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Collaboration between parents and speech and language therapists (SLTs) is seen as a key element in family‐centred models. Collaboration can have positive impacts on parental and children's outcomes. However, collaborative practice has not been well described and researched in speech and language therapy for children and may not be easy to achieve. It is important that we gain a deeper understanding of collaborative practice with parents, how it can be achieved and how it can impact on outcomes. This understanding could support practitioners in daily practice with regard to achieving collaborative practice with parents in different contexts.
To set a research agenda on collaborative practice between parents and SLTs in order to generate evidence regarding what works, how, for whom, in what circumstances and to what extent.
A realist evaluation approach was used to make explicit what collaborative practice with parents entails. The steps suggested by the RAMESES II project were used to draft a preliminary programme theory about collaborative practice between parents and SLTs. This process generates explicit hypotheses which form a potential research agenda.
A preliminary programme theory of collaborative practice with parents was drafted using a realist approach. Potential contextual factors (C), mechanisms (M) and outcomes (O) were presented which could be configured into causal mechanisms to help explain what works for whom in what circumstances. CMO configurations were drafted, based on the relevant literature, which serve as exemplars to illustrate how this methodology could be used. In order to debate, test and expand our hypothesized programme theory for collaborative practice with parents, further testing against a broader literature is required alongside research to explore the functionality of the configurations across contexts. This paper highlights the importance of further research on collaborative practice with parents and the potential value of realist evaluation methodology.
Current policy in education, health and social care advocates for family‐centred care and collaborative practice with parents. Thereby, collaborative practice is the preferred practice for SLTs and parents. In this paper, we explore collaborative practice and use a realist evaluation approach to achieve the aim of setting a research agenda in this area. Researchers use realist evaluation, a methodology originally developed by Pawson and Tilley in the 1990s, to explore the causal link between interventions and outcomes, summarized as what works, how, for whom, in what circumstances and to what extent. Realist evaluation provides a framework to explore configurations between contexts (C), mechanisms (M) and outcomes (O). We used this methodology to take a first step at making explicit what collaborative practice is and how it might be achieved in different contexts. We did this by drafting a preliminary programme theory about collaborative practice, where we made explicit what context factors and mechanisms might influence outcomes in collaborative practice between parents and SLTs. Based on this programme theory, we argue for the need to develop a research agenda on collaborative practice with parents of children with speech, language and communication needs. The steps between a programme theory and a research agenda could entail exploring each CMO, or step in the programme theory, and evaluating it against the existing literature—both within and beyond speech and language therapy—to see how far it stands up. In this way, gaps could be identified that could be converted into research questions that would stimulate debate about a research agenda on collaborative practice. Understanding how collaborative practice can be achieved in different contexts could support SLTs to use mechanisms to optimise collaborative practice intentionally and tailor interventions to the specific needs of families, thereby enhancing collaborative practice between parents and SLTs.
Keywords: collaborative practice, parents, realist evaluation, speech and language therapyThe purpose of this discussion paper is to stimulate debate and research on effective collaborative practice with parents of children with speech, language and communication needs (SLCN) in speech and language therapy practice. Families are the centre of learning for children, and in situations where additional support is required for learning language, a family‐centred approach is essential. Collaborative practice is identified as a key component in family‐centred care and is essential for goal‐setting, planning and implementing interventions that address family priorities and needs (Kokorelias et al. 2019, An et al. 2018). An et al. (2016: 1844) defined collaboration as ‘mutually supportive interactions through which knowledge and skills are shared, mutual understandings occur, and shared‐decisions are made’. Collaborative practice could be described as having two complementary components (An et al. 2018: 260): ‘relational practice (e.g., showing respect and empathy, active listening) and participatory practice (e.g., engaging the family in the intervention process, and incorporating family needs and priorities into intervention)’. The emphasis on collaborative practice is relevant to interventions supporting speech and language development. Working in collaboration with parents, however, can be challenging for speech and language therapists (SLTs) (Klatte and Roulstone 2016, Davies et al. 2017). Currently, there is little research about how collaborative practice between parents and SLTs can be achieved.
