This is a transcript from our podcast episode published September 5th, 2021. The podcast episode is offered for .1 ASHA CEU (introductory level, related area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime.
A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible.
[00:01:34] Kate Grandbois: So once upon a time, when we first started recording, we recorded an episode on partner training and augmentative, alternative communication we did. And during that episode, we maybe fan girls a little bit over authors of some literature, which was very exciting. And then for some very, very lucky reason that author contacted us and agreed to come onto the show with us today, which is awesome. And what's even better is that she had a really wonderful idea for a new topic and brought along a colleague who we have met and had so many great discussions with. And so today we are so excited to welcome Dr. Cathy Bingerand Dr. Natalie Douglas welcome Cathy and Natalie.
[00:02:15] Natalie Douglas: Hey, thanks so much.
[00:02:16] Cathy Binger: Thank you.
[00:02:17] Amy Wonkka: So you guys are here to discuss implementation science, which I have to say. It's something that we did not know was a thing until you emailed us about it. So we're very excited. Before we get started with that topic, could you please both just tell us a littlebit about yourselves
[00:02:33] Cathy Binger: Sure. I mean, so I'm Cathy banger.
I have to tell you the reason why I actually did find you and contact you has directly to do with the topic that we're talking about today. , I was working on a paper with Natalie and my colleague close colleague, Jennifer Kent-Walsh on implementation science and was looking to see for purposes of the paper,you if, when and how people have been using our partner training or communication partner training program, and that's where I discovered your podcast. And then I've been listening like a mad woman ever since. Cause it's so great. So, anyway, so I am a professor at the university of New Mexico.
I've been here for about 16 years now and I specialize in doing research into child language and specifically child language interventions for children who requireAAC. Natalie?
[00:03:26] Natalie Douglas: Yes. So I am at central Michigan university. I've been here since 2013, but before that I was a clinician in longterm care hospital, outpatient environments.
And that really drove me back to the academic world, those clinical problems that I couldn't solve. So it was there that I kind of fell in love with implementation science around 2009. So I've basically been thinking about it non-stop ever since.
[00:03:55] Kate Grandbois: And what I love so much about the collaboration between the two of you is that you come from very different clinical worlds and I'm so excited to discuss implementation science and how it's really a common - it seems like a common denominator across all of speech pathology.
And we talk about this a lot on our podcast - our scope of practice is so wide.. When I talk to someone who works in a sniff, I can't believe that I have the same degree as them, because I don't know anything about anything that they do. So what I think is really interesting about this topic is that it's something that we can all relate to and really transcends so many different workplaces and clinical areas of expertise.
, if I need to say I'm excited about it one more time, it will just be redundant. So instead I'll just say I'm excited about it. So before we get into it I'm going to quickly read through our learning objectives and disclosures. Sometimes people write in and ask us to not read this part.
I can't not read it. I have to read it ASHA makes me read it. So please bear with me. I will try to make it fast learning objective number one: describe a brief history of implementation science and its recent intersection with speech and language pathology learning objective number two, distinguished between the traditional research pipeline and alternative research designs focused on implementation and learning.
Objective number three, list barriers and facilitators to SLPs engaging in clinical research disclosures. Dr. Natalie Douglas, his financial disclosures. Dr. Douglas receives a salary from central Michigan university and the Informed SLP. She also receives book royalties from plural publishing and has research funding from the American speech language hearing foundation.
Dr. Douglas has no non-financial relationships to disclose Dr. Cathy banger financial relationships. Dr. Banger is employed by the university of New Mexico. Dr. Banger is nonfinancial relationships. Dr. Binger is a member of Attia and special interest group 12. Kate that's me financial disclosures. I'm the owner and founder of groundwater therapy and consulting LLC.
And co-founder of SLP nerd cast my nonfinancial disclosures. I'm a member of ASHA, SIG 12, and serve on the AAC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis therapy, MASS ABA and the associate and the association for behavior analysis, international and corresponding speech pathology and applied behavior analysis, special interest group.
[00:06:09] Amy Wonkka: Well done. That was really fast.
My financial disclosures. I'm an employee of a public school system and co-founder of SLP nerd cast. And my nonfinancial disclosures are that I'm a member of ASHA SIG 12, and I serve on the AAC advisory group for Massachusetts advocates for children. All right. We did it.
The boring bits are done. All right.
[00:06:28] Cathy Binger: I actually, I love that you guys do the learning objectives. It's the only place where I feel like. You actually put them to good use because you revisit them during the podcast and you tie them back in which I need to start doing. So thank you for doing that. It's actually really helpful.
[00:06:49] Kate Grandbois: You're welcome. We like them. We try, I think it's mostly because we're not necessarily auditory learners ourselves, so, so, and we realized that people are listening to this while they're jogging and biking. Maybe not biking, but, or maybe biking. I don't know. People be people. So it was trying to repeat information is, you know, some of the best way to really get it in there.
Anyway, moving on, , implementation science, tell us everything. What is it? Maybe that's where we start.
[00:07:14] Cathy Binger: Take it away, Natalie.
[00:07:17] Natalie Douglas: Okay. So there are so many definitions of implementation science, but a major one. And I think a major way to frame it is implementation. Science is the study of what research gets into typical everyday contexts as delivered by the typical clinician.
So we're not necessarily talking about a research assistant that's like in a school delivering an intervention. We're talking about like the provider that would be there anyway is delivering the intervention to a child who should receive it. Right. So it's the study of what strategies might be better than other strategies.
So implementation strategies, you know, there are implementation outcomes that you could study that would be maybe different than the outcomes of the intervention, right? So it's like, if you think very broadly of. You know, and, and like Kate was saying earlier, you know, no matter which kind of section of speech path you're in, you either want your client to communicate better or swallow better.
Right. So that's, that would be the ultimate intervention outcome. Whereas an implementation outcome might be something a little bit different. Like how did, what was it like administering that intervention as a clinician? Tell me your perceptions about that. Did, what was the cost involved? What are your, what is your leadership or your administrators think at the level of the organization? Is this intervention sustainable? Like after the research team leaves, like, will you keep doing it or will you be like, oh, thank God. I'm so glad they left my school. My day is. Easier now. , so those were kind of some of the basic things that I think about with implementation.
