AJSLP

Research Article

Perceptions of Speech-Language Pathologists Linked to Evidence-Based Practice Use in Skilled Nursing Facilities Natalie F. Douglas,a Jacqueline J. Hinckley,b William E. Haley,b Ross Andel,b Theresa H. Chisolm,b and Ann C. Eddinsb

Purpose: This study explored whether perceptions of evidence or organizational context were associated with the use of external memory aids with residents with dementia in skilled nursing facilities (SNFs). Method: A survey design, supplemented by a small sample of exploratory interviews, was completed within the Promoting Action on Research Implementation in Health Services framework. Ninety-six speech-language pathologists (SLPs) and 68 facility rehabilitation directors (FRDs) completed the Organizational Readiness to Change Assessment (Helfrich, Li, Sharp, & Sales, 2009) in relationship to the use of external memory aids. Five SLPs completed an interview exploring perceptions of evidence and context in relationship to memory aid use.

Results: SLPs and FRDs had favorable perceptions of evidence supporting memory aids. FRDs perceived the organizational context of the SNF more favorably than SLPs. SLP participants used external memory aids in the past 6 months in 45.89% of cases of residents with dementia. For SLP participants, a 26% ( p < .05) increase of external memory aid use was associated with every 1-unit change in favor of the evidence. Interview data revealed barriers to external memory aid implementation. Conclusions: Part of evidence-based practice implementation may be influenced by clinician perceptions. Efforts to increase implementation of external memory aids in SNFs should address these clinician perceptions.

T

Additional barriers have been identified in the physical and occupational therapy literature and include factors within the organization that may influence the implementation of EBP, such as the availability of leadership support and positive or negative organizational cultures (Burke & Gitlin, 2012). Further, in the discipline of mental health service provision, clinician and related leadership perceptions of the evidence for certain practices also influence EBP provision to some degree (Aarons et al., 2012). Although barriers to EBP implementation specific to speech-language pathologists (SLPs) have been identified, these studies do not account for perceptions of evidence and/or perceptions of organizational context as studied in these other related rehabilitation disciplines (Elliot, 2004; McCurtin & Roddam, 2012; O’Connor & Pettigrew, 2009; Vallino-Napoli & Reilly, 2004; Zipoli & Kennedy, 2005). Solutions to such barriers in physical therapy, occupational therapy, and mental health services have included the incorporation of professional learning collaboratives, the service of purveyors or intermediaries, the use of stakeholder engagement strategies, the introduction of organizational change techniques, and the insertion of data systems

he gap between evidence-based treatments and the realities of clinical practice in health care is well documented (Green, Ottoson, García, & Hiatt, 2009). Specifically, in rehabilitation disciplines such as physical therapy, occupational therapy, and speech-language pathology, barriers to the implementation of evidence-based practice (EBP) have been identified (McCurtin & Roddam, 2012; Nelson, Steele, & Mize, 2006; O’Connor & Pettigrew, 2009; Pollock, Legg, Langhorne, & Sellars, 2000; VallinoNapoli & Reilly, 2004; Zipoli & Kennedy, 2005). Barriers include the insufficient nature of high-quality evidence for many interventions, difficulty accessing available evidence, lack of time to analyze and study available evidence, and inadequate clinician training to apply the evidence in a typical practice setting.

a

Central Michigan University, Mount Pleasant University of South Florida, Tampa Correspondence to Natalie F. Douglas: [email protected]

b

Editor: Krista Wilkinson Associate Editor: Yasmeen Faroqi-Shah Received November 21, 2013 Revision received March 6, 2014 Accepted June 16, 2014 DOI: 10.1044/2014_AJSLP-13-0139

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Disclosure: The authors have declared that no competing interests existed at the time of publication.

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to support treatment fidelity (Gitlin, Jacobs, & Earland, 2010; Powell et al., 2012; Varkey, Reller, & Resar, 2007). All of the above techniques are rooted in implementation science, the scientific study of methods to promote the uptake of research findings into routine health care, clinical, educational, or other settings (Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005). Although these implementation interventions may vary in terms of their discipline and local context, it is well accepted that such implementation interventions are helpful in merging scientific research studies with the realities of clinical service provision (Fixsen et al., 2005).

Figure 1. Visual depiction of the Promoting Action on Research Implementation in Health Services (PARIHS) framework

Conceptual Framework A conceptual framework that can be used to systematically address the difficulty of implementing EBP in the health care service professions is the Promoting Action on Research Implementation in Health Services (PARIHS) framework (Kitson, Harvey, & McCormack, 1998; Kitson et al., 2008; Rycroft-Malone, 2004). The framework suggests the integration of three aspects, all of which need to be favorable in order to implement an EBP. These aspects include (a) the engagement of perceptions of the evidence from providing clinicians and related leaders, (b) the support of the local organizational context, and (c) the availability of facilitating systems to sustain the practice. The PARIHS framework has been used to support the uptake of EBP in several areas of health care by addressing these three areas (Brisebois & Doyon, 2010; Brown & McCormack, 2005; Estabrooks, Squires, Cummings, Teare, & Norton, 2009). A critical synthesis of empirical studies using the PARIHS framework was also completed (Helfrich et al., 2010). Results of this synthesis indicated that the framework has been applied to increase uptake of EBP in medication management, pain management, smoking cessation, psychiatric services for women, cardiac services, and continence care in rehabilitation facilities. The Organizational Readiness to Change Assessment (ORCA) is a measure designed to quantify elements of the PARIHS framework in relationship to the implementation of EBP (Helfrich, Li, Sharp, & Sales, 2009). Figure 1 provides a visual depiction of the PARIHS framework, and Appendix A outlines items of the ORCA. The ORCA allows factors related to successful implementation of one specific EBP in one specific setting to be studied. For example, perceptions about the value of a specific EBP from the delivering clinician’s perspective as well as managers’ perspectives are considered in relationship to the EBP. During development of the ORCA, the reliability of the Evidence and Context Scales was assessed with Cronbach’s alpha coefficients. The Evidence Scale obtained a Cronbach’s alpha of .74, and the Context Scale obtained an alpha of .85 (Helfrich et al., 2009). A study demonstrating predictive validity of the scales to implement best practices in substance abuse clinics is also promising (Hagedorn & Heideman, 2010).

