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Episode
Kate Grandbois: Welcome to SLP Nerd Cast. I am so excited for today's episode. I have the privilege of sitting in this room with four other brilliant human beings who I have had the pleasure of working with for the last couple of years. We are [00:02:00] here today to talk about a topic that is under discussed, um, in the field of speech language pathology, especially in the educational space.
And this is a topic related to, um, supervision management and the idea of breaking barriers to being, to bring better practices to our patients, or, uh, elevating evidence-based practices within the field of speech language pathology. Uh, I am here with friends, co-authors, and as I already mentioned, other brilliant speech language pathologists.
Welcome Shauna McGrath, Mary Beth Schmidt, Natalie Douglas, and Sarah Penrod.
Announcer: Hi Kate. Thanks for having us
Kate Grandbois: I'm really excited about today's conversation. It has been one of the joys of my professional career working with everyone in this room, uh, for the last couple of years. And I wonder if we could start off with each of you just telling our audience a little bit about yourselves.
Shana McGrath: I can start off. So I'm Shauna McGrath. I have been a speech pathologist [00:03:00] for 15 years. Uh, I have always worked in healthcare and currently work, uh, primarily in the outpatient setting. Um, I also work as an evidence-based practice team lead, which I think can give me, give some insight into this topic today.
And I'm really excited to be here. So thanks for having me.
Sara Penrod: Yeah, and I'll go. My name is Sarah Pen. It's Kate said, I work for Maine Health, Maine Medical Center as a clinical specialist, which, um, involves a lot of program development, um, education and knowledge, brokering between staff, um, the rehab department, SLP providers, um, respiratory department.
So we'll get into some of the details about what I do, but I'm also really excited to be here and always happy to work with all of you guys.
Mary Beth Schmitt: Hi, I am Mary Beth Schmidt. I, um, Shauna, you made me do the math. I
Announcer: think I've been
Mary Beth Schmitt: a speech pathologist for like 27 years. Um, started off in public [00:04:00] schools. Um, did the bulk of my clinical career in, um, educational public.
Public educational settings. Um, and then made the crazy decision later in life to go back and get my PhD. And so now I kinda sit at the intersection of research, clinical practice, and, um, supporting SLPs in public schools.
Natalie Douglas: Great. And I am Natalie Douglas and Shauna. You inspired me to do th this and show my calculator.
You're mad showing her. I forgot. How many years does that take? 23. 23. Um, so I started off in medical settings and I've been in academic settings. I'm an associate professor at University of Louisiana at Lafayette, and I'm really interested in how we can solve real world problems with implementation science.
Most of my clinical work is in nursing homes with people living with dementia. And I also have recently been working with [00:05:00] SLPs in a. Course that we're offering through the informed SLP called evidence-based practice in real life where we're trying to coach, um, and brainstorm and work together. Like how do we practices that we know work well?
How do we get them into the real world? So that's why I'm excited to be here today, especially with all of you. So thanks, Kate.
Kate Grandbois: One of the things I love so much about this group is the breadth of experience that all of you bring to the table. So we've got, you know, barriers of implement and, and concepts of implementation science.
We've got two individuals working in medical SEC settings. We've got Mary Beth Schmidt, which lots of research experience in the educational space, clinical experience in the educational space. Um, and I think that the, this, this group really does encapsulate the spectrum of what we see in the field of speech language pathology operating.
At a kind of a 30,000 foot view, asking questions about what [00:06:00] infrastructures are we all working in, regardless of our workplace settings, regardless of our clinical specialties, and what infrastructure, how does that infrastructure impact the clinical decisions that we are all collectively making? So it's this really cool idea of a shared, common, common denominator across the entire field, which is awesome.
Uh, before we get into the real, the real interesting pieces of today's discussion, we, I do need to read our learning objectives, so I'm gonna get through that as quickly as possible. Uh, after listening to this episode, participants will be able to self-report knowledge gains related to barriers to using evidence-based practices in real world clinical settings.
Participants will also be able to self-report knowledge gains related to the role of knowledge brokering in healthcare and education, as well as reporting knowledge gains related to action steps that SLP managers can take to shift culture and share best practices within their [00:07:00] organizations. So, even just thinking about those learning objectives, um, it's a, it's really interesting to think about anybody who's listening, whether you're in acute care in some other sort of medical setting, in an elementary school, in a high school, in a private practice.
These are concepts and issues that each one of us deals with. Um, and I love thinking about the ways that bring us together as a field, because there are also so many, you know, our scope of practice is so wide. Every time I talk to one of you brilliant medical people, I'm like, I don't even know how to say dysphagia slash dysphagia.
Um, much less do anything about it. And yet we have the same license, right? So we're, we all bring so much to the table and I love thinking about the things that bring us together, um, and the things that we all have in common. And that's one of these topics. The bulk of the conversation we're gonna have today is available in a paper that came out in 2024 that these brilliant individuals were authored on.
Um, and we are gonna reference the, the link to the paper will be [00:08:00] in the show notes for anyone who wants to do some further reading. Uh, also if anybody is interested in learning more about any of the financial and non-financial disclosures for this course, those will also be listed in the show notes and on the landing page.
And finally, if anyone is interested in using this episode for Ashes, eus, or Certificates of Completion, the link to the post-test will also be included in the show notes and on the landing page. Okay. So now that we have some of that stuff behind us, I wonder if we could open the discussion by talking about really why are we all here?
What is the problem that we are collectively trying to address by talking about the power of, uh, middle management?
Shana McGrath: I can start us off, Kate. So for me, I think back to 15 years ago when I graduated, and you know, I had learned all of this information in graduate school, I was so ready to go out and be an exciting brand new clinician and apply all my knowledge.
And then I [00:09:00] found in working in different places that we weren't all doing exactly the same thing. And so there were things that people were doing that didn't seem in alignment with. What I had learned was best practice. So the, that was like really shocking to me per starters. And then as I looked into it further, really realizing that there is a well established research practice gap that I had no idea existed.
