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Journal of Evaluation in Clinical Practice ISSN 1365-2753

What are the primary influences on treatment decisions?

How does this reflect on evidence-based practice?
Indications from the discipline of speech and
language therapy
Arlene McCurtin PhD and Amanda M. Clifford PhD
Lecturer, Clinical Therapies, University of Limerick, Limerick, Ireland

Keywords Abstract
evidence-based medicine, practical
reasoning, science Rationale, aims and objectives Four pillars of evidence underpin evidence-based behav-
ioural practice: research evidence, practice evidence, patient evidence and contextual
Correspondence evidence. However, it is unknown which of these pillars or other factors are used by
Dr Arlene McCurtin clinicians such as speech and language therapists (SLTS) when making treatment choices.
Clinical Therapies The aim of this study was to identify the factors underpinning SLTs’ treatment decisions
University of Limerick and contextualize findings in terms of evidence-based practice (EBP).
Limerick, Ireland Methods Ethical approval was obtained for the electronic questionnaire-based study. A
E-mail: [email protected] questionnaire was designed, piloted and then sent via gatekeepers to SLTs to ascertain
agreement with a range of statements potentially underpinning treatment choices.
Accepted for publication 16 April 2015 Results A total of 249 respondents completed the survey. The respondents defined them-
selves as dynamic and pragmatic practitioners with an appreciation for the four pillars of
doi:10.1111/jep.12385 EBP. Using factor analysis, treatment decisions were found to rely primarily on practice
evidence and pragmatic considerations. Qualifications, clinical experience and the patient
group an SLT works with further influenced attitudes and treatment decisions. Those
with additional qualifications and experience were identified as more autonomous, more
scientific in their treatment choices and less influenced by patient preferences.
Conclusion Factors influencing decision making did not clearly align with the four pillars
of EBP, the principal influences being practice evidence and pragmatic constraints. The
findings of this study have implications for understanding why specific treatment choices
are made. Attempts to improve practice should focus on a range of evidence sources and
take into account clinician’s specific needs depending on career stage, post-qualification
status and patient group factors of their practice.

such decisions [5,6]. However, it is currently unknown what

Introduction exactly underpins SLT treatment choices and whether these cli-
Evidence-based practice (EBP) is typically constructed using the nicians value scientific knowledge such as research evidence
three pillars of research evidence, practice evidence and patient when making decisions about patient management. Thus, the aim
evidence. It is a key contemporary model informing the treat- of this study was to explore and identify the constructs under-
ment decisions of health professionals. More recently, the inclu- pinning SLTs treatment decisions. The identification of factors
sion of a fourth pillar in decision making has been recommended supporting decision making will have implications for the edu-
– that of contextual evidence [1], which can refer to a broad cation of health professionals and provide perspective on
range of influences including resources and service policies and evidence-based behavioural practice.
potentially further include pragmatic considerations. Despite the
popularity of EBP in the literature, studies repeatedly indicate a
Science and research evidence
less than anticipated influence of research evidence on speech
and language therapist’s (SLT) treatment decisions [2–4]. There Scientific practice is perhaps most equated with the use of research
are suggestions that practice evidence has a greater impact on evidence. Thus, the use of therapies that are evidence-based is

1178 Journal of Evaluation in Clinical Practice 21 (2015) 1178–1189 © 2015 John Wiley & Sons, Ltd.
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A. McCurtin and A.M. Clifford Treatment decisions of SLTs

interpreted as ‘good’ clinical behaviour particularly if that evi- SLTs in treatment selections [26,27] either by directly eliciting
dence is based on high-level research such as randomized control treatment preferences, supporting participation in defining goals
trials and systematic reviews. However, SLTs often make treatment or enabling access to the information and education on treatment
decisions in the absence of guidance from research findings given options. Rather, key patient factors which tend to influence treat-
the shortage of high-quality research evidence to inform those ment choices are patient characteristics such as age and cogni-
decisions [7]. Moreover, scientific practice can be considered to be tion. There may also be a gap between SLTs’ beliefs and actions
more than the application of evidenced-based interventions. regarding patient involvement. Indications are that while SLTs
Science after all is not merely a body of knowledge but a way of tend to engage patients in service delivery, they do not neces-
thinking [8] using the principles of reason and logic. It is manifest sarily include them in service planning [27,28]. This is despite
in an organized, structured approach to decision making rather patient engagement in the therapeutic process being shown to
than randomness and unsubstantiated guesswork [9]. Therefore, result in long-lasting change, with outcomes being better in
scientific thinking can include a variety of analytic behaviours patients who attribute change to their own efforts [29,30]. The
such as generating hypotheses, questioning, problem solving and research is equivocal regarding whether self-efficacy and health
challenging other opinion [9–13]. Clinicians can also demonstrate locus of control are valuable predictors of treatment benefit for
their commitment to scientific practice by valuing theoretically chronic conditions [31,32]. However, legitimate questions are
sound therapies [14]. While few studies examine use of theory in provoked regarding the role patients play in contributing to out-
SLT, what does exist implies limited theoretical engagement by comes and how SLTs perceive this contribution.
such clinicians [15]. The scientific basis of SLTs’ treatment deci-
sions remains underexplored.
Pragmatic and contextual reasoning
Practice evidence
The emphasis on the patient role in therapy highlights that the
Clinical experience or practice evidence has been found to therapeutic process is not acontextual but occurs in what has
strongly influence SLTs’ treatment decisions [3–5,16], with thera- been described as a complex, multifaceted clinical environment
pies being chosen based on an SLT’s own experience or the experi- [33]. Thus, it is likely that pragmatic and contextual reasoning
ence of colleagues and experts. Such evidence may include the may also have a bearing on SLTs’ treatment decisions. Pragmatic
SLTs’ direct experience of using therapies and be embellished by considerations may be observed, for example, in SLTs, being
routine unpublished activities such as monitoring of outcomes and more likely to adopt therapies if they result in better or quicker
service evaluations. Evidence also suggests that both SLTs and functional outcomes [22,34] as is seen with physiotherapists
allied disciplines rely on practice knowledge acquired via training, [35]. Pragmatic and contextual reasoning may additionally
either from university [16] or continuous education [17] — what be stimulated by factors such as mandated care pathways,
has been referred to as treatment through allegiance to training funding sources, staff and resource availability. Study findings
regimens [18]. The use of practice evidence to inform treatment are not definitive on influences such as resource availability.
choices may partly explain why unvalidated therapies, that is, While lack of equipment has been identified as influencing
therapies without supporting evidence or with negative research choices in dysphagia [36] for example, other findings suggest
evidence, continue to be utilized within the profession and further no association between the availability of resources and specific
why therapies that are easier to understand and communicate to recommendations for the same population [37]. Moreover,
others are preferred [19]. Therefore, popularity or consensus rather little is known about how factors such as organizational policy
than science may inform therapy choices [20]. impact on treatment decisions. Thus, the influence of pragmatic
While it has been argued that clinical decision making should and contextual factors on treatment choices remains less than
be free of belief influences [21], practice evidence may also transparent.
include belief-based decision making. This is perhaps most high-
lighted by the ‘I believe it works’ argumentation often used to
rationalize treatment selections [22]. Therefore, the quality of Aims
thinking supporting treatment decisions is fundamental with
defensible judgements being based on evidence and reasoning EBP proposes a model based on three to four pillars to facilitate
[8], not beliefs. Despite this, treatment outcomes reflect on more intervention decision making. However significant gaps exist in
than the treatments used by clinicians and it has been suggested knowledge regarding the overall, individual and relative influences
that specific intervention techniques may have little to do with of such factors. This study aims to identify the constructs contrib-
treatment results [18]. Other factors that may influence treatment uting to SLT treatment choices in order to better understand what
outcomes include, for example, the clinician’s interpersonal factors influence those treatment decisions and thus poses the
skills [23,24]. Aphasic patients have also described clinician con- following questions:
fidence as important in SLTs [25], concurring with SLTs’ self- 1 What are the primary influences on SLTs’ treatment decisions?
reports [26]. What is still unclear is the relative influence of such 2 How do these influences reflect what we describe as EBP?
factors on treatment decisions.