For this study, the use of nonelectronic external memory aids for residents with dementia residing in skilled nursing facilities (SNFs) was examined. One of the most effective interventions that SLPs can implement in the SNF environment with residents who have dementia is the use of nonelectronic external memory aids (Andrews-Salvia, Roy, & Cameron, 2003; Bourgeois, 1992, 1993; Bourgeois, Burgio, Shulz, Beach, & Palmer, 1997; Bourgeois, Dijkstra, Burgio, & Allen-Burge, 2001; Burgio et al., 2001; Eagan, Berube, Rancine, Leonard, & Rochon, 2010). People with dementia have significant difficulty communicating because of the loss of memory, problem-solving, reasoning, and language abilities. Although dementia is usually progressive and without cure, nonelectronic external memory aids boast a convincing level of evidence to promote positive communicative interactions and decrease behavioral problems that are often present in individuals with dementia (Eagan et al., 2010). The use of nonelectronic external memory aids is a practice guideline for SLPs to support memory for communication in other cognitive-communicative diagnoses resulting from brain injury as well (Sohlberg et al., 2007). Examples of nonelectronic external memory aids include visual schedules and reminders with large print. For example, relying on the relatively spared reading abilities of most individuals with dementia, words written on a note card, such as “Sally will visit at 4:00 PM,” may alleviate repetitive questioning and decrease overall anxiety (Bourgeois, 2007; Bourgeois & Hickey, 2009; Hoerster, Hickey, & Bourgeois, 2001). Further, memory wallets with pictures or family scrapbooks with contextually relevant events rely on preserved memory. When integrated at appropriate times, these wallets promote client dignity and fit well within efforts toward person-centered care (Buron, 2008).

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Aims The purpose of this study was to determine the relationship of perceptions of evidence and organizational context with EBP implementation. Specifically, SLPs’ use of nonelectronic external memory aids for residents with dementia in SNFs was studied. Study aims addressed the following questions: 1.

Are there differences between the perceptions of SLPs and those of facility rehabilitation directors (FRDs) about the evidence for the use of nonelectronic memory aids with residents who have dementia?

2.

Are there differences between SLPs’ and FRDs’ perceptions about the organizational context in an SNF setting?

3.

Are the perceptions of SLPs about the evidence for nonelectronic external memory aids associated with SLPs’ reported percentage of use of nonelectronic external memory aids?

The long-term goal of this work is to develop, implement, and assess methods to support the use of EBP by SLPs within the PARIHS model, so the quantitative approach was supplemented with a small set of exploratory interviews with SLP participants. Interview questions were posed according to components of the PARIHS framework, and a final research question was posed: 4.

How do SLPs describe the evidentiary and contextual factors associated with the use of nonexternal memory aids in the SNF setting?

Method The institutional review board at the University of South Florida approved all study procedures. This study used a survey design, supplemented by a small sample of exploratory interviews, to investigate the potential usefulness of the PARIHS framework to this novel clinical and population group. To the authors’ knowledge, this is the first time this framework has been applied to the field of speech-language pathology to date. Study results were interpreted within the elements of the PARIHS framework.

Participants Given the nature of the research questions, study participants were SLPs or FRDs working in SNFs. Participants were recruited in two ways: First, participants were recruited based on personal contacts of the first author because of her clinical experience. In these cases, a snowball sampling methodology was used as the primary investigator gave contact information to personal contacts for those contacts to forward to potentially interested participants. This resulted in approximately 25 contacts in this recruitment phase. Second, materials were mailed to every SLP and FRD in every SNF in the state of Florida, including forprofit, not-for-profit, and independent facilities. Addresses for each facility were available through the Florida Agency

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for Health Care Administration public listing of SNFs. A total of 1,352 letters were mailed to the FRD and the SLP of each facility (676 facilities). At 1.5 weeks, a reminder letter indicating the date of data collection closure for this project was sent to each potential participant. Recruitment ceased for the study 2.5 weeks after the mailing date. The first SLPs who agreed to participate in the study were also asked to participate in a semistructured interview. Consecutive participants were asked to participate in the semistructured interview until five SLP participants had completed the interview. Participants in the study chose whether to complete the measures electronically or on paper. If the participant chose to complete the measures electronically, they were provided with a unique, secure link to the measure via Survey Monkey. Participants in the study who chose to complete the measures on paper were provided with the measures via mail along with stamped return envelopes addressed to the primary investigator. All potentially identifying information was changed or coded for the protection of the participants.

Instrumentation and Procedure for Data Collection Measures used to collect data from participants were (a) a brief questionnaire about descriptive information for both SLPs and FRDs; (b) a question for only SLP participants relating to percentage of use of nonelectronic external memory aids in treatment of residents with dementia; and (c) the Evidence and Context Scales of the ORCA to both SLPs and FRDs. Questionnaire Data Descriptive data about facilities were collected from the FRDs by asking them to report information about facility characteristics, such as profit status, chain status, number of certified beds, and percentage of occupancy of beds. In addition, FRDs reported years of professional experience in current facility and years of professional experience in the SNF industry as a whole. Further descriptive information was not collected to protect the anonymity of participants. Descriptive data from SLP participants were also collected by asking them to report years of experience as an SLP, years of experience in SNF setting, years of experience in current facility, number of hours per week working in any SNFs, and number of hours per week working in the current SNF building. Facility characteristics were not collected from SLP participants. Further descriptive information was not collected to protect the anonymity of participants. Self-Reported Percentage of Use of Nonelectronic External Memory Aids Current data do not exist regarding the frequency of SLP actual use of nonelectronic external memory aids for residents with dementia in SNFs. For the purposes of this study, the SLP’s actual use of nonelectronic external

