Evidence-Based Practice in Speech Pathology

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1 Level 2 / Bank Place T Melbourne Victoria 3000 F Position Statement Copyright 2010 Speech Pathology Association of Australia Limited Disclaimer: To the best of the Speech Pathology Association of Australia Limited s ( the Association ) knowledge, this information is valid at the time of publication. The Association makes no warranty or representation in relation to the content or accuracy of the material in this publication. The Association expressly disclaims any and all liability (including liability for negligence) in respect of the use of the information provided. The Association recommends you seek independent professional advice prior to making any decision involving matters outlined in this publication.

2 Acknowledgments Project Officer Dr. Jenny Harasty, National Adviser, Evidence-Based Practice Councillor 2009 Jade Cartwright (Continuing Professional Development and Scientific Affairs) Senior Advisor Professional Issues Marie Atherton This position statement has been developed in consultation and discussion with speech pathology clinicians and managers across Australia. Contributions were sought via Councillors, Professional Standards and Practice, Workplace and Government Portfolio Leaders and Committees, Heads of Speech Pathology Programs and professional contacts. Those consulted contributed to the project on the basis of their work context and personal viewpoints and as a whole represented the range of contexts in which speech pathologists work. Review Date August 2016 Copyright 2010 The Speech Pathology Association of Australia Ltd 2

3 Position Statement It is the position of Speech Pathology Australia (The Association) that speech pathology is a scientific and evidence-based profession and speech pathologists have a responsibility to incorporate best available evidence from research and other sources into clinical practice. Speech Pathology Australia has a strong commitment to promoting and supporting evidence-based practice. The development of a coordinated, national evidence-based practice strategy is a key strategic goal of the Association. Background There has been a measurable shift in many areas of health care towards the incorporation of evidencebased practice into professional health and medical practice (Druss, 2005; Guyatt, Cook and Haynes, 2004). Evidence-based practice has been endorsed by a number of key governing bodies including the American Speech-Language-Hearing Association (ASHA), The Royal College of Speech Language Therapists and The Australian Medical Association, due not only to the ability of evidence-based practice to facilitate improved client outcomes, but also as part of a general trend towards greater accountability and professional responsibility (Dollaghan, 2007). This position statement outlines the position of Speech Pathology Australia with regard to the integration of evidence-based practice into professional speech pathology practice. Speech Pathology Australia expects that speech pathologists will progressively incorporate the best available evidence into their clinical practice to the best of their ability and that there will be an increasing reliance and absorption of evidence into daily professional practice over time. Speech Pathology Australia believes evidence-based practice is paramount to the practice of speech pathology in Australia, ensuring identification and use of the best available assessment tools and clinical interventions in clinical practice and facilitating the best outcomes for clients. What is evidence-based practice? Evidence-based practice originated within the field of clinical medicine where it was defined as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. evidence-based [practice] means integrating individual clinical expertise with the best available external clinical evidence from systematic research" (Sackett et al., 1996, p. 71). ASHA defines evidence-based practice as an approach in which current, high-quality research evidence is integrated with practitioner expertise and client preferences and values, into the process of making clinical decisions (ASHA, 2005, p. 1). It involves moving the foundation for clinical decisions from clinical protocols centered solely on expert opinion to the integration of clinical expertise, the best current research evidence, and individual client values (ASHA, 2005). Evidence-based practice ensures that the latest research evidence from high quality scientific studies is used to inform expert clinician management of assessment and treatment in conjunction with client needs and values. Such an emphasis underpins the growing maturity of a research-focused profession. Advances in evidence-based practice within the profession of speech pathology Advances in the knowledge base, service provision and scope of practice of speech pathologists have significantly impacted the complexity and diversity of the profession (Speech Pathology Australia, 2005). These advances have resulted in significant work changes, requiring practitioners to not only consider factors relating to individuals and families they serve (such as client needs, values and preferences) but Copyright 2010 The Speech Pathology Association of Australia Ltd 3