Patient-centred evidence Method

While patients should undoubtedly contribute to clinical deci- Ethical approval was granted by the university research ethics
sions, research suggests that they are not necessarily involved by committee.

© 2015 John Wiley & Sons, Ltd. 1179

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Treatment decisions of SLTs A. McCurtin and A.M. Clifford

13-factor model was selected as it favoured fewer factors while

Participants
explaining over 51.5% of data variance (Table 2). Statements
SLTs currently practising in Ireland were recruited via gate- were considered to load on a factor if the factor score met or
keepers, specifically Special Interest Group secretaries and the exceeded 0.30 [38]. Where items loaded onto multiple factors,
administrator of the researchers’ university practice educator they were assigned to the factor with the highest loading score
database. Participants completed an electronic survey (www [39]. Cronbach’s alpha coefficient was used to measure the inter-
.surveymmonkey.com), which opened and closed within 6 weeks nal consistency of items within the factor. Once phenomena or
with two reminders at 2 and 4 weeks. Consent was assumed on factors were extracted, these were named based on the principal
survey completion. characteristics of statements within the factor (Appendix B).
Seven statements were not loaded onto the model (S3, S12, S14,
S44, S53, S55) during factor analysis leaving a total of 46 state-
Questionnaire design
ments in the model.
The survey contained a demographic section and a rating scale
consisting of 56 statements (Appendix A). Respondents were
asked to rate each item on a 5-point Likert scale where the first
point (1) represented strong disagreement and the last point (5)
Results
represented strong agreement. The statements were selected from
Demographics
a large pool of potential items (n = 185) derived from a systematic
search of key content areas followed by a critical review of the A total of 271 respondents commenced the survey, 249 com-
literature to inform the questionnaire. Items included were pleted it. The potential sample was n = 589 (special interest
intended to represent a range of potential influences on clinical groups) and n = 225 (practice educator database). No cross-
decision making. Using a codebook – a systematic record of matching of databases was possible given the use of gatekeepers,
coding and decisions – the original 185 statements were developed and thus, no response rate is reported. Demographic data is
and modified for clarity with duplications removed and unclear presented in Table 1. To represent respondents main areas of
statements rephrased. The statements were assigned to the follow- practice, the sample were clustered into three groupings: devel-
ing key content categories: clinician-based influences; patient- opmental disabilities (SLTs working in a range of settings with
based influences; profession-based influences; therapy-specific individuals with developmental disabilities such as intellectual or
influences; scientific values; sources of information; and miscel- physical disability); adult-acquired communication and swallow-
laneous. In order to reduce the numbers of items, two researchers ing disorders (SLTs working with adults with acquired disorders
then independently ranked all items for meaningfulness and cat- in various settings such as those resulting from acute or progres-
egory representation. For each category, the eight highest rated sive neurological disorders), and community speech and lan-
items were retained and all other items discarded. The final guage delays/disorders (SLTs working with children in the
number selected considered balanced category representation and community with speech and language delays/disorders). A
amenability to statistical analysis. Piloting was carried out for number of respondents (n = 48) represented a diverse range of
readability, clarity and survey length using a convenience sample settings and populations and were not included in the above
of SLTs (n = 5) with no amendments made. groupings as they did not represent a discrete category. Thus, for
analyses centring on client groups some sample bias may be
inherent as not all potential areas of practice and various settings
Data management
are represented.
All data were exported from the web site and entered into the
Statistical Package for the Social Sciences (SPPS) V18 (SPSS
Inc., Chicago, IL, USA ). The Kruskall–Wallis test was used to
What are the primary influences on SLTs’
examine differences in averages between various groupings and
treatment decisions?
the direction of significant differences. A Bonferroni adjustment
to the P-value (0.025) was implemented to account for multiple The 56 items were summarized using a 13-factor model outlined in
testing and size effect was calculated. Subsequent to tests of Table 2.
matrices (KMO and Bartlett’s test of sphericity) being employed Some factors are considered more robust than others based on
to test whether the data would support factor analysis, principal the number of statements loading onto a factor, Cronbach’s alpha
axis factoring followed by varimax rotation with 100 iterations score, factor score covariance matrix and post-hoc findings. The
(for a converged solution) was used to identify interrelationships factors with the highest internal consistency were factors 7, 3, 1, 4,
among the 56 items. This reduced the data by grouping state- 5 and 11 as highlighted in Table 2. The technique of factor analysis
ments into factors that had common characteristics, highlighting suggests that what underpins clinical decisions does not clearly
specific phenomena and producing a reasonably simple structure. align with the four pillars of EBP. Pragmatic/contextual factors
Factor analysis is a technique that requires a large sample size (factors 1, 4 and 7), practice evidence and discipline influences
for correlations to stabilize. On average, there were 247 (factors 5 and 11) and components of ethical-scientific pra-
responses per statement representing a fair-good sample size ctice (factor 11) appear to most strongly underpin treatment deci-
[38]. The scree plot of un-rotated factor eigenvalues indicated sions. Factor 13 (specific training) consists of two statements
anywhere between a four and 36 factor solution (using the latent indicating a negative covariance and poor construct. Each factor
root criterion or eigenvalue-one criterion of eigenvalues >1). A was composed of extracted statements (Appendix B).

1180 © 2015 John Wiley & Sons, Ltd.

