The knowledge, confidence and attitudes of Australian speech-language pathologists in augmentative and alternative communication for children and young people

Abstract

Augmentative and alternative communication (AAC) is a core component of speech-language pathology practice however international literature has highlighted that speech-language pathologists (SLPs) do not feel confident in this area. An online survey was used to investigate the self-perceived knowledge, confidence, and attitudes of Australian SLPs in relation to AAC for children and young people using a 7-point Likert scale; 205 participants responded. Participants reported moderate levels of knowledge (M = 4.95; SD = 1.07) and confidence (M = 5.09; SD = 1.25); attitude had the highest overall ratings (M = 5.64; SD = 1.20). Generally, knowledge, confidence and attitude scores were greater for SLPs who worked in a metropolitan area, had more experience and a higher percentage of AAC users on their caseload. SLPs rated the adequacy of their pre-professional training in AAC for children and young people as low (M = 3.69; SD = 2.05). These findings suggest further investigation into the training of SLPs in AAC is required to ensure that this training is preparing SLPs for the contemporary workforce.

Keywords:

• Speech-language pathologist
• augmentative and alternative communication (AAC)
• knowledge
• confidence
• attitude
• survey

Augmentative and alternative communication (AAC) refers to systems and strategies used to augment or replace natural speech for individuals with complex communication needs (Speech Pathology Australia, 2020a). Speech-language pathologists (SLP) are responsible for assessing and providing intervention and support for these individuals including the prescription of AAC systems (Speech Pathology Australia, 2020a). While there is no current Australian data, in 2005, Sutherland et al. identified that approximately 0.15% of students aged 0-21 years in New Zealand presented with complex communication needs indicating that AAC users can form a considerable portion of a caseload for an SLP who works with children and young people. In fact, in a survey of early intervention services in the United States, each SLP supported an average of seven AAC users (Binger & Light, 2006). This data highlights that all SLPs working with children and young people need knowledge and prior training in supporting people with complex communication needs including the use of AAC.

AAC was not formally recognised as an area of practice for Australian SLPs until 2012 when Multi-Modal Communication (MMC) was included as a range of practice area by Speech Pathology Australia (SPA). Therefore, prior to 2012 university programs in Australia were not required to explicitly teach or assess competencies associated with AAC. It is therefore not surprising that only 21-34% of respondents in a 1998 survey (Balandin & Iacono) of Australian SLPs reported good or extensive knowledge in unaided, low technology and high technology systems. More recently, Australian SLPs in early childhood settings have reported mixed levels of clinical skills in AAC (Iacono & Cameron, 2009) but it remains unclear if the inclusion of MMC in speech pathology training programs in Australia has contributed to improved knowledge in this area.

In addition to knowledge, training has also been associated with health professionals’ confidence and attitudes (Meredith et al., 2018). Internationally, low levels of confidence and competence in delivering AAC services has been associated with prior training (Biggs et al., 2022; Sanders et al., 2021), workplace (Biggs et al., 2022) and current AAC caseload (King, 1998; Sanders et al., 2021; Simpson et al., 1998). SLPs around the world report that their pre-professional training in AAC has been limited (Chua & Gorgon, 2018; Matthews, 2001; Wormnaes & Abdel Malek, 2004) leading them to rely on post-professional training. Unfortunately, SLPs report many barriers to increasing their post-professional knowledge, with time identified as particularly problematic (Iacono & Cameron, 2009). To provide high quality care to people with complex communication needs, SLPs need to have adequate knowledge, skills, and confidence in their clinical capabilities. Low confidence can lead to task avoidance, increased stress levels and general burn out (Jackson et al., 2019).

Given MMC has now been listed as a range of practice area for Australian SLPs for 10 years, this inclusion should be contributing to greater training for SLPs, and subsequently, improved knowledge, confidence, and attitudes toward working with AAC users. Thus, the aim of this research was to evaluate the knowledge, confidence and attitudes of the current workforce supporting children and young people and explore factors that may impact these variables, including pre-professional training. Specifically, we aimed to answer the following research questions:

1. What is the knowledge, confidence, and attitudes of Australian SLPs in AAC for children and young people?

2. What factors impact the knowledge, confidence, and attitudes of Australian SLPs in AAC for children and young people?

3. Do Australian SLPs feel their pre-professional training adequately prepared them to support children and young people who use AAC?