4 also develop new clinical skills that are underpinned by a sound knowledge base that is based upon published research and thus open to scrutiny. Recently developed models of evidence-based practice suggest that speech pathologists undertake a defined process when determining appropriate treatment for clients (Larrabee, 2009; Dollaghan, 2004, 2007; Gillam & Gillam, 2006). This process commences with the creation of a general or specific clinical question, for example, What is the evidence that computer-based programmes improve the language function of children with language delay? A search of the databases then follows, with specific attention paid to identification of evidence that pertains to the question and the level of evidence that is represented (such as whether the evidence arises from a systematic review or a randomised controlled trial). Epstein, Nazario and Yu (2009) suggest that speech pathologists require the skills of library searching and critical appraisal of research to evaluate information and incorporate research into his or her knowledge base and value system (Epstein et al., 2009, p. 32). Critical appraisal of the evidence then follows. This step of evaluating the evidence is easier than it used to be as there are now many guides available. One such guide developed by the National Health and Medical Research Council (NH&MRC), 1 provides a hierarchy from which the different levels of scientific information can be evaluated. This hierarchy of evidence is summarised below in Table 1. Table 1 Levels of evidence Level I Level II Level III Level IV Evidence obtained from a systematic review of all relevant randomised controlled trials. Evidence obtained from at least one well-designed randomised controlled trial. Evidence obtained from well-designed controlled trials without randomisation. Evidence obtained from well-designed cohort or case control analytic studies, preferably from more than one centre or research group. Evidence obtained from multiple time series, with or without the intervention. Dramatic results in uncontrolled experiments. Opinion of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. As indicated in Table 1, the highest level of evidence (Level I) is considered to be a systematic review of a number of randomised double blind placebo controlled trials. In a randomised control trial, participants are randomly assigned to either a placebo group (which receives some form of intervention that does not include the intervention being evaluated), or a treatment group (that receives the intervention being evaluated). Outcome data from both groups are collected and analysed. Double blind means that neither the research participants nor the researchers know which group the participants were in until after the data are collected/analysed. A systematic review examines all the randomised control trials published in an area and makes a general finding regarding the overall effect of an intervention, using specific meta-analytic statistics. 2 Whilst systematic reviews of randomised controlled trials are considered to be the gold standard in medical research (Greenhalgh, 2001; Tate et al, 2008), recent work draws attention to the value of n=1 randomised control trials (Guyatt, et al 1990; Sackett, Straus, Richardson, Rosenberg & Hayes, 2000; Tate et al, 2008). n=1 randomised control trials are highly methodologically-controlled single case design trials that currently comprise the largest proportion of studies in some areas of clinical practice Copyright 2010 The Speech Pathology Association of Australia Ltd 4