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A. McCurtin and A.M. Clifford Treatment decisions of SLTs

Table 1 Demographic information

Demographic n % Total

Years of clinical Early years (0–4.11 years) 101 40.7 248

experience Middle years (5–14.11 years) 98 39.5
Later years (15+ years) 49 19.8
Self-reported Emerging 89 35.7 249
level of skill Experienced 119 47.8
Expert 41 16.5
Level of Professional qualification only 192 77.1 249
qualification Additional professional degrees 57 22.9
Area of clinical Developmental disabilities (all ages) 74 29.7 249
practice Adult acquired communication/swallowing 46 18.5
Community speech and language (paediatrics) 81 32.5
Various other populations 48 19.3
Age of patient Paediatric 167 67.1 249
population Adult 78 31.3
Adolescent 4 1.6

Table 2 Extracted factors of the extracted factors relate directly to practice evidence spe-
cifically factors 5 (patient and colleague evidence), 9 (autono-
Cronbach’s
mous clinical experience), 11 (college learning) and 13 (specific
Factor Factor label alpha
training).
1 Basic practice 0.618
2 Scientific practice 0.454
3 Ethical-scientific practice 0.634 Patient evidence
4 Constrained/pragmatic practice 0.571
5 Patient and colleague evidence 0.570
Patient statements largely rate highly (Statements13, 56, 14 and
6 Personal influences 0.525 11) although there is a trend towards less valuing of patient influ-
7 Standards of practice 0.691 ences with clinical experience. The most experienced respondents
8 Less scientific sources 0.424 evidenced a disagreement rate of 9.8% for all patient statements
9 Autonomous clinical experience 0.426 compared with 3.8% for least experienced respondents. Significant
10 Research belief 0.448 differences are highlighted in Table 5. Two extracted factors relate
11 College learning 0.566 to patient evidence – factor 5 (patient and colleague evidence) and
12 Patient responsiveness 0.353 factor 12 (patient responsiveness); however, factor 12 is a less
13 Specific training −0.090 robust factor.

Pragmatic/contextual evidence
Two of the factors extracted relate to pragmatic/contextual con-
How do these influences reflect on EBP?
straints – factor 1 (basic practice) and factor 7 (standards of prac-
tice). Factor 1 is loaded with the most statements of any factor
Research evidence and other scientific attitudes
suggesting an important construct influencing decisions. Signifi-
Scientific statements (statements 9, 10, 1, 7, 8, 29, 30) were highly cant differences between statements are highlighted in Table 6. For
valued (Appendix A) with one-quarter of all respondents strongly example, although there are high levels of agreement for factor 7
agreeing with scientific statements. Three such statements (pro- statements as a rule, differences between SLTs based on area of
viding rationales, using testable goals and defending treatment practice are evident suggesting a work setting impact on decision
choices) rank in the highest 10 agreed items. Only 3% of respond- making.
ents report that research does not influence their decisions.
Furthermore, four of the extracted factors predominately relate to
scientific attitudes. These are factors 2 (scientific practice), 3 Discussion
(ethical-scientific practice), 8 (less scientific sources) and 10 While differences were identified between groups particularly
(research belief). Significant differences are highlighted (Table 3). with regard to experience, expertise and qualifications, the overall
picture is one of a fairly cohesive culture with strong levels of
general agreement regarding the influences on treatment decisions.
Practice evidence
It especially implies a fairly dominant experiential, cultural and
A number of statements regarding clinical experience (statements discipline influence on treatment decision making, irrespective of
45, 41, 43) ranked highly overall (Appendix A). However, some any differences produced in analysis. On the whole, it can be stated
differences are evident and are highlighted below (Table 4). Four that Irish SLTs define their clinical decisions as patient centric,

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Treatment decisions of SLTs A. McCurtin and A.M. Clifford

Table 3 Significant differences for scientific constructs

Effect
Factor Item Variable and P value size Explanation

2 S30 Years’ experience (P = 0.003) 0.48 More years of experience, more expertise and additional qualifications correlated with
Skill (P = 0.002) 0.51 reading more research
Qualification(P = 0.001) 0.40 Working in community practice correlated with reading less research
Area of practice (P < 0.000) 0.112
S33 Qualification (P = 0.017) 0.23 Additional qualifications correlated with adopting new practices most
3 S40 Years’ experience (P = 0.009) 0.39 More years of experience, more expertise and additional qualifications correlated with
Skill (P = 0.003) 0.37 more valuing of the harm potential of unvalidated therapies
Qualification (P = 0.003) 0.47 Working in community practice correlated with least valuing of harm potential of
Area of practice (P < 0.000) 0.102 unvalidated therapies
S39 Qualification (P = 0.004) 0.34 Additional qualifications correlated with more agreement regarding the potential to
waste time by using unvalidated therapies
S5 Qualification (P = 0.003) 0.37 Lack of additional qualifications correlated with belief in therapies being used in absence
of supporting research
4 S19 Years’ experience (P = 0.002) 0.50 Less experience and least skill/expertise correlated with difficulties in converting/
Skill (P = 0.002) 0.49 translating

Table 4 Significant differences for practice constructs

Effect
Factor Item Variable and P value size Explanation

1 S54 Area of practice (P < 0.000) 0.395 Area of practice correlated with use of fun/engaging therapies (adult-acquired SLTs least
use these types of therapies)
S4 Qualification (P = 0.001) 0.44 Lack of additional qualifications correlated with more reliance on commercial products
than research-based therapies
S49 Skill (P = 0.012) 0.36 Less expertise correlated with valuing of therapies in long-time use in the discipline
S51 Qualification (P < 0.000) 0.51 Lack of additional qualifications correlated with use of easy-to-implement therapies
S52 Qualification (P < 0.000) 0.83 Lack of additional qualifications correlated with easy to understand therapies
5 S46 Years’ experience (P = 0.002) 0.53 Less experience, lack of additional qualifications and less expertise correlated with
Skill (P = 0.002) 0.49 reliance on experts
Qualification (P = 0.015) 0.17
S43 Skill (P = 0.009) 0.38 Lack of additional qualifications and less expertise correlated with learning most from
Qualification (P = 0.002) 0.40 working with other clinicians
S27 Qualification (P = 0.022) 0.16 Lack of additional qualifications correlated with most reliance on textbooks
9 S41 Years’ experience (P = 0.007) 0.40 More experience correlated with more influence of own clinical experience
S42 Qualification (P = 0.003) 0.36 Lack of additional qualifications correlated with prioritising of clinical experience as guide
in selecting treatments
11 S24 Years’ experience (P = 0.004) 0.46 Less experience, less expertise, lack of additional qualifications and area of practice
Qualification (P = 0.014) 0.25 correlated with higher influence of college learning. SLTs working with patients with
Skill (P < 0.000) 0.69 developmental disabilities were most influenced.
Area of practice (P = 0.015) 0.42
– S9 Years’ experience (P = 0.001) 0.28 Less expertise and less experience correlated with most valuing of colleague opinion
Skill (P = 0.003) 0.47

grounded in both practice evidence and science and consider them- own skills and experience and specific training. It appears as
selves to be dynamic and pragmatic practitioners. They are most Justice argues [40], ‘the most critical component of EBP remains
strongly influenced by practice evidence and pragmatic considera- our craft’ (p. 86). The evidence for valuing practice evidence is
tions. The narrative of what informs SLT treatment decisions can fortified by the extraction of factors 9 (autonomous clinical experi-
be considered under the following headings. ence), 11 (college learning) and 5 (patient and colleague evidence)
specifically. It is emphasized by high agreement with the selection
of therapies based on the ‘because it works’ reasoning as proposed
Decisions as practice evidenced
by Kahmi [22] and the contention by respondents that clinical
SLTs in this study were found to be strongly influenced by experience is the best decision guide. The high regard for practice
discipline-specific sources especially colleagues and experts, their evidence concurs with studies within the discipline [4,5], reflects