Method

This study was approved by the Central Queensland University Human Research Ethics Committee (reference number 23676).

Survey design and distribution

A survey was developed by the first author in consultation with the second to investigate the knowledge, attitudes, confidence, competence, and training experiences of SLPs in AAC as part of a larger study. The results reported in this study represent a subset of data from this survey, derived from 11 demographic questions and 21 Likert scale statements, 19 of which were adapted from the Knowledge, Confidence and Attitude (KCA) scale created by Meredith et al. (2018). The remaining two Likert scale statements were added to investigate SLPs’ attitude towards AAC as a practice area and the adequacy of their pre-professional training in AAC. Participants were asked to rate each statement (e.g., I have a good understanding of the ways in which AAC may be relevant for children with complex communication needs) using the following 7-point Likert Scale: 1 = strongly disagree, 2 = disagree, 3 = slightly disagree, 4 = neutral, 5 = slightly agree, 6 = agree, 7 = strongly agree. A pilot version of this survey was distributed to two SLPs and one SLP student to provide feedback on readability, length and any errors present. After piloting, no changes were required. A full list of the statements comprising the KCA scale used for this study is provided in Appendix 1.

The online survey was created using Qualtrics software (Qualtrics, 2022) and distributed through social media platforms including Facebook and Twitter, through the SPA digital newsletter, and through email to professional networks. The survey was opened on 25 September 2022 and closed on 10 November 2022.

Participants

Eligible participants were SLPs who completed their SLP qualification in Australia, were eligible for Speech Pathology Australia membership and were currently working with children and young people aged 0-18 years. Since the purpose of this survey was to capture an overall snapshot of the workforce supporting children and young people including those who may avoid provision of AAC services due to low knowledge, confidence, or attitude, all Australian SLPs working with children and young people aged 0-18 years were eligible to participate regardless of whether they currently work with AAC users.

Data analysis

All data were exported from Qualtrics into the Statistical Package for Social Sciences (SPSS) (IBM Corp., 2021). All demographic questions (e.g., workplace setting) yielded categorical data and were analysed using descriptive statistics. Responses to the knowledge, confidence and attitude statements were in the form of 7-point Likert scales. Out of 20 Likert scale statements, five were negatively worded and therefore reverse coded prior to data analysis. The median and mean for each statement was calculated and is provided in Appendix 1. Likert scale statements were then collapsed into three domains: knowledge (n = 6), confidence (n = 7) and attitudes (n = 7). These domain scores formed the basis of statistical analyses for this study.

The internal consistency of each domain was tested using Cronbach’s alpha reliability coefficient. An alpha above .70 was calculated for knowledge (α = .774), confidence (α = .903) and attitude (α = .914) indicating good internal consistency and reliability for each domain (Morgan et al., 2020). The sample sizes were similar between groups (Mircioiu & Atkinson, 2017) for each composite domain (i.e., knowledge, confidence, attitudes) in the scale with sufficient sample size to assume fairly normal distribution (Mircioiu & Atkinson, 2017; Norman, 2010). Moreover, parametric testing of Likert scale data was deemed appropriate as the Likert scale contained more than five ordered categories (Mircioiu & Atkinson, 2017). Parametric testing used included paired t tests, Pearson correlations and one-way analysis of variance (ANOVA). If the ANOVA identified a significant difference (p <.05), a post-hoc test was used with a Bonferroni correction applied to reduce the risk of a type 1 error.

Results

Demographic information

Overall, 234 responses were received. Partial survey responses were kept and analysed if the participant met the inclusion criteria and completed all questions associated with at least one domain of the KCA scale (e.g., knowledge). As a result of these criteria, 29 responses were removed. Therefore, final participant numbers ranged from 200 to 205 depending on the variable. Demographic information for the final 205 participants has been outlined in Table 1.

Table 1. Demographic information.

Item	n (%)
Geographical location
Metropolitan	114 (56%)
Rural	86 (42%)
Remote	4 (2%)
Employment setting^a
Private practice	98
Non-government/Not for Profit	78
Hospital or Health	94
Education	19
Other	3
Years’ Experience
<1 year	4 (2%)
2-5 years	94 (46%)
6-10 years	4 (26%)
11-15 years	23 (11%)
>15 years	30 (15%)

^a Participants were asked to tick all employment settings in which they worked.