5 (Perdices et al, 2006). As they closely mimic a clinician s work with individual clients, their importance to evidence-based practice is apparent (Tate et al, 2008). Such trials have recently been the subject of a new rating scale (known as the Single-Case Experimental Design (SCED) scale, that aims to ensure quality of design and facilitate the inclusion of such trials into evidence-based practice databases such as the psychbite and speechbite (Tate el al, 2008). The SCED scale complements the PEDro scale that methodologically rates group randomised control studies (Maher, Sherrington, Herbert, Moseley & Elkins, 2003). The SCED scale enables a critical rating of n=1 randomised control studies on features such as inclusion of well-designed baseline data and the randomisation of treatment and control conditions. It is also important to acknowledge that randomised control trials will not be appropriate for all research studies (see Greenhalgh, 2001, p. 47). Indeed, many important and valid studies in the field of qualitative research do not feature in the hierarchy of evidence and rate poorly on the scales outlined above. For this reason, it is important that clinical practice be informed by information obtained from different sources, including information from other levels of evidence such as controlled trials without blinding or random allocation, cohort studies, cross sectional surveys and non-experimental single case designs. There are many in-depth guides to assist further understanding of these research designs, including Dollaghan (2007) and Greenhalgh (2001). Valuable information to inform clinical practice is also available by means other than that provided through research projects. For example, papers that describe hypotheses and theories will facilitate understanding of theoretical frameworks underpinning clinical interventions. They will also provide a first step to designing research studies that aim to investigate the efficacy of treatment interventions. Information provided in workshops and seminars will also provide relevant information, particularly when the information is underpinned by research that is robust in design and interpretation. How evidence can be incorporated into daily clinical practice A readily accessible evidence based practice process has been described by Gillam and Gillam (2006, p. 304). The steps in this process are: 1) creating a general or specific clinical question; 2) finding external evidence that pertains to the question; 3) determining the level of evidence that the study represents and critically evaluating the study; 4) evaluating the internal evidence related to client-patient factors; 5) evaluating the internal evidence related to clinician agency factors; 6) making a decision by integrating the evidence, and 7) evaluating the outcomes of the decision. An addition to the seven steps as described above is to evaluate the evidence relating to clinicianagency factors (Nelson & Steele, 2006). This extra step addresses the importance of an intervention being effective and economical. Specifically, should an intervention require a mode of service delivery that may be difficult to implement and sustain (e.g., requiring implementation four times a day), it will likely not be implemented. Consideration of clinician-agency factors ensures that practical aspects of the intervention program (such as frequency and duration) as well as its costs are taken into account as part of the evidence based process. The process as described above may be incorporated into clinical practice in the following way: A clinician is confronted with a client who presents with a disorder the clinician is not familiar with. As a first step to identifying appropriate treatment options for the client, the clinician should frame a relevant clinical question and then access a specialised evidence based database such as speechbite, or Copyright 2010 The Speech Pathology Association of Australia Ltd 5

6 journals such as Evidence-Based Practice (EBP) Briefs, 3 to search for systemic reviews or randomised control trials of relevant intervention programs. Often within these databases the studies will already be rated or reviewed and critically appraised, thereby providing the clinician with an easily accessible summary of the evidence for an intervention. The clinician is then able to evaluate the internal evidence related to their client and integrate the evidence for the intervention with internal factors such as client preferences and agency factors. A decision regarding the evidence for and efficacy of the intervention may then be made. Overview of the tools, resources or support required to use evidence based practice and increase confidence in critical appraisal skills Speech Pathology Australia acknowledges the importance of providing opportunities for speech pathologists to obtain formal and informal training in the incorporation of evidence into clinical practice. The Association supports the development and the provision of a range of continuing professional development activities in evidence-based practice, including training in use of the speechbite website, workshops at national conferences, and continuing education packages. Evidence-based practice is supported within the Association s Professional Self-Regulation Program. Points are earned by members who undertake activities related to the development or use of skills which support evidence based practice. Such activities include documented evidence of critical appraisal of evidence related to clinical management, attendance at relevant workshops, accessing databases and websites such as MEDLINE, 4 Embase, 5 the Cochrane Library 6 (Cochrane Database of systematic reviews, the Database of Abstracts of Review Effects, Cochrane Central Register of Controlled Trials), speechbite and ASHA journal websites. Challenges faced by clinicians in their use of evidence based practice The Association acknowledges the inherent difficulties that clinicians may face in incorporating evidence into their daily practice. There may be limited availability of high quality research directly related to particular assessments and/or intervention techniques and/or clinicians may experience difficulties accessing relevant journals, texts and workshops. There may be limited time to read and absorb new information within the demands of a clinical caseload. Another challenge is that of reaching a common understanding of what constitutes evidence-based practice and being able to implement this in a practical way. It may be difficult for speech pathologists not trained in evidence-based practice to understand the principles of evidence-based practice and implement evidence-based programs that move beyond those informed solely by lower levels of evidence, such as clinical experience and the opinions of colleagues (Zipoli & Kennedy, 2005). Speech Pathology Australia acknowledges these difficulties and seeks to provide educational resources such as workshops and published articles to inform speech pathologists as to how to integrate the evidence into their daily clinical decision making. A further challenge may be that time and environmental constraints (such as organisational directives; limited budgets, etc) reduce the ability of clinicians to implement those interventions informed by robust research and a strong evidence base. In these cases different interventions also supported by evidence but meeting the unique constraints faced by clinicians may need to be found and implemented openmenu=-2 6 Copyright 2010 The Speech Pathology Association of Australia Ltd 6