[00:09:25] Kate Grandbois: Would it be fair to say that based on that definition, implementation science is really more about the clinicians perceptions perspectives, behaviors than it is about the client outcomes.
[00:09:37] Natalie Douglas: I think that the clinician's perspective and perceptions is one thing that you could measure of many. So I think implementation science is still ultimately most concerned about the client and patient outcome. , but then you also have different layers to get to that. Patient client outcome, where you're going to look at things at the level of the clinician at the level of the healthcare system, perhaps of the school system and of the organization. Cathy I don’t know if you would agree with that.
[00:10:11] Cathy Binger: Yeah, absolutely. I actually just pulled up one of the frameworks to help me, so yeah, I mean, uh, you have your intervention itself and that intervention, as you said, like you have your typical intervention outcomes, you're expanding like the veterans or whatever, but it's really, it's really, you're you're you can do both of those things, basically the same time in the same study.
And you're looking at things that Natalie talked about. So for example, in a, , what we're working on right now in the initial stages for our own partner instruction program, like two of the, , implementation outcomes that we're planning to look at are the appropriateness of that. Intervention. Right.
How appropriate do clinicians think that our impact program is? , as an example, how appropriate, what about the educational assistants who are implementing it in the schools? Like what are their perceptions of it? If we're working with families, what are their perceptions of it? , are there ways in which this isn't appropriate?
So it's, you know, like we present that to them. We present them with the the intervention and we talk to them about it and they tell us, you know, oh yeah there's no way we can do this because of this, you know, because of these organizational level factors, like, or my case load is way too big.
Like there's no way, you know, like all that kind of stuff, but it can also be what's the school principal have to say about that. , you know, like having the SLPs be the ones who are providing all of this instruction to the teachers in the classroom, , there's maybe there's some real barriers to that, right?
Like, you know, we've got to meet caseload, workload standards, this isn't part of the, like, how do you tie this into IEP? And like all those kinds of things that get in the way of, in our case with, you know, the intervention I'm telling you that right now, with our impact program, what are all the ways, things that get in the way of good implementation of, , a partner is communication partner instruction program.
And then, and then there's the actual doing of it. Like, you know, you're okay, you're running your intervention program. Like you got some feedback, he changed up your program a little bit, , to try to address those concerns. And then while you're doing the intervention. You're still talking to those people.
Like you're doing focus groups, you're doing in-depth interviews, you're doing like some kind of usually qualitative research approach. That's your implementation arm of this project that you're working on. And so while you're doing the intervention, you're continuing to talk to the SLPs who are delivering the intervention, right?
The SLPs in the schools let's stick with the school example. , and also, you know, doing, doing the same thing with the educational assistants or the special ed teachers, or whoever's doing the actual, like face-to-face with the kid, , you know, that sort and getting feedback from them and they're telling you, what's working and what's not working.
So that's, you know, you're measuring the feasibility in that case of your program by talking with the key stakeholders. So they can be very close to the intervention, right? Like in our case, it could be the, again, those educational assistants who are delivering the intervention, it can be the SLP who's teaching.
The end of the educational assistant writes, you'd get your SLP, who knows how to do the program. And they're working with a EA and EA is working with the kid. So like what's going on at those different layers. And then above that, what's going on at the organizational level, how, like, you know, what are the things that are good and that are getting, you know, all that kind of stuff.
So, yeah.
[00:13:41] Kate Grandbois: So to sort of recap, implementation science is sort of the intersection between evidence-based research oriented interventions and real world problems or real, real time, real life interventions, barriers in a work setting, how it's being implemented, but the stakeholders feel about it. It's the intersection of those two things.
[00:14:03] Cathy Binger: Perfect. Oh, good. I'm so glad I didn't screw that up. And is it,
[00:14:07] Amy Wonkka: is it always taking place in a, in a real life environment?
[00:14:12] Natalie Douglas: I think for the most part, yes. You know, and so one thing that I'm sure there could be exceptions to this, but. It makes me think about principles of neuroplasticity in a way, like you want to train what it is that you want in the context that you want it, you don't want to like hope and pray that it's going to generalize to other settings.
Right? So if you want it in the nursing home, do it in the nursing home. If you want it on the acute care unit, do it there just like how you would train a communication strategy, you know, or anything else. Right.
[00:14:49] Kate Grandbois: This makes so much sense. It's sort of like, duh. I mean, if you want, if you know that, that I, I love that there's now a research focus on, on what we, as clinicians working in, in, you know, working with our students, particularly individuals who might have a harder time generalizing, or might have a communication impairment for a specific cognitive re you know, have some sort of overlap with a cognitive issue.
, I think that makes so much sense. I'm wondering where it came from. Like where did this come from? Why am I just hearing about it now in my old age,
[00:15:20] Cathy Binger: my medium. Go ahead, Cathy. Yeah. So this sort of gets to the question, but at a point you're making a little bit earlier to Kate that, , w if I flip that question around, the question is why haven't we been doing this all along, right. Like, that seems like the, yeah, like what's going on here. So why we haven't been doing this all along, and I'm not saying this is a great answer, but, , as researchers, you know, Natalie and I P we're trained as researchers, you know, first we were trained as clinicians.
We're both SLPs, but then we were trained as researchers. And when you're trained as researchers in the end of the typical medical model, or even a typical, you know, education. Training programs as well. Like when you're doing research, one of the main tenants of doing a good research project is to control your variables.
How, how easy is that to do in the natural environment? Well, good luck with that. It's just it's so it's messy. Like research is so messy. And so, you know, for example, , like back way back when I was doing my dissertation, we really wanted to look at, , this, you know, aided modeling, right? So everybody's been doing the aided modeling.
