Is AAC at the top of your tool bag? Conceptualising clinical competence in AAC

Abstract

Speech language pathology is a competency-based profession of which augmentative and alternative communication (AAC) is a core component of practice. Despite this, competence in AAC is not clearly defined within clinical guidelines or the literature. Semi-structured interviews were used to explore what competence in AAC means to Australian speech language pathologists (SLPs). Sixteen SLPs participated via Zoom. All interview data were coded and collapsed into four themes: (1) Breadth and depth of knowledge in AAC, (2) A range of clinical skills in AAC, (3) Confidence in AAC as a practice area and (4) Beliefs and values of the clinician. The interconnected nature of these themes was apparent throughout the interviews. It is important for SLPs to have a clear understanding of competence within each area of practice, but this is particularly pertinent in AAC where unique knowledge and skills are required. A definition of clinical competence in AAC is proposed.

Keywords:

• Augmentative and alterative communication
• competence
• speech language pathologist

In Australia, the training of speech-language pathologists (SLPs) is competency-based. In order to register as a certified practising clinician, students must graduate from an accredited university program and demonstrate ‘entry level competence’ on clinical placements and practice-based assessments (Speech Pathology Australia, 2017). Upon graduation, SLPs are then expected to maintain clinical competence throughout their career by engaging in reflective practice, continuing professional education and clinical supervision.

Speech Pathology Australia defines competence as ‘an individual’s ability to effectively apply all their knowledge, understanding, skills and values within their designated scope of practice’ (Speech Pathology Australia, 2017, p. 3). A key component of this definition is ‘scope of practice’ which refers to the roles, responsibilities, activities and decisions that SLPs are competent in and authorised to undertake (Speech Pathology Australia, 2020b). In Australia, the scope of practice for SLPs is extremely broad encompassing language (inclusive of augmentative and alternative communication), speech, hearing, voice, fluency, and cognition (Speech Pathology Australia, 2020b); similar to the United States (American Speech-Language-Hearing Association, 2020), United Kingdom (Health and Care Professions Council, 2014) and New Zealand (New Zealand Speech-Language Therapists’ Association, 2012). Therefore, how competence might ‘look’ (i.e., the specific behavioural characteristics), is hypothetically different depending on the role and scope of the SLP. For example, a competent SLP servicing an adult client experiencing difficulties with speech due to an acquired condition would exhibit different knowledge and skills in comparison to a competent SLP servicing a paediatric client with developmental disabilities who requires an augmentative and alternative communication system (AAC). This difference is particularly pertinent for areas such as AAC which are constantly developing and changing due to advances in technology (McNaughton & Light, 2013). For the purpose of this paper, AAC is defined as any communication strategies or techniques used to augment or replace verbal output including the use of an aided (e.g., communication book or speech generating device) or unaided (e.g., gesture or sign) communication system (Beukelman & Light, 2020; Speech Pathology Australia, 2020b).

In 2012, AAC was formally recognised as part of an Australian SLP’s scope of practice when Multi-Modal Communication was included as a range of practice area within the Competency-Based Occupational Standards (CBOS) for Australian SLPs (Speech Pathology Australia, 2017). Alongside this inclusion, Speech Pathology Australia released an Augmentative and Alternative Communication Guideline which clearly outlined the knowledge and skills Australian SLPs should have in AAC (Speech Pathology Australia, 2012); this document was then updated in 2020 (Speech Pathology Australia, 2020a). In 2022, CBOS was replaced with the Professional Standards. While the concept of the range of practice areas was removed, the Professional Standards continue to clearly outline that an SLP’s role includes working towards optimising communication inclusive of augmentative and alternative communication (Speech Pathology Australia, 2020b).

