Introduction to Advocacy:

Whether you work in the trauma ICU or in long-term care, advocating for your patients can feel like your full-time job (not to mention advocating for your department, your job and career, and for yourself).

A nurse mentioned the other day how she has to constantly question and speak out on behalf of her patients. She joked: “no wonder I go home exhausted.” She said she started work one day telling herself: “just try not to pick any fights today,” and she noticed the difference in efficiency and accuracy. She also remarked on the added benefits of her constant advocacy: “At least I go home knowing I did everything I could, and I sleep well.” She realized that advocating for patients was just part of the job of being an excellent nurse. A nurse who is constantly thinking critically and asking appropriate questions is a nurse we all want at our bedside.

I have been thinking a lot about the many kinds of advocacy we do as speech-language pathologists and dysphagia specialists (see prior blogs: Decision-Making in Dysphagia Management and SLP as Agent of Change). Our evaluations and treatments are not simply to label the dysphagia and change the diet, but also to listen. We synthesize the underlying issues that may be contributing to or exacerbating the eating and swallowing difficulties. We can strongly advocate for the patient by making appropriate referrals, recommending therapy techniques, asking appropriate questions, and suggesting other concomitant factors to consider (i.e., effects of medications, xerostomia, delirium, etc). Let’s think about an example of a patient referred for a bedside swallow evaluation due to choking on breakfast yesterday. As you think about the whole person and not just the swallow, you realize that she has a baseline of esophageal dysmotility, she was recently put on a fluid restriction, she has a history of feeling dry mouth, and two days ago she was put on a Scopolamine patch for nausea. (Scopolamine has a major side-effect of dry mouth. See also prior blogs on oral hygiene and saliva). Did your medical record review uncover related issues? Was your bedside exam thorough enough to notice the Scopolamine patch behind her ear and ask her about dry mouth? This thoroughness and holistic view is also part of advocacy, which is our standard of care.

I have been discussing advocacy with Dr Martin Brodsky, PhD, ScM, CCC-SLP (Assistant Professor in the Department of Physical Medicine & Rehabilitation at Johns Hopkins University), and he summed it up perfectly:

“Advocacy is taking the time to learn what patients and their families/caregivers want, then carrying out their interests and goals in line with what is therapeutically necessary or appropriate. As SLPs, sometimes we’re the first voice a patient has because we were the ones who broke the code to understand.”

Advocacy is not only what we do for our patients, but also what we do for our field, our careers and ourselves.

This November at the American Speech-Language Hearing Association’s Convention (#ASHA16), we will have the privilege of hearing more about the many forms of advocacy in the field of Speech-Language Pathology from a team that includes Dr Martin Brodsky, PhD, ScM, CCC-SLP. The ASHA session will be lead by Rachel Mulheren from Johns Hopkins University and will also include John King from Walter Reed National Military Medical Center. See session information below on their Saturday talk called: Speak Out! Professional Advocacy Through Negotiation. 

Read on to find out more from Dr Brodsky on the importance of advocacy.

Dr Brodsky’s Sneak Peak into #ASHA16 Session on Advocacy:

The term advocacy conjures multiple meanings in professional life, among them support, influence, and aid. From the mid-14th century, the word advocate (from Latin: advocatus) was defined as “one whose profession is to plead cases in a court of justice” (Harper, 2006), perhaps suggesting that advocacy began in law and/or with lawyers. Long before the law and lawyers, as far back as the very first animals and when homo sapiens began inhabiting the planet, advocacy was simply, “helping each other out” (Morgan, 2014).

By focusing on the latter definition, the ASHA 2016 course taught Speech-Language Pathologists to advocate for their patients and themselves through multiple tools at their immediate disposal.

Typically, the Communication Sciences and Disorders (CSD) graduate curriculums do not include formal education on effective advocacy, nor do continuing education forums for professionals offer material on this topic. At the graduate level, courses focus on clinical aspects rather than occupational issues. Even during teaching practicums, internships, and clinical fellowships, the primary educational focus is on clinical care and established institutional practices. Maybe you learned how to request more therapy services or obtain an assistive device for a patient, but did you learn how to make sure your professional needs are met? For examples:

• acquiring money for supplies,
• funding for continuing education programming,
• increasing the number of full-time employees on staff,
• getting assistance from other departments for research projects, or
• asking for a raise.

Speaking up for oneself and others, or advocacy, requires at least one additional but foundational skill:

the ability to negotiate the known (and unknown) barriers of the workplace.