Knowledge, confidence and attitude scale

Participants provided the lowest mean rating for knowledge (M = 4.95; SD = 1.07), followed by confidence (M = 5.09; SD = 1.25); attitude received the highest rating (M = 5.64; SD = 1.20). Paired sample t-tests showed that the overall rating for knowledge was significantly lower than both confidence [t(199) = 2.69, p = .008)] and attitude [t(202) = 10.31, p<.001]. Pearson correlations indicated that knowledge had a strong positive correlation with both confidence [r(200) = .83, p<.001] and attitude [r(201) = .66, p<.001].

Factors impacting knowledge, confidence and attitudes

Years in workforce

As shown in Figure 1, knowledge, confidence and attitude for AAC generally increased with greater years of work experience leading to a significant between groups effect for each [Knowledge, F(4, 200) = 10.59, p<.001; Confidence, F(4, 195) = 11.12, p<.001; Attitude, F(4,198) = 11.46, p<.001]. However, it is important to note that clinicians with less than one year in the workforce reported higher levels of knowledge, confidence, and attitude than those with two to five years experience; none of these differences were significant (p>.05).

Figure 1. Years in the Workforce.

Caseload

A significant main effect was also found for the proportion of AAC users on SLPs’ caseloads and their ratings for knowledge [F(4, 192) = 13.28, p<.001], confidence [F(4, 187) = 17.23, p<.001] and attitude [F(4, 190) = 28.14, p<.001] however no specific between group differences were identified. As shown in Figure 2, similar to years of work experience, there was a general trend of increased knowledge, confidence and attitude with one exception – SLPs who reported that AAC users formed 21-40% of their caseload had significantly lower knowledge and attitude ratings than remaining groups, ps<.05. They also had significantly lower confidence ratings compared to all groups except SLPs who reported less than 20% AAC users on their caseloads, t(107) = 1.08, p = .140.

Figure 2. AAC Caseload.

Geographical area

SLPs were asked to select the geographical area (metropolitan; rural or remote) where they provide the majority of their services using the Health Workforce Locator (Department of Health and Aged Care, 2022) (see Table 1). Since only four respondents indicated they worked in a remote area, this category was collapsed with rural for a combined total of 90 respondents. A significant between-groups effect was found for SLP ratings for knowledge [F(1, 202) = 27.56, p<.001], confidence [F(1, 197) = 39.83, p<.001] and attitude [F(1, 200) = 28.661, p<.001] (see Figure 3) with SLPs in metropolitan areas reporting higher mean scores in all domains.

Figure 3. Geographical Area of Services.

Pre-professional training

When asked about their pre-professional training, only 35.3% of the 205 participants agreed that their pre-professional education adequately prepared them to provide services to children and young people using AAC (M = 3.69; SD = 2.05); only 5.2% strongly agreed. In total, 44% disagreed with this statement and 17.5% strongly disagreed.

Pearson correlations indicated no significant relationship between knowledge scores and pre-professional training [r(205)=-.01, p=.820]. However, there was a small positive correlation with confidence scores [r(200) = .21, p = .003] and a small negative correlation with attitude scores [r(203) = -.19, p = .006]. Adequacy of pre-professional training ratings did not differ according to the number of years spent in the workforce, F(4, 200) = 1.15, p = .335 (see Figure 4).

Figure 4. Adequacy of Pre-professional Training and Years in the Workforce.

Note. Participants were asked to respond to the statement ‘My pre-professional education adequately prepared me to service paediatric AAC clients once I entered the workforce’.

Discussion

Survey participants reported moderate levels of knowledge and confidence when working in AAC with children and young people in addition to a positive attitude towards AAC. Knowledge had a strong positive correlation with confidence and attitude highlighting that these variables are interconnected. Factors that were positively associated with each domain were increased years of work experience, larger AAC caseloads and practicing in a metropolitan area. SLPs rated the adequacy of their pre-professional training in AAC for children and young people as low with no significant group differences based on number of years work experience.

What is the knowledge, confidence, and attitudes of Australian SLPs in AAC for children and young people?