While it is clear that AAC is a core part of a SLP’s role in Australia and internationally, competency in AAC is not clearly defined. Although the Augmentative and Alternative Communication Clinical Guideline does not define clinical competence in AAC, it does suggest that both theoretical knowledge and clinical experience, through education and training, supports the development of competence (Speech Pathology Australia, 2012, 2020a). The literature in this area similarly fails to provide a clear definition or picture of competence in AAC. In research investigating the self-perceived competence of SLPs in AAC in the Philippines (Chua & Gorgon, 2018) and the United States (Kovacs, 2021), competence was simply defined as ‘the ability to adequately provide services’ (Chua & Gorgon, 2018, p. 158; Kovacs, 2021, p. 1041). This definition is quite vague and is open to the interpretation of the individual SLP regarding what they perceive to be adequate services. Other prior research into competence in AAC has simply not defined competence at all (e.g., King, 1998; Marvin et al., 2003; Simpson et al., 1998; Sutherland et al., 2005). It is important to have a clear definition and understanding of competence specific to AAC in order to capture the unique aspects of this practice area. Therefore, this research aims to answer the following research question: How do Australian speech language pathologists define competence in Augmentative and Alternative Communication?

Method

Research design

An experiential qualitative approach was used to focus on the current workforce’s perceptions of competence (i.e., practicing SLPs) to provide a contemporary and clinically relevant perspective on the topic (Braun & Clarke, 2013). An individual interview format was selected to ensure the interviewees felt comfortable in expressing their subjective experiences and point of view (O’Leary, 2021). This format also aligns with the research question which seeks to understand the personal perceptions and experiences of SLPs. An online format was selected to reduce the logistical barriers present when scheduling time to meet with a busy SLP and to ensure participants from across a large geographical area (i.e., Australia) could be included (O’Leary, 2021).

All data was collected and analysed by author one. The data analysis process in qualitative research can be viewed as subjective, as different people’s views may form multiple realities (Saldana, 2021). Therefore, the positionality of each author is considered pertinent to the data analysis process. Author one is a qualified SLP trained in Australia with experience working with children who use AAC. Author one teaches AAC within higher education and is a doctoral candidate under the supervision of authors two and three. Author two has extensive experience in qualitative research in the public health sector; author three is a qualified SLP with extensive experience in quantitative and mixed methods research.

This study was approved by the Central Queensland University Human Research Ethics Committee (reference number 23676).

Participants

Sixteen Australian SLPs were interviewed regarding what competence in AAC meant to them. All SLPs completed their SLP training in Australia, were eligible for registration with Speech Pathology Australia and worked with children aged 0–18 years. As outlined in Table 1, five SLPs provided services in a rural area and the remaining 11 in a metropolitan area. As per the inclusion criteria for the overarching mixed methods study, all SLPs provided services to children however seven SLPs also provided services to adults. SLPs varied in their years of experience as an SLP which ranged from two to five years to more than 15 years. All SLPs currently provided services to AAC users except for one.

Table 1. Participant profile.

Participant Number	Location	Caseload	Years’ Experience	% AAC Users on Caseload
1	Metropolitan	Paediatric	2–5 Years	21–40%
2	Metropolitan	Paediatric	2–5 Years	61–80%
3	Metropolitan	Mixed	6–10 Years	21–40%
4	Metropolitan	Paediatric	6–10 Years	21–40%
5	Metropolitan	Paediatric	2–5 Years	41–60%
6	Metropolitan	Mixed	11–15 Years	41–60%
7	Metropolitan	Mixed	6–10 Years	21–40%
8	Rural	Paediatric	6–10 Years	41–60%
9	Rural	Mixed	2–5 Years	<20%
10	Metropolitan	Paediatric	6–10 Years	0%
11	Rural	Paediatric	>15 Years	41–60%
12	Rural	Mixed	6–10 Years	81–100%
13	Metropolitan	Mixed	6–10 Years	81–100%
14	Metropolitan	Paediatric	>15 Years	<20%
15	Rural	Mixed	11–15 Years	<20%
16	Metropolitan	Paediatric	>15 Years	<20%