7 Members responsibilities Speech Pathology Australia considers it imperative that speech pathologists develop and maintain skills in searching for, identifying, evaluating and selecting research that is appropriate to the clients and families they are servicing. It is essential that speech pathologists maintain skills that enable them to evaluate the evidence from a variety of sources such as published research papers, textbooks, conference reports and continuing education seminars. To provide high quality care speech pathologists must implement the principles and steps of evidencebased practice by asking answerable clinical questions and rapidly finding and accessing all best current evidence pertinent to these answerable, objective questions. They must critically appraise the research evidence for validity and relevance to the clients they are seeing, considering each client s unique situation. They must provide high quality care in line with the research and client and agency needs, evaluate the effectiveness of the clinical care and update the process as new evidence occurs (ASHA, 2005). Clinicians are obliged to communicate clinical alternatives to clients and to continually update and extend their professional knowledge and skills, thereby working towards the best possible standards of care for clients (Speech Pathology Australia, 2000). Workplace and employers responsibilities Employers and team leaders have a duty to their employees and their clients to ensure that speech pathologists have access to both time and resources (for example speechbite ) that enable them to access the tools and develop the skills to implement the principles and steps of evidence-based practice. Workplaces are expected to actively support continuing professional development and education opportunities for staff and provide access to other training tools such as online packages that inform employees of best practice and general evidence-based practice relevant to their areas of clinical practice. Researchers responsibilities Researchers are expected to conduct high quality, clinically useful research and report research findings within evidence-based formats. It is important that collaboration between researchers and clinicians occur so that not only are the principles of evidence- based practice communicated and demystified, but that the research undertaken remains relevant to daily clinical practice. Universities must incorporate the teaching in evidence-based practice into their curriculum, including introducing new researchers to the research principles underpinning evidence-based practice. Researchers and university staff within the speech pathology profession are encouraged to support speech pathologists to gain further skills in the use of evidence-based practice through continuing education activities such as workshops, lectures and other training methods. The Association s responsibilities Speech Pathology Australia is committed to facilitating the knowledge and skills of speech pathologists in evidence-based practice and to providing access to resources that promulgate the best current evidence. This will occur through a number of means, including the ongoing provision of research grants and support of research initiatives, development and provision of access to databases and online resources such as SpeechBITE, access to continuing professional development opportunities through the Continuing Professional Development program and conferences, and the development of web-based tutorials and information. Speech Pathology Australia believes it important to continue to develop links Copyright 2010 The Speech Pathology Association of Australia Ltd 7

