collaboration

Pulling in the same

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if you want to initiate a collaborative approach allocate more time to joint planning and evaluation introduce total communication environments

To achieve a total communication environment in a special nursery class, Rachel Baker and colleagues introduced a collaborative approach. Importantly, new skills which developed as a result of everyone pulling in the same direction can now be used to benefit other projects.

right (1996) suggests collaboration is an active, evolving process that requires commitment, energy and effort, to succeed. I discovered this for myself when we initiated a collaborative approach into a nursery class at a local special school. Although not a process that can be entered into lightly, the result has been rewarding clinically, professionally and personally. As speech and language therapists we work with numerous professionals from different backgrounds and services on a day-to-day basis, with varying degrees of success. Collaborative working has become ever more widespread as service provision moves from a withdrawal model, where the clinician is the expert, towards a more holistic one, with the professionals working in partnership. There are several levels of collaborative working and terms vary from multidisciplinary through interdisciplinary to transdisciplinary and collaboration. Whichever model may be used, we are constantly striving for a successful partnership. Collaborative working has been described by Kersner & Wright (1996) as, absolutely essential for teachers and therapists to establish reliable and effective working practices. This is recognised also by the Code of Practice (DoE, 1994). Our Community Team Learning Disability speech and language therapy service used to begin work with reception age children as they entered school. The level of involvement depended on the needs of the children, and varied from initial advice and monitoring to running language groups in the classroom. Generally we had initiated input, as the children were transferred from the preschool team in the summer holiday.

The principles of total communication were incorporated into the communication sessions and it was intended that teaching staff would...continue to implement these principles throughout the school day.

Reorganisation
In 1999, following reorganisation of special educational needs provision in Newcastle upon Tyne, a large number of children (15) from two years old attended a new nursery class. Given their younger age and more complex problems, the nursery staff requested more speech and language therapy time

as they felt our specialist input was needed from the outset. After discussion with the nursery staff we decided that the speech and language therapy service would see the children in class on a weekly basis for a whole morning (covering two school sessions). What evolved was a collaborative approach, with the clinicians and teachers identifying and working on joint rather than discipline specific goals, with the aim of creating an educationally inclusive communication environment. This approach went beyond team working where individuals only perform tasks that are specific to their respective disciplines into a successful partnership whereby all staff involved were pulling in the same direction. In 2002, following two years of this approach, two final year students from Newcastle upon Tyne undertook a review of service provision in the form of a face-to-face questionnaire as part of their professional context placement. The report brief was to evaluate the service provided over the two years. The aim of the questionnaire was to discover the differing attitudes of staff towards the approach taken, and their perception of the benefits or disadvantages to the children and to professional relationships. Research has shown that effective collaboration between teachers and speech and language therapists has advantages for the children involved, as they benefit from the more holistic approach to their needs. There are also advantages for the professionals themselves, as they are able to provide each other with support, exchange knowledge and skills, and develop a greater awareness of each others roles (Wright, 1996). However, McCartney (1999a; 1999b) described potential barriers to effective collaboration between teachers and speech and language therapists as occurring at several levels, including service policy and curriculum related. The ultimate aim of the nursery sessions was to establish a total communication environment that would meet all the childrens individual communication needs, and that would last throughout the week. This involved making both physical changes to the classroom environment (for example multisensory experiences including objects of reference) and the adaptation of current communication rou-

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direction
tines (such as intensive interaction techniques and manual signing). The principles of total communication were incorporated into the communication sessions and it was intended that teaching staff would acquire the knowledge and skills and be able to continue to implement these principles throughout the school day. Given the high physical dependency of the children and diversity of needs, the communication session allowed for a mixture of individual and small group work, with a staffing ratio that was not available at any other time throughout the week. The students interviewed the two speech and language therapists, including me, and the nursery staff (three learning support assistants and one teacher) individually. All the responses indicated a positive learning experience, as this summary of outcomes shows:

1. Relationships

The teaching staff described their relationship with the speech and language therapists as being open, friendly, co-operative, a partnership and lastly a lot of mutual respect, while the speech and language therapists described it as educational, rewarding, two way, and enjoyable. All of the teaching staff commented that time spent with the speech and language therapists raised their awareness of the childrens communication needs and enabled them to interpret the childrens communication responses. The teaching staff also felt that the activities they did with the children during the communication sessions gave them ideas for activities at other times of the week which encouraged repetition and the development of the skills of both the staff and children. The speech and language therapists felt that they were able to get to know the children and their environment better and could use this information to set more appropriate targets. The target setting gradually became a joint activity; however this tended to be speech and language therapist / teacher rather than assistant led.