And then when I found out how broad that gap is, I was completely shocked. So I would say on average, on average, a 17 year from practice to or from paper to practice gap. Of only 14% of the research that is published, which is so shocking to me. Um, but it really explained why I was seeing such variation in practices in different, uh, settings or even within a setting amongst different SLPs.
So I think that really is, and that gap, that gap has existed for a really long [00:10:00] time. So I think that's one of the things that really is like a call to action of how do we narrow that gap and get more of this work that is being done through, through us and out to our kids and our patients and the people that we are working with.
So I think that's one of the big reasons I think we're here.
Kate Grandbois: And just to say that back to you, you know, if it takes 17 years for the information that we're using in our clinic room, so I'm imagining anybody listening or even myself showing up to work tomorrow, getting my coffee, going into work, going into my treatment room, what's the big deal?
So I know what I know from graduate school and I'm gonna show up as my best self, uh, and, and apply my knowledge to help my patient. So what is, what's the big deal with this gap? Why do we care? I mean, that's a rhetorical question. I know why we care, but I'm asking it on per, I'm asking it on purpose.
Shana McGrath: I'm, I am happy to tell you my thanks for asking, Kate.
I'm happy to tell you why we care. So, I, I [00:11:00] think what I mentioned before of where, you know, even within the same setting or facility, having such a wide variation of care that affects our, our patients and our kids, right? So if they're getting outdated, if, or. Ineffective interventions, then they're essentially missing out.
And we're here to help our patients communicate and, um, engage in life and engage in school. And if they're getting different care within a setting, that's a bit concerning. But then thinking, you know, if that someone comes and sees me where I am and then pursues care closer to home or in a moves to a different city, they get different care.
So we have such a wide variation. And then I think one of the other things that I wanna point out on that is, even as a clinician, you know, if I come in and as a clinician who has this great knowledge of, you know, this great journal article I read, or, um, you know, this great CEUI went to, and then I go back to my facility and it's.
You know, if we're [00:12:00] not following those practices, that can really lead to this ethical tension too, and a sense of, you know, I'm not doing what I really see as best practice. So that can kind of contribute to burnout, which I know is a very hot topic in all of our fields, but that's what really stands out to me as one of the issues with this knowledge practice.
Natalie Douglas: I think part of what we want to bring to the table to today is how we think that leveraging middle level managers, and we'll get into that more, but is one way to kind of solve this research to practice gap.
And I always like to. Mention that in addition to the research to practice gap, there is a practice to research gap in terms of the research that gets funded. The research that gets completed is not [00:13:00] usually applicable to clinical settings, and part of that is because science needs to be slow, to be rigorous and to be, um, conducted in a way that can be replicable.
And we know how important that is.
The practices that we know are helpful and beneficial, as Shauna was saying, are not getting to the people who need them the most in a consistent way to where if I get, as Shauna was saying, if I get care in this particular area of the country. And I, and again, I'm in the medical, more of the medical space.
Let's say I have a stroke in a rural area, maybe I'm gonna get this aphasia treatment, but then if I get have a stroke in an urban university hospital, I'm gonna get this type of treatment. Same with schools kind of across the lifespan. [00:14:00] And we have to do better. Right? So we have to be thinking about innovative ways to approach that.
Mary Beth Schmitt: Yeah. And Natalie, I was thinking the same thing of that. It's not just research to practice, but like how you said practice back to research. So much of the reason that I went back to get my PhD was the. The gap in research, um, for the patients that I was serving or the, the client, the students that I was serving.
You know, we left graduate school with that, that onus of part of your job is continuing to read the research, and I did, and this is like true confession time like I did for a while. And then after a while I'm like, this is pointless. Like this. I, my, the people I am serving are not represented in the literature and the type of research that's being done on the students I'm serving doesn't even come close to mirroring real world.
And so I. I stopped. [00:15:00] Um, and it was just like, well, we're gonna do the best we can with what we have and, you know, continue doing professional development and other types of learning. But in terms of like accessing real time research, it felt like a waste of time. And I do think that Tide has shifted and we're having more and more research that's, um, that is more clinically relevant, that's truly a partnership with clinicians so that the research, um, is a better mirror for clinical world.
But it makes me wonder, like, had I not gone back to school, I don't know if I would've ever been privy to the fact that the tide had turned. Right, because it was like, it, it was so useless for so long that it's like, oh, actually look like Now there is some research that applies to my patients, but by, but for so many, um, clinicians in schools, the workload is insurmountable.
And so having the time of [00:16:00] going through and finding the research and figuring out what's relevant and how, um, it's just, it's a real, it's a real big challenge.
Kate Grandbois: When I hear these, when I think about this problem, I actually have never said this to any of you, and so you might dis you might disagree with me, I wanna hear everybody's thoughts.
But when I, when I think about this problem sometimes about how long it takes for good information to land in our brains, to land in our treatment rooms, right? I think about myself as a patient and imagine myself in an instance where I am sick or I, you know, have had some medical event and I'm in need of medication, right?
So flipping the script and kind of thinking about this through a medical lens and my doctor prescribes me a medication and it might work a little bit, but there's a better medication out there. But I'm, my doctor's not gonna know about it for 17 years and that makes me mad. That makes me angry, right?
Like as a patient, I'm like, no, I want the [00:17:00] medicine that is going to help me yesterday. I want the best available evidence. And in a way, if you look at it through that lens, our patients and our students also deserve to know what is going to help them in the most realistic, in the most realistic way.
Right? I mean, does any, do any of you have some, I'm opening myself here in a vul vulnerable moment for critical feedback, live and in real time. Does anybody disagree with me?
Shana McGrath: I agree wholeheartedly, and I think about it a lot as being that's, that's why we, that's why we get on. Um, I think about it a lot, uh, in those situations where the, the script is flipped and I'm, I'm the patient, you know, and thinking, why is this so different?