Data collection

All 16 interviews were conducted by the first author. Data for this study were collected as part of a larger mixed methods project which aimed to investigate the confidence, competence, attitudes, and training experiences of Australian SLPs supporting children who use AAC. SLPs were initially asked to complete a survey via Qualtrics (Qualtrics, 2022) which was disseminated through social media, the SPA newsletter and emails to professional networks. The survey collected demographic information in addition to quantitative data. At the end of the survey, SLPs were asked to provide their contact information if they would like to participant in a semi-structured interview. Those SLPs were contacted by the first author to organise an interview time at their convenience. In total, 16 SLPs completed an individual, semi-structured interview via Zoom. An interview guide was developed and piloted (Saldana, 2011) where all SLPs were asked to outline their experience with AAC followed by the question, ‘describe what competence in AAC means to you?’. While further questions were posed as part of the interview guide, only responses to this question have been analysed and discussed here. Probing questions were asked as required. All interviews were audio and video recorded, transcribed verbatim and uploaded to NVivo 12 (QSR International Pty Ltd, 2020)

Data analysis

Inductive thematic analysis was applied using the six steps described by Palmer and Coe (2020). After each interview, the first author wrote a reflection which contained any themes that had emerged (Saldana, 2021). After all interviews were completed, the first author transcribed and read all transcripts while making annotations. Next, the first and second author generated initial codes for three interviews. Structural coding was used as it allowed for concepts to be represented in relation to a specific research question (i.e., how do Australian SLPs define competence in AAC?) (Saldana, 2021). To ensure data quality and trustworthiness, author one and author two met to confirm intercoder agreement was achieved (Creswell & Plano Clark, 2018); the first author then coded the remaining 13 interviews. Codes from the interviews were then collapsed into four themes by the first author and depicted in a mind map (see Figure 1). These themes were reviewed and verified by authors two and three.

Figure 1. Data analysis mind map.

Findings

Themes

When defining competence in AAC, four main themes emerged (1) Breadth and depth of knowledge in AAC, (2) A range of clinical skills in AAC, (3) Confidence in AAC as a practice area and (4) Beliefs and values of the clinician. While these themes are described separately, the interconnected nature of these themes was highlighted throughout the interviews. The themes appeared to interact, interconnect and impact upon one another when considering competence in AAC. Figure 2 demonstrates these relationships whereby a directional arrow indicates one theme is impacting upon another. For example, Values → Knowledge indicates values impacts on knowledge. A bi-directional arrow indicates both themes impact upon one another. For example, Skills ←→ Confidence shows that skills impact on confidence and vice versa.

Figure 2. Conceptualisation of clinical competence in AAC.

Theme 1: breadth and depth of knowledge in AAC

Knowledge or understanding of AAC was a strong theme throughout the interviews. While SLPs discussed knowledge in a range of areas including assessment options and knowing where to find information, there was particular emphasis placed on the importance of knowing a range of AAC systems or devices. Participant 14 captured why this knowledge is so important, ‘I think competence in AAC to me means that I have an understanding of the options that I can give a client in terms of the AAC, to help give them a voice’. SLPs felt that knowing a breadth of systems is required to be competent because SLPs should be able to consider all AAC options when selecting the best match for the client. As highlighted by Participant 5, depth of knowledge is also critical to ensure the most appropriate system is selected and trialled ‘…knowing how to accurately select a system and implement an appropriate system in a way that supports the client…’.

While knowing a range of AAC options is an important component of competence, Participant 1 felt that SLPs should also be aware of any bias and ‘… sort of not necessarily having, like a preferred system to always fall back on’. This can be difficult when there is a large array of AAC systems available which are constantly changing with technological advances. Participant 7 captured this sentiment when they outlined the importance of knowing what you do not know, ‘I think in AAC it’s a lot of at least knowing what you don’t know and knowing that options that are out there, and the companies that are out there to contact and guide you to the right solution’. SLPs spoke about the importance of constantly seeking up to date information on AAC demonstrating a key link between knowledge and an SLP’s values and beliefs surrounding lifelong learning.

