Logical and Inferential Generality

 
Remember Evidence-Based Practice (EBP)?  I have recently been thinking about it, and about the relationship between research and clinical practice.  Indeed, clinical expertise is one component of EBP, but what about the link between evidence and practice?  Statistical significance is important, but what are logical (and meaningful and appropriate) ways in which clinicians can translate evidence into daily practice?

Brackenbury, Burroughs & Hewitt (2008) demonstrated the massive challenges of EBP for SLPs. The authors highlight the critical importance of EBP and provide suggestions for clinicians.  Even if you are not interested in reading about EBP, I would highly recommend the article as it is a neat qualitative study.  (As an aside, look out for me thinking more about qualitative methods within Speech-Language-Hearing Science, as I am super duper into them.  Basically, I want to be an ethnographer.)

In my research seminar we have been discussing the very real divide between research and clinical practice. Initially, we considered the differences between inferential generality and logical generality.  Inferential generality allows us to make inferences about a population based on a sampling of subjects.  Logical generality is the application of information (derived from a sampling of subjects) to an individual.  (See Meline, 2009)  More recently, our discussions have centered about quality of evidence. Within both of these conversations, it is seems reasonable to state that researchers and clinicians consider evidence, but from arguably quite different perspectives.

For example, researchers may consider characteristics of the design, or if the statistical analyses were appropriately applied and interpreted. Clinicians consider evidence to support their understanding of a clinical population, or to support a certain intervention model or technique. Researchers consider evidence to substantiate a model. Clinicians may think about research with one specific client in mind. This divide is real, and we need to think creatively about ways to move the science of our field forward while considering how we are contributing to the clinical day-to-day system.

How can we (as researchers) produce research that is clinically meaningful? How can we (as clinical practitioners) develop better strategies for understanding and applying research in appropriate ways?

Developing a Robust Process for Improvement Part 1 of 4: Adapting

As a Speech & Language Pathologist, I (Alaina) am driven to continually improve my methods. I don't believe this is an unusual drive, and over the years I, like the professionals around me, have been advancing my knowledge and skills. The services I provide are becoming more and more effective. But recently I have been thinking about making this a more robust process.

It is more appealing to improve a lot and quickly and steadily rather than a little bit and slowly and haphazardly.

So, my ears perked last summer, when I heard a clip of a show on Minnesota Public Radio.  Kerri Miller was interviewing Tim Harford about his book, Adapt: Why Success Always Starts with Failure. I immediately downloaded the podcast, and then added myself to a long request list to get this book from my library.  A couple of weeks ago, I finally got to the front of the line, picked up the book, and began reading.

This sentence, his recipe for successfully adapting, has been reverberating in my head ever since: "The three essential steps are: to try new things, in the expectation that some will fail; to make failure survivable, because it will be common; and to make sure that you know when you've failed" (p.36).

It has given me a lot to think about, which I'm looking forward to sharing in this series of posts about improvement. The posts that follow will go into detail about this process of improvement. But for now, I want to end here, so that you may reread the quote from above, and so that it may reverberate in your head as well.

Taking the Time for Culturally Responsive Care

We have recently been thinking about the auxiliary services that Speech & Language Pathologists (SLPs) may be providing when committed to providing culturally responsive care.

Many SLPs will serve clients who differ from them in terms of both culture and language background. The American Speech-Language-Hearing Association’s 2010 demographic statistics indicate that the racial and ethnic makeup of ASHA members (about 89% white, 4% Hispanic/Latino, and 7% members of a racial minority) differs from the racial and ethnic makeup of the U.S. population (about 56% white, 16% Hispanic/Latino, and 28% members of a racial minority), making cross-cultural match-ups between SLPs and clients inevitable. (See also: Kohnert, et al., 2003)

Our thoughts about working with a culturally and linguistically diverse (CLD) caseload of clients have been informed by a course that we took as part of our MA degree program at the University of Minnesota, Twin Cities. During this excellent course, we developed a greater understanding of both typical and atypical bilingual language acquisition, as well as theoretical knowledge of how language can exist as a system composed of one or more languages. We explored the empirical evidence that points to a conclusion that supporting all languages used by a client is the most appropriate way to facilitate his or her language learning. We also investigated the concept of culturally responsive care, which must be effective and considerate despite the challenges faced by cross-cultural differences in worldview.

Over the past few years, we have refined our understanding of what culturally responsive care encompasses in actual, clinical practice. Indeed, one of the most critical variables of culturally responsive care, is time. When doing both long-term and short-term planning, we now take into account the auxiliary services typical of culturally responsive care, in terms of time spent with family members, time spent in dual-language treatment activities, and time spent advocating for our client.

During time spent with family members:

- We use conversation and observation to create a working picture of this specific client, understanding that the picture, similar to the client, will be evolving over time.
- We consider how therapeutic suggestions may be understood in a different cultural framework (which may require reading about that culture and/or lived experience interacting within that cultural group and/or members of the group).
- We partner with family members who will likely be providing support of the language spoken at home. This requires explaining techniques in a detailed but non-technical way.
- We employ flexibility in what we understand to be ‘best,’ reminding ourselves that the individual’s family may have different priorities. Sometimes this means accepting the family’s way of teaching the client when it differs from our vision of ‘best practices.’ (See also: The Spirit Catches You and You Fall Down)
- We support the family as they attempt to navigate other therapy services, the health care system, social services, and the educational system, understanding that they may not have the benefit of cultural ‘insider knowledge’ about these systems.
- We exert the extra communicative effort required when speaking through an interpreter to maintain an authentic connection with the client and family members.

During time spent in treatment:

- We engage in English-language activities if the client is currently part of an English-speaking community
- We engage in activities that develop the other language(s) spoken by the client. This is done directly when we have sufficient skills in that language, and indirectly when our skills are not sufficient. Indirect treatment activities will be family-centered, perhaps with an interpreter. (See also: Kohnert, et al., 2005)

During time spent advocating:

- We ensure the translation of SLP-specific documents (e.g. plans of care, assessment reports)
- We help interpret related documents (e.g. from other therapists)
- We take a leading role in advocating to insurance companies or school administrators for the client’s need for speech & language services. This may include explaining the additional components when planning and delivering an appropriate intervention for a bilingual client.
- We partner with interpreters (who may also be cultural brokers) and provide detailed, non-technical background information that may allow them to convey information in a more meaningful way

Irrespective of the number of clients whose cultural and linguistic background differ from yours, the time required may seem daunting. We don’t intend for this information to be overwhelming, but rather to be useful in helping you substantiate a case for the time you need to provide culturally responsive care.