From an initial idea to dissemination: a case study of novice practitioner research in South Western Sydney

Abstract

This paper describes the work of practitioner researchers in South Western Sydney Local Health District (SWSLHD), undertaking a project investigating a unique Augmentative and Alternative Communication (AAC) intervention. We outline the journey from an initial, practitioner-generated research idea through to research implementation and dissemination. The research journey is described in terms of research processes recommended in current practitioner research literature. This case study shows that with appropriate support and guidance, practitioner researchers can identify, develop, and implement clinically relevant research projects to generate evidence for clinical interventions.

• practitioner research
• capacity building
• community health
• allied health
• AAC

Building research capacity in allied health is an important aspect of health care policy (1–4). Allied health practitioners are increasingly expected to become involved in research at the workplace, and to report and disseminate findings (5–7). However, many allied health disciplines can be considered ‘research emergent’ (2, p. 347) as they have historically lacked a solid tradition of research and therefore the infrastructure to conduct research. Research clearly indicates that allied health practitioners require focused support to plan, implement, and disseminate research findings (1, 2) (4)– 6, 8– 10. The limited research infrastructure means that allied health disciplines lack the strong evidence base required for evidence-based practice when compared with medical- and hospital-based research (1–4). In the area of augmentative and alternative communication (AAC), there are urgent calls for published evidence to validate and guide clinical interventions (11, 12). Since AAC interventions are typically undertaken by speech-pathology and occupational therapy practitioners (11, 13), it follows that practitioners in these disciplines would require focused support to undertake research as part of regular clinical duties (2–4). The focus on building research capacity and supporting research in clinical practice is also timely given the urgent need for evidence to underpin assistive technology (AT) and rehabilitation interventions in AAC (12, 14).

In 2010, the Primary and Community Health Research Unit (PCHRU) was established in South Western Sydney Local Health District (SWSLHD). PCHRU aims to build research capacity and research skills in primary and community health practitioners from allied health, nursing, and general practice disciplines (15). PCHRU began a researcher mentoring program (RMP) in early 2011 to support novice practitioner researchers engaging in small-scale research projects within their clinical services (15). PCHRU's model for the 2011 RMP is described elsewhere (15). Briefly, the RMP uses three strategies to build research capacity in novice practitioner researchers (15):

1. Linking each research team with academic and/or clinical mentors in their core discipline.

2. Providing targeted research skills training in literature reviews, research design, and research methods.

3. Encouraging dissemination of research through conferences and publication in peer-reviewed journals.

PCHRU's second RMP was initiated in January 2012 with a particular focus on practitioners working in the SWSLHD Division of Community Health. Based on experiences with the 2011 cohort, PCHRU modified the RMP to provide greater support to research teams in the first 6 months. This change enabled a greater focus on developing research protocols and preparing applications for ethical review.

This paper describes the research journey of one research team within PCHRU's 2012 RMP cohort, undertaking a project on a unique AAC intervention in SWSLHD. This single case study outlines the progress from the initial, practitioner-generated research idea through to research implementation and dissemination. The research journey is described in terms of the research process for novice practitioner researchers, outlined by Dahlberg and McCaig (16). The major stages are problem and planning, research proposal or brief, data collection, data analysis, conclusions, and dissemination (7).

Background to the AAC research project

Classroom-based AAC interventions

Students with physical disabilities and complex communication needs require AAC systems to communicate (17). AAC systems are used by an individual to communicate and may include high- and low-tech devices such as a computerized speech generating device or symbol-based communication book (17). For students with physical disabilities, communication competence in using AAC may be essential for participation in the classroom and achievement of educational goals (18). In terms of service delivery, speech pathology and occupational therapy for students who have minimal verbal communication usually involves individual or consultative sessions (11), with students generally being removed from the classroom for the duration of therapy sessions (11). Recent evidence suggests that rather than working on AAC use only in individual therapy, integrating AAC devices into education practice allows students to experience immediate benefits in their everyday school and classroom activities (12, 19) (20). These classroom-based interventions allow students to interact with their communication partners, including other students and teachers (11), and may also contribute to lower rates of abandonment of AT and AAC devices (20). While these interventions appear promising, published studies to document and evaluate them are limited (11, 12) (19–21).