In order to strengthen understanding of how best to achieve effective collaboration with parents in intervention, this paper uses realist principles to develop a preliminary programme theory and begin to identify core components of collaborative practice. A programme theory can be developed from existing research, debated within the professional field and evaluated, in order to make explicit how collaborative practice with parents can be achieved in speech and language therapy, taking context and mechanisms into account. In this way, we argue for a reconceptualization of collaborative practice with parents based on the evidence and recommend a research agenda to explore collaborative practice more extensively.
The relational practice component of collaboration has gained traction in the speech and language therapy literature and is underpinned by a reciprocal relationship between clients and professionals. For example, a range of terms has been used to represent this relationship, with some focusing primarily on the role of parents, such as ‘parental involvement’ (Watts Pappas et al. 2008) and ‘parental engagement’ (Melvin et al. 2019, Klatte et al. 2019), whilst others used the term ‘co‐practice’ to reflect a more reciprocal process (McKean et al. 2017). For the purposes of this paper, we adopted the phrase ‘collaborative practice’, shifting the focus from ‘engaging with’ a service or professional, which implies a more one‐way relationship and attendance at services, to working together collaboratively through reciprocal relationships to enhance children's learning (Goodall and Montgomery 2014). This focus on enhancing children's learning and reciprocal relationships could potentially encourage SLTs, as well as parents, to think differently about how they work together. In our view, collaborative practice places an equal emphasis on the different, but complementary, roles of both parents and SLTs.
Although the notion of working with parents in partnership/collaboratively has been in existence for many years (Pugh 1987), there is relatively little research about how collaborative practice can be achieved with parents in speech and language therapy. SLTs can draw on literature from other professional contexts that provide useful principles for collaborative practice (e.g., An et al. 2018). However, contextual and profession‐specific factors are likely to have a substantive influence on the success and quality of professional–parent relationships presenting an impetus to investigate the specific SLT–parent collaboration. In a systematic review of interventions for preschool children at risk of developmental speech and language disorders, Roulstone et al. (2015) found only one study (Tardaguila‐Harth 2007) that attempted to build in a measure of parents’ understanding of their role; there were no studies that provided descriptions or evaluations of how collaboration was established as part of an intervention for these children.
Despite the espoused benefits of collaborative practice and the evidence that parent‐implemented language interventions can have positive effects on children's language outcomes when compared with control groups (Roberts and Kaiser 2011), there is also evidence to suggest that collaboration between parents and SLTs may be difficult to achieve. For example, collaborative practice may break down when parents are unclear about their roles in intervention, when they undervalue their own role and instead view the SLT as the ‘expert’ (Carroll 2010, Davies et al. 2017, Lyons et al. 2010). Parents may come to intervention with preconceived beliefs about language development, causes of language disorder and speech and language therapy services (Marshall et al. 2007, 2017) which may not be congruent with SLTs’ beliefs and in turn may influence collaboration. Likewise, SLTs come to the intervention process with beliefs and attitudes that will influence their approaches to collaborative practice (Davies et al. 2019). In some cases, SLTs may believe they can encourage parents to take an active role in intervention. However, in examining more closely how SLTs express their work, it seems that they assign parents and carers (intentionally or unintentionally) more passive roles (Davies et al. 2017, 2019). Parents had a clear conception of their role as advocates for their child but expressed a vague notion of being able to intervene and make a difference in their child's language development. SLTs, on the other hand, articulated a clear role of planning and treating but rarely referred to negotiating roles or enabling parents to be decision‐makers during intervention, inevitably assigning a predominantly passive role, or, at best, a helper role to parents (Davies et al. 2017, 2019). Furthermore, Klatte and Roulstone (2016) found that implementation of parent–child interaction therapy (PCIT) differed across therapists and was influenced by organizational constraints as well as family needs and practicalities. The evidence, therefore, overwhelmingly suggests that collaboration is indeed complex and differs according to context that may be very specific to individual parents, children and SLTs.
