Diagrama hierro – carbono

In Figure 7.2, we see that the clinical engagement is influenced negotiation of the issues above by the SLT and his or her clients. However, for the scope of this study,

CLINICAL ENGAGEMENT Affective factors - frustrations - demotivation - sadness - care Personal self - age - ideology of self Professional self -developed from the acculturation -undervaluing the profession - unable to provide quick solutions Contextual factors - context and environment of practice

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the focus was on the SLT, as the phenomenon under study was the communication of SLTs in the world of work.

The affective factors were found to be a driving force in the communication strategies that the SLTs used. Feelings of sadness, hopelessness and despondency were noted. Of importance is that one’s emotional state significantly influences the communication used such as your choice of words, tone of voice, body posture, projection of voice, and inflection in speech. These all can reveals one’s emotional state. Their emotional states were affected by the clients with whom they worked and the backgrounds of these. The participants mostly discussed negative emotions, which led to them use descriptors such as ‘overwhelmed’, ‘helpless’, ‘sad’, ‘feeling hollow’, ‘frustrated’. The personal self was another construct that influenced the clinical engagement. The personal self was drawn from the participants’ biographies and their personal experiences. It is necessary for SLTs to understand their personal self through reflection as this underlies their practice. The process of reflection can be expected from the student entering the profession, for this is when they have an understanding of the desire to pursue a profession in healthcare. This reflection should continue throughout the course of study to ensure that there is alignment between the personal and professional selves. Kamhi (2011) points out that clinical practices can often be traced to the personal and professional history of practitioners, such as where they went to school, who their mentors were, where they have worked and so forth. I wish to extend this notion that it is not just the clinical practices that are affected but also the communication that is used as the subject, method and object of the clinical engagement that is at the crux of the matter.

The professional philosophy is related to the acculturation process that SLTs underwent during initial professional education. It is the professional ethos and hegemony of the profession that makes one feel like a professional and part of a community of practitioners. It was found that the participants often reflected on their initial professional education to navigate through clinical engagement in the world of work.

Context of practice influenced the clinical engagement because the data showed that long-term care facilities required different communication strategies to an acute care setting. Each context generated unique clients, families and expectations of the

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therapy offering. This influenced the relationship developed between the SLTs and clients and the levels of care shown in these contexts.

The study of the atypical participants served a twofold purpose. The first was a validity check of the emerging thesis argument. Hence, this served as a negative case analysis. I needed to see beyond the obvious problematics of clinical engagement in speech-language therapy. Our profession is often so fixated with the helpless mentality of language and racial differences (most of the time referred to as ‘cultural differences’) that we neglect to see the other dynamics at play during problematic clinical encounters. The analysis of these cases brought forward the point that the negotiation of communication strategies at the heart of clinical engagement was laced with complexities. The complexities go beyond language. Fundamentally, the clinical engagement is influenced by more than just the obvious differences in language, race and culture. It was revealed that when there is incongruence between one’s personal and professional selves as well as between context and affective factors, this then set up a process of difficulties negotiating communication in the clinical engagement. 7.5 Section Three: Response to the second critical question

How do speech-language therapists (SLTs) negotiate communication strategies during clinical engagement within workplace contexts? (the world of work)

The communication strategies provided by participants included those learnt at university during their undergraduate training either directly (intended as part of the curriculum) or indirectly (based on observation or informal conversations with lecturers or tutors) as well as those strategies that they have improvised on and picked up through experience and on-the-job training.

The narrative data clearly showed that there are many elements within clinical engagement that an SLT has to negotiate when planning his or her communication. For instance, when engaging with the family, one has to establish the role that the family plays in speech-language therapy in terms of contact with the patient or client and stimulation of communication for therapy outcomes. Some family members play a more or less dominant role in the rehabilitation of the patient’s or client’s communicative function. This also lends to the argument on the environment or context within which the clinical engagement occurs.

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The SLT has to explore the influence that a particular context or environment has on an SLT’s communication with his or her patient or client, for example, the differences or similarities between public healthcare and private healthcare, or hospital contexts versus school contexts, and the influence of context and environment on the negotiation of communication in the world of work.

The language of instruction used in the relevant contexts influence the negotiation of these communication and language choices. In the school context, for example, English was mostly used as the language medium of communication because this was what the participants believed to be the ‘school language policy’, which in reality is far more complex than simply a view that ‘English is the language of instruction’. However, this reasoning was used as a justification for the use of English as the medium of instruction in the clinical engagement. I will explore this further in Chapter Eight. In the public healthcare contexts, attempts were made to access interpreters. However, this was often difficult due to financial, human and linguistic constraints. In the private practice context, the participants hardly ever encountered language differences between their clients and themselves.

Often, levels of motivation were low from the perspectives of the participants (SLTs) and this affected how they perceived their clients’ level of motivation (or that of the client’s family), which affected their communication. Reasons for low motivation could be related to the clients’ ill health and their concern and uncertainty about the future. The methods of communication used to facilitate and negotiate the SLTs’ communication in the therapy sessions with their clients included verbal and nonverbal communication. The attitudinal behaviours of clients and/or their parents toward speech-language therapy were found to be mostly negative. This was a puzzling finding as it was difficult to rationalise why the clients then continued to attend therapy. The SLTs were left to engage with these attitudes and behaviours in therapy, which they felt were challenging. The SLTs perceived this to be an undervaluing of the profession.

