THE LIVED EXPERIENCE OF BEING A SPEECH-LANGUAGE THERAPIST IN THE WESTERN CAPE PUBLIC HEALTH SERVICE

This study explores the lived experience of being a Speech-LanguageTherapist (S-L Therapist) in the South African Western Cape public health service.The lived experience of seven S-LTherapists with varied clinical experience was illuminated using a qualitative phenomenological research design. S-LTherapists, working in the three Western Cape tertiary hospitals, provided an in-depth account of their experiences as S-LTherapists.Theaudiorecorded interviews weretranscri bed verbatimandanalysedusinganadaptationofColaizzi's (1978) method of analysis. The rigour and trustworthiness of the research process was informed by consid­ eration of issues of credibility, applicability, confirmability and dependability as they relate to phenomeno­ logical design. Five main themes emerged from data analysis: expectations of practice and practice realities; being partofthe"underdog"profession:roledefinitionandstatus;beingconnected;theholisticnatureofthe S-LTherapist'spractice;anderosionorpromotion.TheimplicationsfortrainingandsupportofS-Ltherapists by managers and policymakers and peers are highlighted. K eyw o rd s : phenomenology, lived experience, Western Cape public health service, Speech-Language

Recent models describe a mutual participation (Fadlon 8c Werner, 1999) and an encounter o f cultures, background, families and aspirations. As the S -L Therapist-patient re lationship develops, it creates its own "dynamic quality that is affected by what the S -L Therapist and client bring to it" (Flasher 8c Fogle, 2004, p. 87). The trust which devel ops between the StL Therapists and their patients has been referred to as "professional closeness" (Purtilo, 1990, p. 22) and the manner in which the client behaves toward the S-L Therapist is suggested to be directly linked to how the S -L Therapist thinks, feels and behaves towards the client (Flasher 8c Fogle, 2004, p. 88).
The approach o f the medical profession to the manage ment o f illness, disease and disability has changed signif icantly over the last few decades (Sahler, 2002). As more medical professionals have begun to appreciate the patient s right and desire to participate in the management o f his or her illness, the patient is no longer seen as a passive recipi ent o f medical science and treatment. This has led to health professionals taking a more holistic approach described by Engel (1977) as the biopsychosocial model o f healthcare. This model recognizes other aspects o f the person as possi ble contributing factors to the presenting problem. The shift in the management o f patients, illness and disease has im pacted significantly on the S -L Therapy practice, particu larly at a relational level.
The hybrid nature o f the S -L Therapy profession, which draws on fields such as neurology, psychology, anatomy, physiology, physics, education and computer science makes it a highly integrated profession that is not limited to one approach to the treatment o f patients and their disorders. This makes the profession consistent with the principles that guide the biopsychosocial model o f healthcare.
As a consequence o f the complex range o f issues shap ing the work o f S -L Therapists, and those involved in "peo ple work" (Farmer, Monahan, 8c Hekeler, 1984, p. 43), many stress-related factors have been described. Factors which are inherently stressful within human service professions in clude the complexity o f clients and their needs, the difficulty in evaluating success, the poor perceptions o f the helping re lationship by others, lack o f support from the organization, ambiguous decision-making processes, and tension o f client needs and organization demands (Farmer et al., 1984, p. 45). Maslach (1982) stated o f health professions that "because by definition the recipients o f most helping relationships are people with problems, the health professional inevitably sees the part o f her patient that is negative or needing interven tion" (p. 18).
A major source o f stress for S -L Therapy professionals is that o f conflicting priorities in settings where S -L Ther apy intervention is regarded as merely a supportive function within the hospital team (Byng et al., 2002). The only pub lished South African study on burnout among S -L Ther apists reported that, at the time o f this study, S -L Thera pists and Audiologists were experiencing moderate levels o f emotional exhaustion, low levels o f depersonalization, and high levels o f personal accomplishment. Hospital thera pists in particular perceived themselves as being under large amounts o f pressure and susceptible to burnout (Swidler 8c Ross, 1993).