Why, why would I get. You know, a certain medication if I go see a physician in, in my hospital versus the hospital down the road versus a hospital in another city. Why is that so consistent? And what are those barriers that are pre, that are presenting themselves [00:18:00] in speech language pathology, where we're not getting the same thing and recognizing that our work is very complex.
And not to say medicine isn't, but there is a very big difference between giving a medication for something, um, and then coming up with an entire speech, language, pathology, intervention, evaluation, and intervention across our really broad scope of practice.
Kate Grandbois: So we've already talked about a few. You know, we, we've covered why this is important, right? Why should we care? We've talked a little bit about. Some of the reasons why this has, this phenomenon exists. Right? Some of the barriers, Marybeth, you mentioned burnout, uh, or somebody mentioned burnout, unreasonable workload in the schools, right?
There are so many barriers that clinicians face in their everyday work environments to getting access to this information. And I wonder if anyone wants to take a stab at kind of [00:19:00] talking about what that, what those realities are, what those barriers are.
Natalie Douglas: I can just chime in just a little bit about thinking through the system.
Does the systems where we work as SLPs, the organizational cultures and climates do not necessarily support the uptake of best practices across the spectrum. So as much as what we're trying to think about what we can do as individual clinicians, um, which is important, an important piece. When we think about the layers of the system, meaning thinking about from a medical perspective, right?
What types of practices do your leaders incentivize, right? Do they care what you're documenting? Do they care what you're doing? Do they know what you're doing? Do they have an idea of what is within your scope of practice? Do they understand that? [00:20:00] Best practices in speech language pathology could lead to increased patient satisfaction to decrease hospital length of stay.
These outcomes that are important to organizations, there's not necessarily a straight line between what the individual SLP is doing and buy-in at that organizational level. So you have your leaders and then even above that, a lot of what we do has to be driven by who's gonna pay for it in the United States anyway.
So you can't necessarily make a decision based on this is the best treatment, as you were saying, this is the best medication for this. Well, I'm, I'm gonna pay for a fourth of that pill, Kate, because that's what I'm gonna do
Kate Grandbois: and that Right. So that makes me mad. I want,
Natalie Douglas: I want you to pay for the whole pill.
Exactly right. So it's like you've got [00:21:00] these system barriers that are compounding the issues with the, with individual clinicians and contributing to job satisfaction. So I think as we think about the very real realities for a clinician in our field, we have to also be cognizant that there is so much outside of our control in terms of organizational culture and climate and even the sociopolitical factors that are influencing service provision.
There's a lot at play here that contribute to the individual clinician experience.
Shana McGrath: Natalie, I appreciate that you brought up the the system part of this, because one of the things that. I that really stood out to me is when I heard, um, it, it [00:22:00] actually came from nursing when they were talking about evidence-based practice and saying that one of the worst cultures to encounter is a culture of quote, this is the way we've always done it, unquote.
And so I think it is something that really resonated with me. 'cause I have heard those things where maybe I suggest, you know, a, an intervention or a, a new approach or something and, and it's immediately shut down as this is the way we've always done it. And I, I don't think that we always realize how deeply that embeds itself into the organization and the mindset and the frame that we take as clinicians and how that, you know, that also presents such a huge challenge to trying to do what is best for our patients and our students.
Mary Beth Schmitt: And I'll just add on to everything that you guys just said. Act, it applies in schools too, with the added layer of legal expectations and ramifications, right? Of like, [00:23:00] there's, there's a legal process that SLPs have to document, you know, that students are receiving what was proposed in their IEPs. And the uptake of, um, research is tricky when, for instance, you know, certain districts have more money to spend on, on personnel and resources or, um.
Or even just the, um, the procedural rules, right? Of like, here's the certain times during the day you're even allowed to see kids. Right. It, it really then shapes how much and at what to what extent, Kate, to your example of like, I'll pay for a fourth of a pill, or Natalie, you know, whoever said that of, of, it's similar in the schools of like, great, we have new research to show that classroom-based intervention is really advantageous.
But, but then we've got a district where, no, you're actually not allowed to even go into the schools or into the [00:24:00] classrooms, right. To provide it. And so there are so many layers of, of challenge and again, I'm just, I'm glad to be having this conversation.
Kate Grandbois: So to kind of back up a minute and, and summarize all of this, we know that there's this research practice gap.
We know we should all care about it regardless of our setting. We know that each of us as speech language pathologists are working. In settings that are impacted by policy, by culture, by organizational infrastructure, right? We're all working in an industry. We're all workers. We all show up, we all get a paycheck, right?
There are components out of our control. There are barriers to fixing this gap, right? I'm just kind of summarizing. We, you know, um, we're busy, we're stressed, we've got unreasonable workloads. We have leaders who might not care, uh, about fixing this problem. They might not know that there is a problem. Um, we, I mean, even Shauna, to your point earlier about, you know, reading the research [00:25:00] and or actually I think Natalie, it was you that said this.
The research isn't necessarily written for us. There are paywalls. We don't have time to search for it, right? There are all of these things in the way. And the, we started this conversation by talking about the role of supervision and the role of managers and the role of middle managers specifically, and how those roles are in key positions to bridge this gap.
But before we get there, I wanna talk about a strategy that's been, um, pretty well documented or is in the literature as a pro, as a proposed strategy to help fix this problem. And that's called knowledge translation or knowledge and or knowledge brokering. And I wonder if any of you could talk about what knowledge translation is and the role that it plays in trying to bridge this gap.
Natalie Douglas: Sure. I can do that. So, I mean, I think, um, when it comes to knowledge translation, right, that's like getting knowledge from [00:26:00] one place to another, right? And so we all know when we think about. How we learn new skills and habits. It certainly doesn't happen when we are given a handout on something and then we just go along on our merry way, right?
There's these components of active learning that help us situate this knowledge to actually use it. So one particular, I think, helpful. Model is the capability, opportunity, and motivation model, right? So it's like the combi from Susan Mitchie and colleagues. So basically, if I want to get knowledge and I want to actually use it and not just let it linger, I have to be capable of doing it.