Theme 2: a range of clinical skills in AAC

SLPs discussed the range of skills in AAC they believed a competent clinician should have including skills in assessment, feature matching, AAC trials, therapy, and explaining AAC to stakeholders. Seven SLPs felt that a competent clinician needed skills that are specific to assessing a person with complex communication needs and/or an AAC user. SLPs felt that assessment was an important component of AAC practice as it informs feature matching and AAC trials. For example, Participant 8 stated, ‘So I think competence is about being able to assess the client properly… in terms of their whole environment… to find a system that’s going to work with them and their family’. Participant 7 felt that a robust feature matching process was the best way to find the perfect system for a client: ‘I think feature matching is a really big component that’s often skipped over, and that bias creeps in… having a robust feature matching process… where you’re actually trialling different devices…’. However, feature matching and AAC were clearly linked with knowledge as an SLP needs to have knowledge about a range of AAC systems to then trial that range of systems with their clients. Participant 8 demonstrated this linear relationship: ‘Knowing what those systems are… how to find one that works properly and how to trial different ones’.

SLPs also outlined the importance of being able to explain and justify AAC to communication partners including parents, carers, educators, and other clinicians. Participant 14 described that a competent clinician ‘…can also explain to parents, why we’re using it, why we need to do this, having those skills to engage parents to say that this is their kid’s voice…’. Participant 10 explained why this is so important: ‘training communication partners or whoever else is involved in their care… needs to know how to use AAC’. When working with communication partners, SLPs also felt that a competent clinician can justify why AAC is important and bust myths surrounding AAC. Participant 6 explained, ‘I think competence for a clinician is… being able [to] bust myths around AAC, both for clinicians and parents, or caregivers and educators… to respond to those sceptical queries about AAC…’. Developing skills in educating and training communication partners appeared to be influenced by an SLP’s values surrounding family-centred practice, ‘I guess competence would also [be about] being able to talk about it with families, so to bring them along on that journey of understanding what AAC is…’ (Participant 16). However, the ability to explain and justify AAC is linked to an SLP’s knowledge of AAC including evidence-based practice. Participant 5 described SLPs with competency in AAC: ‘…they have good clinical reasoning and justification and evidence to support the AAC that they’re implementing’.

While overarching themes were consistent throughout the interviews, there was a discrepancy in SLPs’ views on whether competence means having skills to use a range of AAC systems. Some SLPs believed a competent clinician had the skills to fluently use many systems such as Participant 14, ‘… but also like not fumbling through an AAC system like Proloquo2go, like you know where things are, you can just use it smoothly’. Other SLPs believed that clinicians needed knowledge of a range of systems but not necessarily the skills in using or navigating all systems such as Participant 11, ‘I think it’s really hard for again the competence of actually using the device because there’s so many and they’re changing all the time which makes it difficult, but I don’t think it matters, that we’re not fabulous at every system.’ This discrepancy between the views of SLPs was not aligned with location, caseload, years’ experience or the proportion of AAC users on the SLP’s caseload.

Theme 3: confidence in AAC as a practice area

Five SLPs discussed the role of confidence in being a competent clinician. SLPs felt that speech pathologists would not take AAC users onto their caseload unless they felt confident in the first place which could subsequently impact their ability to feel more confident due to lack of experience or exposure. Furthermore, SLPs described that someone who is competent in AAC is more likely to introduce or trial AAC as a communication strategy. Participant 15 aptly likened competence in AAC to an SLP’s tool bag: ‘I guess it fits in with the confidence of it as well, like, if you’re not competent, then it’s [AAC] sort of maybe at the bottom of the tool bag, and you only get it out if you run out of other options’.

When considering the relationship between confidence and knowledge, some SLPs felt that a competent clinician doesn’t need to know everything about AAC, but they do need to have the confidence to tackle the unknown. For example, Participant 16 stated, ‘… so not necessarily to know everything, but to feel confident enough to at least get started…’. While SLPs felt that confidence and competence were linked, they also recognised that the terms are not synonymous: ‘I guess like at a base level it means you kind of know what you’re doing, so feeling, I was going to say feeling confident, which I know is not the same as competent!’ (Participant 5). SLPs talked about confidence as a ‘feeling’ an SLP would possess. While they related this feeling to competence, many SLPs spoke about competence as a more complex and multi-faceted phenomenon.