Evidence suggests that parents may face challenges when working with SLTs. For example, parents may not have time to implement interventions, may find the therapy activities difficult, feel uncomfortable with roles or tasks or may not understand the benefits of the intervention (Justice et al. 2015, Kaiser et al. 1995, Watts Pappas et al. 2008). Sugden et al. (2019), in a qualitative study of parental experiences of homework practice with children with speech sound disorders, found that although parents were keen to work with their children, some reported that it was difficult when the SLT did not consider the context of family life and provided suggestions that they considered were unreasonable. Collaborative practice may be even more important when working with families from disadvantaged backgrounds or who are underserved. In these cases, ‘interventions are likely to be most effective in engaging parents when designed around the needs, concerns and lifestyles of the populations that they are seeking to reach’ (Pote et al. 2019: 6). Pote et al. (2019) argued that this includes not only viewing families as recipients of interventions but also involving them in the design and implementation of interventions.
Implementing a collaborative approach requires that SLTs have the prerequisite knowledge, skills, attitudes and confidence to collaborate effectively with parents (Klatte et al. 2019, Watts Pappas et al. 2009). According to Klatte et al. (2019), SLTs require training on how to achieve mutual understanding and develop constructive relationships with parents, taking specific parental needs into account, in order to enable them to take up their roles in the intervention process. Increasing it is important that SLTs develop cultural competence in order to provide a sociocultural approach that is tailored to the needs of parents who are from backgrounds that are culturally and linguistically different from those of the SLT (Klatte et al. 2019).
In summary, current policies advocate family‐centred care and collaborative practice with parents. However, it is important that this aspect of speech and language therapy practice with children is made explicit and supported by a greater body of research. Interventions for children with speech and language disorders are complex, since these interventions contain several interacting components and active ingredients (Craig et al. 2008). In order to implement complex interventions in real‐life clinical contexts, it is important to find out how change is achieved across a range of contexts (Craig et al. 2008). It is not clear how collaborative practice with parents is used, in what contexts and with what outcomes. It is important that we gain a deeper understanding of collaborative practice with parents, how it can be achieved and how it can impact on outcomes.
Wong et al. (2017) argued that RCTs provide data on what works on average, but they do not indicate how to maximize impact or where to target resources. They argued that people respond differently to interventions. Therefore, what works for one family in one context may not work for another. The principles of realist evaluation provide a framework to explore systematically the complexity of collaborative practice with parents and a useful structure for framing this discussion and setting a research agenda.
Realist evaluation was originally developed by Pawson and Tilley (1997) in the 1990s to explore systematically the link between interventions and outcomes, summarized as ‘what works, how, for whom, in what circumstances and to what extent’ (Wong et al. 2014: 1). There is a range of useful resources on realist evaluation on the RAMESES Projects website (Realist and Meta‐narrative Evidence Syntheses: Evolving Standards—RAMESES 1) and the quality and reporting standards and resources and training materials for realist evaluation (RAMESES II). 1
Realist evaluation is a theory‐driven approach, that is, one develops a theory of the intervention programme as a basis for the evaluation; in realist evaluation, this ‘programme theory’ is used to explain the mechanisms by which different outcomes are generated in different contexts. Therefore, the programme theory refers to ‘the description, in words or diagrams, of what is supposed to be done in a policy or programme (theory of action) and how and why that is expected to work (theory of change)’ (RAMESES II 2017).
According to the realist approach, programmes provide opportunities and resources to enable changes in thinking and behaviour. In order to understand collaborative practice with parents, it is important to understand the underlying mechanisms that lead to successful outcomes and the specific contextual factors that cause mechanisms to have an effect. Researchers using a realist evaluation approach strive to uncover the hidden mechanisms (M) and to understand the conditions or contexts (C) in which they occur, and the outcomes they generate (O) (Cunningham et al. 2018). Marchal et al. (2012) described this process of defining CMOs as opening the black box to make causal links more explicit. RAMESES II (2017) defines context (C) as a set of rules, norms, values and interrelationships that operate and make a difference to the outcomes. These contexts include social, economic and political structures, programme participants and staffing, geographical and historical context. Mechanism (M) is defined as the interaction between what the programme provides (in this case, collaborative practice with parents) and the participants’ reasoning (in realist evaluation this term refers to understanding, values and beliefs of both parents and SLTs) that enables the programme to work. Outcomes (O) refer to the intended and unintended consequences of a mechanism. Given that there are different contexts and mechanisms at play for SLTs and parents, we argue that outcomes may vary, for example, including change in children's language or in parents’ feelings of well‐being.