I built up many skills clinically, professionally and personally which I now endeavour to take into other teams.

clear understanding of each others roles. The teaching staff all had previous experience of working with speech and language therapy, and therefore views of the clinicians role. This experience had been of the speech and language therapist visiting to assess and advise about individual children or to run a group. Over time the speech and language therapists felt that the teaching staff were able to play an increasing role in planning and problem solving. We gradually began to discuss situations from outside the specific communication session and how ideas could be adapted and incorporated. The interviewees repeatedly referred to the value of the group discussions. After each session thirty minutes was spent reviewing and planning. Staff had to give up their lunch break for this. The majority of staff thought that there was sufficient time, however it was also suggested that more time for discussion would have provided further benefits. The responsibility for record keeping and monitoring progress was taken entirely by speech and language therapists. Despite targets being set in the childrens Individual Education Plans, they were not mentioned by any of the teaching staff in the interviews.

essary for speech and language therapists to remain directly involved. All felt there would be a negative impact and loss of focus for the sessions if speech and language therapy input was withdrawn. However, Kersner & Wright (1994) suggest that, following collaborative projects, teaching staff often develop new skills that they are then able to use when speech and language therapists are unavailable. In the year following the interviews the numbers in the nursery halved. Staff had acquired much knowledge and skill, so we decided that only one therapist should facilitate the communication session. This was a different therapist from the previous years. As 2003 has seen the smallest intake of children, we agreed that a speech and language therapy assistant should facilitate the session, with the teacher taking the lead on planning. A speech and language therapist has been available in a consultant role. The staff have kept up the planning / review sessions, including the speech and language therapy assistant who has increasingly become involved in making resources such as picture symbols as the education staff have limited time. This time factor has a significant influence on the maintenance of the total communication environment.

Commitment
The nursery teacher continues to show commitment to the collaborative approach due to the specific benefits which have been identified (see also case examples in figure 1). This commitment is mirrored by the Community Team Learning Disability speech and language therapy service. Following the interviews I had hoped to take this approach to other classes in the school as the children moved on. Despite school management support for this to happen, it has occurred with varying levels of success. This level of collaboration cannot be achieved overnight. It is an active process that requires all involved to be equally committed - with personality issues being a strong influencing factor. The findings of the interviews provide evidence of a positive experience, with insight into how a collaborative approach can work. During the two years working in the nursery I built up many skills clinically, professionally and personally which I now endeavour to take into other teams. The most important is developing flexible problem solving strategies which enable staff to meet a diversity of complex needs in the classroom environment. This approach allows us to deal with issues there and then, with shared responsibility and respect.

3. Disadvantages
None of the staff thought there had been any major difficulties but there had been a challenge initially as the speech and language therapists took a developmental approach while the teacher came from a curriculum background. However the teaching staff were very open to the developmental approach and, as the children were nursery age, curriculum restraints were less of an issue than they might have been. A study of this type has limitations. Although effort was made to ensure non-bias, all the participants were aware that the researchers were students from the speech and language therapy service, and the speech and language therapist continued to provide input at school. Over the two years the partnership had strengthened and the total communication environment had developed in the classroom. In the interviews the teaching staff were asked if they felt it was nec-

2. Role boundaries
Wright (1996) warns that it cannot be assumed that collaborative partnerships will occur because teachers and therapists spend time in the classroom together. McCartney (2001) asserts that one of the hallmarks of good practice in working together is a

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Rachel Baker is a speech and language therapist with the Community Team Learning Disability in Newcastle upon Tyne.

References
Enderby, P. & John, A. (1997) Therapy Outcome Measures - Speech and Language Therapy. Singular. Kersner, M. & Wright, J. (1996) Collaboration between teachers and speech and language therapists working with children with severe learning disabilities. British Journal of Learning Disabilities 26 (1), 33-37. McCartney, E. (1999a) Barriers to communication: an
Figure 1 Case examples

analysis of systematic barriers to collaboration between teachers and speech and language therapists. International Journal of Language and Communication Disorders 34 (4), 431-440. McCartney, E. (1999b) Scoping and Hoping: the provision of speech and language therapy services for children with special educational needs. British

Journal of Special Education 26 (4), 196-200. McCartney, E. (2001) ICAN Seminar Snapshot: Teachers and Therapists working together. ICAN Publications. Wright, J. (1996) Teachers and Therapists: the evolution of a partnership. Child Language Teaching and Therapy 21 (1), 3-16.

Reflections
Do I understand that collaboration is an active, evolving process? Do I engage students in practical projects to review therapy and services? Do I recognise new skills as they develop - and purposely apply them in new situations?

