COVER STORY: SKILL MIX

Are you listening?

A new communication development worker post, collaboration with speech and language therapy and a robust training plan has made a respite unit called Tayavalla an inspiring inclusive communication environment. Elaine Crighton, Isabel Forsyth and Lois Cameron explain how children and young people are now getting the most from their break.

espite presents specific communication challenges in that the children and young people are away from their most familiar communication partners and most familiar communicative context. However, it also provides a huge communication opportunity because of the emphasis on individual care and providing meaningful activity to make the stay fun. So how can we ensure a consistent approach to communication when children go to respite? Tayavalla is a residential short break unit in Falkirk run by the childrens charity NCH Scotland. It provides a respite service to approximately 35 young people who live in the Forth Valley area. This large geographical part of Central Scotland encompasses three councils - Falkirk, Stirling and Clackmannan - each with a range of schools attended by young people who also access Tayavalla. There are 10 speech and language therapists providing input to these schools. In addition, a few children attend schools outwith these local authority areas, which further increases the complexity of liaison and ensuring the communication needs of the young people are addressed. The speech and Language therapy service has always had good informal links with Tayavalla, although input in the past was on an ad hoc, caseby-case basis. We had also delivered two days of training on Inclusive Communication to staff at Tayavalla. This gave them background information about different levels of understanding and how to recognise communication breakdown, and an overview of strategies that could support the communication skills of the children. The training had highlighted to the staff the areas they would like to explore and have time to develop further. They were keen to support the children requiring alternative and augmentative communication (AAC) to participate more fully in activities and decision making, but felt they lacked the practical skills and confidence to put this into place.

nication Development Worker was appointed for 25 hours a week for a year. The appointee, Isabel Forsyth, came from the staff of the respite setting and knew the staff and children very well. The focus of the Communication Development Workers post was to develop and extend the communication environment for the young people attending respite. Staff from Tayavalla and the speech and language therapy service established a steering group to oversee the Are You Listening? project. The group agreed the design of an Action Research model, set clear goals and provided a mechanism for measuring outcomes. It also identified two key areas: 1. children and young peoples communication 2. staff development needs. The initial stage of the project involved devising before and after questionnaires for both the staff and the young people. The staff questionnaire was designed to highlight communication development needs so that appropriate training could be provided. The young persons questionnaire was devised to look at how they were communicating, and whether this information was available to staff at Tayavalla. The staff questionnaire looked at: Knowledge of communication development and augmented systems Knowledge and confidence for switches, objects of reference, signing and the computer Confidence in drawing to facilitate choice Access to resources (symbols, communication aids, digital photography). The areas of need identified for training were: using switches, the computer, and photography.

Training plan

Learning with Care

At around the same time, Falkirk Council approached NCH offering Learning with Care, a fund to develop Looked After Childrens educational attainment. Since communication skills were seen as fundamental to the childrens development and attainment, a proposal was developed in partnership with key staff from the speech and language therapy service to create a post to promote childrens communication. As a result, a Commu14

From this information, a training plan was developed involving informal and formal methods. Informally, the Communication Development Worker was available and had the time to support other staff to operate the computer and the digital camera. She was able to assist with practical difficulties such as how to use the software and how to download photos, so that as many staff as possible were able to create visual supports for the children. The speech and language therapy service also provided a training session on AAC and using simple technology for the staff at Tayavalla. This was kept practical with just a short introduction to what is meant by AAC. We divided the staff into small groups and gave each group a scenario they might

come across in a respite setting, involving a child with a communication difficulty. We asked them to carry out the role-play initially without the use of simple technology, as this gave them the opportunity to explore how it might feel to have a communication difficulty in this setting. We then asked them to re-try using the equipment we gave them. This created a lot of discussion, and staff were able to identify other situations where they could use the technology. They reported feeling more confident about having a go now they had been given a chance to play with the tools and to see they could easily be incorporated into daily routines. Analysis of the before and after staff questionnaires showed that staff knowledge, confidence and competence increased in every area covered in the questionnaire, except knowledge of communication development which stayed the same. (This could have been because the team already had a high level of training in this from speech and language therapy.) Staff became more confident in using the computer and were able to produce digital images to support communication, which in turn made the digital photography more accessible. Childrens questionnaires were completed using the project files (in consultation with children and families where required). As the study was time limited, the steering group highlighted 12 children with high level communication needs to work more closely with. The questionnaire consisted of only two questions. The first focused on the information available to staff on how the child communicated. The second question focused on the childs communication and looked at: 1) how the child was communicating, i.e. the systems being used 2) what the child was communicating, i.e. the communicative functions was it just needs and wants, was it to make a joke? 3) where the child was communicating, i.e. the different settings.