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A. McCurtin and A.M. Clifford Treatment decisions of SLTs

Table 5 Significant differences for patient constructs

Effect
Factor Item Variable and P value size Explanation

4 S21 Patient age (P = 0.008) 0.29 Patient age correlated with valuing of placebo effect with SLTs working with paediatric
patients disagreeing most
5 S16 Years’ experience (P < 0.011) 0.37 Less experience and lack of additional qualifications correlated with valuing of patient
Qualifications (P < 0.000) 0.70 responsibility for ensuring treatment success
S11 Area of practice (P = 0.008) 0.48 Area of practice correlated with patient preferences influencing treatment choices with SLTs
working with patients with developmental disabilities most influenced in this regard.
6 S15 Qualifications (P = 0.016) 0.24 Lack of additional qualifications correlated with agreement with the influence on outcome of
what a patient brings to therapy
S22 Patient age (P = 0.002) 0.39 Patient age correlated with agreement regarding the importance of the therapeutic alliance
with SLTs working with paediatric patients least valuing.
– S14 Area of practice (P < 0.000) 0.116 Area of practice correlated with influence of patient-specific deficits with SLTs working with
adults with acquired disorders most influenced
S12 Skill (P = 0.015) 0.34 Less expertise correlated with influence of family preferences

Table 6 Significant differences for pragmatic constructs

Effect
Factor Item Variable and P value size Explanation

1 S20 Area of practice (P = 0.001) 0.77 Area of practice correlated with use of purchased therapies with community practitioners
most likely to use
4 S17 Qualification (P = 0 = .019) 0.23 Lack of additional qualifications correlated with choices limited by availability
S38 Qualification (P = 0.003) 0.35 Lack of additional qualifications correlated with lack of treatment options
S19 Qualification (P = 0.005) 0.32 Lack of additional qualifications, lack of expertise and lack of experience correlated with
Skill (P = 0.002) 0.49 difficulties translating research to practice
Years’ experience (P = 0.002) 0.50
S32 Skill (P = 0.007) 0.41 Less expertise correlated with less confidence in treatment choices
7 S47 Area of practice (P = 0.005) 0.53 Area of practice correlated with influence of workplace standards on choices. SLTs working
with patients with developmental disabilities most influenced
– S48 Area of practice (P = 0.016) 0.41 Area of practice correlated with influence of department policy. SLTs working in community
practice most influenced

findings from other disciplines [41] and points to practice as con- throughout factor 1 (basic practice). Tacit knowledge, it has been
taining strong elements of craft and culture. Thus, it appears that argued, should be valued because of its potential to deepen under-
decision making is clearly hinged on what has been referred to as standing, provide immediate solutions and help manage uncer-
practical reasoning (knowing how) [42]. tainty [49]. While some authors [50] state that EBP gives due
Dowie and Elstein [43] argue that clinical decision making can authority to practice knowledge, it can also be argued that EBP
only be successful if it is logical, quantitative, detached and sta- may not sufficiently reflect the actualities of clinical work and that
tistical. Practice or experience-based reasoning is often con- practice evidence has suffered from a lack of definition and devel-
structed as requiring careful interpretation as it might be opment in this model.
misleading [44], being based more on expediency than rational
thinking [45]. This concern with clinical judgement may not be
Decisions as scientific and autonomous – traits
warranted. Charman [46], for example, points to several studies in
that increase with clinical experience
the field of autism that show expert clinical judgement to be more
reliable than the standard diagnostic instruments. Even if consen- Valuing of scientific practice is evident, particularly in the extrac-
sus, as some authors [20,47] suggest, dictates what interventions tion of four factors related to science (factor 2: scientific practice;
are used, this may also be considered reasonable given the ‘ration- factor 3: ethical-scientific practice; factor 8: less scientific prac-
alising forces that comes from humans sharing their judgments tice; factor 10: research belief). However, changes in reasoning,
collectively’ [48]. Neither does this regard for practice evidence specifically the impact of scientific factors and autonomy are
necessarily suggest ‘lazy’ practice, as respondents clearly identify evident with amassed experience. The influence of colleagues, for
with notions of active practice including but not limited to a strong example, is appreciated most by those with less clinical experi-
valuing for research evidence. ence, less expertise and without additional qualifications. This
Practice evidence thus asserts a powerful influence on treatment positions the earlier years of practice as a time when the influence
selections. This may reflect a pragmatic valuing, especially evident of craft-based [40] or practice knowledge is at its highest and craft

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Treatment decisions of SLTs A. McCurtin and A.M. Clifford