They did modeling as a part of any AAC intervention programs since AC intervention programs began. And everyone's been assuming that it's a really important component and you know, me as well. , but I wanted to isolate. Aided modeling to see, is it, is it really necessary, right? Is it just one of many things that's, you know, a good thing to do, or is this an essential component of our interventions?
If you want to answer a research question like that, you have to control your variables. Like you've got to, you know, do everything the same. You got to do like everything in baseline that you would normally do in intervention, except for the modeling. And then add the modeling in and see what happens.
Like that's one way to look at that and answer that question. So there's a lot of control that's going on there. , I could give you lots of other examples, but you know, like we get in trouble in our own research for the kinds of approaches that we take because people think it's really narrow, but what, you know, it's what a clinician might have a hard time understanding because they don't have a training.
Is that there are really good researchy kinds of reasons for doing that to keep things under control. So that by the time we're done with the study, we have actually learned something new, not like, oh, we tried a bunch of stuff and the kids made progress. Like, yeah, we do. That's great. We do that in clinical work all the time.
And we need to document that, but research is a different thing. , so when you're, when you're in the business of trying to really answer very specific questions, you can't always do that in this real world kind of setting. And there are important questions to be answered that, that, , that can't be done in the real-world setting.
, I think where, so, so that's kind of like the background of why, like there's so much resistance to all of this is a lot of, you know, well-trained researchers kind of freak out. I think about this because. Oh, my God. Like if you're just doing stuff in the real world all the time, you lose all that control that you have in your lab.
[00:18:38] Amy Wonkka: I think that's such a good point. , and when we think about, for me not knowing very much about this, but having spoken with you guys a little bit about it, feeling very excited feelings. , I almost wonder if it's, if it's like, you know, I don't think it has to be one or the other because there is that piece.
I mean, I've, I've wondered that in aided modeling is a really good example, is somebody who's, who's also been working in AAC, you know, I I've questioned are there certain client characteristics that make. Make it a much more effective inter prevention for some people compared to other people. And I do, you know, I mean, I, I do go back to the research and I want those studies to be controlled so that I can, you know, read what somebody else teased out.
I think, you know, what's really exciting to me about the idea of implementation science is that you could apply sort of a similar structured way of looking at kind of the next step beyond that. Like, okay. So, you know, Cathy did this research and found this interesting stuff about, about how you could manipulate different things for students.
What does that mean for me? Cause I can't replicate that. So it's, you know, it's, it's like an intermediate step. I feel like that would help
[00:19:52] Cathy Binger: clinicians. So,
[00:19:55] Kate Grandbois: yeah. Sorry, go ahead Kate. Oh, I was just going to say so, so here we are sort of thinking about implementation science as the common denominator across all speech pathology and this, you know, start contrast between what you need in the research world to conduct actual research and what we need in the trenches of speech pathology to actually do our jobs and get things done and have those good outcomes for our clients research practice gap.
We've heard this a thousand times and here you are, like laying it out. So sort of back to my original question, why haven't we been doing this all along and where did, where did implementation science come from?
[00:20:33] Natalie Douglas: Yeah. So I think there have been some, and I would have to go back and look for you, , to get the exact information.
But there's a couple of stories in terms of growing corn and citrus use, like we're talking like way back, right? Where there, like, there were like food shortages and like one person had this like, amazing thing that they did to their corn and they grew all this corn. Right. And then there were other people who were like trying to grow corn and I'm like, why can't I grow corn?
And then it took like 300 years to like, get like this secret corn recipe, like to I'm
[00:21:13] Kate Grandbois: laughing because like, that's the last thing I expected to come out of your mouth. I
[00:21:17] Amy Wonkka: was expecting
[00:21:18] Kate Grandbois: like, oh, it came from the medical path. Something, no corn.
[00:21:25] Natalie Douglas: Well, and citrus is the other one. There was like these people on a ship.
And like, all of these people died of like curvy. Yes.
oh my God. These people who ate the lemons and the oranges, like, why are they still here with us? But then it took so long to like, get that message of like, oh, it's the
[00:21:45] Kate Grandbois: vitamin C. That seems well, I'm sorry. I just I'm so laughing. I just never thought I would scream the word scurvy on our speech pathology podcast.
But before
[00:21:53] Amy Wonkka: we, before we deviate too far from the
[00:21:56] Kate Grandbois: learning objectives, , I just, I guess when did it come into the world of speech and language pathology? Because I've never, again, in my medium old age I have, this is like, like, this is huge. This is so.
[00:22:10] Natalie Douglas: Right. So Jackie Hinckley, who was my PhD mentor, gave me a monograph back in 2009.
, Dean fixing and colleagues there, I'm at the UNC chapel hill now. And they have a really renowned implementation science Institute. Well, they published what is now I consider to be like a Seminole monograph of implementation science research first in 2005. , but you will find examples within that monograph kind of moving, you know, way far back.
, but that's kinda when I first, , came across this and when I was going through and reading that monograph, I just, it was like a million aha light bulb moments because it really, I could see mechanisms for the first time as to why I couldn't. Implement what I wanted to do in my speech path, job. Like I would like be in the nursing home and I would know something about an intervention that I wanted to implement, but I couldn't do it not because I had, I needed continuing education on the topic.
Like I knew what it was I was supposed to do or wanted to do for my client, but I couldn't do tell us the marker story. Yes, the marker story is when, so my, a lot of my work is in Y , hopefully helping the uptake of communication supports for people with dementia in nursing homes. , based off of Dr.
Michelle work in external memory aids and for people with dementia. And so when I did my dissertation, so this is work that she did for. 30 years of research on the efficacy of external memory aids for people with dementia. And when I did my dissertation, it was like, Nope, like less than half of the people.
, I was in Florida at the time were using external memory aids. And I know why, like, so I went to try to do make an extra, I was working PRN in a nursing home at the time. And I wanted to, you make an external memory from one of my clients with the dry erase board. And I couldn't find it. My stinkin marker.
And so I was like, went around and I asked everybody and I'm like, I asked the nurse and they were like super busy. And I was like, hi, do you have a dry erase marker? And I was like, really a little bit afraid, you know, to talk to them. And they're like, no. And, , cause obviously there's more important things to do, right?