8 with international associations, local and international governments and to foster collaborations with other key stakeholders including but not limited to consumers and consumer groups. Future developments The Association sees future expansions in this field to include the development of educational forums, such as online education packages designed specifically for Australian speech pathologists, and the continuation of regular education workshops, columns and articles in Association publications such as in ACQuiring Knowledge in Speech, Language and Hearing. 7 Evidence-based practice will become and remain a prominent and recurring aspect of Speech Pathology Australia s continuing education activities. Continued collaboration across the speech pathology community will also be essential. Conclusion It is crucial that speech pathologists incorporate the best available evidence into their clinical practice. To this end, Speech Pathology Australia is committed to supporting speech pathologists to develop and maintain the skills necessary to ensure the proficient use of evidence to inform clinical practice. The Association acknowledges the limitations that currently exist in relation to the evidence base for particular speech pathology interventions and strongly supports appropriate research to inform the profession. To develop and maintain the highest quality of clinical standards, speech pathologists have a duty to clients, employers and colleagues to obtain, understand, evaluate and then incorporate the highest available form of research evidence into their client care. Employers have an obligation to employees and clients to support access to continuing professional development opportunities and resources that will develop clinicians skills in evidence-based practice. The Association is aware that limited time and skills may create challenges to the use of the best evidence in practice, and seeks to provide appropriate tools, education and support to members to overcome such barriers. The Association is committed to ensuring evidence-based practice is promoted as a culture throughout the profession in Australia. References American Speech-Language-Hearing Association (ASHA). (2005). Evidence-Based Practice in Communication Disorders: Position Statement. Available at: Dollaghan, C. A. (2004). Evidence-based practice in communication disorders. What do we know, and when do we know it? Journal of Communication Disorders, 37, Dollaghan, C. A. (2007). The handbook for evidence-based practice in communication disorders. Baltimore: Paul H. Brookes. Druss, B. (2005). Evidence based medicine: Does it make a difference? Use wisely. British Medical Journal, 330, Epstein, L., Nazario, A., & Yu, B. (2009). Evaluation of evidence in evidence-based practice and how library science can help. Perspectives on Issues in Higher Education, 12, Gillam, S. L., & Gillam, R. B. (2006). Making evidence-based decisions about child language interventions in schools. Language, Speech, and Hearing Services in Schools, 37, Greenhalgh, T. (2001). How to read a paper. (2nd ed.). London: BMJ Publishing Group. 7 Copyright 2010 The Speech Pathology Association of Australia Ltd 8

9 Guyatt, G.H., Keller, J.L., Jaeschke, R., Rosenbloom, D., Adachi, J.D., & Newhouse, M.T. (1990). The n-of-1 randomized controlled trial: Clinical usefulness. Our three year experience. Annals of Internal Medicine, 112, Guyatt, G., Cook, D., & Haynes, B. (2004). Evidence based medicine has come a long way. British Medical Journal, 329, Johnson, C. J. (2006). Getting started in evidence-based practice for childhood speech-language disorders. American Journal of Speech-Language Pathology, 15, p Larrabee, J. H. (2009). Evidence-based practice. New York: McGraw-Hill Medical. Maher, C.G., Sherrington, C., Herbert, R.D., Moseley, A.M., & Elkins, M. (2003). Reliability of the PEDro scale for rating quality of RCTs. Physical Therapy, 83, Nelson, T.D., & Steele, R.G. (2006). Beyond efficacy and effectiveness: A multifaceted approach to treatment evaluation. Professional Psychology: Research and Practice, 37, Perdices, M., Schultz, R., Tate, R.L., McDonald, S., Togher, L., Savage, S., et al. (2006). The evidence base of neuropsychological rehabilitation in acquired brain impairment: How good is the research? Brain Impairment, 7, Sackett, D. L., Rosenberg, W. M. C., Muir, J. A., Gray, R., Haynes, B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn t. British Medical Journal, 312, Sackett, D.L., Straus, S.E., Richardson, W.S., Rosenberg, W., & Haynes, R.B. (2000). Evidence-based medicine: How to practice and teach EBM (2 nd Ed.). Edinburgh: Churchill Livingstone. Speech Pathology Australia. (2000). Code of ethics. Melbourne: Speech Pathology Australia. Speech Pathology Australia. (2005). Work value document for the speech pathology profession. Melbourne: Speech Pathology Australia. Tate, R.L., McDonald, S., Perdices, M., Togher, L., Schultz, R., & Savage, S. (2008). Rating the methodological quality of single-subject designs and n-of-1 trials: Introducing the Single-Case Experimental Design (SCED) Scale. Neuropsychological Rehabilitation, 18, Zipoli, R. P. Jr., & Kennedy, M. (2005). Evidence-based practice among speech-language pathologists: Attitudes, utilizations and barriers. American Journal of Speech-Language Pathology, 14, Acknowledgments Project Officer: Dr. Jenny Harasty, National Adviser, Evidence-Based Practice Review Date: August 2016 Copyright 2010 The Speech Pathology Association of Australia Ltd 9

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