A realist evaluation is a theory‐driven iterative explanation‐building process (Wong et al. 2012) and is comprised of multiple steps, which include: hypothesizing about CMOs; collecting data from practitioners about the aims of a programme and from clients about experiences of the programme, using qualitative or quantitative methods; analysing data to confirm, refute and refine emerging programme theories; testing theory by looking for disconfirming or contradictory data and alternative interpretations; writing and refining an overall explanatory account; and repeating the process in a different setting with a different cohort. In our view, realist evaluation provides a useful methodology to explore collaborative practice with parents in different contexts; it has been used recently in the speech and language therapy literature regarding the translation of research into practice (Swift et al. 2017) and intervention for speech sound disorders (Nicoll 2017).
The aim of this paper is to set a research agenda on collaborative practice between parents and SLTs in order to generate evidence regarding what works, how, for whom, in what circumstances and to what extent. The paper foregrounds collaborative practice between parents and SLTs with a view to understanding further and optimising outcomes for children with speech and language disorders. We present how the principles of realist evaluation could be used to understand the components of collaborative practice between parents and SLTs. We propose a preliminary programme theory that can be debated, tested and refined. We give examples of CMO configurations based on the existing literature and make suggestions for further research. The intention is to stimulate debate and contribute to the research agenda with regard to collaborative practice with parents of children with speech and language disorders.
The present authors, all of whom share an interest and have expertise in collaborative practice with parents, formed a research group connected with the COST Action IS1406 ‘Enhancing Children's Oral Language Skills across Europe and Beyond: A Collaboration Focusing on Interventions for Children with Difficulties Learning their First Language’. 2 (COST stands for European Cooperation in Science and Technology.) COST Actions are networks dedicated to scientific collaboration that aim to advance science and they provide financial support for meetings, short‐term scientific missions and conferences. The aim of the COST Action IS1406 was to enhance the science in the field internationally, improve the effectiveness of services for children with language impairments/disorders and to develop a sustainable network of researchers well placed to investigate the key questions in this area. Collaborative practice with parents was a cross‐cutting theme relevant to two working groups in the COST Action: the delivery of interventions for children with language disorders and the social and cultural context of intervention for children with language disorders. The first and second authors took a lead role in the process and consulted with other members of the research team throughout the process.
The process involved iterative cycles of debate, redrafting of models by leads followed by requests for feedback. The steps included the following:
A research group of speech and language therapy academics experienced in research in collaborative practice (n = 7) developed the scope of inquiry for ‘SLTs working with parents’ to include ‘the effects and characteristics of successful parent–SLT collaboration in interventions for children with speech, language and communication needs (SLCN)’. The research group met on four occasions to formulate and refine a programme theory and CMOs, map previous evidence and identify research gaps. Frequent Skype meetings were held to discuss and develop the emerging programme theory and to write a paper to prompt discussion and research in the field of SLT.
A preliminary programme theory was then developed with regard to the placing of the SLT–parent collaboration component within a model of complex intervention of SLT for children with SLCN. We described ways in which we hypothesized how SLT–parent collaborative practice interacts with other intervention components. We drew here on the literature on family‐centred models as well as our own clinical experience and research on collaborative practice with parents, from the perspectives of both parents and SLTs (Davies et al. 2017, 2019, Klatte et al. 2019, 2016, Lyons et al. 2010, Marshall et al. 2007, 2017, McKean et al. 2017, Roulstone et al. 2015). We also drew on theoretical perspectives about behavioural change (Michie et al. 2011), patient activation (Hibbard and Gilburt 2014) and shared decision‐making (Elwyn et al. 2012). We reviewed what collaborative practice with parents meant, how it might lead to outcomes and drafted visual representations of the collaborative practice process. Gaps in underpinning theory about how collaborative practice is achieved and empirical evidence for collaborative practice were identified. Of note was an absence of detailed testable theories as to the mechanisms that create optimal SLT–parent collaborative practice. We drew upon realist theory and the RAMESES I and II resources, specifically questions from the ‘Theory’ in Realist Evaluation 3 resource to reflect critically on collaborative working with parents, shape our thinking and develop a preliminary programme theory about collaborative working with parents. The first author also attended a one‐day training event on realist evaluation methodology facilitated by Wong, who is an expert in this methodology.