Like someone's bleeding or like pukey. I mean like clearly no one cared about my marker. So I just ended up walking across the street to, , CVS and just buying a marker and then like coming back and then doing it, , making the memory. But I felt so like, man, like there is such a gap between what I'm supposed to be doing and like, I can't even find a dry erase marker in this building to write on the board.
Like, this is just, what, what are, what are we going to do here? Like how do we fix it?
[00:25:15] Kate Grandbois: And I think everybody listening can probably relate to that. To some degree, they have their, a marker story of their own a day where they couldn't take a break or their caseload was crazy, or they were spent, you know, extra time dealing with a grieving parent who was crying.
And, you know, I think that the, and this is what I love about this implementation science idea is that common denominator, all disciplines. Thank you for telling your
[00:25:39] Natalie Douglas: story anecdote.
[00:25:43] Cathy Binger: Yeah. So that is a great show. In terms of, you know, modern day, Natalie, you stopped me where I'm wrong. But, you know, as Natalie said, it's only been a couple of decades that implementation science has really been a part of the research conversation period in the medical world.
, so this is, uh, this is a new conversation that we're having and it's really a rapidly growing rapidly expanding discipline. So there are a couple pockets that were early adopters of this, like in cancer and in mental health. , but what in our own discipline back in 2014, , the. Foundation arm of Attia, the American speech language hearing foundation sponsored the implementation science summit and, , really have to take our hats off to Leslie Olswang.
Leslie Olswang and Nancy min Getty were really key in putting that whole science at the summit together. So they invited researchers who did intervention research from across the disciplines of speech pathology and audiology to come learn about implementation science in 2014. And it was the introduction.
To that for, I think, you know, most of the people, if not all of the people who were there. , and so Jennifer Kent Walsh and I were invited fortunately to go to that summit and we left there like this, oh my God. Oh my God. Oh my God. Like, we have to do this. This is what we got into this gig for, you know, in the first place.
Like, this is why, like, we were both clinicians. I worked for eight years, , doing various things before I went back to school and was so frustrated by, you know, being in my own head, you know, just feeling like I was never good enough. I could never do what was in the journals. I, I, I just felt like such a failure, especially very early on.
I mean, really, you know, throughout that time of, , not being able to do what, what I was reading about and thought I was supposed to do in reading a journal article and being like, oh my God, okay. I just spent all that. I did what I was supposed to do. I just spent all that time reading that article. I don't know how to apply any of this.
I have no clue, but you know, and again, it's that research to practice gap where, , W w you know, the great, I think the, one of the great, uh, secrets that's out there that for some reason, no professor wants to tell their students is that, , the research journal articles that they're reading were not written for clinicians, right.
Were written for researchers. They're, you know, they're in research journal articles and they have to meet research standards. And I'm not saying like, you know, there are some more clinically oriented journals than others and some work, you know, all that stuff, but they are not written for clinicians.
Clinical newsletters are written for clinicians. Research journal articles are written for researchers and they have to meet all kinds of research standards. , and, , You know, like, oh, I just stepped to Kate. When you, when, when I listened to the podcast that you guys did on our communication partner instruction program, and Kate was like, oh my God, that one article, I could do that article.
[00:28:40] Kate Grandbois: Honestly, the fact that you listened to that, and now I'm looking at your face and you, you heard me say that I couldn't read your article. Like I'm just bearing my soul and the most humble moment to our entire audience.
[00:28:53] Cathy Binger: But I was still glad that you did because it's true. Like, and we know that when we write this stuff, because it's not Kate, it's fine.
Cause it wasn't actually written for hearing. And yet we tell our students and our clinicians that they're supposed to Amy looks like she's going
[00:29:13] Natalie Douglas: to
[00:29:13] Kate Grandbois: because I'm like, it was a really good article. I'm sorry.
[00:29:16] Cathy Binger: I told the world. I know it's so funny. I was laughing so hard listening with you and not somebody
[00:29:22] Kate Grandbois: else who just now has any feelings
[00:29:23] Cathy Binger: about me.
But it's directly applicable to this conversation because that stuff is not written for you. And yet we expect clinicians be able to take that stuff and adapt it. And we wonder why, like, why isn't everybody doing all this evidence-based practice? And we pointed the clinicians. You're not doing your job.
And it's total and utter nonsense and implementation science is there to fill in the gaps. And so, you know, that implementation science summit, that Jennifer Kent Walsh and I went to back in 2014, like we left saying, that's a, again, that like this, this is gonna change our lives. , and it's taken us all these, like, we're still, we're not there yet.
Where that finally planning, implementation, true implementation projects. , you know, it's a long road.
[00:30:06] Kate Grandbois: I have a question about, , the intersection between implementation science and single subject design. So we've talked a lot on our podcast about ASHA's evidence-based practice triangle, just for anybody who's listening, who needs a refresher.
It's, multi-pronged our, our approach to evidence-based practices. Multi-pronged you have your client and family values and perspectives and stakeholder perspectives. You have clinical judgment, and then you have evidence, but evidence is external evidence as well as internal evidence. And that's, you know, the data that you collect on your client's student patient to make sure that your intervention is working.
And that's really where we start getting into single subject design research. And I'm wondering if there is a big overlap between these two things
[00:30:53] Cathy Binger: between single case design research and implementation this based practice or implant and implementation. , I don't Natalie, let me take a quick stab at this and then you follow up.
Sure. You know, I don't know that doing single case design research is necessarily inherently that much closer in getting us from here to there then doing big group designs, because you still have the same issue where you haven't necessarily consulted your stakeholders in order to develop and test your intervention.
Right. You can still do it in your lab. You can still do it in a nice clean setting with controlled materials and blood, like all the same stuff. So I don't think that methodology necessarily, , is inherently closer in some ways. I kind of think maybe it is because you're looking at client behaviors, every single session, which you're not doing with your larger group designs, which are just, okay, how are they doing at the beginning?