Knowledge

When asked to respond to statements about their knowledge of AAC for children and young people, the majority of SLPs did not indicate high levels of knowledge (M = 4.95). This is surprising given that 95.7% of respondents reported that they were currently providing services to AAC users. In Australia, an individual SLP’s scope of practice “includes that which the individual is educated, authorised and competent to perform” (Speech Pathology Australia, 2020b, p. 7). ‘Educated’ infers that an SLP would have the knowledge required to work in a certain practice area (such as AAC). The Augmentative and Alternative Clinical Guideline (Speech Pathology Australia, 2020a) further reinforces this by referencing a range of areas in which SLPs should have knowledge including appropriate assessment tools/strategies, level of evidence for AAC interventions and unaided and aided AAC systems. This study investigated the self-perceived knowledge of AAC for children and young people using broad statements e.g. I have a good understanding of the theory underpinning use of AAC generally (M = 5.41, SD = 1.31) and therefore future research should explore SLPs knowledge in specific areas of AAC practice.

The need for further knowledge in AAC has been reported previously in Australia (Balandin & Iacono, 1998; Wen & Sutherland, 2022), the United Kingdom (Matthews, 2001), Taiwan (Tsai, 2019), Egypt (Wormnaes & Abdel Malek, 2004) and the United States (Gohsman & Johnson, 2023); each of these studies highlighted the need for SLPs to have more knowledge and training in AAC. Furthermore, previous research in Australia of parents’ experiences of speech generating device service delivery described therapist knowledge and expertise in AAC as ‘pot-luck’ (Anderson et al., 2014). SLPs may lack knowledge in AAC due to insufficient training at the pre-professional level (Chua & Gorgon, 2018; Costigan & Light, 2010) which was identified as an issue within the results of this study. While the amount and quality of pre-professional training may be increasing due to the formal recognition of AAC as a practice area in Australia, the increase in training doesn’t seem to have impacted SLPs self-perceived knowledge yet. However a compounding factor could be the fast changing pace of the AAC landscape due to technological advances (McNaughton & Light, 2013) which may make staying up to date with knowledge difficult for SLPs regardless of geographical location in Australia. SLPs’ reduced knowledge in AAC is a complex issue which requires more in-depth exploration so that key stakeholders can provide effective training to support SLPs throughout their career.

Confidence

SLPs reported moderate levels of confidence (M = 5.09) when working in AAC for children and young people. While this response is promising, the range of responses (2 to 7) for this composite demonstrates that many SLPs continue to not feel confident in this practice area. Within this study, knowledge had a strong positive correlation with confidence. While this could be viewed simply as knowledge having a positive impact on confidence, these factors most likely have a more complex, symbiotic relationship. While increasing knowledge in an area through training or supervision is viewed as a way to increase professional confidence (Hecimovich & Volet, 2011), clinicians who are more confident in an area (such as AAC) may be more likely to seek further knowledge in that area.

Attitudes

While the mean rating for attitude was positive (M = 5.64), these scores ranged from 2.43-7.00 indicating that many SLPs within the Australian workforce may have a negative attitude towards AAC. This is concerning given that negative attitudes of professionals has been linked to parental decision-making leading to AAC abandonment (Moorcroft et al., 2020). Even more concerning is that 21% (n = 42) of respondents did not agree that ‘provision of AAC services is within my scope of practice as an Australian speech pathologist’. It is possible that some of these respondents were referring to their own scope and how educated, authorised and/or competent they themselves felt to provide AAC services to children and young people. However, this is quite alarming given that AAC is within an SLPs scope of practice as long as they are educated, authorised and competent to perform the inherent clinical tasks (Speech Pathology Australia, 2020b). Moreover, Speech Pathology Australia has clear guidelines in place for AAC (Speech Pathology Australia, 2020a). Even more alarming is that all but three of these 42 respondents currently provided AAC services to children and young people for at least 21% of their caseload. Interestingly, the majority of these respondents (n = 32) provided services in a rural or remote area. Therefore, these SLPs may feel that AAC is not within their scope of practice but are still providing AAC services due to a lack of other service options in their area. If SLPs do not consider AAC to be part of their scope of practice, then this could negatively impact on the type and quality of services provided to children and young people with complex communication needs, particularly for children living in areas with limited access to speech pathology services. Given the overwhelming evidence on the benefits of AAC for people with complex communication needs (Langarika-Rocafort et al., 2021; Logan et al., 2017), it is vital for Australian SLPs to be strong advocates.

