My reflections on applying for the HEE & NIHR Internship.
by Helen Robinson, AAC Service Lead and Assistive Technology Clinical Specialist.
For a long time, I found it hard to image a day where I would actually start my career in research, yet here I am, one month in to my nine-month internship with Sheffield Hallam University, funded by Health Education England (HEE) and the National Institute of Health Research (NIHR). I knew from other colleagues that the journey into a career as a clinical academic is never easy, and that it was typical to be rejected several times when applying for funding, which offered some reassurance as I received my rejection email for the second year in a row. I was amazed to finally be accepted at the end of 2020, having submitted my third application with little expectation of success. It was a welcome ray of hope after such a challenging year working in the NHS.
I may have been just as pleased as I am today, had I been accepted the first or second time around, yet I feel that having the three years to consider, reflect on and develop my research ideas has been immensely beneficial, and ultimately led me down a better path. I’ve spent these three years networking, reading and attending research groups and seminars. I wonder if I would have got quite so much out of this internship had I been accepted on my first, or second, application?
The what and the why
My first two applications to the scheme were linked to existing research projects. Whilst I was genuinely interested in the projects, I realise now that I was very much attempting to make them ‘fit’ the internship scheme because they were easily available at the time of the applications, rather than following an idea I was passionate about. I was starting with the internship and working backwards to find a research interest. That clearly showed during my interview, and after the second rejection the feedback given was that I should follow my own clinical interests to develop a research question of my own. This advice felt a little daunting. With little research experience since the couple of lectures in statistics whilst studying for my degree almost twenty years ago, I felt apprehensive about embarking on a solo project. Thanks to an experienced supervisor and my colleagues in the Barnsley AT Team, I gradually started formulating ideas for a research question.
Beginning my internship
My hope is to follow the HEE and NIHR’s Integrated Clinical Academic Programme, starting with the Internship, then progressing through the Pre-doctoral Clinical Academic Fellowship (PCAF) and onto the Clinical Doctoral Research Fellowship to complete a PHD. If I am to do this, I knew I needed to focus on a subject that I felt passionate about, that would be worth putting my heart and sole into for quite a few years to come (though I try not to think too much about the duration!)
Due the COVID 19 Pandemic, it’s not been the start I might have hoped for, with all university sessions taking place online. However, I’ve found it to be a thoroughly enjoyable start despite this. We’ve all had a year to settle into the world of online meetings, so I don’t feel my learning or experience has been diminished as a consequence.
Having been a student almost twenty years ago, I have been amazed at how much the university experience has progressed! Most lectures have been recorded and made available, as have the presentation slides. There are discussion boards where I can chat with other programme participants, and endless offers of support from University staff. The scope of the online library has amazed me, so many of the books I’ve wanted have been available to view online immediately without me having to leave the house. Sheffield Hallam’s student website also offers a wide range of live webinars relating to carrying out research, and countless downloadable guides and links to other websites. My only criticism is that It’s easy to get lost in the web of resources available and suddenly find yourself far from your original goal with tens of web pages open and new routes to investigate!
Going around in circles!
Pinning down my research interest has been a challenge, as my job as Assistive Technology Clinical Specialist covers a broad spectrum of client groups within the field of AAC, most of which ignite a spark! Many times, I’ve convinced myself I knew what my research interest was, only to wake up the next day with a totally new idea. It was a relief to finally settle on a research question and submit my internship application. Whilst waiting for the programme to start, I allowed myself to put the idea aside, confident that I would approach it fresh in the New Year with the start of the programme.
I am completing the internship one day a week, whilst continuing in my clinical role for the remaining four. This change has been very welcome, it feels like a luxury to be given this time to really immerse myself in the research process, without the guilt of unanswered emails and phone calls. I spent my first 3 sessions exploring the wealth of resources available to me, as well as attending the two online study days which are part of the internship scheme. Then, it was time to look back at that research question. As I did, that familiar niggle hit me again, why did I decide that was a good question? How was that achievable? Was that even what I wanted to know? What seemed so certain and so comfortable a few months ago, suddenly didn’t even feel like I’d even written it. I found myself full of doubt and self-criticism.