And how are they doing at the end? You know, it's a much. Fine tuned kind of approach. , so you're learning more about what's going on with the client, but you know, it's still like, there's nothing you have implementation outcomes when you're doing civil cases
[00:32:07] Kate Grandbois: and research. Now, Natalie, before you jump in and pepper, your brilliance onto that, I would love to circle back at some point and talk about the role and importance of the communication partners and stakeholders.
, I just wanted to say that so that I didn't forget. Go on.
[00:32:23] Natalie Douglas: Yeah. So here's what I think about that because when I was working as a clinician, , and even though I took research methods classes, I, I did not know. And I still, probably only in the last like bit of time did I realize what is single subject design?
So if I was a clinic I could not administer. For clinical payment purposes, a single subject design, because that would mean I would have to choose to not treat certain items of the disorder because I'm having to hold those in control while I'm only treating one aspect. Right. And that's kind of an ethical issue as a clinician.
Like if I have a client with aphasia who has naming and reading difficulties, and I want to see this treatment X have an impact on reading and naming, right. I'm going to, I'm going to kind of hold, I'm going to try to hold naming and control. Right. , so I'm wondering if, what we're thinking of when we're thinking about clinician data is something that we refer to as like practice-based evidence.
So like. I am not holding these things in control. I put a document for you. This is everything that I'm doing, and these are the outcomes that I had. Right. So it's like, I had this person come to my session. We worked on this, this and this. , and these are the outcomes, right? And so that makes me. I think that that might be more of the intersection is like practice-based evidence.
So one thing that we really haven't talked about yet is in all of the models that we've talked about so far, it's still very top down from the researchers perspective. So the researcher says, okay, I studied this intervention in the lab. I got this with ideal conditions and now we're ready to go. So let's like pop it into a school and let's okay, we'll talk to stakeholders.
You know, we'll talk to the principal, we'll do this. That's still a pretty top-down approach. There is room in implementation science for something known as co-construction where I, you tell me like, this is the clinical problem that I'm having as a researcher. And I'm like, huh. And then like from the ground up, right.
The researcher and the clinician, and potentially even the client's family, right. Or the client themselves from the ground up, you're working that intervention and developing that intervention to be studied kind of from the beginning. Right. So it's like less of, I have this intervention now, how am I going to like, tweak it and get that in?
Like we have to be doing that. Absolutely. Like there's room for all of this, but there's kind of another approach where you can kind of co-construct what that intervention. And I just wonder from Cathy's perspective and we'll probably never know this, you know, what would your intervention look like if you started.
From the very beginning. Right. And more of that code, maybe you don't want to talk about that. I'm happy to talk
[00:35:48] Cathy Binger: about it. It might look different. It probably would look different and we'd be much further along with it in terms of being able to get it widely implemented, right? Like it's also more efficient to develop interventions using implementation science because you don't waste 2, 5, 10, 15 years, , doing stuff that's just not going to work in the real world.
, so it's, it's just, you know, if I were to start my career over right now, , we would have done all those things very differently. , we would have been doing implementation science as we built that intervention from the beginning and our other interventions that we're working on as well.
[00:36:28] Natalie Douglas: I
[00:36:28] Kate Grandbois: would love to talk a little bit about.
I know I mentioned, I wanted to hear about the role of the communication partner, but I think in thinking more broadly about that, the role of the environment and implementation science and the role of, I guess, the role of the, just acknowledging the role of the environment and communication partners in implementation of intervention in general, , and you know, sort of also thinking about our third learning objective with barriers and facilitation and facilitators for, , you know, how to get to some of that ground up or co-construction co-constructed literature or research, I guess that was a lot of questions at once.
We can start, we can start with the, with the, , with the environment and, and role of the communication partners.
[00:37:13] Natalie Douglas: Yeah. I can give an example about the environment. So there was one study that I did a few years ago that looked at kind of practice patterns of speech pathologists in skilled nursing facilities and speech pathologists, , who had.
If a higher productivity pressure and felt, , more negative aspects of organized organizational culture actually provided less, , language and communication services when compared to dysphagia services. So again, you know, this was a correlational study, so we can't say that, you know, it was the absolute cause of it, but there really appeared to be some type of association between perceived productivity, pressure and aspects of the organizational culture and the type of services that were provided.
Almost like, you know, in my mind, I just think about, well with these swallowing referrals, I have to put these fires out and make sure like nobody gets readmitted to the hospital and everybody, and of course that you know, needs to be done, but then there's maybe less time. For language and communication services in that type of environment,
[00:38:28] Cathy Binger: potentially.
So Kate to circle back around to your question about partner instruction and how that all fits in. So with implementation science, we're looking at things like, , you know, how can we implement an intervention in a real world? And if we are going to implement it with teachers, with educational assistance, with whoever, , can, what are the, what are the things that lend themselves well to an intervention?
And what are the things that keep that intervention from being something that you can, you know, tackle? So there may be caseload issues. There may be, , you know, everybody's only being seen in group settings and it's an intervention designed for individuals. It can, you know, there, there are all those things that come into play that are just real life stuff that you have to face when you're a clinician and you face that stuff every day.
, so implementation science, when you bring that in, you're involving your stakeholders and figuring out, oh, like in the case, again, it's easy for me to talk about our own program, the impact program that, , the, is it, are there things that are part of that program that are just not implementable in the school setting?
, we tried to make it as flexible as possible. For example, you know, you don't have to spend 60 minutes doing X in one shot, you can break it up, but there are probably any number of other things that are not ideal in a real-world setting. So, , how do you do that? I'll give you, oh, I'll give you a really tangible example of a paper that, , just got accepted into the AAC journal.
We did a, a hybrid telepractice. , and face to face version of the impact program. , and it was just a first shot, just three kids. , oh, there's this one component of it is telepractice, but, , one of the things that we found was that, , oh, this was with parents. So, you know, the program was implemented three days a week.
And the feedback we got from parents was no can do, like that's too much. This needs to only be two days a week because this was just more than we could handle. Right. So like getting, getting that kind of feedback from them. , and then how we parsed it. Oh, I know what a big thing was that that Erica Tempe was in charge of this study.