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memory aids with residents with dementia was measured in terms of percentage of self-reported use in cases of people with dementia in the last 6 months. Participants were asked to estimate the number somewhere between 0% and 100%. Pictures of common nonelectronic external memory aids were provided to the SLP participants to ensure clarity. The ORCA The ORCA is a measure designed to assess organizational readiness to change when attempting to implement a specific EBP into an organization (Helfrich et al., 2009). The ORCA includes three scales to quantify elements of the PARIHS framework: Evidence, Context, and Facilitation. The Evidence and Context Scales were administered to both SLP and FRD participants in this study. Evidence Scale. The Evidence Scale consists of 13 items that measure the participant’s opinion of the strength of the evidence and any differences between the individual’s opinion and the opinion of coworkers. It additionally assesses clinical experiences with the practice; patient experiences, needs, and preferences concerning the practice; and local information concerning the practice (Hagedorn & Heideman, 2010; Stetler, Damschroder, Helfrich, & Hagedorn, 2011). Eleven out of the 13 items were administered to SLP and FRD participants in this study, as the other two items were not relevant to the SNF setting. Items are assessed by asking participants to rate agreement or disagreement on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). All of the items of the Evidence Scale are averaged to obtain an evidence score for each participant. Mean scores may range anywhere from 1 to 5, with 5 indicating high or favorable perceptions of evidence. Context Scale. The Context Scale consists of 23 items, and it assesses the leadership and staff culture of the organization. It also assesses leadership practices, leadership feedback, readiness to change among opinion leaders, and the perception of resources to support any changes in practice (Hagedorn & Heideman, 2010; Stetler et al., 2011). As above, participants are asked to rate agreement or disagreement on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). All of the items of the Context Scale are averaged to obtain a context score for each participant. Mean scores may range anywhere from 1 to 5, with 5 indicating high or favorable perceptions of the organizational context. Please see Appendix A for all ORCA items administered to both SLP and FRD participants. Exploratory, Supplemental Interviews These measures were supplemented with a small set of exploratory interviews with SLP participants. A semistructured interview format allowed for the primary investigator to ask appropriate follow-up questions as indicated (Patton, 2002). Eleven interview questions were developed based on specific elements of the PARIHS framework and adapted from Stetler and colleagues (2011) and Kitson and colleagues (2008). Please see Appendix A for interview

questions and corresponding elements of the ORCA and PARIHS framework. All interviews were audio-recorded and then transcribed verbatim by the investigator to allow for further analysis. Twenty percent of interview transcripts were transcribed by the second author. These transcripts were compared with those of the first author for point-to-point reliability of transcripts. Point-to-point reliability of transcripts was 94%. Reading and rereading of transcripts was completed by the first two authors, who then independently coded the transcripts according to suggestions from Stetler and colleagues (2011). After two meetings between the first and second author, consensus was reached that each conversational turn would result in the opportunity for one code. For example, it was mutually agreed that every time the interview participant spoke continuously until the primary investigator again spoke, that thought unit would be coded. A priori codes were used according to the PARIHS framework and the ORCA and are also described in Appendix A.

Results Description of Participants Of the 1,377 potential participants, 96 SLPs and 68 FRDs completed the measures (total = 164 respondents), resulting in a response rate of 12%. Of the 1,377 potential respondents, 1,352 were mailed materials. Of the 164 respondents, 145 (88.4%) completed the questionnaires manually on paper, and 19 (11.6%) completed the questionnaires electronically. In total, 13 SLP and 11 FRD participants were removed from the analytical sample because of incomplete or missing data, resulting in 83 SLP and 57 FRD participants for a total of 140 participants. The average years of experience in the current facility was 3.63 years (SD = 3.13) for SLP participants and 5.73 years (SD = 6.15) for FRD participants. Table 1 further describes participant characteristics. Facility characteristics were collected from all but one of the participating FRDs (n = 56). Most FRDs were working at for-profit facilities that are part of a corporate chain (63%). The mean number of beds at these facilities was 125.18 (SD = 45.19, range = 42–294), and the average occupancy rate of these facilities was 91% (SD = 5.97, range = 80%–100%). According to Medicare’s Nursing Home Compare tool (www.medicare.gov/nursinghomecompare/ search.html), 96% of the facilities that were mailed measures accept both Medicare and Medicaid for reimbursement purposes.

Differences Between SLP and FRD Perceptions To determine whether there were differences in perceptions of SLPs and FRDs (n = 83 SLPs, n = 57 FRDs), as measured by Evidence and Context Scale scores of the ORCA, mean difference data were calculated between participants in the two groups. The mean evidence score for the SLP group was 3.83 (SD = 0.55), and the mean

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Table 1. Characteristics of SLP and FRD participants in quantitative portion of study. SLP (n = 83) Characteristic Years of experience in current SNF Years of experience in SNF industry SLP hours per week in current SNF SLP hours per week in any SNF Years of experience as SLP

FRD (n = 57)

M (SD)

Range

M (SD)

Range

3.63 (3.13) 8.47 (7.02) 37.03 (8.48) 38.8 (8.02) 11.32 (9)

0.08–13 years 0.25–30 years 5–60 hr 5–60 hr 0.25–41 years

5.73 (6.15) 12.76 (7.44)

0.08–34 years 0.5–34 years

Note. SLP = speech-language pathologist; FRD = facility rehabilitation director; SNF = skilled nursing facility.

evidence score for the FRD group was 3.95 (SD = 0.56). The mean context score for the SLP group was 3.7 (SD = 0.72), and the mean context score for the FRD group was 3.95 (SD = 0.64). An independent-samples t test was performed to compare mean values of the evidence and context scores between the SLP and FRD participants. There were no significant differences between SLPs’ and FRDs’ perceptions of the evidence, based on the mean Evidence Scale scores on the ORCA. FRD participants viewed the organizational context more favorably than the SLP participants did, and this difference was statistically significant, t(138) = 2.1, p = .03.

Relationships Between SLP Perceptions and SLP Nonelectronic External Memory Aid Use SLP participants reported using nonelectronic external memory aids in the past 6 months in 45.89% (SD = 28.55%, range = 0%–100%) of their caseloads of residents with dementia. Figure 2 shows the distribution of SLP reported use of memory aids per participant. To further evaluate potential relationships between SLPs’ evidentiary and organizational context perceptions as measured by the ORCA Figure 2. Distribution of self-reported use of memory aids with residents with dementia over the past 6 months for SLP participants.