What factors impact the knowledge, confidence, and attitudes of Australian SLPs in AAC for children and young people?

Three factors were positively associated with an SLP’s knowledge, confidence, and attitude: AAC caseload; working in a metropolitan area; and years in the workforce. The association between AAC caseload and SLP confidence is consistent with previous research which also showed this relationship for SLPs in the United States (King, 1998; Sanders et al., 2021; Simpson et al., 1998).

SLPs working in a metropolitan area reported greater knowledge, confidence, and attitude in comparison to those working in rural and remote areas. This could be due to the additional barriers rural and remote SLPs face accessing professional development including the cost and time of travel (Curran et al., 2006; Lincoln et al., 2014; O’Toole et al., 2010). Although these barriers have been somewhat reduced in recent years due to the increase in online professional development (Berndt et al., 2017; Ramsden et al., 2022), it is possible that the gap in access to professional development has not yet closed. Alternatively, this difference may be due to SLPs in rural and remote areas having a more generalist role (O’Toole et al., 2010), leading to less clinical experience in AAC and the need for professional development in a large range of clinical areas. This would be consistent with findings in this study whereby AAC users made up less than 40% of a caseload for the majority (75%) of rural SLPs whereas the majority of metropolitan SLPs (57%) reported more than 40%. Building the capacity of SLPs in rural and remote Australia is extremely important given that families living in these areas already face significant barriers to accessing services equitable to their metropolitan counterparts (Verdon et al., 2011).

While knowledge, confidence and attitude generally increased with years in the workforce, SLPs with one year experience reported higher levels of knowledge, confidence, and attitude compared to SLPs with two to five years of experience. This may suggest that there was an increase in the quality of training at a pre-professional level for recent graduates that was not present for students who graduated two to five years ago; this is a trend that has been noted in the United States (Johnson & Prebor, 2019). Alternatively, due to their limited experience within the workforce, new graduates may have a less refined understanding of their own capabilities, leading them to potentially over-estimate their knowledge, confidence, and attitudes in AAC. Though SLPs with six to 10 years of experience reported increased levels of knowledge, confidence, and attitude, their increased time in the workforce could have given them more access to post-professional education in AAC.

Do Australian SLPS feel their pre-professional training adequately prepared them to support children and young people who use AAC?

The majority of SLPs reported that they did not feel that their pre-professional training adequately prepared them to enter the workforce. This is not surprising given that MMC was only included as a practice area for Australian SLPs in 2012 and participants’ time in the workforce spanned from 0 to more than 15 years. However, ratings for training adequacy by SLPs who entered the workforce more recently were not significantly higher than other groups. This is surprising, since the inclusion of MMC as a range of practice area should have presumably increased the amount and quality of training received by SLP graduates who are newer to the workforce. It is possible that some Australian universities may not have had access to academics with expertise in this area since their training would have occurred prior to the inclusion of MMC as a range of practice area, which may have impacted the quality of teaching received by students. This was a phenomena experienced in the United States where only 29% of university staff teaching AAC identified it as their primary area of expertise in 2008 compared to 81% in 2018 (Johnson & Prebor, 2019). Additionally, while students may have received training in AAC post-2012, they still may not have received sufficient clinical experience in this area. It is hoped that clinical placement opportunities that provide exposure to children with complex communication needs may increase over time given the changes to therapy funding for this population with the introduction of the National Disability Insurance Scheme. Given these factors, changes to the knowledge, confidence, and attitude of the Australian SLP workforce could still be on the horizon.

Limitations

While this survey was open to all SLPs working with children and young people regardless of caseload, the recruitment materials for the survey mentioned AAC. This may have discouraged SLPs who do not work with AAC users to complete the survey. This would explain the under-representation of this population (n = 9; 3.9%) in the data. This survey was focussed on children and young people so this information cannot be generalised to SLPs who work with adult AAC users. Research question 3 explored the adequacy of SLPs pre-professional training in AAC however this data related to only one Likert statement. Further information regarding the year, location, length, and type of pre-professional training the SLPs had received would have resulted in more robust data. Furthermore, pre-professional training was found to not be associated with when SLPs had graduated from university however this data was taken from the question ‘How many years have you been working as a speech pathologist’? Time since graduation and time in the workforce may not be commensurate if SLPs deducted time spent on leave from the profession (e.g., parenting leave). This survey collected quantitative data only using multiple choice questions and Likert scales. While this method provides initial information about the knowledge, confidence, and attitudes of SLPs, interviews or focus groups would be required to explore this topic in more detail (e.g., to explore why SLPs have a positive or negative attitude towards AAC).