We applied a realist lens to papers about collaboration between SLTs and parents to serve as exemplars and illustrate ways in which a realist approach could be used. These papers were selected because they described different aspects of collaboration between SLTs and parents across a range of contexts, for example, organizational characteristics (service level) and individual characteristics of participants (individual level). We identified potential CMO configurations in these papers that could be used to make mechanisms more explicit and therefore testable.
The aim of this paper was to set a research agenda on collaborative practice between parents and SLTs, in order to generate evidence regarding what works, how, for whom, in what circumstances and to what extent. The use of realist principles provided a way to understand further the contexts and mechanisms evident in collaborative practice between SLTs and parents. We proposed a preliminary programme theory which will be discussed and offer exemplars of potential CMO configurations to illustrate the potential relationships between contexts, mechanisms and outcomes. Programme theory is important because it provides the foundation for future evaluation questions and a research focus. The preliminary programme theory, which focused on parents who do attend and initially engage with speech and language therapy services, is presented in figure 1 . We are cognisant that some parents do not engage with speech and language therapy services and, as can be see below, the process of testing CMOs challenged the preliminary programme theory. In figure 1 , bold arrows indicate the main causal mechanisms; light arrows indicate secondary outcomes. Drawing on the literature, we argue that both parents and SLTs come to intervention with understandings, values and beliefs (reasoning in realist terms) that may not necessarily be aligned (Marshall et al. 2007, 2017, Davies et al. 2019). In a collaborative practice model, we argue that if the SLT makes time to have a conversation to explore parental reasoning, then a shared understanding of respective preferences, expectations, roles and responsibilities will be achieved. This mutual understanding will stimulate parents’ motivation to work with their child. In realist terms, resources (information, time, support and skills) may also need to be aligned, potentially through a process of co‐designing activities tailored to the child. This co‐design would lead to agreement about how the intervention will be delivered in a way that is tailored to the individual needs and preferences of the family. For example, in some cases it may be agreed by both parties that the intervention will be delivered by the SLT, if that is what works best for some families. In other cases, it may be agreed that parents become agents of change for their child. Collaborative practice enables parents (the participants) to make informed choices about their behaviour (e.g., interactions with their child). Whether the intervention is delivered by the SLT or parent, as discussed and agreed by both parties, the primary outcome will be improvement in the child's language and participation in daily life. We also argued that there may be secondary outcomes for both the parent and SLT, for example, feelings of well‐being for both. The SLTs’ role in this preliminary programme theory involves supporting changes in parents’ reasoning (e.g., understanding, values and beliefs) and their use of resources (e.g., information, time, skills and support), acknowledging that such changes may be challenging for parents. This may require changes in SLTs’ reasoning and use of resources in response to the distinctive interplay of beliefs, knowledge, wishes or competence of the parents (figure 1 ).
Preliminary programme theory underpinning collaborative practice with parents.
Our preliminary programme theory included consideration of potential contexts, mechanisms and outcomes that could be configured to explore causal links. Table 1 documents the potential contexts, mechanisms and outcomes that may interact with each other. At this point, we are not making inferences about causality between specific configurations of contexts, mechanisms and outcomes, but rather we highlight potential CMOs that may interact with each other. There is not always a clear delineation between context and mechanism. For example, Dalkin et al. (2015) argued that resources and reasoning of the agents delivering the intervention (in this case SLTs) can be construed as an inherent part of the mechanism rather than the context. We have included the SLTs in both the context and mechanism columns in table 1 , cognisant that their actions may be influenced by these factors, which in turn may influence the outcomes. For example, SLTs may wish to implement collaborative practice but may be unable to do so because of service and time constraints. In other instances, SLTs may not implement collaborative practice because they do not have the knowledge and skills to do so. On the other hand, parental choice to change may be influenced by many factors such as their previous experience, beliefs and attitudes, as well as access to resources. It is entirely plausible that these beliefs, or in realist terms reasoning, and the resources available to parents may influence outcomes for different parents, in different ways in different circumstances. In order to understand how collaborative practice with parents happens, it is important to make context factors and mechanisms that influence outcomes explicit.
Potential contexts, mechanisms and outcomes in collaborative practice with parents that warrant investigation