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and their reported usage of nonexternal memory aids in the SLP sample (n = 64), we analyzed data in a two-stage process. First, Pearson product–moment correlations were computed to facilitate model building. Following that, multivariate linear regression analyses enabled evaluation of predictive relationships among the variables of interest. Tables 2 and 3 summarize the correlations of these data. There were statistically significant positive correlations among the number of years of experience as an SLP, years of experience in the SNF industry, and years of experience at the current facility, suggesting that most SLP respondents in this sample had spent most of their career working in SNFs. There were also significant positive correlations between SLP mean evidence scores and SLP mean context scores, suggesting an association between SLPs’ perceptions of evidence and context. In this vein, a more favorable view of the organizational context may be associated with more favorable views of the evidence supporting external memory aids. There was an additional significant positive correlation between SLP mean evidence score and SLP usage of nonelectronic external memory aids, suggesting an association between favorable perceptions of the evidence and use of the practice. For FRD participants, there were statistically significant positive correlations between the number of years of experience as an FRD in the SNF industry and in the current building, suggesting that most FRDs remained in the same building during their SNF industry experience. Results of the correlational analyses facilitated model building of the regression analysis. Given these relationships, years of experience as an SLP, SLP evidence score, and SLP context score were entered as predictor variables. This multivariate analysis allowed for the control of years of experience as an SLP. It also facilitated the examination of evidence scores in relationship to memory aid usage independent of the context scores and vice versa. As noted in Table 2, these variables were entered into the model not only because they were statistically significant but because they also did not greatly covary with other variables. These three independent variables were entered into the regression model simultaneously. The outcome variable in the model was reported percentage of use of nonelectronic external memory aids by the SLPs. Perceptions of the evidence supporting nonelectronic external memory aids was significantly related to the reported use of nonelectronic

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Table 2. Correlates of SLP experience, SLP evidence and context scores, and SLP use of memory aids (n = 83 SLPs). Variable 1. Years of experience as an SLP 2. SLP years of experience total in SNF industry 3. SLP years of experience in current facility 4. SLP evidence score 5. SLP context score 6. SLP-reported percentage of use of nonelectronic external memory aids

1

2

3

4

5

6

— .875** .515** −.133 −.041 −.190

— .563** −.158 .026 −.146

— .66 .083 −.089

— .383** .518**

— .192



**p < .01.

external memory aids. Specifically, the regression model supported the result that for each additional positive point on the ORCA Evidence Scale, the reported use of external memory aids increased 26% while controlling for the context score and years of experience as an SLP. Table 4 shows the estimates, standard errors, and p values for this multivariate linear regression model.

Exploratory, Supplemental Interviews Each SLP who completed the questionnaires was asked to participate in the semistructured interview until five participants agreed. The five SLPs who participated in the interview were similar to the overall SLP sample in years of experience in the SNF industry and years of experience in the current building. Table 5 summarizes interview participant descriptors as well as an account of their experience in training on dementia interventions. The duration of the interviews averaged 19 min (range = 13.5–23 min). The interview transcripts yielded a total of 318 codes. Figure 3 summarizes the distribution of codes, and Appendix A details the interview questions with corresponding elements of the ORCA and the PARIHS framework, along with the a priori code and code description. In summary, data coded as contextual readiness, receptivity to the targeted innovation or change, was the most popular code. Almost one third of all codes, 99 of 318 (31%), related to this category. The next most frequently occurring codes were contextual readiness, leadership support (17.6%); and evidence, clinical experiences and perceptions (16.7%). The least frequently occurring code was evidence, local practice information, as this was not present in the interview data.

The interviews served to supplement the evidence and context scores of the ORCA within the PARIHS framework. For example, the role of context was not statistically significant in its association with SLP use of the practice of nonelectronic external memory aids; however, codes concerning context were present in over half (60%) of all codes in the interview data. Organizational contextual issues related to the implementation of nonelectronic external memory aids, including participating staff members, communication channels within the building, leadership support, and physical resources in terms of materials, were also highlighted in the interview data. Appendix B highlights barriers to the use of nonelectronic external memory aids with residents with dementia in SNFs.

Discussion This study revealed that SLPs and FRDs were in agreement on their favorable perceptions of the evidence supporting nonelectronic external memory aids. Further, FRDs perceived the organizational context of the SNF as more favorable for the implementation of external memory aids than did the SLPs. Results of this work also indicate that the range of SLPs providing the treatment of nonelectronic external memory aids to individuals with dementia is as wide as it could possibly be, from 0% to 100%. A 26% increase of SLP use of the practice of nonelectronic external memory aids was associated with every one-unit change in favor of the evidence for the SLP participants. Finally, the supplemental, exploratory interview data revealed that factors such as lack of necessary staff, physical materials, and time were frequently reported barriers to the implementation of nonelectronic external memory aids in SNFs.

Table 3. Correlates of FRD experience and FRD evidence and context scores (n = 57 FRDs). Variable

1

2

3

4

1. FRD years of experience total in SNF — 2. FRD years of experience in current .561** — facility 3. FRD evidence score −.145 −.059 — 4. FRD context score .335* .240 .154 — *p < .05. **p < .01.

Table 4. Multivariate linear regression analysis for SLP years of experience, evidence scores, context scores, and memory aid usage (n = 64). Outcome

Estimate

SE

p

Constant Years of experience as SLP SLP evidence score SLP context score

−48.62 −0.39 26.05 −0.253

21.23 0.31 5.37 4.08

.205 ≤.001 .951

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Table 5. Characteristics of SLP interview participants.

Participant

Years of experience in SNF industry

1

5

2

1

3

12

4

6

5

4

Time status Full-time and as needed Part-time and as needed Full-time and as needed Full-time and as needed Full-time and as needed

Years of experience as SLP 9 3 13 6 5

Training experience in dementia interventions “Briefly touched on in master’s degree, no class”; “learned mostly on my own or through colleagues” “Grad school class, dementia and TBI elective” No grad class, “we didn’t talk about it at all in grad school”, attended CEUs from Dr. Michelle Bourgeois “My program did not have a good cognitive track in it, there was adult communication disorders but very little about dementia; I have to search out education on my own.” “Heard of it generally in master’s program”; “found CEUs on own”

Note. TBI = traumatic brain injury; CEU = continuing education unit.