READ THIS IF YOU WANT TO FORM PARTNERSHIPS WITH LOCAL AUTHORITIES AND THE VOLUNTARY SECTOR OFFER EFFECTIVE TRAINING WITH FOLLOW-UP SUPPORT ENABLE CLIENTS TO DEVELOP COMMUNICATION IN DIFFERENT CONTEXTS

Communication Support Plan

The results showed that, for some young people, there was no formal information accessible to the staff at Tayavalla at the beginning of the study. This highlighted the need to have accessi-

SPEECH & LANGUAGE THERAPY IN PRACTICE SUMMER 2008

COVER STORY: SKILL MIX

Isabel with Zoe and Ashleigh and a Talking Mat at Tayavalla. Photo by Paul Reid.

ble information on the young persons communication skills available to all staff, and prompted the idea of writing a Communication Support Plan for each young person. Speech and language therapists working in one of the secondary schools attended by the young people using Tayavalla had introduced Communication Profiles (adapted from Valentine, 2003) as a way of sharing information with teaching staff. This had proved very useful in school as it is one A4 sheet with information about the pupils communication skills, their likes and dislikes and any other important information. The key issue in developing a summary sheet is around the rigour and process of gathering the information to ensure its accuracy and relevance for the young person. The profile gives a summary of the kind of information that might be in a Communication Passport (Millar, 2003) but is a quick reference sheet that can be read by supply teachers or new members of staff who need to get to know the pupil quickly before the class starts. Where young people had a Communication Profile already in place, this made the information more accessible and easy to translate into the Communication Support Plan being introduced at Tayavalla. Where these were not available the same type of information could be gained from speech and language therapy reports and Individual Education Programmes, but the information was not as readily accessible and often included jargon that was not easy to translate. For us, the key results of this project are: 1. All staff had access to appropriate and up-todate information to support the young peoples communication. 2. Improved staff confidence in using switches, Voice Output Communication Aids and the digital camera to support communication.

3. Improved staff confidence in facilitating choice, and in their ability to communicate more effectively to meet the range of childrens needs. 4. A significant increase in the young peoples opportunity to communicate because of improved access to communication systems. This resulted in improved quality of interaction and an increase in their participation. 5. Inclusive communication strategies are well embedded in the project to the benefit of the young people, parents, staff and other agencies. There is easy access to a library of relevant symbols and photographs. A key indicator of success is that these resources and the AAC equipment box now require frequent tidying! 6. Promotion of good practice in interagency working. 7. Significant parental involvement in the communication strategies promoted by the project was unanticipated but welcome. 8. It provides a good example of inclusive communication in practice that can support the overall objectives of the speech and language therapy service. It is invaluable to be able to show people what we mean by an inclusive communication environment - and one visit to Tayavalla has a huge impact. The project has shown there are many benefits from having a Communication Development Worker. While some of these were predictable, others were unexpected. She is able to: take ownership and disseminate to the other staff involved in a way that they find easy to understand and relate to. understand the opportunities provided as part of the routines in the respite setting and encourage realistic targets. contribute knowledge about communication in a setting other than school to enable a more holistic approach.

Case Example Alison Before the communication development work, Tayavalla staff had no formal information on how Alison communicated. She had yes/no symbols on her tray but during the summer break the tray had been replaced and staff werent sure if the symbol position for yes/no had been significant! However, once all the information about Alisons communication had been gathered and the Communication Development Worker had observed her using the Etran frame at school, staff were able to offer her much more appropriate support at Tayavalla. She could eye point really quickly and was so obviously motivated when she got the opportunity. Staff were then able to move on from yes/no questions to using the Etran frame with a range of symbols and photos to involve her in many more aspects of life at Tayavalla than had been possible in the past. The AAC training session had also included a scenario of a child using eye pointing to participate in a story, and had given staff an opportunity to practise the skills of interpreting eye pointing and presenting information in this way. This led on to an opportunity to support Alison in providing a report for her review. She attended Tayavalla with her mum two days before and did some opinion-forming type communication using the Etran Frame in a Talking Mat format (Murphy & Cameron, 2002). We took photographs of the results and compiled a review report. The meeting was then held at Tayavalla to help Alison make the link between the work shed done and the meeting. She came on the day of the meeting and chose to present the report in person. When the meeting turned to talk about adaptations in the bathroom because she had grown she drew herself up to full height in her chair, letting those around her know she understood. When the staff acknowledged how tall she was becoming she smiled confidently. This had a significant impact on all present.