The sociological and cultural issues that affected the interaction between the SLTs and the mothers of the children were factors such as teenage pregnancy in lower socio-economic communities and the high incidence of babies born with congenital impairments. Society is negatively affected, as socio-economic factors, such as

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poverty, unemployment and poor literacy are interrelated with adolescent pregnancies (Van Rensburg, 2004). Given that teenagers have less prenatal knowledge, their general health behaviour and prenatal health practices (such as substance abuse) may affect pregnancy outcomes (Reddy, Sewpaul, & Jonas, 2016) as substance abuse is strongly associated with health complications for the mother and the baby (Bhutta, Darmstadt, Hasan, & Haws, 2005). Lower socio-economic living conditions exacerbate the problems of teenage pregnancy and birth anomalies.

Gender identity issues in professional roles, dissonance between the economic backgrounds of the participants and those of their clients and a lack of resources were all factors that had to be negotiated when communicating with the clients. The way the participants used their communication to negotiate these issues was the focus here. The participants reflected on their context-specific work issues encountered on a daily basis. These included their frustrations, anxieties, insecurities, challenges, strengths, successes, preparedness and comparisons to the world of academe. Newly qualified therapists and experienced therapists shared commonalities. There were however, unique differences also noted between the two groups across contexts. A myriad of feelings and emotions experienced by the SLTs in the world of work as well as when reflecting on their undergraduate education were noted.

There was also an overwhelming sense of belonging to an undervalued profession. This undervaluing was evident by the way in which clients, families or caregivers of clients and other healthcare professionals interacted with the SLTs. In turn, it was found that the SLTs started undervaluing themselves because they strongly felt that the inability to offer an immediate remedy and cure or answers of certainty gave the impression of the lack of value within the profession. These findings contradict previous studies (e.g. Pillay, 2003b), which argued that the profession previously occupied an elevated status. The participants felt that their clients were in the search of certainty, immediate cures and remedies, which the participants were not comfortable committing to, because they suspected that they might not achieve such results. The participants themselves were in search for certainty, which resulted in three of the five novice therapists moving to what they considered to be ‘more suitable contexts’.

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Changes in the physical work space were common amongst the novice SLTs as the therapists often changed work contexts after the mandatory year of community service. It was thought that the therapists moved to ‘comfort’. Comfort was deemed to be found in the financial, social and emotional situations in the new work environment. I will explain each of these constructs further.

Three of the novice SLTs moved from a public hospital setting to private practice after their community service. This was motivated not only by the lack of available posts in the public healthcare sector but also by private practice tending to appear a more ‘controllable’ context as the therapist has more autonomy over the private caseload with which he or she works. Financially, private practice is often considered to be a financially more lucrative option than other contexts of employment. The physical space in which SLTs operate plays a significant role in the negotiation of their communication strategies. The participants in community service placement sites were often unhappy with their physical work space because these were small, under- resourced spaces, often shared with other health professionals. In two contexts, the SLTs had to move their work space around the schedules of the other healthcare professionals. This brought up feelings of marginalisation and alienation of the professional as a less-than-important member of the healthcare team; hence, yet another tenet in the undervaluing of the profession.

7.6 Synthesis of the chapter

This chapter presented the thematic analysis of the narratives, and the atypical cases were discussed to present an alternative perspective to the phenomenon. I chose to highlight the embedded complexities of negotiating communication in the clinical engagement, which influences the choices and strategies used with communication. The atypical cases were selected as Zandi and Mbali were black African SLTs proficient in speaking isiZulu and English. Therefore I wanted to remove the one variable (language) in exploring the negotiation of communication during clinical engagement, in order to explore the other communication factors participating SLTs had to negotiate during clinical engagement. Taylor (1973, cited in Peters-Johnson & Taylor, 1986) writes that it is not enough to know the sociolinguistic behaviours of adults in order to conduct speech and language therapy that is culturally appropriate. In the cases of Zandi and Mbali, they had sufficient background to their clients’ sociolinguistic behaviours. However there were other factors influencing the clinical

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engagement. The affective issues, professional and personal selves and contextual issues were shown to influence communication during clinical engagement even without the influence of cross-linguistic–cross-cultural communication.

The response to the second critical question of the study was also presented. SLTs had to negotiate how they could utilise families in the therapy process. They also had to explore the influence that the context and environment had on the clinical engagement. Linguistic challenges had to be negotiated as English was often used as the medium of instruction and interpreters were accessed to bridge the language differences between therapist and client. Low levels of motivation and emotion affected SLTs’ approaches to their clinical engagement with clients as well as differences in sociology and culture. The main consideration in Chapter Eight will be to theorise critical question three, which will delve into what explains the SLTs’ choices of communication strategies during clinical engagement.

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PART THREE: MOVING FROM THE FIELD TO THEORY BUILDING