These findings suggest the importance of addressing not only SLP knowledge of the evidence for a practice but also SLP perceptions of the evidence for that practice. Specific interventions determining how to most effectively influence clinician perceptions should be studied. The reported mean use of the treatment was 46% of cases of people with dementia in the past 6 months, and this variability alone suggests a need for a more systematic approach to implementing the practice in SNF settings. Favorable perceptions of the evidence by both SLPs and FRDs may facilitate such implementation efforts (Fixsen et al., 2005). This finding is in contrast to general attitudinal surveys of EBP, in which SLPs were found to view EBP as inapplicable to their clinical settings (Mullen, 2005; Vallino-Napoli & Reilly, 2004). In the Mullen (2005) Figure 3. Distribution of codes in interview data. EvR&PG = evidence, research, and practice guidelines; EvClinExp = evidence, clinical experiences, and perceptions; EvPtExp = patient experiences, needs, and preferences; EvLocalPrac = evidence, local practice information; EvOtherChar = evidence, characteristics of targeted evidence-based practice; ConLeader = contextual readiness, leadership support; ConCulture = contextual readiness, organizational culture; ConEval = contextual readiness, evaluation capabilities; ConReceptiv = contextual readiness, receptivity to targeted innovation or change.

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study, American Speech-Language-Hearing Association members were surveyed from varying practice settings, and in the Vallino-Napoli and Reilly (2004) study, SLPs in Australia were surveyed, the majority of whom were working as clinical service providers within a larger organization. Most SLPs in this sample view the EBP of nonelectronic external memory aids in a positive fashion, applicable to their clinical populations of residents with dementia. The more favorable perception of the organizational context possessed by the FRDs likely points to their position of leadership within the organization. For example, there is the distinct possibility that FRDs are aware of resources in terms of physical resources and staff resources for which the SLP is not aware, thus leading the FRDs to have a more favorable view. The link between perception of support and actual support in terms of both leadership and physical resources may also be linked to the implementation of EBP (Aarons et al., 2012). Also, it is a possibility that FRDs may not be fully cognizant of the challenges of ongoing professional development for SLPs and/or the challenges SLPs face in intervening with residents with dementia. An example of a stakeholder engagement and data systems implementation intervention that may help address some of these challenges is the use of plan–do–study–act improvement cycles. These cycles originated in the 1920s as a quality improvement strategy for manufacturing (Shewhart, 1931), and use of the cycles has improved health care outcomes in other disciplines (Varkey et al., 2007). After the targeted clinicians are explicitly trained in the intervention, the intervention is then implemented for a specific time period. After a designated period of time, all relevant stakeholders provide qualitative and quantitative feedback concerning what is working and what is not working in the implementation of the intervention. Agreed-upon changes are made to the intervention while adhering to the core components of the intervention. These opportunities provide an ongoing assessment of how the intervention is being adhered to in the local context. It further allows for mechanisms to support sustainability and maintenance as local, relevant stakeholders are included throughout the process and over time.

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It was hypothesized that SLPs who possessed favorable perceptions of the organizational context in the SNF would be associated with higher percentages of SLP use of nonelectronic external memory aids for residents with dementia. This hypothesis was not supported by results from the data in terms of predicting use of the practice. However, in a study by Aarons and colleagues (2012) of mental health care practitioners working both in public mental health and private agencies, a robust association along these lines was found between favorable clinician attitudes toward EBP and perceived competence of the organizational culture. Issues of staffing and problems with communication channels within the organization were noted in a study examining barriers to the implementation of stroke rehabilitation guidelines (Bayley et al., 2012), and these themes were also present in the supplemental interview data of this study. The large number of individuals receiving care in SNFs, the aging population, and the overall increased longevity of individuals warrant best practices in this setting. Recently, the Centers for Medicare and Medicaid Services (CMS), the organization charged with ensuring quality standards in SNFs through its survey and certification process, initiated a national partnership to improve the behavioral health of individuals living with dementia in skilled nursing facilities (www.nhqualitycampaign.org). Although this initiative began as an effort to reduce the administration of unnecessary and dangerous antipsychotic medications, the partnership also encourages person-centered and interdisciplinary care within SNF settings. Nonelectronic memory aids promote positive communication interactions and have been shown to reduce behavioral problems for residents with dementia (Bourgeois et al., 2001). Such an individualized, nonpharmacological treatment should be more accessible to residents living with dementia in SNFs. SLPs should be well positioned to lead such quality care efforts in long-term care settings for residents with dementia. However, as noted in the interview data, explicit preprofessional training in both dementia and the longterm care setting appear to be significantly lacking. It is perhaps at this level that we can also address barriers to the implementation of best practices. Furthermore, aspects of working as interdisciplinary health care team members and clearly communicating the value added of SLP services in the long-term care setting should be unequivocally and practically addressed at the preprofessional level.

Limitations and Future Directions Although the sample size was small, it was of specific interest as most of the SLP sample had spent their careers in long-term care settings, suggesting this sample would be aware of issues specific to geriatric practice and dementia. Recruitment of participants in this study proved difficult, and most of the potential participants did not respond, nor did the FRD and the SLP from the same facility respond. Ideal implementation efforts are fostered on positive relationships