So I have to have the knowledge and skills, right? I have to have the opportunity to do it. So I need to have opportunities for [00:27:00] practice and I have to be motivated, right? So whether that comes from an internal motivation or an external motivation, such as an incentive to do it. And I think if you think about what we're expecting of our students of clinicians, when we say, okay, here's the knowledge, just go right.
It's not accounting for all of these areas. And so knowledge translation is a way to say, how do I do this in an active way? And I think one of the things that we know, so sometimes you'll hear the words knowledge translate, knowledge translation, knowledge brokering, implementation, science, implementation practice.
There's a lot of different words for this process of actively translating what you know into action. And I think one of the things that. We're learning more and more about is that [00:28:00] that most effectively happens in the context of functional relationships and that relationship of being able to, I trust you and you trust me, and I know this and you might not know this yet.
So how do we work through this, um, together in a active way?
Shana McGrath: Natalie, I really like that you talked about the relational aspect of evidence-based practice translation or research translation, because I, I think that that is one of the things that is missing when we talk about, you know, access to research or, um.
Organizational culture, a lot of that is that sense of psychological safety to be able to even talk about these things, to be able to ask questions or say, I don't know, or, um, act with professional humility around these topics. And some of the, I'm getting a little [00:29:00] bit of ahead of, ahead of myself, but when I think about the unique position of a middle manager or you know, a job title that has a lot of different names, but that person who can kind of, uh, be that, that in-between, between, here's this research and here's clinical practice, if you have that.
Clinical credibility, like you're in the trenches with all of our clinicians and, and we're, we have some familiarity with the issues that are out there. It really does help that trust and buy-in. So I really appreciate the, the call out of the relational aspect of this because just as we have a relational aspect with our students and our, our patients, we also have a relational aspect with each other, and that's like such a huge part of the entire process.
Kate Grandbois: I'm gonna jump in and, and I think that's a great transition to start talking about managers and particularly middle level managers and why they are in such unique positions to help bridge this and help solve this problem with an [00:30:00] organization. So if you think about it. Middle managers, by definition, are in the middle, right?
So they have generally have, uh, individuals that report to them or they're in a relative position of power or, uh, uh, they're in a position that has relatively more power than other people within the organization. And yet at the same time, they are in positions of less power in when compared to others.
So they have people they report into, so they're not necessarily upper management, right? They're, they're in, in positions in the middle. And inherently, when you are in a position in the middle, you have relationships that go up and you have relationships that go down, right? You are in a position to have visibility not only into the overarching goals of the organization.
Maybe you have budgetary knowledge that other people don't have or knowledge about upcoming policy or knowledge about what the upper management leaders, what their vision is for the [00:31:00] long-term components of the organization. And at the same time, you have knowledge about what working clinicians are actually experiencing on a day-to-day basis.
You have knowledge about the hardships that clinicians are facing, the risks that they have for burnout, the caseloads that they have, and if they're reasonable or unreasonable. How many years outside of graduate school are they? How much mentoring might they need? Do they have a patient that they were a student that they've never seen before?
Right? Because our scope of practice is so wide. These individuals, and if you are listening and you are in the middle, we are talking to you. These are unbelievably important positions because of this relative, relative visibility that we, that you all have to the rest of the organization. Not only that visibility, but the visibility coupled with the relationships.
So middle managers, we know from a lot of management research that's been done over the [00:32:00] last couple of decades kind of function as these linking pins within organizations, and they have opportunities to shape so much about an organization. Not only can they leverage relationships to get better buy-in.
That includes buy-in, like managing up, right? So talking to your leaders about why something is important, advocating for something that workers might direct care workers might need, but middle managers also have the opportunity to shape the policies to say, no, we need this, or, yes, we need more of this.
Or, I know that the budget might be tight, but Right. So there are components of this position that are incredibly unique within an organization and can have a lot of influence when it comes to that organizational climate and culture that Natalie referenced. When it comes to bringing in components of EBP, middle managers are also in a role to be the brokers of [00:33:00] knowledge specific to best practices within healthcare and education.
And I know we've talked about. Both, uh, organizational types, healthcare and education are so different. We have different funding structures across these two different types of organizations. We have different hierarchies, right? So the, even the title middle manager. Might not even apply in schools. It might be the department head or the lead, SLP or I don't know, Mary Beth.
What other, what other titles do these peoples have? Maybe even the principal, maybe not the principal. I don't even know. I've never even, never even worked in schools. Yeah. But there are so many different titles because of, um, the different types of organizations. And I think that that is a contributing factor to us undervaluing the power of these positions in the middle.
Marybeth, do you wanna talk a little, I know we're kind of jumping ahead, but since I brought it up, um, talk a little bit about the structure of schools. I feel like structures of healthcare are a [00:34:00] little bit more, not to be redundant, a little more structured, right? You've got direct care workers, middle management, upper management.
They're a little bit more corporate in their structure of levels and hierarchy, but schools are very different. So can you tell us a little bit about how that might be structured and, and how that role in the middle might look a little different?
Mary Beth Schmitt: Yeah, absolutely. And it, it is unique. Um, and then the complexity is that every district is also gonna look a little bit different.
But generally speaking, kind of from a, um, hierarchical standpoint for speech pathologists, most districts have what we would call a special education director. And so that person really is full administrative, um, covering, um, all aspects of special education, right? So special education teachers, occupational therapists, physical therapists, nursing, um, gifted and talented, even in [00:35:00] speech pathologists, like all fall under this like very, very, very large umbrella.
Um, most districts have, um, what's termed a, a lead SLP. And so like you were describing, Kate, kind of that, that administrative in between, between the special education director who may not actually know much about speech pathology depending on what their background is. Right. Um, and, um, so serving as kind of the in-between, between the special education director and the individual SLPs, um, at schools, but then you have this added component of lead SLPs aren't necessarily tied to any one school, right?