AAC interventions in SWSLHD

Within SWSLHD, services to children with severe physical disabilities and complex communication needs are provided by the Pediatric Physical Disability Team. This team comprises expert speech pathology and occupational therapy services delivered in the community. Prior to 2011, practitioners in the Pediatric Physical Disability Team withdrew students from the classroom for AAC therapy. The team had observed that AAC skills used during therapy were not generalized to the classroom environment. The team was also concerned that prescribed AAC devices were either not used during classroom activities or in some cases were completely abandoned. After reviewing available literature on classroom-based AAC interventions (11, 12) (19–21), the team developed a ‘whole class’ therapy program and implemented it in a primary school support unit classroom in Terms 3 and 4 of 2011. The aims of the ‘whole class’ therapy were to reduce barriers to students accessing AAC devices and increase student participation by using each student's AAC during classroom activities (11). As part of the ‘whole class’ therapy approach, the speech pathologist and occupational therapist, along with the teacher and teacher's aide, provided a 90-min session in the classroom every week for the entire duration of each school term (approximately 10 weeks). The content for each session was developed by the speech pathologist and occupational therapist, in consultation with the teacher and teacher's aide. The sessions focused on functional communication tasks, social interaction, and physical access to AAC devices associated with established curriculum goals. Both the speech pathologist and the occupational therapist also addressed the needs of individual students that had been identified in earlier clinical interventions.

Planning the research

As Dahlberg and McCaig (7) note, practitioners are well-placed to identify questions or issues in their workplaces. In early 2012, a speech pathologist (author KM) and occupational therapist (author SC), working in the pediatric physical disability team, began exploring ways to review the pilot therapy program they had developed. They decided to formally document and systematically evaluate the next therapy program scheduled for Term 2, 2012. As part of the program, students would receive and learn to use new AAC devices that had been previously trialled and prescribed by the two allied health practitioners. Training students on how to use AAC in the classroom was considered a key part of the ‘whole class therapy’ approach.

In order to progress with the research project, the two practitioners successfully applied for PCHRU's 2012 RMP cohort. PCHRU staff (authors EF and EC) then met with the two practitioners to discuss the research idea and the next steps in the research process. One aim of the RMP is to facilitate development of mentoring relationships by linking each project with researchers with expertise in relevant disciplines (15). Authors EF and KS joined the research project as mentors and were subsequently listed as co-investigators on the formal project documentation. The mentor roles had two aims. The first was to provide ‘outsider’ input into the research project (7) in terms of expert knowledge on research methods in communication (author KS) and AT outcomes (author EF). The second was to provide the mentors with experience in supervising research projects, which has been a secondary goal of the PCHRU RMP (15). The PCHRU director (author EC) was engaged as expert in epidemiology and research methods, providing research skills training and advice on research dissemination as required.

Refining the methodology

With the research team established, attention was directed toward refining the research design and methodology (22). The research team met to discuss the overall research aims and possible methodologies for conducting the project. The research team looked at a major text in the field (17) and reviewed literature describing evaluations of multi-disciplinary, classroom-based AAC interventions (11, 12) (19–21). By reviewing the literature, the research team developed an understanding of the ‘current state of play’ (7), as it related to AAC interventions and classroom therapy. The literature review also highlighted a key gap in current knowledge of school-based service delivery of AAC, in terms of descriptive studies documenting these interventions (11, 19). The research team then reviewed the clinical data already collected by the Pediatric Physical Disability Team as part of their routine service delivery and clinical practices. This ensured that the research team could integrate the data collection for the research into the existing standard clinical processes used. The research team settled on a ‘case series with pre- and post-test’ design as the most appropriate methodology (23). In this design, each student becomes a case study, with objective measures taken both pre- and post-intervention. The research team decided that the primary method of data collection would be participant observation, involving coding visual data from videos of classroom activities. Although visual data can be both complex and time-consuming to code (24), the research team felt it was critical to ensure that instances of both verbal and non-verbal communication were dentified and coded (17). Communication acts were defined using Dore's Speech Acts (25). The research team hypothesized that the number and types of communication acts would change as a result of the classroom intervention. The Participation Model (17) formed the theoretical framework for coding the barriers to communication acts between the children, their teachers, and peers. Expected barriers included a lack of access to an AAC device or the communication partner being unavailable. The research team planned for data collection to occur both pre- and post-planned ‘whole class therapy’ intervention.

Each researcher also began keeping research diaries to note the research activities undertaken, and record observations, personal thoughts, and ideas on the research process (24). Research diaries allow practitioner researchers to reflect on the research, and on how prior experiences with the research participants may impact on the objective analysis of data (24). Observations in the research diary can also form the basis of the discussion section of publications.