(Powell et al., 2012), and within this study design, there was no relationship between the primary investigator and the participants. There were no relationships among the researchers and the clinicians and other staff of participating SNFs. It is suspected that participation would have been higher if the researchers could have formed relationships with the staff at each building. For example, if the staff at the SNF knew that these research endeavors were indeed being undertaken to assist better care for residents and to improve employee satisfaction, and if there were tangible products to improve practice patterns collaboratively with SNF staff at the end of the project, the project may have been received with more enthusiasm. Because results of this project indicated that clinician perceptions and organizational variables contribute to the use (or not) of nonelectronic external memory aids, addressing these variables in one-two pilot SNFs, with observation and documentation review and treatment fidelity monitoring of the use of nonelectronic external memory aids for residents with dementia, is a logical next step to this project and would allow opportunities for such relationships as above. For example, according to the limited but present interview data, data systems to monitor use of nonelectronic external memory aids for residents with dementia do not appear to be in place. Through a collaborative partnership with the SNF, interventions targeting key players within the system including nursing, housekeeping, and leadership staff could be completed, while piloting such data monitoring systems. In addition to resident outcomes, this project could also incorporate outcome measures at the employee and organizational level. A collaborative partnership may also facilitate participation and recruitment as proposed above. Another limitation of the study is in the response variable of reported percentage of use of nonelectronic external memory aids. The most rigorous method would have been to observe the SLP using the practice, and the next best method would have likely been to review documentation of the SLP. However, this latter method is not certain due to the electronic reduction of many documentation programs in the SNF setting. Future studies designed to examine outcome variables in this type of research would also be helpful. For example, a study comparing reported use of a treatment, observed use of a treatment, and electronically documented use of a treatment would provide insight into the optimal outcome variable for implementation research in speech-language pathology. If there are meaningful differences between a clinician’s reported use of a treatment, what he or she documents electronically for reimbursement purposes, and what is observed to be actually occurring, this would impact the influences of perceptions of evidence and perceptions of organizational context in EBP implementation efforts. Finally, treatment fidelity was not accounted for in this project. For example, if an SLP reported that he or she used nonelectronic external memory aids in 50% of cases, within this study design there was no way to monitor or report the degree to which the treatment was implemented

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with fidelity. For example, if the investigator reviewed a treatment protocol specific to nonelectronic external memory aids, reported percentage of use may have been more accurate. This work suggests two main aspects for consideration in both conducting treatment research and in implementing EBP that has already been studied: First, clinician perceptions of evidence should be addressed. Accounting for the practicing clinician’s perception of the evidence and his or her clinical experiences is important to at least some element of EBP implementation. At least a portion of the use (or not) of an EBP is accounted for by the practicing clinician’s perception and experiences with that evidence. If researchers consider the perceptions and experiences of the practicing clinician at an earlier stage in the research process, this may result in a more robust mechanism for implementation efforts once the treatment has been fully studied. As suggested by Kagan and colleagues (Kagan, Simmons-Mackie, Gibson, Conklin, & Elman, 2010), incorporating multiple points of contact between research and end research users will facilitate knowledge transfer, ultimately leading to more readily implementable practices. Second, the end organizational context should be considered and engaged. As noted in the interviews, issues of organizational context often precluded a clinician’s use of an EBP. It is doubtful that repeated randomized controlled trials of memory aids in different labs would sufficiently tackle the following, as per an interview participant: I feel like, honestly, because I know that there is poor follow-through for the longer-term residents with dementia, um, developing these kinds of tools, unfortunately, I feel like it’s kind of an exercise in futility because I, my experience has shown that it, there isn’t a good follow-through on it, so if there was, kind of a systemwide approval and appreciation and training on how these tools can be effective, the administrator, the nurse manager, the CNAs, the, all staff, laundry, the kitchen staff . . . I think it would, could be a better utilized tool. Considering context, the overall mean years of experience in their current building was less in years for the SLPs than the FRDs. This may contribute to the finding that SLPs had a less favorable view of the organizational context than did the FRDs. It appears that the ability to stay within the organization for longer periods of time may be somewhat associated with more favorable views of the organization. This may be relevant for SLPs who tend to feel undervalued by their organization at times, as expressed here from the interviews: “Yeah, I would have to say . . . to answer the value question, I would have to say that they [leadership/administration] don’t . . . just because they’re not aware of it. . . . I think they don’t know enough about [the treatment] to, to value it.” With the changing health care tide, including the onset of reimbursement based on the value of services, researchers and clinicians would benefit from informing each other of their priorities. Results of this study suggest that clinicians’

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perceptions of evidence, in part, impact EBP provision. It is reasonable to suggest that attempts to influence such perceptions in both preprofessional and continuing education efforts would be beneficial to SLP practice patterns and overall patient outcomes. Results of this study provide foundations for conceivable benefits for a greater number of patients with cognitive-communicative disorders, practicing SLPs, and the organizations in which SLPs practice.

References Aarons, G. A., Glisson, C., Green, P. D., Hoagwood, K., Kelleher, K. J., & Landsverk, J. A. (2012). The organizational social context of mental health services and clinician attitudes toward evidence-based practice: A United States national study. Implementation Science, 7, 56. Andrews-Salvia, M., Roy, N., & Cameron, R. M. (2003). Evaluating the effect of memory books for individuals with severe dementia. Journal of Medical Speech-Language Pathology, 11, 51–59. Bayley, M. T., Hurdowar, A., Richards, C. L., Korner-Bitensky, N., Wood-Dauphinee, S., Eng, J. J., . . . Graham, I. D. (2012). Barriers to implementation of stroke rehabilitation evidence: Findings from a multi-site pilot project. Disability and Rehabilitation, 34, 1633–1638. Bourgeois, M. S. (1992). Evaluating memory wallets in conversations with persons with dementia. Journal of Speech and Hearing Research, 35, 1344–1357. Bourgeois, M. S. (1993). Effects of memory aids on the dyadic conversations of individuals with dementia. Journal of Applied Behavior Analysis, 26, 77–87. Bourgeois, M. S. (2007). Memory books and other graphic cueing systems: Practical communication and memory aids for adults with dementia. Baltimore, MD: Health Professions Press. Bourgeois, M. S., Burgio, L. D., Shulz, R., Beach, S., & Palmer, B. (1997). Modifying repetitive verbalizations of communitydwelling residents with AD. The Gerontologist, 37, 30–39. Bourgeois, M. S., Dijkstra, K., Burgio, L., & Allen-Burge, R. (2001). Memory aids as an augmentative and alternative communication strategy for nursing home residents with dementia. Augmentative and Alternative Communication, 17, 196–210. Bourgeois, M. S., & Hickey, E. M. (2009). Dementia from diagnosis to management: A functional approach. New York, NY: Psychology Press. Brisebois, A., & Doyon, O. (2010). Applying the PARIHS model of evidence-based practice to implement a systematic evaluation of delirium in a cardiac surgery intensive care unit: Impact on delay of treatment and nurses’ knowledge. European Journal of Cardiovascular Nursing, 9(1), S5. Brown, D., & McCormack, B. (2005). Developing postoperative pain management: Utilising the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Worldviews of Evidence-Based Nursing, 2, 131–141. Burgio, L. D., Allen-Burge, R., Roth, D. L., Bourgeois, M. S., Dijkstra, K., Gerstle, J., . . . Bankester, L. (2001). Come talk with me: Improving communication between nursing assistants and nursing home residents during care routines. The Gerontologist, 41, 449–460. Burke, J. P., & Gitlin, L. N. (2012). How do we change practice when we have the evidence? American Journal of Occupational Therapy, 66, e85–e88. Buron, B. (2008). Levels of personhood: A model for dementia care. Geriatric Nursing, 29, 324–332.