, she was Jennifer Kent, Walsh's doctoral student. And, , she came in from a strong clinical background and she said, I love the impact program, but I can't bill for the impact program because you got all these role plays in here and, you know, like, uh, I can't bill for that time. So I can't do this this way.
[00:41:00] Kate Grandbois: Indirect service, every episode we mentioned indirect service.
[00:41:06] Cathy Binger: Yeah. So we, , you know, Jennifer and I were both kind of like, you know, especially me, I think, you know, fighting around the role-plays are so important and blah, blah, blah. And Eric was like, yeah, well, I can't bill for it. So what, what are we going to do?
So she really talked us into doing a version of the program with no role-plays and the kids there for every session so that you can bill for it. So like, that's an example of what happens when you get good steak. You know, she came in as an SLP with that stakeholder feedback and we have to Bob and weave like, you know, we had to change, make changes to the program.
So I think that's a really good example. Like what can happen when you're really getting that stakeholder input.
[00:41:45] Amy Wonkka: I love that example. And Kate and I, I mean, we have, we do have our soap box about indirect service broken record. Yeah. We feel like I'd love to see more advocacy around that because it's such an essential service to be able to provide to our teams and our families.
, but you know, we also talk a lot about the set framework and just the different barriers and facilitators that are unique to every environment. And so I think that's something that is really exciting to me about the idea of implementation science, because it's also that you could potentially be flexible within different types of environments and with different stakeholders.
, I had a question kind of back to that learning objective, number two, just to help wrap my mind a little bit better around implementation science. Like how, how is that different from sort of traditional research that I'm used to reading? Like are the dependent variables different? Do they change. If, if they do kind of, how do they change?
, is it more, you're looking more at sort of a treatment package, then you are able to kind of isolate those little, very bulls that you might do in more of a clinical setting. How, how are those differences? How does that play out with implementation science, with speech and language?
[00:42:59] Cathy Binger: Yeah,
[00:43:01] Natalie Douglas: those are such fantastic questions.
, wow. Amy, you
[00:43:06] Cathy Binger: might be an implementer.
[00:43:09] Natalie Douglas: I mean, wow. I
[00:43:11] Kate Grandbois: am lettuces SLP. Nerd cats
[00:43:13] Cathy Binger: slammed on, I'm wearing my out of my hair and
[00:43:18] Natalie Douglas: like stand up. I mean, this is like, okay, so here's here. Here's the thing I think. And Cathy had touched on this earlier. Traditional research was not designed for a clinician. And I think that is the even clinical research, right? Because we take our model for behavioral clinical research from a pharmacological research model.
Right. And this is really relevant now because of the COVID vaccine. Right. And so when all of these scientists are working on the COVID vaccine, like, I don't want them to Bob and weave. I want them to get it right. All the variables, all the variables
[00:44:04] Kate Grandbois: that is such a good analogy.
[00:44:07] Natalie Douglas: I don't want you to, I don't care about the stakeholders fricking get that thing in my arm.
Like, we don't care about that. Right. But that's not what we're doing. We're not giving a pill. We're not giving a vaccine. We're looking at levels of behaviors. In the traditional research pipeline. Right? The first thing that you do is look at treatment efficacy, right? So you're trying to figure out is my treatment safe?
Is it going to kill anybody? Not many things that we do. Well, I might not say that I was going to say that not many things that we do cause harm because I think that's not true. I think sometimes we really can cause harm. Right. So I think that's kind of the first step is to think like, does my research cause harm?
, so if your research is determined, your intervention is determined to be safe, then it would move to more of like an advanced efficacy stage where you, like, you increase the number of participants, but you're still kind of in the lab, you're still controlling for all the variables. Right. And then you would move to.
Effectiveness where now you're maybe in a real-world setting and instead of your research assistant, giving the intervention in the lab, maybe the research assistant is giving the intervention in the school. Right. , you know, and
[00:45:24] Cathy Binger: that pipeline, it
[00:45:28] Natalie Douglas: doesn't support clinical practice for behavioral interventions, I think in most cases.
Right. , and Cathy, I know you wanted to add something to that.
[00:45:40] Cathy Binger: Yeah. To just, , so the piece I wanted to add was that. Really what we are talking about with implementation science is the intervention package. Right? So I think you were also asking about what about these narrow or questions like aided modeling and isolating that that's, that's still the same stuff.
Like I would do that same study the same way if I, you know, like to answer that question, but what implementation science is really getting at is this bigger question of the intervention. It's an intervention that you have that, you know, that you think is a complete intervention that you're trying to walk down the research pipeline to get it to the point where it's ready for mass dissemination.
And that's where you guys come in. Like the podcast is on the dissemination end of things. Once you have good information. , so we really are talking primarily about, you know, some kind of cohesive intervention in our discipline, you know, currently the intervention package that we're, that we're looking at.
Yeah,
[00:46:40] Natalie Douglas: we're working on a scoping review right now, , with where we are trying to look at, like all of the implementation science studies in communication, sciences, and disorders, like in all of time, basically. , and we're still working on it and we'll have to submit it, blah, blah, blah. But one of the things that we ended up doing is we called it a practice of interest.
Right. Because I think sometimes it's an intervention. Sometimes it's like an assessment package that you're trying to get in. Sometimes it's education, you know, I think like all of those are potentially part of the intervention, but it's this idea that you have some type of thing, right. That you're trying to move in to every day kind of practice practice.
Yeah.
[00:47:26] Cathy Binger: Does that
[00:47:26] Natalie Douglas: help any? Yeah.
[00:47:27] Amy Wonkka: Yeah. Thank you. You guys answered my question really well. I feel like I have a much better, like, because I think that, you know, we're not saying. I mean, I'm obviously real excited about this, but not to the point that we're saying, throw everything else away. All right. We're not saying, we're saying these are doing different tasks and it's exciting because this implementation science component is something that, I mean, I didn't even know it was a thing before evidently there are enough published studies out there that you can do a scoping review.