They serve all of the speech pathologists across one district, but then each speech, each speech pathologist then is at one or more campuses, right? And so there's individual variation based on what campuses will allow and what the principals, um, work with. And so lead LPs really have this really complex role as you know, I think [00:36:00] their role of middle managers, like we were saying before the show, like I, I had never heard that actual term, but it makes sense, right?
So they are standing in between the clinicians and administrators, but not just one. Upper administrator, like several of them, some lead LPs also carry a caseload depending on the needs of the, of the district. Um, but then in terms of thinking about like within a school, like who is in this position to be able to be a broker of knowledge, um, some districts also then have individual teams, right?
So they might have an a, a C team or an assessment team, or, um, an a SD team where the SLP is part of a larger team, um, working to, to serve students with specific needs. And so, um, even under the, the lead SLP, there might be sub leads where speech pathologists, um, might serve in these additional administrative roles.
Kate Grandbois: I appreciate that clarification [00:37:00] because I, I think anyone listening is likely, hopefully reflecting on their own organizational structure, considering where they are within the organizational structure. Thinking about who is in the middle, right? Who is in this position of potential influence and power.
Ps if it's not you, please forward this episode so we can get some good effective change happening happening out there. But, you know, everybody's organization is different. All of these labels are gonna be different. Um, all of these. Roles and job descriptions are gonna be different, but the common denominator here is the ability to leverage those relationships and, and be the linking pins to diffuse knowledge, both up and down to, to impact change.
The real point of today's episode is not, um, necessarily talking about organizational culture, but you can't really talk about the potential impact that middle managers have. Without addressing organizational culture and the power to influence change within [00:38:00] organizations. So, uh, as everybody probably assumes organizational culture is related to shared sets of values, shared sets of beliefs, that the comment that Shauna said earlier, this is what we do here, the, the standard, the status quo of your organization.
And in so many instances, back to what Shauna was saying at the beginning of the conversation, that status quo is not necessarily best practice. And that status quo, that culture could be shifted through the power of middle management and leveraging communication. To better, um, embrace best practices to better embrace evidence-based practices.
And I'm just gonna nerd out, nerd out for like one hot second on a piece of literature, uh, a little of research that was done through the Veterans Affairs Hospital, where they looked at what middle managers can actually do, what behaviors they engage in to influence change. So it has been documented that middle managers can do this work.
Effectively, uh, and some of the [00:39:00] things that they did were, uh, communication. So leveraging communication in a really rich, bi-directional way. So talking to staff, getting feedback from staff, doing in-person observation, uh, middle managers to impact change positively. Uh, worked specifically on clinical innovation projects.
So identifying something that wasn't going well within their organization, calling it a project, going out of their way to, to diffuse resources and, and, you know, make it a goal of the organization. They worked a lot on capacity building, so using their own time to help the time to help therapists use their time in a more efficient way, or to create time for therapists to engage in evidence-based practice related activities.
They did a lot of training, a lot of coaching, a lot of organizing and scheduling in services. They also did what they call [00:40:00] selling innovation, and that kind of sounds like a skeevy, salesman's tactic, but it's essentially leveraging your relationships and, and that component of trust that Natalie brought up earlier to get buy-in from other people to.
Again, if you're in an organizational cult culture that doesn't value evidence-based practice or doesn't value best practices, talking about that, why don't we value best practices? Um, you know, really trying to shift the narrative and shift the conversation to get buy-in around why best practices are important for the entire organization.
For the rest of the episode, I really wanna spend some time talking with Shauna and Sarah about your roles, uh, and give us some examples of what you have done. Um, so we didn't really clarify this at the beginning, but both Shauna and Sarah are in positions of middle management doing this job right now in two different healthcare settings.
And I wanna take some time to hear from both of you [00:41:00] about what you've done in your settings as examples of leveraging your role to build capacity, influence, change, and really bring best practices to the forefront.
Sara Penrod: Yeah, super happy to talk about this anytime. As you know, Kate, and I think it's interesting for the listeners that I, myself didn't really have any of this vocabulary before Kate and I built a relationship and, and I was brought onto this fantastic team. Um, I just thought of myself personally as a, an extremely passionate and very nerdy speech pathologist who really just had a question about every aspect of what I was doing.
And always going back to the, I mean, when you go to the literature, you have a very specific question, usually about a specific treatment or a specific patient and, and finding that either literature is too broad or, or doesn't include 55 comorbidities that you're seeing in patients. Um, so to hear you describe what I do in this [00:42:00] really flattering way is very humbling.
And I don't know that I necessarily identify with all of these wonderful things, but I also. And doing them. So it's, it's like a weird place to kind of come at it. But, um, though what Natalie was talking about specifically with motivation, I think that my whole job started with motivation. I am just so motivated to provide the best care for my patients that it, it always turned into how can we, what does the literature say?
What can we do better? How can we meet and talk about these topics when there's inconsistencies? And through that motivation and those conversations sort of built the trust with the department and certainly with other departments that I've been in. But at Maine Medical Center, um, with such a culture of excellence and evidence-based practice, those behaviors were promoted to this position.
I'm, I'm called a clinical specialist, which is basically a knowledge broker. Um. Some of the major projects that I'm, I've worked on [00:43:00] have been exactly what you've been describing, Kate. So one that, um, we just rolled out was a decision tree for how and when to treat TRACHEOSTOMIES patients for communication and swallowing.
So when I came to the hospital, there was huge variance in when an SLP would go in and evaluate a patient who has a, a new tracheostomy tube. Some SLPs wanted to wait until the patient was wearing a speaking valve. Some SLPs wanted to go in when the patient was on the ventilator. And all of this comes from varied experience, varied training.
Um, you know, if you've worked in an ltac, you're gonna go see a patient on a ventilator. If you maybe have only done home health, you're gonna wait until the patient's wearing a speaking valve. So within the department, this conversation of if one patient is getting an early assessment and then an early swallow study, and then an early diet, and the second patient.
It gets all of those things later and ends up with a peg tube that potentially was unnecessary. This is those kinds of, um, variants that we were talking [00:44:00] about at the beginning of the hour. So what we created was a decision tree, certainly started with a massive lit search, um, and clinical practice and, um, input from other therapists across major institutions.