Theme 4: beliefs and values of the clinician

Throughout the interviews, SLPs discussed attributes of competence that were interpreted as their beliefs or values regarding service provision for clients who used or needed AAC systems. SLPs discussed these beliefs and values in relation to direct therapeutic supports including individualising their services to suit the needs of the specific client. Participant 3 discussed the importance of providing support for individuals regardless of the type of need and that SLPs should be ‘…competent to be able to flexibly deliver that [individual support] to kind of meet those needs in a really individualised way’. Participant 8 aptly described this as ‘… not just having a one size fits all kind of approach’. SLPs believed that this meant considering the client and their family holistically when prescribing AAC systems in addition to the delivery of AAC supports, ‘Looking at your client holistically and prescribing the best piece of equipment for their needs’ (Participant 12) which Participant 5 indicated should include ‘…identify what features are important to that client or that family’.

SLPs also outlined beliefs and values that pertained to core competencies including reflective practice and lifelong learning. Participant 1 highlighted the link between these two areas, ‘… that ability to be able to reflect on the decisions that you’re making and why you’re making them and being able to learn from that moving forward’. SLPs highlighted that continuous learning is particularly important in AAC due to the fast-changing nature of the AAC landscape: ‘…continually learning and trying to access new information about implementation of AAC, it’s not just you’ve learned one thing’ (Participant 1). These values then inherently linked to AAC knowledge, as SLPs need to keep seeking knowledge to ensure they have up to date information on AAC, ‘being competent in it would be being comfortable in learning new devices, knowing where to go, knowing what’s out there and know to stay fresh with it’ (Participant 9).

Interconnections between themes

‘Values and beliefs about SLP service provision’ appeared to impact upon ‘breadth and depth of knowledge in AAC’ and ‘a range of skills in AAC service provision’. SLPs’ perspectives on life-long learning impacted the knowledge and skills they would seek out through training and mentoring. Their values regarding service provision such as the importance of family-centred practice and individualised services for clients with complex communication needs affected the type of services and skills they perceived to be required when supporting AAC users.

‘Breadth and depth of knowledge in AAC’ impacted upon ‘a range of clinical skills in AAC’ and ‘confidence of the SLP’. SLPs felt that increasing their knowledge of AAC including AAC systems supported their clinical skill development. Similarly, SLPs discussed the positive affect of knowledge acquisition on their self-perceived confidence.

‘A range of clinical skills in AAC’ and ‘confidence of the SLP’ appeared to have a reciprocal relationship. SLPs discussed that increased skills in AAC increased confidence however, an SLP confident in AAC would be more likely to use AAC and therefore develop their clinical skills in this area.

Discussion

This study was designed to explore how Australian SLPs define competence in AAC. Sixteen SLPs shared their views on what competence in AAC means to them through semi-structured interviews. Four interconnecting themes emerged: (1) Breadth and depth of knowledge in AAC; (2) A range of clinical skills in AAC; (3) Confidence of the SLP; and (4) Beliefs and values of the SLP about service provision. These four themes have been summarised into the following statement defining competence in AAC.

An SLP who is competent in AAC provides individualised services that focusses on the needs and perspectives of the client and their family. They are confident in their knowledge and skills to assess the AAC user, feature match against a range of systems, prescribe AAC systems, provide intervention, and support communication partners. They continuously reflect on their own knowledge, skills, values, and bias and actively seek information, support, training, and mentoring where required.

The importance of SLP values and beliefs in AAC service provision

While each of the four themes were interconnected it could be theorised that the values and beliefs of an SLP regarding service provision is the starting point for developing competence. Values and beliefs appeared to have the most influence on each of the other themes via a flow on effect. As outlined in Figure 2, values influenced knowledge which influenced SLPs’ skills, which then flowed forward to confidence. Confidence then appeared to feed back to further influence skills. Without the pre-requisite values and beliefs, SLPs would be less likely to be able to then attain the knowledge, skills, and confidence necessary to competently service AAC clients.