skills are learned. The focus on learning the craft in the early implies a pragmatic–contextual stance as important in influencing
practice years may explain other differences including the lesser treatment decisions and is similar to findings in other fields
use of research evident at this stage and the relative lack of valuing [57,58]. This reasoning revolves more around what can be termed
of EBP as a core component of clinical care noted among clini- pragmatic rather than contextual constraints. Although being
cians generally [51]. Practice becomes more autonomous over limited by available therapies was highlighted in factor analysis,
time with an increase in the valuing of one’s own experience and most issues related to pragmatic constraints such as using previ-
less regard for colleague opinion. With accumulated experience, ously purchased therapies, not having time to learn about other
SLTs have effectively learned the craft, possessing a repository of therapies and using easy-to-implement therapies. Moreover, only
stored skills and information enabling them to operate more rou- one-quarter of SLTs feel department policy plays a role in deter-
tinely than less experienced colleagues [52]. mining practice choices. Thus, pragmatic practice may reflect on
Such autonomous practice more readily incorporates research practice-in-action more than on broader contextual constraints
evidence as apparent in factor 10 (research belief), partly it is such as economics or policies, although clearly contextual factors
postulated because experienced SLTs are more able to engage relating to treatment choices would be expected to vary based on
with relevant external influences. It may also be as Hofmeijer issues such as how health care is funded.
[53] proposes that evidence from expert opinion differs in kind Importantly, differences are apparent based on area of practice
from high-level research evidence. Additionally, the suggestion pointing to work setting constraints. Community practitioners
that experienced practice (particularly represented by additional appear most pragmatically oriented in a number of ways perhaps
qualifications) is more scientific would indicate that evidence use being compelled by the setting they work in. They can be con-
is not necessarily related to availability of research evidence. The sidered as most pragmatic, being most likely, for example, to
perception of time being important to research use is also have a treatment repertoire and be influenced by department
reflected repeatedly in a number of studies across disciplines policy, but least likely to read research. This group may construct
[54,55]. However, it is contended that time should be reframed to practice as generally less complex – for example, they least rec-
include the element of experience. It suggests that irrespective of ognize the harm potential of therapies. This may reflect the less
time limitations, if less experienced clinicians or those without complex patients typically seen in this setting as these clinicians
additional qualifications are to be encouraged to use research, it are less likely, for example, to have severely dysphagic patients
must first be considered whether they have sufficiently learned or engage with individuals in the acute phases of a problem.
the craft, and how more experienced colleagues could be used to While SLTs working with patients with adult-acquired disorders
transmit clinical reasoning and practice knowledge, which incor- are contextually influenced by workplace standards, those
porates research findings. Indeed, peer learning has the potential working with patients with developmental disabilities appear
to work both ways with more recent graduates transmitting least impacted by contextual issues further implying that the
up-to-date knowledge and experienced practitioners sharing work setting or patient group of an SLT contributes to the impact
applied knowledge. Thus, certain strengths evident at each stage of pragmatic/contextual factors on treatment choices. Thus, in
of clinical development would work in harmony to support and designing education programmes for the encouragement of
facilitate each other. As has been argued [56], ‘clinical expertise science-based behavioural practice and research translation, there
is seen to be fundamental to the delivery of EBP’ (p. 108) and needs to be consideration of the requirements of different work
using experienced practitioners to train less experienced col- contexts. Therefore, context and pragmatics rather than treatment
leagues may result in the more meaningful, contextualized appli- effectiveness may help explain some treatment decisions [34].
cation of research into practice. Experienced decision making This does not necessarily infer that such decisions are less valid;
represented by self-reported skill, years of experience and addi- after all, contextual factors are central to rational judgement [48].
tional qualifications also appear more generally scientific. Such It is thus reasonable to consider broadening the EBP model as
clinicians, for example, acknowledge more the harm and waste suggested [1], to incorporate the pillar of pragmatic/contextual
potential of unvalidated treatments evidenced in factor 3 (ethical- evidence.
scientific practice). It is most typified by those with additional
qualifications (who are differentiated across 21/56 statements).
Decisions as patient-centric
This provokes questions as to whether those with further quali-
fications are more naturally inclined towards science or become The generally high ratings for patient statements lead to the con-
so by virtue of their extra educational experiences. Despite group clusion that patient factors are important influences in SLT deci-
differences, the whole sample strongly value research evidence, sion making. There are, however, a number of indications that hint
which suggests that EBP has something to offer clinicians. The otherwise. Only four patient-related statements were extracted
data also imply, however, that SLTs consider scientific practice as during factor analysis (factors 5: patient and colleague evidence
broader than that typified by research evidence suggesting that and factor 12: patient responsiveness) and not as a cohesive factor.
models guiding treatment decision making should incorporate Experienced decision making also appears less informed by
broader constructs of science. patient factors. Furthermore, patient suitability or patient data, as
defined by SLTs [5], were identified as being more central to
decision making than other patient contributions, specifically
Decisions as pragmatically and
patient preferences and extra-therapeutic influences. SLTs were
contextually constrained
found to be neutral about the therapeutic alliance and equal
The extraction of factor 1 (basic practice), factor 4 (constrained/ numbers agreed and disagreed about the placebo effect. This sug-
pragmatic practice) and factor 7 (standards of practice) strongly gests a relatively narrow interpretation of what patient factors both

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A. McCurtin and A.M. Clifford Treatment decisions of SLTs

contribute to therapy outcomes and influence treatment decisions.

It points to gaps in knowledge and educational need, particularly in
Recommendations
initial training regarding the broader nature of therapy and the 1 For the purposes of this study, an Irish sample was utilized.
multiple potential influences on intervention outcomes. Interest- Although research on EBP and clinical practice generally yield
ingly, an SLTs’ area of practice was found to affect the valuing of similar findings both within and across disciplines, variations may
patient factors. SLTs working with individuals with developmental naturally occur in other international contexts and would be worth
disabilities, for example, are most likely to agree with a range of investigating.
patient statements including the therapeutic alliance and patient 2 Managers, educators and health providers could encourage the
preferences. Those working with patients with adult-acquired dis- integration of research evidence and scientific practice through
orders were most likely to be influenced by patient-specific deficits a. Peer learning, specifically the use of expert and additionally
in treatment decisions. Community SLTs and those working with qualified clinicians who demonstrate greater scientific valuing
paediatric patients were most predisposed to patient responsibility and who are in an ideal position to both contextualize such
and least value the influence of placebos. Naturally, it would be evidence and integrate it with practice evidence.
expected that SLTs working with paediatric caseloads (where b. As Harding et al. [51] have recommended, addressing EBP
parental rather than patient influence would dominate) would through small group projects rather than considering it to be an
differ somewhat from those working with adults where influences individual responsibility may be more acceptable to clinicians.
such as age and cognition would be important. c. As those with additional qualifications appear more scientific
The implications for EBP are twofold: the area of practice/ in their treatment choices, recommending further qualifications
patient group being served impacts on how treatment decisions are and training after a period of learning the craft, should be seen
made, and patient data as per previous findings [5,26] are primary as an optimal route.
influences on decisions. This influence of patient group may result 3 Researchers should continue to investigate the nature of clinical
from either the unique nature of different populations or the char- practice and
acteristics of the therapists who choose to work in such settings. a. Produce more critically and theoretically informed studies of
SLTs working in hospital-based settings, for example, may be decision making [59]. Given the dominance of practice and
more naturally inclined towards medical models of patient man- pragmatic factors in decision making, these influences deserve
agement. Thus, educational programmes should naturally target more attention including the role of tradition and discipline
strengths and gaps based on the area of practice of those under- culture on treatment decisions.
taking professional development opportunities. b. Define the various and hierarchical elements of practice evi-
dence including usual practice, expert opinion and service
evaluation-derived knowledge.
4 Clinicians and researchers need to pay more attention to the role
Conclusions of patients as educators and active and guided participants in
SLTs are a cohesive group suggesting clear definitions of clinical decision making. More exploration is required regarding why
practice. They imply in principle an appreciation of scientific more experienced or scientific practitioners may be less inclined to
thinking in practice, practice reasoning, pragmatic reasoning and value patient influences in decision making.
active practice. The technique of factor analysis indicates that
clinical decision making does not align with the four pillars of
EBP as it suggests that treatment decisions are primarily pragmati-
References
cally influenced and rely heavily on craft knowledge or practice
evidence. There is a move towards more autonomous, more sci- 1. Thompson, C., McCaughan, D., Callum, N., Sheldon, T. & Raynor, P.
entific and less patient-influenced practice with experience. Two (2002) The value of research in clinical decision making. Nursing
core characteristics further influence treatment decisions: the Times, 98 (42), 30–35.
patient group an SLT works with and the presence or absence of 2. Brener, L., Vallino-Napoli, L., Reid, J. & Reilly, S. (2003) Assessing
the evidence to treat the dysphagic patient. Can we get it? Is there
additional degrees. Most specifically, those with additional quali-
time? The Asia Pacific Journal of Speech, Language & Hearing, 8 (1),
fications appear more scientific in their treatment choices. 36–43.
These findings have implications for how EBP both reflects and 3. Nail-Chiwetalu, B. & Bernstein-Ratner, N. (2007) An assessment of
influences treatment decisions generally, during different phases of the information-seeking abilities and needs of speech-language
a clinicians’ career and for different patient groups. Making such pathologists. Journal of the Medical Library Association, 95 (2), 182–
decision-making scaffolds explicit should stimulate a broader 188.
debate about decision making and educational influences and 4. Zipoli, R. P. & Kennedy, M. (2005) Evidence-based practice among
avenues and reinforce previous findings, which suggest that the speech-language pathologists: attitudes, utilisation and barriers. Ameri-
dominant pillar supporting treatment decisions is not primarily can Journal of Speech-Language Pathology, 14, 208–220.
research, patient or context evidence but practice evidence and 5. McCurtin, A. & Carter, B. (2015) We don’t have recipes; we just have
loads of ingredients’: explanations of evidence and clinical decision
associated pragmatic considerations. Such findings support sug-
making by speech and language therapists. Journal of Evaluation in
gestions that in going forward, attempts to improve practice and Clinical Practice. doi: 10.1111/jep.12285.
provide education need to focus not primarily on external evidence 6. O’Connor, S. & Pettigrew, C. (2009) The barriers perceived to prevent
and more on internal or local evidence sources including clinical the successful implementation of evidence-based practice by speech &
expertise. It should provoke consideration of a range of practice language therapists. International Journal of Language & Communi-
and educational models compatible with the nature of practice. cation Disorders, 44 (6), 1018–1035.