So that's exciting.
[00:48:00] Cathy Binger: , but I think, sorry, but no, Yeah, Natalie would be happy to tell you, trying to figure out which of those studies even belonged in her scoping review was a monumental task because people were not really doing implementation science. They were calling it. You're not seeing it for good reason, Amy.
It's not that there's a ton of stuff out there and you've missed it. It's not out there, right? Like, you know, people do things like qualitative studies to interview stakeholders and learn more about whatever, but what they're not doing yet. And as a whole in the discipline is putting that within an implementation science framework and saying, here's my implementation science framework model that I'm working with.
I have X that I'm, you know, X intervention and. Move this through the pipeline, and I'm going to make sure that it's, you know, good for stakeholders like that. People are really gonna use it and then it's functional and it's useful. And then we have good outcomes and blah, blah, blah, blah, blah, blah. And so that you have a pathway that you've mapped out for yourself as a researcher and know all the pieces that you need to look at, to put together, to get from here to there.
And that is not happening in the literature by and large right now. That's right.
[00:49:11] Amy Wonkka: Well, and I like just connected with that. It makes, it does make me wonder about like, if we started doing it more than there hopefully would be room to replicate it. And so then even though it's not highly controlled, like your clinical work in the lab, if people are able to replicate it, every replication gives more strength or, or, you know, raises new questions, I guess, about whatever that treatment package is.
, but it is, it's really exciting to think that that's a direction that we're moving as a field. , It's really exciting to think, Hey, in 10 years from now, will we be able to say, oh, this was replicated in all of these different types of places and here were, you know, trends we noticed or, you know, I think as a clinician, I would be very excited to read, to read that.
[00:49:54] Cathy Binger: Yeah. And that's the hope and you know, the reason Jennifer and I left that implementation and some of it's so exciting was because we really saw this as the giant missing hole in our discipline, like in our research, like we've been on and on and on about evidence-based practice forever. Now it's time to be on and on and on about implementation science.
Because what we have is just like every we're not, we're not special. Our discipline is like every other discipline in that a very tiny percentage of interventions make their way through the whole pipeline and into mass use. And even those that do take, you know, 15 to 20 years to get there. And we've got folks who are needy, who are out there who need this.
So, you know, all that, think about all the research that you read when you were in grad school and, and you know, all the things that you were told to go out and do, and how often you have not seen those things being done right. More often than not those things aren't being done. And it's for good reason.
It's because we have not done the work of implementation science to really look at real world stuff. And make sure our interventions are good fits for those settings. Right.
[00:51:03] Amy Wonkka: Well, and I think it's going to help with the dissemination piece too, because Kate and I have already mentioned we're medium old and you know, we, like, I went to school before all of this social media,
[00:51:14] Cathy Binger: I'm just kidding, but I had to go to a
[00:51:17] Amy Wonkka: special room to use it.
So, , but you know, I do feel like that's also confusing for the new clinician. We've touched on this a little bit, you know, or, or the seasoned clinician, who's trying to do their best, but also trying to have some work life balance, and also recognizes they can't fix the whole world and also recognizes they have too many tasks on their plate every single day.
And I think there's also this piece of, and you can go on, you know, and, and here we are, we're, we're on Facebook and we're on Instagram, but it's also hard to. Look through all of those things and you have a critical eye as far as what's the best application for your clinical situation. And I think, you know, implementation science is really exciting in that way too, because it can help connect us as practitioners.
So the things that people are looking for, people are looking for that information online. That's why there is so much information like that online because people want to do a good job.
[00:52:14] Kate Grandbois: ,
yes, yes. And I want to take that one step further and sort of looping back to that time that I asked you like seven questions in a row, , and sort of thinking about that last learning objective of, of, you know, that connection between how speech pathologists.
We, we do want to read the literature. We do want to do a good job where in this field, because we're passionate about it. , That in how is that related to the research practice gap and how can speech pathologists become more involved? Like if there's a listener out there listening to this and says, oh, this is so cool.
Like, I would love to do research, but I don't really want to go get my PhD. Like what, what is the bottom up way that, that we can sort of solve
[00:52:56] Cathy Binger: that problem? Like, what are the barriers
[00:52:58] Amy Wonkka: and facilitators to SLPs and KJ clinical
[00:53:01] Cathy Binger: research? Are you
[00:53:03] Natalie Douglas: reading our
[00:53:04] Kate Grandbois: third learning objective? Yes. That question.
[00:53:06] Natalie Douglas: What are they?
I love it. I love this question and I, okay. I think I did right. That's why I wrote it. Okay. Here's the, this is my, a lot of this is like my opinions. So just F this is my opinions. And all of you feel free to check me on this. I think a couple of things, one, we have a major. Hierarchy here between researchers and clinicians where clinicians do not feel.
Cause like I would say to a clinician
[00:53:42] Cathy Binger: truly, if, uh, and
[00:53:43] Natalie Douglas: this does, this has happened maybe like once since 2013 where a clinician has emailed me about a research article that they have read. And they're like, I really like this research article, you know, could you talk to me, like, could I get involved in something as an author?
I would just freak out. I would be like, oh my gosh, they read that. They found it useful. Like it would make me so happy, but I think most clinicians do not feel comfortable contacting the first author of a paper and being
[00:54:14] Kate Grandbois: like, Hey, just fan girl, about you on a podcast. They don't ever like actually email you.
We just talk about you behind your backs
[00:54:22] Cathy Binger: in public,
[00:54:25] Natalie Douglas: but privately. So I think we got to get rid of that hierarchy and I think there is a. And another kind of unspoken situation where the academic community at large has tried to shame clinicians into evidence-based practice. And that's a terrible
[00:54:46] Cathy Binger: strategy.
Amen to that. Yes, yes, yes, yes, yes, yes. And it's
[00:54:52] Natalie Douglas: like, that is, that is just not, so how, why, why would you want to get involved in something where you're constantly either implicitly or explicitly being told that you're not good enough or that you're doing it wrong or that all of these efforts that you put in are, you know, like nobody, like nobody wants, nobody wants to do that.