The importance of an SLP’s values and beliefs across all practice areas are highlighted in Speech Pathology Australia’s Professional Standards (2020b) under the Professional Conduct, Reflective Practice and Lifelong Learning domains. This finding also aligns with the conceptualisation of global competencies described by Hyter et al. (2017) where dispositions and attitudes were thought to directly impact knowledge and skills. However, it could be argued that values and beliefs have a more direct and considerable impact on competence in the realm of AAC due to clients having one or more developmental or acquired disabilities (Beukelman & Light, 2020). Consequently, AAC users do not form a homogenous group. In addition to having a unique developmental profile, they also present with different cultural and language backgrounds, values, attitudes, and lived experiences. Ogletree et al. (2018) perfectly captures the importance of beliefs and values when working with this population, ‘Becoming aware of society’s diversity requires the ability to look beyond oneself – to achieve a conscious mindfulness of others. This awareness is advanced when, as providers, we solicit and are open to the perspectives of stakeholders close to the potential AAC users as well as the user himself or herself’ (p. 3).

Due to this diversity across clients, AAC can be a complex and challenging area within SLPs’ scope of practice as there are no standardised tests or prescriptive intervention protocols to follow (Beukelman & Light, 2020; Lund et al., 2017; Theodorou & Pampoulou, 2022). For example, if a child has speech sound difficulties, an SLP in Australia may administer the Diagnostic Evaluation of Articulation and Phonology (DEAP). If the results indicate the child has an inconsistent speech sound disorder, the SLP administers core vocabulary intervention which has clear therapeutic steps (Dodd et al., 2006; Flanagan & Ttofari Eecen, 2018). Unfortunately, none of these linear pathways exist in AAC which leaves the SLP to rely heavily on their own subjective perceptions of quality service provision.

Subjective perception of quality service provision may impact the training and support an SLP deems necessary and will therefore seek out. As acknowledged by participants in this study, staying up to date in AAC is difficult as technology constantly changes with new software coming onto the market every year (McNaughton & Light, 2013). This means that SLPs need to constantly invest time and money (often covered by the individual SLP) to stay abreast of these developments. However, how much training is enough training? How many AAC systems should an SLP be familiar with? At what point should an SLP seek mentoring to support a client? These factors all come down to the individual SLP and their own perceptions of lifelong learning and subjective perceptions of what defines quality service provision. This is concerning given that the introduction of the National Disability Insurance Scheme in 2013 privatised the disability sector meaning that any registered SLP can support AAC users and the motivation (of the company or individual SLP) could be financial rather than benevolent.

Knowledge and skills that are specific to the world of AAC

There are many skills an SLP may possess that can be transferred across practice areas and this is acknowledged in the Professional Standards (Speech Pathology Australia, 2020b). For example, speech pathologists may transfer their knowledge/skills in goal attainment scaling across multiple practice areas such as fluency (Eslami Jahromi & Ahmadian, 2021), disability (Steenbeek et al., 2010), communication (Schlosser, 2004) and traumatic brain injury (Finch et al., 2019). However, throughout the interviews reported here, SLPs highlighted knowledge and skills that are very specific to AAC such as feature matching and prescription of AAC systems. Feature matching is the process of comparing different AAC system features to identify a system that will best suit the person’s specific needs (Speech Pathology Australia, 2020a) and prescription refers to the process of recommending a specific system. Both of these skills are reliant on extensive and up to date knowledge in AAC. Unfortunately, SLPs internationally report mixed knowledge and skills in AAC (Matthews, 2001; Wormnæs & Abdel Malek, 2004); this includes Australia (Balandin & Iacono, 1998; Iacono & Cameron, 2009; Wen & Sutherland, 2022). Therefore, consideration should be given as to whether all SLPs should be permitted to prescribe AAC systems or alternatively whether a clearer pathway to developing knowledge and skills specifically in AAC is needed.

Confidence: where does it fit?

Confidence has been strongly connected with competence throughout the healthcare literature (Holland et al., 2012; Jackson et al., 2019; White, 2009) however, these two constructs are differentiated by the fact that confidence is an internal feeling whereas competence has the ability to be externally measured (Jackson et al., 2019; Sears et al., 2014). Cambridge Dictionary (2023) defines confidence as ‘the quality of being certain of your abilities…’. Abilities is the key word within this definition as it is synonymous with skill. Therefore, it is not surprising that participants identified that confidence and skills have a bi-directional or cyclical relationship. In other words, SLPs require confidence to implement AAC which then contributes to developing their skills but SLPs who have more skills in AAC are also more likely to feel confident to implement AAC.