SLP professionals face significant pressures in daily practice, such as productivity, caseload selection, standards of evaluation and treatment, which ultimately pose ethical dilemmas. Identifying barriers to optimal patient care and learning to utilize available resources lay the groundwork for effective and ethical practice. Through the use of SMART (specific, measureable, achievable, realistic/relevant, and timed) goals (Bovend’Eerdt et al., 2009), patients can approach therapy enthusiastically and with grounded expectations. Although SMART goals are primarily used for patients in rehabilitation as a practical method for creating personalized goals, this system may also be adapted to address professional goals as well.

With appropriate application, professionals can exercise specific behaviors to resolve barriers to best practices. A taxonomy of core competencies from The Centers for Medicare and Medicaid Services (CMS) includes behaviors that transform practice with the aims of “better care and better health at lower costs” (Centers for Medicare & Medicaid Services, 2016). For examples:

• engaged leadership,
• organized and evidence-based care,
• continuous and team-based healing relationships that incorporate culture, values, and beliefs,
• patient-centered interactions, and
• systematic efforts to reduce unnecessary procedures

These behaviors are applicable to SLP professionals within each specialty and at all levels of experience.
Successful professional advocacy depends on a number of personal and environmental characteristics, such as:

• education of the situation (e.g., diagnosis, workplace hierarchy, personalities involved),
• culture of the environment (e.g., patient’s home life, workplace, personal philosophies), and 
• knowledge and availability of resources (e.g., money, time, personnel).

Understanding these multifaceted perspectives is a necessary strategy for addressing your goals and your patients’ goals; however, when due diligence is not successful, there are several generalized guidelines that can yield favorable outcomes. This #ASHA16 session will cover methods for effective advocacy, which can be stratified by degree of time and effort required. Participants will also be introduced to effective communication within and outside of the profession (even with examples of email etiquette). This course will help clinicians navigate the many available resources, for examples:

• ASHA members may access Special Interest Groups (SIGs) for a minimal fee.
• Social media offers platforms (e.g., Facebook, Twitter, LinkedIn) for connecting to other professionals through ASHA and NSSLHA pages, state-level groups, and closed groups on Facebook (e.g., “Dysphagia Therapy Group – Professional Edition” or “Medical SLP Forum”) specific to population and therapy type.
• ASHA members may reference ASHA journals and ASHA Leader articles at no cost.
• PubMed and PubMed Central databases (i.e., the course will review how to navigate PubMed, how to find open-access articles, and how to contact author(s) to request copies of articles).

Summary

Many times patients and their families don’t have the words to express their needs. In some sense, that’s where Speech-Language Pathologists’ jobs begin—to find the problem, create an appropriate plan of action, and do all of it with the patient’s goals guiding our decisions. That’s advocacy.

References
Bovend’Eerdt, T. J., Botell, R. E., & Wade, D. T. (2009). Writing SMART rehabilitation goals and achieving goal attainment scaling: a practical guide. Clinical Rehabilitation, 23(4), 352-361.

Centers for Medicare & Medicaid Services. (February 8, 2016). Quality Initiatives- General Information. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/index.html on April 6, 2016.

Harper, D. (2001-2006). Online Etymology Dictionary. Retrieved from https://www.etymonline.com/ index.php on April 6, 2016.

Morgan, C. (June 20, 2014). The history of advocacy. Retrieved from: https://borgenproject.org/history-advocacy/ on April 6, 2016.

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From ASHA 2016 Program Planner:

Session Code: 1767
Title: Speak Out! Professional Advocacy Through Negotiation

Day: Saturday, November 19, 2016

Time: 2:30 PM – 3:30 PM
Location: Pennsylvania Convention Center Room: 113A
Session Format: Seminar 1-hour PDH(s): 1 Hrs

Presenter(s):
Rachel Mulheren, Johns Hopkins University
John King, Walter Reed National Military Medical Center
Martin Brodsky, Johns Hopkins University

Abstract:
Identifying barriers to optimal patient care and learning to utilize available resources lay the groundwork for effective and ethical practice. This seminar will address self-advocacy for the professional and teaching advocacy to the patient through real-life, practical examples and panel discussion.
Learner Outcome 1: Identify barriers in CSD clinical practice, education, and research forums
Learner Outcome 2: Describe approaches to negotiating in CSD clinical practice, education, and research forums
Learner Outcome 3: List 5 resources for successful CSD advocacy approaches