Section Two: Problematic integration in clinical practice

This section presents a discussion of the problematics encountered during clinical practice and the negotiations that SLTs make, which ultimately and intimately have an effect on the individual within his or her contexts.

8.4.1 Bringer of solutions

The data showed concern and frustration felt by the SLTs that clients and their families look for quick (and easy) answers to the problems with which they present on admission. The SLTs felt that they were not able to offer an immediate remedy or a cure to their clients. This started the process of undervaluing of the SLT and the profession on both the part of the SLT and the client and/or family.

There are certain presumptions and expectations set up by clients on what a clinical engagement ought to offer presumably from their former engagements with other healthcare professionals (Simmons-Mackie & Damico, 2010). In some instances, this could be the search for answers to their communication problems. In order to appear relevant, the SLT acts in accordance with these presumptions and with an air of certainty. As a mark of professionalism in front of the client or colleagues or to validate

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their years of training, overt public manifestations of certainty are paraded. This lends an air of professionalism that suggests the worth of the professional health practitioner. The biomedical model is still being used to acculturate students in healthcare into the respective professions whereby the expectation is set up that they need to be the ‘bringers of solutions’. The biomedical model focuses on objective findings that emphasises the cause of a disease or disorder that needs to be eliminated by medical interventions to cure the client (Lundström, 2008). Hence, the biomedical model of medicine tends to limit the interpretation of a disease or disorder to mere physical signs and symptoms (Chin, 2001).The healthcare–practitioner relationship has long been assumed to be a straightforward association and encounter between an expert in healthcare and a person in need of healthcare (Chin, 2001; Pillay 2003b). However clinical engagement is a co-constructed event (Simmons-Mackie & Damico, 2010) hence this engagement will define how the participants function in therapy. If there is an expectation for the SLT to effect a solution, then the client might become a passive communicator and not realise their own power and responsibility or they might lose their other competencies as communicators (Simmons-Mackie & Damico, 2010). The biopsychosocial model is a scientific model, which was developed to address the missing dimensions of the biomedical model (Engel, 1980), namely client-focussed intervention and it motivates the healthcare practitioner to become more informed and skilful in the psychosocial areas of practice. Therefore the salvation mentality by clients looking for ‘cures’ from the healthcare practitioner does not align to the shared decision-making prerogative that the co-construction of therapy and the biopsychosocial model aim to provide.

8.4.2 Conception of care

In the conception of care and being an emotional caregiver, the SLT has to draw from his or her previous experiences and on role models from their communities, and negotiate between their personal and professional roles to assist the client.

Foucault (1973) makes the distinction between ‘assistance’ and ‘care’, where ‘assistance’ refers to the observing, clinical gaze of the health professional that is focussed upon assisting the alleviation of symptomatology; while ‘care’ is a deeper construct in which the symptoms of the disease are perceived and treated as part of an integrated and compassionate whole.

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An unexpected experience and role that the SLTs had to negotiate was that of being an emotional caregiver to clients and their families. As seen in the stories by Lynn, Zandi and Mbali, this was not something that the SLTs expected in practice and it was not something for which they were prepared during their undergraduate education. During their undergraduate education, speech-language therapy students are not taught how to ‘care’ for their clients, but they are taught the professional ethical codes of practice and they are told to practice within these guidelines in ‘assisting’ the client. The student has to negotiate his or her own understanding of care and his or her role as an SLT within the boundaries of the ethical codes of practice. Students in healthcare education are taught about boundaries of professional behaviour such as to be empathetic and not sympathetic with their clients. It is considered to be ‘professional’ to maintain emotional distance and affect has been constructed in this way.

What then happens when the client’s family abandons the client as related in the narratives in Chapters Four and Five? A client’s caregiver ‘takes responsibility’ of the client’s well-being. This is a show of the primary expression of a caring communicative relationship. The data suggests that the family who should offer ‘care’ to the client abandons this role and foist this responsibility onto the SLT. The SLTs acknowledged this engagement that they needed to activate assistance and care toward the client however; it appeared that they were not able to embrace this ‘foisted care’. The SLTs could have seen that the foisted care was an over-extension of their professional roles. Perhaps they were not entirely prepared for the emotional investment that they would have to make beyond the scope of therapy with their clients. This draws us to acknowledge the significant irony of how the training programme aimed at educating professional communicators and providing ‘helping’ educational training has actually de-legitimised ‘taking responsibility’ and ‘care’.