© 2015 John Wiley & Sons, Ltd. 1185

 13652753, 2015, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jep.12385 by Cornell University Library, Wiley Online Library on [15/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Treatment decisions of SLTs A. McCurtin and A.M. Clifford

7. Law, J., Garrett, Z. & Nye, C. (2004) The efficacy of treatment for 28. Iacono, T. & Cameron, M. (2009) Australian speech-language
children with developmental speech & language delay/disorder: a pathologists’ perceptions and experiences of augmentative and alter-
meta-analysis. Journal of Speech & Hearing Research, 47 (4), 924– native communication in early childhood intervention. Augmentative
944. & Alternative Communication, 25 (4), 236–249.
8. Sagan, C. (1996) The Demon-Haunted World: Science as a Candle in 29. Lambert, M. J. & Bergin, A. E. (1994) The Effectiveness of Psycho-
the Dark. New York: Random House. therapy. In Handbook of Psychotherapy and Behavior Change, 4th edn
9. Kida, T. (2006) Don’t Believe Everything You Think: The 6 Basic (eds A. E. Bergin & S. L. Garfield), pp. 143–189. New York: Wiley.
Mistakes We Make in Thinking. Amherst, New York: Prometheus 30. Delsignore, A. & Schnyder, U. (2007) Control expectancies as pre-
Books. dictors of psychotherapy outcome: a systematic review. British
10. Jenicek, M. (2006) The hard art of soft science: evidence-based medi- Journal of Clinical Psychology, 46, 467–483.
cine, reasoned medicine or both? Journal of Evaluation in Clinical 31. Keedy, N. H., Keffala, V. J. K., Alttmaier, E. M. & Chen, J. J. (2014)
Practice, 12 (4), 410–419. Health locus of control and self-efficacy predict back pain rehabilita-
11. Klahr, D. (2000) Exploring Science: The Cognition and Development tion outcomes. The Iowa Orthopaedic Journal, 34, 158–165.
of Discovery Processes. Cambridge, MA: MIT Press. 32. Bloch, S., Onslow, M., Packman, A. & Dacakis, G. (2006) Connecting
12. Profetto-McGrath, J. (2005) Critical thinking and evidence-based stuttering management and measurement: IV. Predictors of outcome
practice. Journal of Professional Nursing, 21 (6), 364–371. for a behavioural treatment for stuttering. International Journal of
13. Shermer, M. (2001) The Borderlands of Science: Where Sense Meets Language & Communication Disorders, 41 (4), 395–406.
Nonsense. Oxford: Oxford University press. 33. Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A. &
14. Higgs, J., Jones, M., Edwards, I. & Beeston, S. (2004) Clinical rea- McCormack, B. (2004) What counts as evidence in evidence-based
soning and practice knowledge. In Developing Practice Knowledge for practice? Journal of Advanced Nursing, 47 (1), 81–90.
Health Professionals (eds J. Higgs, B. Richardson & M. Dahlgren), pp. 34. Kahmi, A. G. (2006) Combining research and reason to make clinical
181–200. London: Butterworth Heinemann. decisions. Language, Speech, and Hearing Services in Schools, 37,
15. Law, J., Campbell, C., Roulstone, S., Adams, C. & Boyle, J. (2007) 255–256.
Mapping practice onto theory: the speech and language practitioner’s 35. Papadopoulos, K. D., Noyes, J., Barnes, M., Jones, J. G. & Thom, J.
construction of receptive language impairment. International Journal M. (2012) How do physiotherapists assess and treat patellofemoral
of Language & Communication Disorders, 43 (3), 245–263. pain syndrome in North Wales? A mixed method study. International
16. Mackenzie, C., Muir, M. & Allen, C. (2010) Non-speech oro-motor Journal of Therapy and Rehabilitation, 19 (5), 261–271.
exercise use in acquired dysarthria management: regimes and ration- 36. Regan, J., Walshe, M. & McMahon, B. (2012) Current evaluation of
ales. International Journal of Language & Communication Disorders, upper oesophageal sphincter opening in dysphagia practice: an inter-
45 (6), 617–629. national SLT survey. International Journal of Language & Commu-
17. Bennett, S., Tooth, L., McKenna, K., Rodger, S., Strong, J., Siviani, J., nication Disorders, 47 (2), 156–165.
Mickan, S. & Gibson, L. (2003) Perceptions of EBP: a survey of 37. Pettigrew, C. M. & O’Toole, C. (2007) Dysphagia evaluation practices
Australian OTs. Australian Occupational Therapy Journal, 50, 13–22. of speech and language therapists in Ireland: clinical assessment and
18. Bernstein-Ratner, N. (2006) Evidence-based practice: an examination instrumental examination decision-making. Dysphagia, 22, 235–244.
of its ramifications for the practice of speech-language pathology. 38. Comrey, A. L. & Lee, H. B. (1992) A First Course in Factor Analysis.
Language, Speech, and Hearing Services in Schools, 37 (4), 257– Hillsdale, NJ: Erlbaum.
267. 39. Safren, S. A., Heimberg, R. G., Lerner, J., Henin, A., Warman, M. &
19. Kahmi, A. G. (2004) A meme’s eye view of speech-language pathol- Kendall, P. C. (2000) Differentiating anxious and depressive self state-
ogy. Language Speech & Hearing Services in Schools, 35, 105–111. ments: combined factor structure of the anxious self-statements ques-
20. Roulstone, S. (2001) Consensus and variation between speech & lan- tionnaire and the automatic thoughts questionnaire-revised. Cognitive
guage therapists in the assessment and selection of preschool children Therapy and Research, 24 (3), 327–344.
for intervention: a body of knowledge or idiosyncratic decisions? 40. Justice, L. M. (2010) When craft and science collide: improving thera-
International Journal of Language and Communication Disorders, 36 peutic practices through evidence-based innovations. International
(3), 329–348. Journal of Speech-Language Pathology, 12 (2), 79–86.
21. Sutherland, S. (2007) Irrationality. London: Pinter & Martin. 41. Lenne, B. S. & Waldby, C. (2011) Sorting out autism spectrum disor-
22. Kahmi, A. G. (1999) To use or not to use: factors that influence the ders: evidence-based medicine and the complexities of the clinical
selection of treatment approaches. Language, Speech, and Hearing encounter. Health Sociology Review, 20 (1), 70–83.
Services in Schools, 30 (1), 92–98. 42. Jensen, G. M. & Givens, D. (1999) Clinical reasoning: linking theory
23. Palmadottir, G. (2006) Client-therapist relationships: experiences of to practice and practice to theory. Neurology Report, 23 (4), 137–144.
occupational therapy clients in rehabilitation. British Journal of Occu- 43. Dowie, J. & Elstein, A. (1988) Introduction. In Professional Judge-
pational Therapy, 69, 394–401. ment: A Reader in Clinical Decision Making (eds J. Dowie & A.
24. Williams, A. M. & Irurita, V. F. (2004) Therapeutic and non-therapeutic Elstein), pp. 1–41. Cambridge: Cambridge University Press.
interpersonal interactions: the patients perspective. Journal of Clinical 44. Dopson, S., Locock, L., Gabbay, J., Ferlie, E. & Fitzgerald, L. (2003)
Nursing, 13, 806–813. Evidence-based medicine and the implementation gap. Health, 7 (3),
25. Fourie, R. J. (2009) Qualitative study of the therapeutic relationship in 311–330.
speech and language therapy: perspectives of adults with acquired 45. Coyle, J. L. (2011) Water, water everywhere, But why? Argument
communication and swallowing disorders. International Journal of against free water protocols. Perspectives on Swallowing and Swal-
Language and Communication Disorders, 44 (6), 979–999. lowing Disorders (Dysphagia), 20 (4), 109–123.
26. Joffe, V. & Pring, T. (2008) Children with phonological problems: a 46. Charman, T. (2010) Developmental approaches to understanding and
survey of clinical practice. International Journal of Language and treating autism. Folia Phoniatrica et Logopaedica, 62, 166–177.
Communication Disorders, 43 (2), 154–164. 47. Lum, C. (2002) Scientific Thinking in Speech & Language Therapy.
27. Watts-Pappas, N., McLeod, S., McAllister, L. & McKinnon, D. H. Mahwah, NJ: Lawrence Erlbaum Associates.
(2008) Parental involvement in speech intervention: a national survey. 48. Cronje, R. & Fullan, A. (2003) Evidence-based medicine: toward a
Clinical Linguistics & Phonetics, 22 (4–5), 335–344. new definition of ‘rational’ medicine. Health, 7 (3), 353–369.