So I think, , you know, I think contacting researchers directly, you know, is one way, , and I think cultivating community with other clinicians, like what you're doing is another way, , I'm so like hopeful with all of these, you know, with Instagram and social media. And I mean, I did the disclosure, I work at the informed SLP.
Part-time like, people are really trying to disseminate information and get
[00:55:45] Cathy Binger: it out there. Yeah. Another barrier in the past has been like we've, we've had, , we've been really fortunate to have a number of people contact us about the partner instruction work that we do and our other work as well. But you know, the work that we've done to date has all been in person.
So if they don't live in Albuquerque or New Mexico or Orlando, Florida, we really haven't been able to, you know, really include them in our current projects. But now with that silver lining of COVID and opening us more of us up me in particular and Jennifer too, Jennifer can also do to, to the promise of, , telepractice, , man that starts to open up the whole.
Right. Like we have a huge project. We want to do a whole series of projects that are, we convert the
[00:56:29] Natalie Douglas: whole
[00:56:30] Cathy Binger: partner instruction program that we have into telepractice program, for example. Cool. And, , then yeah, our research participants can come from anywhere. , which is just an amazing, amazing thing to think about, which is, you know, the way that leads to the question then is if we can get clinicians interested, clinicians in contact with us, then we can see, and we're doing implementation science.
And real-world said like, that's the other thing too, is not only is it limited where we are, but then we're doing it in our way. Well, we're going to still do some things in our lab, but we're also gonna be doing projects in the future that are not in the lab. And if it's partner training, you know, I work with Amy and teach her how to do our program.
And then Amy goes and implements it and records everything, and I get it back and I can be there for the telepractice sessions, blah, blah, blah. Well, like that changes everything in terms of clinicians, , being able to be very directly involved in literal research projects.
[00:57:27] Natalie Douglas: That's right.
[00:57:28] Kate Grandbois: That's such a good point.
That's very cool to think about. And also I love your point. I loved your opinions. They were great opinions and I fully support them. , and if anybody is listening to this and feeling, I hope that people who are listening to this feel empowered to
[00:57:46] Natalie Douglas: reach across
[00:57:46] Kate Grandbois: the aisle or cold call a researcher, or, you know, speak up and get involved.
I do feel that. You know, I, I agree that academia sort of seems like this. You had called it in our, in our previous discussions before we recorded the ivory tower, you know, it's like wrapped up in a bow and it's very elite and it's, you know, there are people who have studied for years with postdocs and, you know, devoted their lives to this research.
And, and I totally respect that, but I don't think that it needs to be so substantially separate from, you know, being so stressed out at work that you just need to find a marker and one marker would make your whole day that much better so that you could actually implement what the people in the ivory tower have, have been researching.
So I, I loved your opinions. I think they're great. , I think you're great if you couldn't tell,
[00:58:36] Cathy Binger: is there
[00:58:38] Natalie Douglas: big box
before
[00:58:40] Kate Grandbois: we wrap up, are there any like parting words of wisdom that you would like to
[00:58:45] Cathy Binger: leave our listeners? Is that really a wrap.
[00:58:49] Natalie Douglas: I can talk about curvy some more scurvy
[00:58:54] Kate Grandbois: each vitamin C everyone. And that's a wrap. , okay.
Are there any other words of wisdom that you would like to impart upon our listeners besides each, each lemons?
[00:59:08] Cathy Binger: I think words might be a little bit of a strong statement, but, , I'll take a shot at part of that. So Natalie's point in everyone's point about shame, I think is just such an important one to, , reiterate.
So, you know, just a very quick story about my own experience. When I left, when I left grad school, I had all the hope in the world. And then by the end of my first year of practice, I felt like an utter and complete failure. Like I was trying to be an upbeat, I just felt like there's no way I could keep up with all the literature, even though I tried, I was not, I mean, I had filing cabinets full of papers that I printed out and, you know, blah, blah, blah, blah, blah.
And, but feeling like everywhere I turned, I was getting it wrong and I wasn't able to live up to the expectations of my professors and just, I mean, I almost left the field. I had one foot out the door for multiple years during that time, , after, after year one and I, you know, anyway, so like that was, uh, that was not a good, healthy experience.
And so I really also love implementation science because it changes the story, right. That fundamental story of, Hey clinicians, go out there and read the literature and eat your Wheaties. And, you know, you'll, you'll be the world's best clinician and you should be able to do all of this. And, , you know, it's, it's a, it's a false narrative.
, and we have to, we meaning researchers, you know, academics, we need to be doing things differently. We work in service to all of you. That's why we exist. That's why we do the work that we do. And even more. So we work in service to the clients that all of us serve. And, , when we're not doing a good job of serving clinicians, we're not doing a good job of serving the clients either.
So it's very easy to set up here and say, oh, why isn't anybody using my stuff? Well, that means I didn't do my job. That's what that means. That's exactly what that means. So, , we all, we need to really think differently about how we go about this task of conducting research that is at the end of the day, designed to help individuals who have communication disorders
[01:01:16] Natalie Douglas: here, here.
[01:01:19] Kate Grandbois: Wow. That was beautiful. I don't think any of us can say anything after that. , well, thank you both so much for, for being here. Maybe we can convince you to come back someday, cause this was just so fun and I'm really hoping that everyone feels so empowered and knows about implementation science now and can sort of take action to, you know, help bridge that gap between th that research practice gap, , as much as they can.
Thank you again so much for joining us guys.
[01:01:45] Cathy Binger: You back here again. Awesome. Thanks so much. We really appreciate it.
[01:01:51] Kate Grandbois: Thank you so much for joining us in today's episode, as always, you can use this episode for ashes CE use. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study, please check in with your governing bodies or you can go to our website, www.slpnerdcast.com.
Closing
[01:02:14] Kate Grandbois: All of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us@infoatslpnarcos.com. Thank you so much for joining us and we hope to welcome you back here again. Yeah.
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