1. Jess Jess joined the nursery class in October 2000 (aged 3;4 years) with multiple and profound learning difficulties. When she first started, Jesss communication skills were at a preintentional stage. She was not reported as being able to point. Her hearing was assessed as normal, although her vision was causing concern. Her physical skills were also developmentally delayed. Objects of reference for Jesss routine were introduced and a multisensory approach taken throughout sessions alongside intensive interaction style communication. Jesss eating / drinking skills were also addressed, with work done on increasing her tolerance to drinking from a cup rather than a bottle.
Therapy Outcome Measures (Enderby & John, 1997) 12 February 2001
Diagnosis: 5.9 Pre-verbal skills Severe, multiple areas. No intent consistent but present on variable basis. Inconsistent attempts at communications. Cannot make basic needs known consistently. No effective understanding established. Basic and limited decisions. Shows preferences inconsistently by a smile versus passive response. Does not achieve potential.

2. Lucy Lucy joined the nursery class aged 3;7 years. She has cerebral palsy with severe visual impairment. Lucy was taking medication to control her epilepsy. However, she continued to have frequent absence seizures and periods of tiredness with drop fits on waking. There was concern that she was missing out on activities as a result of the time she spent sleeping during the day. Objects of reference alongside picture communication symbols were introduced for the daily timetable and choice making. A developmental approach including early pretend play and cause and effect was taken. Communication and eating/ drinking aims were also integrated into her individual education plan after collaboration between the speech and language therapist and class teacher.
Therapy Outcome Measures (Enderby & John, 1997) 12 February 2001
Diagnosis: Impairment: Disability: 5.2-3 AAC - Low Tech 2 1 Developmental dysarthria - related to over-riding disability. Able to make basic needs known - more and finished, points and vocalises to request object. Vocalises for attention, uses photographs for choice making - developing understanding of symbols. Better with trained listener and family. Needs contextual cues. Not consistently doing all above. Communicates in familiar and supported situations. Clearly communicates that she has finished or doesnt want song, and will request more and gain attention. Needs encouragement to achieve potential.

3. Jack Jack attended the nursery from 3;2 years until he was 5 years old. He has spastic tetraplegia and feeding difficulties. Long-term communication session aims: To develop consistent, intentional communication To develop true turn-taking with an adult (activities and vocalisations) To explore objects independently To develop protoimperative communication (use an adult to obtain an object / action) To develop protodeclarative communication (use an object to attain joint attention with adult) To develop purposeful means-end understanding through cause and effect and switch toys. Activities used to achieve aims: Intensive interaction to develop response, anticipation, intentionality Sensory stimulation Facial massage, smells, tastes Visual tracking, horizontal and vertical Object permanence Cause and effect Objects of reference Referral to Communicate (the Communication Aids Centre, Newcastle upon Tyne). Feeding: Main source of nutrition = gastrostomy Some oral feeding Feeding plan implemented March 2001
Therapy Outcome Measures (Enderby & John, 1997)

Impairment: 0.5

Disability:

0.5

Handicap:

Handicap:

30 June 2001
Diagnosis: 5.2-3 AAC - Low Tec 2 2 As before. Interested and alert in everyday environment. Able to direct attention to herself, request for example food, her turn, protoimperative and declarative communication, intentionally ends communication and chooses when / when not to participate. More consistent communication attempts. Communicates basic needs and relies on context and familiarity. As before - needs adult support. Impairment:

12 February 2001
Diagnosis: 5.9 Pre-verbal skills Profound and multiple learning difficulties (cognitive, communication and motor). Basic recognition at object level. Intentionality of communication is inconsistent. Limited functional communication developing greeting and reoccurrence. Relies heavily on carer and context.

18 May 2001
Diagnosis: 5.9 Pre-verbal skills Now showing some slight ability in anticipation of familiar routines, for example peek-a-boo scarf, opens mouth when sees spoon. Inconsistency still very evident. Can sometimes make basic needs known by some action such as smile / reach versus passive withdrawal. Hand-over-hand initiation at eating/drinking time.

Impairment: 1.0

Disability:

Impairment: 1

Disability: Handicap:

1.0 2.0

Disability:

Handicap:

18 May 2001
Diagnosis: 5.9 Pre-verbal skills Impairment: 1.5 Basic switch skills emerging (physically limited). Responding to basic stage 1 verbal language eg. chocolate / drink. Disability: Handicap: 1.5 Consistently vocalises for more, expresses preferences objects / toy. 3.0 Greeting activity - consistently able to vocalise as his turn - in response to name. Switch-control equipment.

Handicap: 1.5 Goes to favoured things, reaches for them. Can be variable. Passive when doesnt like. Occasional vocalisations for more / happy etc.

Lucy was able to communicate at a higher level than Jess, and her aims for this period of intervention reflected this. Despite the differences in their individual aims, both pupils made progress as a result of participating in the communication sessions. The nature of the sessions allowed individual aims to be targeted in individual and small group work, in addition to more general aims being targeted during work done in larger groups.

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2004