1186 © 2015 John Wiley & Sons, Ltd.

 13652753, 2015, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jep.12385 by Cornell University Library, Wiley Online Library on [15/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
A. McCurtin and A.M. Clifford Treatment decisions of SLTs

49. Ely, J., Osheroff, J., Ebell, M., Bergus, G., Levy, B., Chambliss, M. & 55. Pollock, A., Legg, L., Langhorne, P. & Sellars, C. (2000) Barriers to
Evans, E. (1999) Analysis of questions asked by family doctors achieving evidence-based stroke rehabilitation. Clinical Rehabilita-
regarding patient care. BMJ (Clinical Research Ed.), 319, 358–361. tion, 14 (6), 611–617.
50. Sain, A. H. M. (2004) Evidence-based medicine revisited. BMJ (Clini- 56. King, G., Currie, M., Bertlett, D. J., Strachan, D., Tucker, M. A. &
cal Research Ed.), 312, 7023. Willoughby, C. (2007) The development of expertise in paediatric
51. Harding, K. E., Porter, J., Horne-Thompson, A., Donley, E. & Taylor, rehabilitation therapists: the roles of motivation, openness to experi-
N. F. (2014) Not enough time or a low priority? Barriers to evidence- ence, and types of caseload experience. Australian Occupational
based practice for allied health clinicians. Journal of Continuing Edu- Therapy Journal, 55 (2), 108–122.
cation in the Health Professions, 34 (4), 224–231. 57. Parahoo, K. (2000) Barriers to, and facilitators of, research utilization
52. Greenhalgh, T. (2002) Intuition and evidence – uneasy bedfellows? among nurses in Northern Ireland. Journal of Advanced Nursing, 31
British Journal of General Practice, 52 (478), 395–400. (1), 89–98.
53. Hofmeijir, J. (2014) Evidence-based medical knowledge: the 58. Rose, A. & MacKenzie, L. (2010) Beyond the cushion’: a study of
neglected role of expert opinion. Journal of Evaluation in Clinical occupational therapists’ perceptions of their role and clinical decisions
Practice, 20, 803–808. in pressure care. Disability and Rehabilitation, 32 (13), 1099–1108.
54. Pennington, L. (2001) Attitudes to and use of research in speech and 59. Oliver, K., Lorenc, T. & Innvær, S. (2014) New directions in evidence-
language therapy. British Journal of Therapy and Rehabilitation, 8 based policy research: a critical analysis of the literature. Health
(10), 375–379. Research Policy and Systems, 12, 34.

© 2015 John Wiley & Sons, Ltd. 1187

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Treatment decisions of SLTs A. McCurtin and A.M. Clifford