Writing the research proposal

Writing a formal research proposal helps to clarify all aspects of the research project, including participant recruitment, resources needed, timescale, and budgets (26). Formal research proposals also form the basis for later dissemination (9). The research team prepared a formal research proposal using a template developed by the SWSLHD Ethics and Research Governance Office. The template had similar headings to those advocated by McCaig and Dahlberg (26). As an experienced researcher in SWSLHD, author EC provided significant guidance in writing the research proposal. As part of the writing process, the research team documented the structured 10-week ‘whole class’ therapy program that had been developed in consultation with the classroom teacher and the teacher's aide. The program incorporated curriculum goals for the school teaching term, and specific functional communication goals for individual students, which focused on accessing and using their new AAC devices. The research proposal was circulated to members of PCHRU's Advisory Group for review (15), thereby gaining peer-review and support (26).

Ethical oversight

Ethical oversight of research is an important aspect of research governance within organizations (27). Members of the research team worked for SWSLHD; however, the research project was being conducted in a school classroom managed by the New South Wales Department of Education. As a result, ethical approvals were needed from both SWSLHD (through the Ethics and Research Governance Office) and New South Wales Department of Education (through the State Education Research Approvals Process, SERAP). The research team completed both applications using forms and templates provided by the respective organizations. The research proposal formed the basis of both applications and was used as a supporting document to the ethics application forms (26, 27). The research team took around 3 months to complete the applications. Once submitted, it took another 2 months for the applications to be approved.

Setting up data collection tools

While waiting for ethical approval, the research team developed a form for video coding using Microsoft Excel (Redmond, Washington). Author KM then undertook a pilot test of the form using sample video recordings taken from outside the research period. This pilot testing led to some refinements, which made the form more usable and codes more specific.

Data collection and analysis

Once ethical approval was granted by both SWSLHD and the New South Wales Department of Education, the research team recruited a total of seven students, aged between 5 and 11 years. The two clinicians completed the pre-intervention videos, and further diagnostic testing for AAC device prescription, at the start of the term. The 10-week program was implemented, and the two clinicians conducted the post-intervention videos. The research team, led by clinicians KM and SC, began coding the pre- and post-test intervention video data in July 2013. The research team created a code book for all coding, which described and defined each type of communication act and each barrier to undertaking communication. The research team met regularly to discuss progress and resolve any coding issues. The coding took significantly longer than anticipated due to research team members experiencing changes in clinical caseloads and work duties, and taking periods of personal leave. The coding also became more complex in the post-intervention video, as communication between the children, their teachers, and peers increased greatly in both frequency and complexity. Data analysis included assessing both the number of communication events and the type of communication. Again, this has proven both complex and time consuming. Although the data analysis is not yet completed, initial results suggest that each child within the study showed substantial changes in the types of communication they used, and have become more likely to initiate communication rather than respond to a question from teachers in the classroom. However, the data also suggest that as communication becomes more complex, the children's’ access to, and skills in, using AAC becomes more critical and potentially a barrier to increased conversation. The research team is now reviewing results of other AAC studies to better understand the implications of the findings.

Disseminating and reporting

A critical part of practitioner research, and of PCHRU's RMP, is in the dissemination of research to a wider audience (9, 15). Although this AAC research project is not yet completed, the research team has presented updates to colleagues and researchers through the SWSLHD Allied Health Research Day (28) and in discipline-specific in-services across SWSLHD. These events are designed to highlight research taking place within SWSLHD, enable novice practitioner researchers to gain experience in presenting their work to peers, and encourage others to participate in research. The research team presented aspects of the research to national and international colleagues at the biennial AGOSCI conference (29), gaining valuable experience in preparing a conference presentation and getting feedback from peers on the work. The research team was also invited to present at a local professional training forum in education (30). The research proposal formed the basis for these presentations (9, 10) (26). A manuscript for submission to a peer-reviewed journal is currently being drafted, led by EF and KS. The manuscript will be finalized once data analysis is completed (9). Finally, the research team's activities are also regularly reported to the PCHRU Advisory Group and the SWSLHD Community Health Executive Committee through PCHRU's current reporting arrangements (15).

Conclusions

The research team has made good progress toward its goal of generating and disseminating evidence for AAC interventions. This case study shows that with the right technical and academic support, practitioner researchers can participate in research teams to undertake clinically relevant research projects. However, finding time to complete research tasks alongside clinical duties and responsibilities can prove challenging and lead to projects taking longer than expected to complete. Resources on practitioner research provide structured advice to help practitioners understand the research journey, from the initial, clinician-generated idea and development of a research proposal to data collection, analysis, and dissemination.

Conflict of interest and funding

The authors report no conflicts of interest associated with this study.

Acknowledgements

SWSLHD Division of Community Health supported this research. Initial infrastructure funding for PCHRU (2010–2011) was provided by the Ingham Institute for Applied Medical Research. The Ingham Institute provides on-going in-kind support to PCHRU staff.