The fact that confidence is interconnected with competence in the realm of AAC is not a new idea. For example, when discussing SLP clinical expertise in Australia, Iacono and Cameron (2009) identified that SLPs required confidence to complete clinical tasks such as convincing families of the benefits of AAC. Supporting families to shift their perception of communication from typical socio-cultural expectations (i.e., speaking) to a mode that is often (initially) unfamiliar, confusing, and intimidating is just one of many unique clinical skills that are specific to AAC. Participants in this study highlighted additional skills unique to AAC (i.e., feature matching, completing AAC prescriptions) as critical components of competence. White’s (2009) concept analysis of self-confidence in nursing highlights that ‘…self-confidence is highly contextual and task-specific’ (p. 106). Therefore, having a practice area (such as AAC) with unique skills could be problematic for clinicians; particularly those who work across multiple practice areas and therefore complete AAC related tasks less frequently. Furthermore, the diversity of clients requiring AAC systems means that each and every day presents with a novel context or new task for a clinician working in AAC. This could be an initial explanation for why speech pathologists internationally report low confidence levels in the area of AAC (Biggs et al., 2022; Sanders et al., 2021; Ward et al., 2023).

So where does confidence ‘fit’? Confidence has a reciprocal relationship with clinical skills which is by no means a novel idea (Holland et al., 2012). However, the impact of confidence within AAC is particularly pertinent given the unique skillset required of SLPs which may not transfer from other practice areas. Given the growing research supporting the effectiveness of AAC for people with complex communication needs (Morin et al., 2018; Walker & Snell, 2013; White et al., 2021), SLPs should have AAC at the top of their tool bag but this is not possible without self-belief in their clinical abilities (i.e., confidence). While concept analyses of confidence have been completed in other health disciplines (Holland et al., 2012; Jackson et al., 2019; White, 2009), an exploration of the antecedents, consequences, and components of confidence and competence for SLPs specifically is needed, particularly in the practice area of AAC.

Limitations

This research presents an initial exploration into defining and conceptualising competence in AAC for Australian SLPs. However, the findings only represent the views of the 16 SLPs who volunteered their time to complete a semi-structured interview and therefore, the definition proposed here may not represent the views of all SLPs in Australia. In addition, the conceptualisation depicted in Figure 2 represents a definition of competence from the viewpoint of practising SLPs and may not align with the viewpoints of other key stakeholders such as professional organisations, universities, people who use AAC or families of people who use AAC. Although AAC is part of an SLPs scope internationally, the focus of this research was on Australian SLPs and therefore is limited to the Australian context.

Future research directions

Future research should seek to further understand, define, and conceptualise competence in AAC for SLPs in Australia and internationally. While a definition of competence in AAC has been proposed by the authors, this definition requires review and feedback from key stakeholders including practising SLPs from across Australia to ensure accuracy and applicability to the current workforce. Furthermore, this study only provided a basic description and discussion of professional confidence and its role in the development of competence (specific to AAC). Confidence within itself is a complex and multi-faceted concept which requires in-depth analysis within the field of speech pathology.

Conclusion

Being a clinician with no clear description of clinical competence in a practice area is like trying to complete a puzzle where you have no picture to use as a reference point and some of the puzzle pieces are missing. To address this conundrum, this research proposes a definition of clinical competence in AAC based on the perspectives of Australian SLPs. Competence was inherently linked to breadth and depth of knowledge, clinical skills, the belief and values of the clinician and clinical confidence. The field of AAC presents with unique clinical skills that may be novel to many SLPs. However, the authors challenge Australian SLPs to put AAC at the top of their tool bag when working with any client with complex communication needs as a way to facilitate clinical confidence and competence.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the School of Graduate Research – Central Queensland University.