And we created this decision tree and we assessed pre and post, um, a bunch of outcomes for patients such as length of hospital stay, time to feeding tube time spent without communication. Um, we could not have done any of this without the buy-in from executive leadership leadership and, and we sort of have that inherently, um, because those values are understood and those values are propagated in our department.
I think that something like this kind of undertaking. Could still have been done, but without the, the buy-in from executive leadership, it's really harder to get, you know, the time in your day scheduled to do these kinds of trainings. Um, the [00:45:00] encouragement from leadership that we carry things forward so that this is not just a one SLP intervention, this is no, this is, we're adopting this, this plan, um, and this, this plan of care.
So it has been fabulous to work on. I mean, there's countless examples, which I'm sure you also have Shana. But even starting a, um, a fees program, if anybody in in healthcare has started a FEES program, this is not something that SLPs can kind of do on their own. It has to come from executive leadership.
We buy the, the equipment we pay for the trainings, we, we do the trainings in the hospital. So this bi-directional higher level goals combined with working with the SLPs in the department, um, on the ground in front of the patient's. That is how this, this role for me here works. And I have just absolutely loved it.
Kate Grandbois: I think something that you said that I wanna highlight for a second is the support you've had from executive leadership and for [00:46:00] those who are listening, who are thinking, oh man, I don't have that support, or I don't have that kind of exec, you know, that kind of culture. We can, you can get there. I think that there are, I, I wonder if you could tell us a little bit about how your position came to be.
In other words, before you had this role, what was it like and how did you advocate for it?
Sara Penrod: You know, I would love to ask my director where this role came from. I think it, she had had this role elsewhere in other institutions where she worked. So I don't know that it had anything to do with me in particular, but I think I was already demonstrating these, these practices.
So, you know, getting the SLPs together, looking at literature, we have, um, specific deep dives where we just try to look at modified barium swallow studies and talk about complex dysphasia cases. Um, always trying to talk about which patients are getting recommended for PEG tubes and which ones aren't. So that there's that consistency within the department.
And also the kind of [00:47:00] double checking. And I think that on one hand, that is what we're supposed to do as clinicians, right? So on one hand you're elevating your practice by having, you know, 20 years experience in the field. You're simultaneously hiring clinicians who are newer in the department and you become.
Sort of without yourself even realizing it, kind of an expert in the field. Um, and then when I think people in outside departments, the respiratory, um, clinical nurse leadership are, are starting to ask you to partnership on some of the projects that they're working on. You know, the, the trauma team is redoing their clinical practice guidelines.
They need input, they would like input from speech pathology. They're reaching out to you when you start to become, like you said, that forward facing person in the department. Um, not that I'm the only one by any stretch, but that other groups are reaching out for your knowledge because they want that, that back and forth and that brokering.
Um, I think that's how that [00:48:00] position comes to be. And we, in our department we have PT, OT and speech, which you probably do too, Shauna, um, in this role. And we're all kind of acting in our fields to increase this programming. Um. Patient outcomes and, and constantly kind of measure the work that we're doing and, and reassess to make sure that this is best for the patients.
So I didn't advocate, but my director is, is one who advocates for and recognizes the importance of this, this role.
Kate Grandbois: I think the only other thing I wanna point out that's really important about your story, and then Shauna, I'm gonna direct the same question over to you, is that. One of the awesome things about being an SLP and a and a manager in a, in this position is that you have clinical experience, right?
You have clinical knowledge, and so many of these management positions are hybrid roles. So still carrying a caseload, still being involved in direct patient care to keep those skills [00:49:00] sharp, right? You're not just an administrator sitting at a desk all cushy, well, nine to five, I'm gonna have time for my lunch and maybe leave early to go do whatever I need to do.
Right? No, the these are, you're working as a clinician while also working to kind of push an an EBP agenda forward, which is so awesome. Shauna, I wonder if you could tell us about your experience in this role.
Shana McGrath: Yeah, so I was actually reflecting on, uh, Sarah's evolution into her position and kind of had a, we had a model here, so I'm at an academic medical center, so there was a lot of.
Emphasis on learning and education. And one of our strongest departments for this actually is our nursing department. And they have a really great, well established EBP kind of pipeline, uh, from nurse leadership to the floors. And one of the things that happens sometimes at really big medical centers is things become very siloed.[00:50:00]
So they've been, they've existed for a couple decades now, uh, published work and did big leaders in the field. And it was only recently, so I've been in this role for I think seven years, about half my speech pathology career. Um, it was only about seven years ago that our department, or maybe 10 years ago, our department started to look at that and say, well, why does nursing have this and why does rehab not have this?
So luckily it was something that was supported out of, um, a desire to kind of keep up with the, with the nursing department, which is really cool. But I, I. I think it really did shift us into that mindset of, okay, so now we have these roles, what are, what, what are we gonna do? What opportunities do we have?
And just like Sarah mentioned, I've always been someone who's super curious. I love learning, I love research, I love getting to, I, I love exposing myself to all of this information. And I think having that natural passion has helped me be good in this position because I share that passion with the people [00:51:00] that I report to and the people that I influence as well, and other clinicians.
Um, so I guess I'll share an example. So Sarah mentioned the kind of having these dysphagia groups or reviewing modified barium swallow studies. And that's something that our department has done, or our speech pathology group has done for a long time. Very much so driven by our ENTs, but we have an entire continuum here.
We have acute care, we have inpatient rehab, we have outpatient rehab. And these discussions about modified variant swallow studies weren't always relevant to everyone in the continuum, but it was sort of a, well, maybe we should go to these meetings. Maybe we, maybe we should show up. But engagement wasn't really high, so what a great opportunity as a new EBP lead, um, to maybe make a change there.
So one of the things that I did at, from a relational standpoint is really get feedback of what's missing in your, your education. What would you like to know across the [00:52:00] continuum? It's very different working in acute care, which is where I started to working in outpatient and, and what kind of patients that you end up seeing.