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Eagan, M., Berube, D., Rancine, G., Leonard, C., & Rochon, E. (2010). Methods to enhance communication between individuals with Alzheimer’s disease and their caregivers: A systematic review. International Journal of Alzheimer’s Disease, 1–12. Retrieved from http://dx.doi.org/10.4061/2010/906818 Elliot, E. J. (2004). Evidence-based speech pathology: Barriers and benefits. International Journal of Speech-Language Pathology, 6, 127–130. Estabrooks, C. A., Squires, J. E., Cummings, G. G., Teare, G. F., & Norton, P. G. (2009). Study protocol for the Translating Research in Elder Care (TREC): Building context—An organizational monitoring program in long-term care project (project one). Implementation Science, 4, 52. Fixsen, D. L., Naoom, S. F., Blasé, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature (FMHI Publication No. 231). Tampa: University of South Florida, Louis de la Parte Florida Mental Health Institute, and the National Implementation Research Network. Gitlin, L. N., Jacobs, M., & Earland, T. V. (2010). Translation of a dementia caregiver intervention for delivery in homecare as a reimbursable Medicare service: Outcomes and lessons learned. The Gerontologist, 50, 847–854. Green, L. W., Ottoson, J. M., García, C., & Hiatt, R. A. (2009). Diffusion theory and knowledge dissemination, utilization, and integration in public health. Annual Review of Public Health, 30, 151–174. Hagedorn, H. J., & Heideman, P. W. (2010). The relationship between baseline Organizational Readiness to Change Assessment subscale scores and implementation of hepatitis prevention services in substance use disorders treatments: A case study. Implementation Science, 5, 46. Helfrich, C. D., Damschroder, L. J., Hagedorn, H. J., Daggett, G. S., Sahay, A., Ritchie, M., . . . Stetler, C. B. (2010). A critical synthesis of the literature on the promoting action on research implementation in health services (PARIHS) framework. Implementation Science, 5, 82. Helfrich, C. D., Li, Y. F., Sharp, N. D., & Sales, A. E. (2009). Organizational Readiness to Change Assessment (ORCA): Development of an instrument based on the Promoting Action on Research in Health Services (PARIHS) framework. Implementation Science, 4, 38. Hoerster, L., Hickey, E. M., & Bourgeois, M. S. (2001). Effects of memory aids on conversations between nursing home residents with dementia and nursing assistants. Neuropsychological Rehabilitation, 11, 399–427. Kagan, A., Simmons-Mackie, N., Gibson, J. B., Conklin, J., & Elman, R. (2010). Closing the evidence, research, and practice loop: Examples of knowledge transfer and exchange from the field of aphasia. Aphasiology, 24, 535–548. Kitson, A., Harvey, G., & McCormack, B. (1998). Enabling the implementation of evidence-based practice: A conceptual framework. Qualitative Research in Health Care, 7, 149–158.

Kitson, A. L., Rycroft-Malone, J., Harvey, G., McCormack, B., Seers, K., & Titchen, A. (2008). Evaluating the successful implementation of evidence into practice using the PARIHS framework: Theoretical and practical challenges. Implementation Science, 3, 1. McCurtin, A., & Roddam, H. (2012). Evidence-based practice: SLTs under siege or opportunity for growth? The use and nature of research evidence in the profession. International Journal of Language & Communication Disorders, 47, 11–26. Mullen, R. (2005). Survey tests members’ understanding of evidence-based practice. ASHA Leader, November 8. Nelson, T. D., Steele, R. G., & Mize, J. A. (2006). Practitioner attitudes toward evidence-based practice: Themes and challenges. Administration and Policy in Mental Health and Mental Health Services Research, 33, 398–409. O’Connor, S., & Pettigrew, C. (2009). The barriers perceived to prevent the successful implementation of evidence-based practice by speech and language therapists. International Journal of Language & Communication Disorders, 44, 1018–1035. Patton, M. (2002). Qualitative research and evaluation methods (3rd ed.). Thousand Oaks, CA: Sage. Pollock, A. S., Legg, L., Langhorne, P., & Sellars, C. (2000). Barriers to achieving evidence-based stroke rehabilitation. Clinical Rehabilitation, 14, 611–617. Powell, B. J., McMillen, J. C., Proctor, E. K., Carpenter, R. C., Griffey, R. T., Bunger, J. C., . . . York, J. L. (2012). A compilation of strategies for implementing clinical innovations in health and mental health. Medical Care Research and Review, 69, 123–157. Rycroft-Malone, J. (2004). The PARIHS framework: A framework for guiding the implementation of evidence-based practice. Journal of Nursing Care Quality, 19, 297–304. Shewhart, A. (1931). Economic control of quality of manufactured product. New York, NY: D. Van Nostrand. Sohlberg, M. M., Kennedy, M., Avery, J., Coelho, C., Turkstra, L., Ylvisaker, M., & Yorkston, K. (2007). Evidence-based practice for the use of external aids as a memory compensation technique. Journal of Medical Speech Language Pathology, 15, xv–li. Stetler, C. B., Damschroder, L. J., Helfrich, C. D., & Hagedorn, H. J. (2011). A guide for applying a revised version of the PARIHS framework for implementation. Implementation Science, 6, 99. Vallino-Napoli, L. D., & Reilly, S. (2004). Evidence-based health care: A survey of speech pathology practice. International Journal of Speech-Language Pathology, 6, 107–112. Varkey, P., Reller, M. K., & Resar, R. K. (2007). Basics of quality improvement in health care. Mayo Clinic Proceedings, 82, 735–739. Zipoli, R. P., & Kennedy, M. (2005). Evidence-based practice among speech-language pathologists: Attitudes, utilization, and barriers. American Journal of Speech-Language Pathology, 14, 208–220.