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COVER STORY / user involvement help ensure that skills learnt in the school setting can be transferred to a respite setting. use her increased contact with parents and families to ensure strategies are consistent across all environments, and offer invaluable support. Using the strategies in a care setting provides an important role model for parents. The study has shown the important role that residential units can play in furthering childrens communication skills when they provide a setting in which children can continue to develop and practise them. The partnership between the Communication Development Worker and the speech and language therapy service has been key to the success of developing a quality communication environment. Isabels energy to focus solely on communication proved a huge impetus to change and success. To embed inclusive communication practice into organisations is a challenge but this respite service has achieved it and is able to make sure staff have the skills to listen to what the children and young people are saying, no matter how they are able to say it. Are you Listening? won the Scottish Care Accolade Award 2007 for Innovative and/or imaginative training programme. We are delighted that this project has also received funding for a further three years from the Big Lottery. Part of this funding includes the extension of the skills developed within the respite setting to other places that the children and young people use in the community. This will continue to ensure that everyone is listening to them, no matter how complex their communication needs. Elaine Crighton and Lois Cameron are Speech and Language Therapists working for NHS Forth Valley, Speech & Language Therapy Department, Euro House, Wellgreen Place, Stirling Fk8 2DJ, e-mail lois.cameron@ fvpc.scot.nhs.uk, and Isabel Forsyth is the Communication Development Worker for NCH Tayavalla. SLTP

Looking in the mirror

User involvement whats your experience? Let us know at the Summer 08 forum, http://members.speechmag.com/fo

Editor Avril Nicoll introduces our new series on user involvement.

I originally planned to do a single feature on user involvement but was so overwhelmed by offers of help that I decided to run a series instead. While user involvement is enshrined in all NHS policy documents, I have a very personal reason for wanting to see this aspiration put into practice.

REFLECTIONS DO I NURTURE THE ABILITY OF SUPPORT STAFF TO GIVE TIME AND PRACTICAL SUPPORT TO INDIVIDUALS? DO I NOTICE SIGNS OF CHANGE IN PRACTICE SUCH AS A REGULARLY UNTIDY RESOURCE BOX? DO I MAKE INFORMATION ABOUT A CLIENTS COMMUNICATION ACCESSIBLE?
How has this article been helpful to you? Do you have other stories from inclusive communication environments? Let us know via the Summer 08 forum at http:// members.speechmag.com/forum/. References

Millar, S. (2003) Personal Communication Passports: Guidelines for Good Practice. Edinburgh: Call Centre. Murphy, J. and Cameron, L. (2002) Let your mats do the talking, Speech and Language Therapy in Practice Spring, pp.18-20. Valentine, C. & McConkey, R. (2003) The Communication Profile & its use with a learning disabilities population, Evidencebased practice: a challenge for speech and language therapists. CPLOL 5th European Congress. Edinburgh 57 September.Further information from cathvalentine@devon.gov.uk.

When I qualified 20 years ago it was normal practice for therapists to call clients patients. Both children and adults were seen on their own, or with parents and partners present merely as onlookers. The patient had an impairment that needed to be fixed, and the therapist was the expert who held the answers. Case notes, reports and discussions were reserved for professionals. Choice really came down to whether or not a client chose to turn up. For whatever reasons, this made me uneasy and I was keen to do things differently. From the start I tried to be responsive to individual need and to involve families. I was also very influenced by the pioneering work on empowerment by people like Carole Pound who went on to co-found Connect, the communication disability network. I enjoyed campaigning during Speak Week to get the needs of people with communication impairments in the public eye. But the real change in my attitude came about when I had my children. A deep rage at the way I had been treated led me to become involved in campaigning for improved, woman-centred services. I have now been a user representative at Montrose Maternity Unit for 8 years (www.birthinangus.org.uk). Although I was nervous at the start (who was I to be telling professionals how to do their job?) I now feel incredibly privileged to have been part of the driving force behind major changes that have benefited so many women and babies. The midwifery team leader says, The changes at Montrose have been more than cosmetic there has been a fundamental shift in our attitude, philosophy and our very language. This evolution may have taken place without the input of our users, but it is unlikely. They held a mirror to our service, and we did not like the reflection (Winters, 2006). But the midwives hold a mirror up to me too, and I learn such a lot. I now understand far more about the benefits of helping people locate and draw on their own internal resources, to find their own way and solutions and about using language with other people that constantly reinforces a belief in their strength and ability. I also have a deeper appreciation of the importance of the relationship between client and therapist and what it means for the personal development of both. As Santorelli (1999) says, For too long care has been conceived of as either practitioner-centred or patient-centred. In actuality, the healing relationship has always been a crucible for mutual transformation. I hope this series will inspire you to have the confidence to make genuine user involvement a reality. Please use the forum to share your own experiences - http://members.speechmag.com/forum/.
References Santorelli, S. (1999) Heal Thyself Lessons on Mindfulness in Medicine. New York: Bell Tower. Winters, P. (2006) Holding up a mirror: the impact of user involvement, AIMS Journal 18(3), pp.12-13. Available online at http://www.aims.org.uk/Journal/Vol18No3/holdingUpAMirror. htm (Accessed: 8 May 2008).

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