So we pivoted our, based on that feedback, we pivoted our, uh, dysphagia discussion into more of a medical speech pathology grand rounds. And it started off with each of our departments, so our acute care therapists, our outpatient therapists, our inpatient rehab therapists. Bring up any topic in the scope of SLP.
So this could be cognitive communication, this could be head and neck oncology, whatever that topic is. And let's present, let's talk about it. And it, it was a bit of a transition just because we were so used to this,
Mary Beth Schmitt: you
Shana McGrath: know, dysphasia modified during swallow review. But over the years with, and we continue to get feedback on this is like, is this working?
What would be better? Is there room for discussion? Um, but over the years it's really just become now embedded where we have really good engagement. We have good attendance from across the board. [00:53:00] And also we've evolved this into having, um. More outside individuals come and talk to us. And what I mean by that, it's not just speech pathology driven, but we recently had a, um, a dentist who specializes in oral care in, uh, developmental disability and um, TBI and cognitive impairment, which was really cool, having, um, our physicians come and talk to us.
We have had palliative care come in and talk to us. So I think it's really allowed us to a connect better as a continuum of speech pathologists from acute to outpatient and not feeling so siloed that nothing belongs to anyone. That these concepts and topics just help level us as clinicians. And then it's also helped build those relationships within our medical center with those speakers who are happy to come in and, and talk with us and share their knowledge.
And, and it really has now sustained itself for a good. I wanna say four or five years pre pandemic. So at least five [00:54:00] years, uh, since we've started this process. And it's, it's ongoing now. So it's really cool to see that, um, come to fruition and to be sustained over time, which is really nice.
Kate Grandbois: I appreciate these examples so much.
I wanna make one kind of comment, reflection before I pivot to talk. Give a little example in the educational space, both of your stories and both of the, the activities and, you know, the, the journal clubs, the, the grant clinical ground rounds that you're talking about. Those are incredibly rich learning experiences.
And I know we're not here to talk about professional development in Asha CEUs, and I will not. Go on a rage spiral about our continuing education industry. But so many of our organizations and our leaders make assumptions that, oh, well, that's what your PD stipend is for. Oh, that's what your uh, that's what your CEUs are for, right?
But you're talking about embedded rich bi-directional learning experiences that are not [00:55:00] necessarily a webinar online. And I know the irony. We're here talk on a podcast for professional development. Okay. The irony is not lost on me, but my point is, if you're in a position of middle management and you have the opportunity to advocate or create a role like this that is hybrid, that is focused on shifting organizational culture, you can embed rich learning experiences within an organization.
That take us so much farther than what our traditional professional development, you know, quote unquote webinars will take us. Uh, and that is all I'm gonna say about that before I get on my professional development soapbox, because that, that is not why we're here. Are you all so proud of me? I'm reigning myself in really, really well.
I'm getting, I'm getting lots of air clap in the zoom room for those of you who are listening. Um, so quickly pivoting to talk about a little education example. And Mary Beth, maybe you can elaborate. Um, there is one in the paper, there is a description of, uh, a [00:56:00] lead, SLP who kind of serves in this similar high hybrid role to both you, um, to both you Shauna and Sarah, who has a small caseload but manages a department and the things that you're talking about also replicated in an educational space, right?
So there's always staff meeting, there's always these components of infrastructure in a school. And this particular SLP, shout out to Sarah Valley. Here in Massachusetts, uh, who shared her experiences for the purposes of this paper that was published. Um, creating things like journal clubs, creating things like clinical rounds, creating things like a peer mentoring circle where you bring your challenging cases, you create a hive mind, you create, um, you know, opportunities and increasing capacity for SLPs in a school to, it's not trachs.
I mean, I don't even understand half the words. You're, you met SLP brilliant met SLPs use, but you know, it, it's not about the same clinical topic, but it's the same infrastructure. Uh, and those can be created [00:57:00] as created in schools as well and, and have been. Mary Beth, I don't know if you wanna, um, back me up or tell me that I'm wrong.
Both options are completely appropriate.
Mary Beth Schmitt: Oh, a thousand percent.
Kate Grandbois: Okay,
Mary Beth Schmitt: good. I would never say you're wrong. No.
Kate Grandbois: So, you know, going into our last couple of minutes here, um, I, I just wanna recap and talk a little bit about just in summary, how important knowledge brokering is in the role of, of ma of the SLP manager.
Um, and how by leveraging our relationships and creating capacity, we are really in, I say we, like, I'm a middle manager. I'm not managing anybody, but you all brilliant human beings of the world are in these positions to mediate the flow of information to advocate. Um, and I wonder if all of you might be willing to share a few just action [00:58:00] steps or suggestions for anybody listening of what they could do when they go into their spaces tomorrow.
Mary Beth Schmitt: I'll start just in the kinda leading off from where we ended with education. Um, I've learned so much from middle managers in education. Like I said, I, I've never heard the term, but that's, that's who they are, right? That's, that's their capacity. Um, and one of the most quick story, if I may, um, one of the most, um, powerful in bidirectional examples of bidirectional learning, there was a lead, SLP, um, who reached out to me from my research perspective, it's saying, Hey, would you come, um, partner with us?
And we set up monthly professional learning communities, which is, um. Which is one avenue in schools. Um, and 20 SLPs [00:59:00] showed up every month, right, to these, and it was this exchange of the lead. SLP was there literally as the middle manager in these spaces. I shared a little bit of research on like, okay, here's what the research says, but then the clinicians then were able to ask questions about the feasibility, right?
Of like, okay, the research says this, but then how do we actually go about practicing in the middle manager the lead, SLP was there to help navigate, well, here's what the law says. Here's like, well, we're, you guys are actually making assumptions, right? Like we, we've created this story that this is a barrier when it's actually not a barrier or right.