Conclusion

This study investigated the knowledge, confidence, and attitudes of Australian SLPs in AAC with children and young people through an online survey. Results indicate that Australian SLPs have moderate levels of knowledge, confidence, and attitudes in AAC for children and young people which are correlated with their years in the workforce, AAC caseload and location of services. SLPs reported the adequacy of their pre-professional training in AAC for children and young people as low. Given that MMC was only introduced as a practice area ten years ago, we could still be on the precipice of change. Further investigation into the pre-professional and post-professional training experiences and needs of Australian SLPs in AAC is needed.

Additional information

Notes on contributors

Clancy Conlon

The first author has completed this research as part of Research by Higher Degree at Central Queensland University.

Appendix 1.

Survey questions – knowledge, confidence and attitude scale

Table

Statement	Mean (SD)	Median	Min/Max
K. I have a good understanding of the ways in which AAC may be relevant for children with complex communication needs.	5.15 (1.85)	6	1/7
C. I am confident I would be able to use AAC-based approaches with a child with complex communication needs.	5.05 (1.57)	6	1/7
K. I have very little knowledge of what to do to help a person manage their communication needs using AAC techniques^a.	5.13 (1.45)	6	1/7
A. It is important that I learn as much as possible about the impact of AAC on supporting complex communication needs.	5.56 (1.51)	6	1/7
C. I have skills I can use to support interventions using AAC-based approaches in paediatric settings.	5.28 (1.45)	6	1/7
K. I have a good understanding of the theory underpinning use of AAC generally.	5.41 (1.31)	6	2/7
C. At my level I would not get involved in helping children with AAC – it’s a specialist area^a.	5.31 (1.51)	6	1/7
A. All paediatric speech pathologists should have some skills and knowledge in AAC to be able to assist children with complex communication needs.	5.57 (1.54)	6	1/7
C. I wouldn’t be able to assist a child with complex communication needs to use an AAC system that meets their individual needs and preferences^a.	5.16 (1.54)	6	1/7
C. I would be quite good at providing interventions using AAC-based approaches with a child with complex communication needs.	4.90 (1.58)	6	1/7
A. Using AAC-based approaches can support a child’s communication development.	5.87 (1.39)	6	1/7
K. I still have a long way to go before I will have enough understanding to use AAC-based approaches with children with complex communication needs^a.	3.63 (1.80)	3	1/7
A. Providing interventions involving AAC is an important role for speech pathologists in paediatric settings.	5.70 (1.39)	6	1/7
C. I am confident that I can use AAC assessment tools in practice.	4.94 (1.64)	5	1/7
A. It is not necessary for all speech pathologists working in paediatrics to be aware of the AAC needs of clients^a.	5.50 (1.48)	6	1/7
K. I know enough to assist children with complex communication needs to access an AAC system.	5.19 (1.43)	6	1/7
A. Understanding the AAC needs of children with a communication disability is important for all speech pathologists.	5.63 (1.51)	6	1/7
K. I know enough to support other staff I work with to understand the value of AAC-based approaches in paediatric settings.	5.20 (1.43)	6	1/7
C. I have access to an extensive range of information and expertise to support my work in paediatric AAC.	4.92 (1.71)	6	1/7
A. Provision of AAC services is within my scope of practice as an Australian speech pathologist	5.59 (1.53)	6	1/7
T. My pre-professional education adequately prepared me to service paediatric AAC clients once I entered the workforce.	3.69 (2.05)	4	1/7

Note. K = question pertaining to knowledge, C = question pertaining to confidence, A = question pertaining to attitude and T = question pertaining to training. Participants were asked to rate each statement as follows: 1 = strongly agree, 2 = disagree, 3 = slightly agree, 4 = neutral, 5 = slightly agree, 6 = agree and 7 = strongly agree.

^a These statements were negatively worded and therefore reverse coded.