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Appendix A (p. 1 of 2) PARIHS Framework Element, ORCA Item, Interview Questions, and A Priori Codes PARIHS framework element

Perceptions of evidence

ORCA item

Statement: The use of external memory aids will improve overall communication and decrease behavioral problems for residents with dementia. 1. Based on your assessment of the evidence basis for this statement, please rate the strength of the evidence, in your opinion, on a scale of 1 to 5 where 1 is very weak evidence and 5 is very strong evidence. 2. Now, how do you think the FRD (or SLP) in your facility will view the strength of the evidence of this statement, on a 1 to 5 scale similar to the one above. For each of the following statements, please rate the strength of your agreement with the statement from 1 (strongly disagree) to 5 (strongly agree). 3. The statement: a) is supported by randomized controlled trials b) is supported by other scientific evidence c) has been found to produce clinically significant results 4. The statement: a) is supported by clinical experience with residents within our facility b) is supported by clinical experience with residents within other facilities 5. The use of nonelectronic external memory aids: a) has been well accepted by residents in our facility b) has been well accepted by residents in other facilities c) takes into consideration the needs and preferences of our residents d) appears to have more advantages than disadvantages for our residents 6. Senior leadership/clinical management in your facility: a) reward clinical innovation and creativity to improve resident care b) solicit opinions of clinical staff regarding decisions about resident care c) seek ways to improve resident education and increase resident participation in treatment

Supplemental interview question

1. Describe your overall impression of the use of nonelectronic external memory aids for residents with dementia in your building. 2. What do we know about the patient /caregiver experience with nonelectronic external memory aids for residents with dementia? 3. How easy or difficult is it for you to use nonelectronic external memory aids for patients with dementia? 4. Where did you first learn about nonelectronic external memory aids for your residents with dementia?

Interview code and description

Research and practice guidelines Clinical experience Patient experiences, needs, and preferences Local practice information Other characteristics of the targeted EBP

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Mention findings from research including practice guidelines Experiences using the EBP; positive/negative experiences using EBP and others’ reactions to its use Patient-related information about patient perceptions of the EBP Local data availability; local data collection on use of EBP Advantages/disadvantages for use of EBP

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Appendix A (p. 2 of 2) PARIHS framework element

Perceptions of organizational context

ORCA item

7. Staff members in your facility: a) have a sense of personal responsibility for improving resident care and outcomes b) cooperate to maintain and improve effectiveness of resident care c) are willing to innovate and/or experiment to improve clinical procedures d) are receptive to change in clinical processes 8. Senior leadership/clinical management in your facility: a) provide effective management for continuous improvement of resident care b) clearly define areas of responsibility and authority for clinical managers and staff c) promote team building to solve clinical care problems d) promote communication among clinical services and units 9. Senior leadership/clinical management in your facility: a) provide staff with information on performance measures and guidelines b) establish clear goals for resident care processes and outcomes c) provide staff members with feedback/data on effects of clinical decisions d) hold staff members accountable for achieving results 10. Leaders in your facility: a) believe that current practice patterns can be improved b) encourage and support changes to practice patterns to improve resident care c) are willing to try new clinical protocols d) work cooperatively with staff to make appropriate changes 11. In general in my facility, when there is agreement that change needs to happen: a) we have the necessary support in terms of budget or financial resources b) we have the necessary support in terms of training c) we have the necessary support in terms of facilities d) we have the necessary support in terms of staffing

Supplemental interview question

5. What are some facilitators to your use of nonelectronic external memory aids for residents with dementia? 6. What are some barriers that may inhibit your use of nonelectronic external memory aids for residents with dementia? 7. To what extent is your FRD knowledgeable about nonelectronic external memory aids for residents with dementia? 8. To what extent does your FRD support your use of nonelectronic external memory aids for residents with dementia? 9. To what extent do key stakeholders value nonelectronic external memory aids for residents with dementia? (such as the FRD, nursing managers, certified nursing assistants, the director of nursing, and the administrator) 10. To what extent does there need to be consensus among nursing, therapy, and you about the use of nonelectronic external memory aids for residents with dementia? 11. What is your perceived quality of the resources (materials/training) available for you to implement nonelectronic external memory aids for your residents with dementia?

Interview code and description

Leadership support Culture Evaluation capabilities Receptivity to the targeted EBP

Behaviors, attitudes, or actions of leaders affecting use of EBP Values and beliefs of clinician that affect use of EBP Ability to produce needed data about use/benefit of EBP Resources, including human, financial, computers, space, materials, and decision-making authority needed to implement EBP

Note. PARIHS = Promoting Action on Research Implementation in Health Services framework; ORCA = Organizational Readiness to Change Assessment; FRD = facility rehabilitation director; SLP = speech-language pathologist; EBP = evidence-based practice.

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Appendix B Barriers to the Implementation of External Memory Aids as Identified by Interview Participants (n = 5) Time to construct Family not available for assistance in memory aid content Lack of interest /cooperation from staff [CNAs overloaded with work]/trouble getting staff buy-in Confidentiality/HIPAA Resident dignity Constraints in training other staff members Lack of resources and materials Productivity demands Accessibility of the aid once it has been made [stuffed in a drawer, in trash] Neutral position of leadership (they don’t care what I do), no knowledge of treatment from leadership level, no real value of it Maintenance over time: “fizzling over time” Note. CNA = certified nursing assistant; HIPAA = Health Insurance Portability and Accountability Act.

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American Journal of Speech-Language Pathology • Vol. 23 • 612–624 • November 2014

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Perceptions of speech-language pathologists linked to evidence-based practice use in skilled nursing facilities.

This study explored whether perceptions of evidence or organizational context were associated with the use of external memory aids with residents with...
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