Of just, it was this really fascinating dialogue between what is the evidence, but then also what are the barriers and what are the realities for implementation. The clinicians went to try it, and then the next month we started with a debrief. What worked, what didn't work? [01:00:00] What questions came up that I can then take back into research world to make the research better, but also then to, um, have some accounta accountability within the, um, the clinicians themselves.
And so I guess in terms of like a, sorry for that. Tangent, but, but it was just so powerful in how it was, it was definitely like that lead SLP served a critical role in bringing everybody together, but in that space, it was all shared learning, right? It was, here's what's gonna work, here's what's not gonna work.
And so, um, you know, just thinking for the educational SLPs listening out there, both advocating for more of those types of conversations, right? Where it's not just, here's the research, go gee, fourth and be blessed, but more the. Okay. Yeah. But, but really, how, how is this working when I've got this caseload and here are the constraints for my individual, [01:01:00] um, caseload.
Um, whether you are an individual SLP asking for that from your lead SLPs, or if you are the lead SLP kind of broadening, and I know, you know, you're, there's already so many things on your plate, but thinking about like, okay, well how could we maybe use our time even more efficiently to weave in some of these, um, evidence-based practices that really ultimately help not just serve the students better, but improve retention and reduce burnout.
Kate Grandbois: I just wanna say go ye fourth and be blessed is the, is the catchphrase of this episode. I was laughing so hard when you said that. That was so good. I'm sorry if interrupted the flow. Please carry on.
Shana McGrath: I'll add, I'll add something in terms of, you know, just thinking if it seems like such a, an uphill battle to do any of these things, I, I'd like to one, emphasize that my role has evolved so much over the past seven years and did not start out with the influence that it currently has. [01:02:00] Um, but it is the persistence that I think is.
Part of what can help shift these cultures, um, I think it really does start with little things. So if you know you're having a, a staff meeting, maybe dedicating x amount of time to talk about a journal article or a clinical practice guideline, uh, taking some time during a staff meeting to have a case review and just talk about any, any challenging cases, any wins, any, anything that you did differently to start to create this momentum for curiosity and questioning and pulling in the evidence as needed.
And I look for any opportunity I. Can probably in a really annoying way to, uh, include evidence of what we're talking about. So for example, if someone is talking about a patient that they are working on a cognitive communication disorder with, I will reach out for the INCOG guidelines and say, you know, there's a really great algorithm in there that talks about that.
Would you like me to share [01:03:00] that with you? And so just create, like normalizing this, this top of licensed best practice culture so that this language starts to become embedded in the day to day. And that really does build momentum Sometimes that will run away from you, which is exactly the goal. Um, but it does start small.
So I just want to say that it is, it is possible, um, with patients, which I don't have. Um, but persistence, which I do have.
Natalie Douglas: Yeah, I would love to just piggyback on that, Shauna, because I think that. If you're in a position where you have this high level of motivation, like what Sarah was talking about, but you don't necessarily have that leadership support, I think one way to advocate for yourself in terms of maybe moving into a role like that is start with something contained and take some data on it, right?
Like, think about an area of practice that you're passionate about [01:04:00] that you wanna champion best or evidence-based practice with, and think about outcomes that are important to your leaders, right? And say, okay, look, we did this for a few weeks and instead of this, and look what happened. Right? And, and you don't, it doesn't have to be a full flow, full blown research study with IRB approval, but you can, you have the autonomy to think about how can I improve this within my organization?
And, and in addition to your like client data. At the individual level, talk to your, and it can be very informal, right? Talk to your other therapists, talk to other professionals and see like, can we show leadership? Look, when we invest just a little bit into this role, we can have these outcomes that are beneficial to the organization.
But it's like we have to pick something and let it be contained and have some boundaries. I think otherwise it gets all over the [01:05:00] place. And I think, I know Shauna, you, your role, if I remember correctly, you started with maybe like 75% of your time was still in an active caseload and it has progressively gone up.
So it's like if you can ask your leader, can I have 10% of my time right? To like broker knowledge and look at the outcomes that. I get right for not just for my clients, but for the whole organization. Like this is such a good return on investment, which is often the language these folks speak.
Kate Grandbois: And I just to piggyback on that, Sarah, before you share, it's exactly what you said.
It's talking to them in a currency that they value. So do they value falls about patient, you know, reports about patient falls. Do they value the budget? Do they value, um, you know, patient surveys? Think about what they value and how that your allocated time could be leveraged to improve something that [01:06:00] they value.
That's that managing up, um, and, and linking, you know, linking pen, leveraging relationships. That's so important. Go ahead Sarah.
Sara Penrod: Well, you guys very much covered everything I was gonna say, but I loved the term from the, the VA article, Kate selling innovation. That's exactly what we're describing here. It's, you're either selling the innovation to the, the people above you or selling innovation to the clinicians and they will buy it if you are selling it.
So go forth and
Kate Grandbois: do well go forth and you go forth and be blessed or whatever, whatever. Before it was so good. Um, I appreciate all of you so much. This has been a wonderful conversation. Uh, I'm feeling like earlier I didn't cite that research. It was angle at all. I can cite that. Um, citation the research about the VA behaviors of middle managers, um, across a VA hospital system.
I'll cite that in the show notes. A quick shout [01:07:00] out to our production team who makes this podcast possible. Dr. Anna Paula Mui, who makes our ashes EU possible. Tegan a Hearn, our production manager who wears a million hats, keeps me in line, uh, and keeps the project alive. Darren Lopez, our production assistant who produces all of our course materials.
Tracy Callahan and Dr. Mary be Schmidt, who is here with us today, who support our, um, uh, peer review process, our advisory board, who engages with our content and elevates the quality. And last but not least, our panel today, Shauna, Mary, Beth, Natalie, Sarah, thank you so much for being here. I'm very grateful for all of you.
Natalie Douglas: Thank you. Thank you. Thanks, Kate.
Outro
Announcer: Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs. You can also potentially use this episode for other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study.
Please check in with your governing bodies or you can go to our [01:08:00] website, www.slpnerdcast.com all of the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at [email protected]
thank you so much for joining us and we hope to welcome you back here again soon.
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