I spent some time with my supervisor, who helped me to unpick and re-frame my question, which actually turned into five questions. I was encouraged to think about the finer details, using tools such as SPIDER and PICO. I found these helped me to clarify my ideas, as they enabled me to reflect on the finer details and what would make a suitable research question. After a morning looking at this, I felt rather disheartened, having felt so sure of my project four months earlier, and having spent several months getting to that point, I was left feeling like I was back at square one! The more I stared at the questions on the screen, the more unsure I was. It was time to step away from that laptop.
I went back to pen and paper, making notes of anything that came to mind; what I was interested in, what bothered me, what assumptions I had, what I knew to be true and what questions I wanted to answer. I then photographed this and saved it to come back to. My preference is always for neatness and order, but it’s these scruffy notes and key words that I found represented my ideas most clearly.
Using my clinical interests to determine my research question
When I first started working in the field of AAC, around 12 years ago, ‘Core Vocabulary’ wasn’t a familiar term, but very quickly this terminology became common place. Symbolised vocabulary packages which had previously often been structured around topics and activities soon became based on a list of ‘core words,’ with topic or ‘fringe’ vocabulary sitting alongside. This approach made sense to me, we were told these core words made up the bulk of spoken utterances in the English Language, such as ‘want’ ‘help’ ‘more’ and ‘go.’ Topic words alone could be ambiguous, especially without context (what does ‘ball’ mean? Want ball? Lost ball? Your ball? My ball?) It certainly makes sense that both ‘core’ and ‘fringe’ words are needed to give a complete message.
Symbolised vocabularies continue to base themselves around these core word lists, often organising words left to right across the screen in subject-verb-object format, to support the formulation of sentences, or ‘language learning.’ For example, ‘I want (the) bubbles,’ ‘you go home’ ‘I see (a) cat.’ The final noun is often accessed through several levels of category folders (i.e. the user has to select a folder and then one or more sub-folders to find the word.)
In my current role, many of the AAC users we support have complex physical and sensory needs, and therefore often find accessing communication aids effortful, sometimes using switches or eye gaze. They become skilled at communicating their messages in as few words as possible: good communicators, but not always linguistically competent. My assumption is that complete sentences are rarely the aim, and if one word will work, why use more? With a supportive, familiar communication partner present, I have observed that AAC users are most likely to use nouns (fringe vocabulary), accompanied by other modes of communication such as eye pointing, gesture and vocalisations. In other fields of Speech and Language Therapy, a core vocabulary approach would usually refer to the topic words as being ‘core,’ which seems to reflect my clinical observations with my AAC caseload. I find myself considering what the goal is for the children I support; is it ‘functional communication’ or ‘language learning?’
When I introduce a family to a core vocabulary package, they are pretty much guaranteed to ask me to hide the core words, and make the topic vocabulary easier to find. I find myself been asked to explain and justify the organization of vocabulary packages frequently. I have also worked with plenty of literate children and adults, and noticed that even they lean towards typing the key words, not grammatically complete sentences. This leads me to question which words are important for symbolized AAC users and how should we be organising the words within communication aids? I am fascinated by the conversations I am part of and reflect on how valuable these interactions could be in designing AAC systems. If we give symbolized AAC users ‘core’ words, do they actually use them? Would they prefer using a ‘fringe first’ approach?
The core vocabulary approach uses list of words based on the language of older, verbal children (Laubscher and Light, 2020) and assumes that AAC users are aiming for comparable language (in terms of the words they use and how they order them) I feel that we should not compare the language development of AAC users with the language of speaking children, nor presume that their communication goals are equal, as this presents an ablest view of language. I argue that we should value one-word on a communication aid, accompanied by a smile and a glance, just as much as a string of ten words. This isn’t to say we shouldn’t give symbolised AAC users access to a rich vocabulary, and shouldn’t be presuming competence and supporting their language development, I have also observed plenty of examples of core vocabulary being used successfully!
What I presume matters most to the majority of AAC users, is getting their message across successfully and efficiently. I hope to be able to explore these ideas through my research, and as such have finally settled on my question for my internship: Are there any studies that have collected language samples from AAC users and used these to develop symbolised AAC systems?
I will be competing a literature review to answer this question and then asking patient involvement group to review my findings and support me to establish further questions for research. It’s felt like a long process already, but I feel very privileged to have been given this opportunity to pursue my clinical interests through this research pathway and am exited by the journey ahead.
If you would like to follow my progress or get in touch, you can find me on twitter @HelenATSLT or email hrobinson@nhs.net.
Barnsley AT Team - Engineering Independence 
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