Appendix A

Respondent agreement with 56 survey statements

Individual statements % Agree Medians

S13 The individual nature of each patient influences my choice of therapy or technique 96 1.5
S9 Clinicians should provide rationales for the therapies and techniques they use 95 1.6
S10 It is important that I am able to argue and defend my choice of therapies and techniques 95 1.7
S36 I make efforts to keep up to date with developments in clinical practice 94 1.8
S45 Specialist/expert clinicians are valuable sources of information when considering therapies and techniques 93 1.7
S41 My decision to use a therapy or technique is influenced by my clinical experience 92 1.8
S1 A therapy or technique should have clear goals that can be tested 91 1.9
S34 I like exploring new treatment options 90 1.9
S37 I use the therapies and techniques I do because they work 90 1.9
S56 I prefer therapies and techniques which are patient-centred 89 1.7
S7 It is important that the therapies and techniques I use have a sound theoretical basis 87 1.9
S8 Understanding why a treatment works is as important as understanding whether it works 87 1.9
S43 I use therapies and techniques I learned from watching/working with other clinicians 85 2.0
S14 I focus on the patient’s specific deficits and choose therapies and techniques based on this 79 2.0
S11 A patient’s preferences and values influence my choice of therapies and techniques 77 2.1
S32 I am confident about the therapies and techniques I use 76 2.2
S23 I use therapies that I learned from doing specific training to learn that particular therapy or technique 76 2.2
S50 The therapies and techniques I use are the standard of care in speech and language therapy 73 2.2
S29 Once a treatment has research attached to it, I am more likely to believe it to be effective 72 2.2
S54 I like therapies and techniques that can be used with a variety of fun games and activities 69 2.2
S30 I read research regularly to keep updated on therapies and techniques 68 2.2
S55 I prefer to use therapies and techniques that are more concrete than abstract for my patient’s sake 66 2.3
S44 I place a high value on the opinions of colleagues when deciding whether to use or stop using a therapy or technique 65 2.3
S47 The therapies and techniques I use are the standard of care in my workplace 65 2.3
S52 The easier a therapy or technique is to understand the more likely I am to use it 60 2.5
S2 Science should be used to decide whether therapies and techniques work 58 2.4
S51 I use therapies and techniques that are easy to implement 56 2.5
S39 SLTS can waste time by the use of un-validated or non-scientific treatments 55 2.5
S16 The patient must take responsibility for ensuring treatment success 53 2.5
S53 I prefer to use hands-on therapies and techniques 52 2.5
S12 Family preference influences my therapy and technique choices 49 2.7
S46 I rely on clinical experts/specialists to help me make decisions about therapies and techniques 49 2.6
S42 Clinical experience is the best guide to deciding what therapy or technique to use 48 2.6
S40 SLTs can do harm by the use of un-validated or non-scientific treatments 47 2.6
S18 I don’t have enough time at work to spend reading and thinking about developing my treatment repertoire and 45 2.8
therefore implement new therapies and techniques
S19 It is difficult to convert research into clinical practice 42 2.8
S17 I am limited in the therapies and techniques I use by what is available to me 39 1.0
S27 I rely on SLT textbooks to inform my use of therapies and techniques 39 2.9
S21 The placebo effect is a factor in outcomes in SLT intervention 35 3.0
S24 I tend to use a lot of therapies and techniques I learned in college 32 3.1
S15 What the patient brings to therapy is more important than the therapy or technique 31 2.9
S48 SLT department policy determines my choice of treatments 27 3.3
S5 I believe in my therapy and technique choices even if there is no research evidence to support them 24 3.2
S20 Once purchased, or learned I will use a therapy or technique to ensure good value 24 3.2
S35 I tend to have a repertoire of favourite treatments which I use with most patients irrespective 19 3.4
S26 I use therapies and techniques that I have read in the print media 18 3.4
S22 The patient therapist relationship is what is important in treatment, not the therapy or technique 16 3.2
S28 I continue to use older textbooks to guide my use of therapies and techniques 15 3.5
S38 I use the therapies and techniques I do because there are no other options available 13 3.6
S3 I use alternative or complimentary practices in my work 9 3.8
S49 If a therapy or technique is in use by the profession for a long time then it must be good 8 3.6
S4 I rely more on commercial products than research in making treatment choices 5 4.0
S31 Any treatment or technique will work if the therapist believes in it 4 4.1
S33 I don’t tend to adopt new therapies or techniques in clinical practice 4 4.0
S6 Research evidence does not influence the therapies and techniques I use in clinical practice 3 4.1
S25 I use therapies and techniques that I have seen/heard on the radio or TV 2 4.2

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A. McCurtin and A.M. Clifford Treatment decisions of SLTs

Appendix B

Extracted factors and statements loaded onto each factor

Factor no. Factor label Statements loading onto factor

1 Basic practice S4 I rely more on commercial products than research in making treatment choices
S6 Research evidence does not influence the therapies and techniques I use in clinical practice
S18 I don’t have enough time at work to spend reading and thinking about developing my treatment repertoire
and therefore implement new therapies and techniques
S20 Once purchased, or learned I will use a therapy or technique to ensure good value
S35 I tend to have a repertoire of favourite treatments which I use with most patients irrespective
S36 I don’t make efforts to keep up to date with developments in clinical practice (reversed statement)
S49 If a therapy or technique is in use by the profession for a long time then it must be good
S51 I use therapies and techniques that are easy to implement
S52 The easier a therapy or technique is to understand the more likely I am to use it
S54 I like therapies and techniques that can be used with a variety of fun games and activities
2 Scientific practice S1 A therapy or technique should have clear goals that can be tested
S7 It is important that the therapies and techniques I use have a sound theoretical basis
S9 Clinicians should provide rationales for the therapies and techniques they use
S10 It is important that I am able to argue and defend my choice of therapies and techniques
S30 I read research regularly to keep updated on therapies and techniques
S33 I tend to adopt new therapies or techniques in clinical practice (reversed)
S34 I like exploring new treatment options
3 Ethical-scientific S2 Science should be used to decide whether therapies & techniques work
practice S5 I don’t believe in my therapy & technique choices if there is no research evidence to support them (reversed)
S39 Speech & language therapists can waste time by the use of un-validated or non-scientific treatments
S40 Speech & language therapists can do harm by the use of un-validated or non-scientific treatments
4 Constrained/ S17 I am limited in the therapies and techniques I use by what is available to me
pragmatic S19 It is difficult to convert research into clinical practice
practice S21 The placebo effect is a factor in outcomes in speech and language therapy intervention
S32 I am not confident about the therapies and techniques I use (reversed)
S38 I use the therapies and techniques I do because there are no other options available
5 Patient and S11 A patient’s preferences and values influence my choice of therapies and techniques
colleague S16 The patient must take responsibility for ensuring treatment success
evidence S27 I rely on speech and language therapy textbooks to inform my use of therapies and techniques
S43 I use therapies and techniques I learned from watching/working with other clinicians
S45 Specialist/expert clinicians are valuable sources of information when considering therapies and techniques
S46 I rely on clinical experts/specialists to help me make decisions about therapies and techniques
6 Personal S15 What the patient brings to therapy is more important than the therapy or technique
influences S22 The patient therapist relationship is what is important in treatment, not the therapy or technique used
S31 Any treatment or technique will work if the therapist believes in it
7 Standards of S47 The therapies and techniques I use are the standard of care in my workplace
practice S50 The therapies and techniques I use are the standard of care in speech and language therapy
8 Less scientific S25 I use therapies and techniques that I have heard/seen on radio or TV
sources S26 I use therapies and techniques that I have first read about in the print media
S28 I continue to use older textbooks to guide my use of therapies and techniques
9 Autonomous S37 I use the therapies and techniques I do because they work
clinical S41 My decision to use a therapy or technique is influenced by my clinical experience
experience S42 Clinical experience is the best guide to deciding what therapy or technique to use
10 Research belief S29 Once a treatment has research attached to it, I am more likely to believe it to be effective
11 College learning S24 I tend to use a lot of therapies and techniques I learned in college
12 Patient S13 The individual nature of each patient influences my choice of therapy or technique
responsiveness S56 I prefer therapies and techniques that are person-centred
13 Specific training S8 Understanding why a treatment works is as important as understanding whether it works
S23 I use therapies which I learned from doing specific training to learn that particular therapy or technique

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