen Centre (Pepper et al., 2004). Staff feedback was mainly positive. Nine of the ten members of staff completed the final reflections questionnaire (one was off sick). Five said they did not know anything new about themselves or the children following the workshops. However, seven stated that they had changed the way they interacted with children, for example by asking fewer questions and waiting longer for children to respond and initiate. Three noted a difference in the way children communicated with them following the training. Most members of staff found the training helpful, some found it very helpful and one person found it less than helpful. Some staff did not enjoy the role play, while others found it helpful. Eight said they would recommend the workshops to other nursery staff. Less positive comments included: The training about routines was patronising; Hated having to be [role play] a child, what was I meant to say / do? Positive comments included: Feel we learned a lot from each other and we feel more confident in what we can do to support SLT and our own targets; Daunting but worthwhile; Proud of myself and the child; Youre never too old to learn. Informally, several members of staff approached me individually and stated that they found the training helpful and interesting. One of them told staff at a different nursery that the training had been helpful, and they have now requested it for themselves. The staff who had less positive comments also felt able to speak to me about this personally and some issues appeared to be resolved in this way. The head teacher wrote a letter of thanks to my line manager recording her appreciation that we were able to adapt the sessions to the needs of the education team. The early childhood educator who I was working most closely with appeared to be empowered by the training and more able to suggest strategies to be used with the child who was on my caseload. She independently suggested the use of Signalong signs and Boardmaker symbols (which were very appropriate for the child) and, along with other members of staff, also played a significant role in preparing materials and implementing this. Previously, the suggestion and preparation would have come from the speech and language therapist and working collaboratively to follow this through was a challenge. This particular member of staff also developed in her ability to explain and recommend the use of these strategies to the childs parents, and helped them to problem solve in using them at home. As this was done alongside me, it reinforced and supported my recommendations. Following the workshops, the nursery staff made further requests for training in the use of Signalong and Boardmaker, and have also suggested that interaction training be given to parents whose children attend the nursery. I plan to take this forward with a speech and language therapy colleague, in collaboration with the education staff. The differences between the video sessions taught me a lot which will be useful in planning future training. Firstly, staff reported that individual feedback was a lot more helpful and less daunting than group feedback. Secondly, staff found it more beneficial to have time spent discussing their interaction goals in detail before making the video. Discussion around interaction goals within a routine included: 1. Identifying how the routine would start 2. How the educator would plan for the child to take a turn 3. How the routine could be changed to enable the child to take a turn 4. The actions, sounds and words that the educator would repeat during the routine 5. How the routine would end. These points (adapted from Pepper et al., 2004) can be filled in on a worksheet before the video is made. I have learned that a significant change to service delivery can be necessary to achieve positive outcomes for children, and that implementing it is both rewarding and challenging. My confidence has developed and I look forward to building on the changes and taking them further in other nurseries and schools. I have seen the positive effects of taking into account the evidence in the literature when providing training and have booked a place on a three day course that goes into more detail about providing training. I now feel more able to contribute to change in service delivery, and to work more collaboratively with education colleagues. The nursery at the heart of it has become a more enabling environment, the relationship between the speech and language therapist and the education staff has become more genuine and collaborative, and outcomes for children are encouraging. Esther Black is a speech and language therapist with NHS Fife, e-mail estherblack@nhs.net.

Key learning

As a year 2 Flying Start NHS speech and language therapist, I completed a reflective essay for the Scottish Government on the key areas of my learning from this change in service delivery. The Flying Start initiative for newly qualified allied health professionals is intended to promote effective practice and encourage us to remain in NHS Scotland. I noted that through the experience my knowledge and skills increased in several different areas including negotiation, flexibility, and planning and delivering presentations. I also developed in my ability to model strategies, give other people positive feedback on their performance and to enable and facilitate their learning by allowing them to come up with answers themselves.

Acknowlegement

With thanks to Roma More, speech and language therapist, for her support in planning and implementing the training, and to the nursery staff for the opportunity to take forward the change in service delivery, and develop my own SLTP practice through this.
REFLECTIONS DO I SEEK SUPPORT AT A DEPARTMENTAL LEVEL WHEN MY JOB IS CHALLENGING? DO I ASK FOR AND RESPOND TO FEEDBACK TO ENSURE THE TRAINING I OFFER MEETS THE NEEDS OF THE PARTICIPANTS? DO I MODEL THE STRATEGIES I AM ASKING OTHER PEOPLE TO USE? How have you gone about making changes in service delivery? How do you support new graduates to be involved in this process? Let us know via the Winter 08 forum at http://members.speechmag. com/forum/.

References

Duffy, M. & Griffin, E. (2000) Facilitating Organisational Change in Primary Care. Oxon: Radcliffe Medical Press. Hulme, S. (2005) ACT!: Innovative training for childcare staff, Bulletin of the Royal College of Speech and Language Therapists December, pp.12-13. Learning and Teaching Scotland (2008) Curriculum for Excellence Aims, purposes and principles. Available at: http://www. ltscotland.org.uk/curriculumforexcellence/ (Accessed 8 October 2008). Malcomess, K. (2001) The Reason for Care, Bulletin of the Royal College of Speech & Language Therapists November 595, pp.12-14. Pepper, J., Weitzman, E. & McDade, A. (2004) Making Hanen Happen, Leaders Guide for Hanen Certified Speech-Language Pathologists. It Takes Two to Talk, The Hanen Program for Parents. Toronto: The Hanen Centre. Royal College of Speech & Language Therapists (2006) Communicating Quality 3. London: RCSLT. Scottish Executive (2008) Additional Support for Learning website. Available at: http://www.scotland.gov.uk/Topics/Education/ Schools/welfare/ASL (Accessed 8 October 2008). Spiegal, N., Murphy, E., Kinmoth, A-L., Ross, F., Bain, J. & Coates, R. (1992) Managing change in general practice: a step by step guide, BMJ 304, pp. 231-4. Available at: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1881432&blobtype=pdf (Accessed 8 October 2008). Sutton, C. & Sedgemore, J. (2005) Enriching the early years, Speech and Language Therapy in Practice Summer, pp.10-12.

Resources
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Boardmaker - www.mayer-johnson.com/ Signalong - www.signalong.org.uk

SPEECH & LANGUAGE THERAPY IN PRACTICE WINTER 2008