Why is this so? Many therapeutic approaches in speech-language therapy advocate and encourage family and parent involvement in speech-language therapy. Such programmes include the Palin Parent–Child Therapy programme (Michael Palin Centre for Stammering Children, 2008, cited in Guitar, 2014) and Parents and Children together in Therapy (Bowen, 2009) in order to achieve progress and success with the client. Family-centred intervention is seen as more beneficial and favourable to achieve therapy outcomes as opposed to traditional one-to-one speech-language

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therapy. Therefore, dissonance could be created between what the SLTs were taught during initial professional education and what they experience in clinical practice. It might be conceived that SLTs have challenges negotiating their communication and therapeutic interventions in cases where parental or family involvement is lacking or when greater levels of [foisted] care are expected of the practitioners. This could possibly highlight a gap in the undergraduate curriculum as students might be exposed to these realities of practice where families are absent, mothers abandon their premature babies and clients are left unstimulated in isolation however the students do not know how to negotiate these realities as professionals. Perhaps the aim of clinical teaching is to construct ‘ideal’ teaching and learning experiences that allow students to develop expertise in assessing and treating particular pathologies, which will enable the SLT to understand ‘assistance’ as the primary goal of the therapeutic encounter as opposed to ‘care’ (Beecham, 2002). Therefore, when SLTs are expected to displayed deeper levels of ‘assistance’ in other words ‘care’, they appear to have difficulty in negotiating this role in real-life practice. Perhaps the HE curriculum also tends to emphasise the “unit of one”: where the graduating professional’s competence is interpreted to reside only within the one individual, rather than in relational connectivities. The HE curriculum promotes individualism, whilst professional practice warrants shared collaborative effort between ranges of partners.

8.4.3 Cross-cultural–cross-linguistic communication

Cross-cultural–cross-linguistic communication is perceived as a significant dilemma in the provision of effective services in South Africa even though multilingualism and cultural diversity is a global phenomenon. It is the SLT’s responsibility to be knowledgeable about and to provide culturally and linguistically appropriate services. There is a lack of interpreters due to human resources challenges in the public healthcare context, hence this was problematic for the practitioners. Even if interpreters were available at the hospital, the interpreters often could not help because they themselves did not speak the languages of the clients who were from other African countries.

Sharon, a bilingual speaker, desperately asks in her story in Chapter Four, “What kind of multilingual [speech-language therapist] do I need to be to be a competent speech therapist?”

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Further layered on this argument of language issues is that the school context has additional complexities where language is the medium of instruction for teaching and learning in the classroom. Hence, collaboration between the SLT and teachers becomes very important, as SLTs are well equipped to support teachers with in- service programmes in facilitating language for literacy (Wium & Louw, 2013) in ways to facilitate the learners’ access to the concepts being taught. However, as evidenced in the data, this collaboration is lacking between these two professionals in the school context where the SLT has an important role. Hence, this requires attention at an undergraduate level in how the SLTs can negotiate their communication to promote and advocate for their skills in the school setting. The SLT might know the role that they could play however; they do not seem know how to bring this across to colleagues.

Besides not being able to speak the languages of the clients, the participants had difficulty negotiating the clinical engagement when there were cultural differences between the therapists and clients. These cultural differences could present as the SLT not knowing how to respond to the resistances offered by the client or his/her family. In Carl’s narrative, there is cultural dissonance between himself and the client in terms of differences in age and cultural conceptions of therapy. Carl might be able negotiate the engagement in terms of knowledge of the communication disorder as well as the need to know about Zulu linguistics, however what Carl is uncertain of is how the client has configured pathology and disorder, hence the client’s overt resistance to therapy.

This section highlighted the professional and personal conflict felt by the SLTs. They are perceived to be the bringer of (communication and social) solutions for their clients, carers which they consider and over-extension of professional role, while negotiating differences in language and culture between themselves and their clients and families. Hence, the clinical engagement goes beyond the propositional knowledge and taps into the craft knowledge of the practitioner on a professional and personal level. It is such problematics that leave the practitioner with unresolved issues in clinical engagement which only perpetuate from one client to the next. The lack of resolution leaves the practitioner destabilised.

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8.5 Section Three: Policy and guidelines influencing communication strategies