T H E L IV E D E X P E R IE N C E O F B E IN G A S P E E C H -L A N G U A G E THERAPIST
Organizations in which people work, create motivation through factors that are either intrinsic or extrinsic to the work itself (Bratten, Callinan, Forshaw, 8c Sawchuk, 2007). Reporting on extrinsic and intrinsic factors which correlated with career satisfaction and desire to stay in the job amongst hospital-based occupational therapists, physiotherapists and S -L Therapists, Barnes (as cited in Randolph, 2005) stat ed that the only significant positively correlating extrinsic factors were productivity expectations and a flexible work schedule (Randolph, 2005). Intrinsic factors that positively correlated with job satisfaction an d desire to stay in the job were stable work environment, opportunity for professional growth, input into departmental decisions, and practising in an environment that was in line with the professionals values. Intrinsic factors that positively correlated with job satisfaction only, were opportunities for direct patient care, feeling competent, accomplishing career objectives, and meaningful work. Intrinsic factors that positively correlat ed with desire to stay in the job only were fair policies, and closeness with co-workers. Harrison (1983, p. 224) stated "a sense o f competence and a feeling o f efficacy are the results o f being able to af fect the environment and meet its challenges". It has been proposed that significance is a core motive for all people, especially those engaged in a profession, and that people in the helping professions want to feel that they are making a difference in others' lives (Cherniss, 1995). Professionals may develop positive affective responses to their jobs if they believe that what they are doing is valuable and makes a d if ference to the lives o f their patient(s).
Harrison's social competence model o f burnout (1983, p. 224), although developed over twenty years ago, illustrates clearly the nature o f transactions between the individual and his or her work environment. In relation to S -L Therapy and other healthcare professions, the model demonstrates that while the motivation to help and serve others is an impor tant pre-requisite for the professional, the presence o f sup portive aspects (helping factors) significantly affect the pro fessional's sense o f competence and resultant motivational enhancement. Similarly, the presence o f non-supportive aspects (barriers) significantly decreases the professional's sense o f effectiveness, leading to burnout and a reduced mo tivation to help others. Some cited supportive aspects include: participation in peer counselling and support from colleagues, feeling sup ported by managers, feeling training had prepared them for the working environment, feeling their expectations o f the job had been satisfied, feeling a sense o f pride and achieve ment when goals were attained, and experiencing work as interesting and rewarding (Akroyd, W ilson, Painter, 8c Figuers, 1994;Collings 8c Murray, 1996;Culbreth, Scar borough, Banks-Johnson, 8c Solomon, 2005;Hasselkus 8c Dickie, 1994;Jenkins, 1991;Jenkins 8c Elliott, 2004;Kilfedder, Power, 8c Wells, 2001;Lloyd, King, 8c Chenoweth, 2002;Lloyd 8c King, 2001;Moore, Cruikshank, 8c Haas, 2006a;Moore, Cruikshank, 8c Haas, 2006b;Reid et al., 1999;U m 8c Harrison, 1998).
The literature has shown the multidimensional influenc es on S -L Therapy as a profession. It is a helping profes sion challenged by having to construct its identity in rapidly changing socio-political contexts, continuously shifting to wards a social model, questioning its practice, and practi tioners experiencing the same professional stress and burn out felt by other helping professionals. Despite the depth and breadth o f the literature, the essence o f the experience o f being a S -L Therapist is an area which has not been suf ficiently explored. This study explores the lived experience o f the S -L Therapist, to contribute to the body o f knowledge in this area.

Methodology Aim
The aim o f this study was to explore and describe the lived experience o f being an S -L Therapist in the Western Cape public health service.
Research question: W h at is the lived experience o f being an S -L Therapist in a rapidly changing public health service in the Western Cape?

Participant selection criteria
Participants were required to meet the following inclu sion selection criteria: A t least two years work experience as a S -L Thera pist in the Western Cape public health service (hospital or community) Currently a full-time or part-time S -L Therapist in the Western Cape public health service (hospital or com munity) I f on a dual register (S -L Therapy and Audiology), 50% o f the participants'weekly activities had to be dedicat ed to S -L Therapy.
Voluntary participation with openness to share ex periences Participants who were at different stages o f their careers were selected as this was assumed to broaden the range o f experience which might emerge during interviews (Patton,

2002).
Purposive sampling was used in order to select partic ipants (Guba 8c Lincoln, 1989;Schofield and Jamieson, 1999). Purposive sampling is appropriate for small studies as the "logic and power o f purposive sampling lies in select ing information rich cases for study in depth" (Patton, 2002, p. 230).
The study was limited to the Western Cape as it was a context which was undergoing rapid change and there was a need to understand experiences within this context. The re searcher also had close knowledge o f the context which was a strength in an exploratory study o f this nature. The study was limited to this area to allow the researcher ease o f access to participants to enable personal communication.

Access to participants
Following approval from the University o f Cape Town Faculty Research Ethics Committee, the medical superin tendents and Speech Therapy heads o f department o f the three tertiary hospitals were contacted. Information about the study aims and what participation would involve for staff members was provided. Once permission was grant ed, all S -L Therapists in each hospital were individually e-mailed with the study information and participant re quirements, and requested to respond indicating either will ingness or unwillingness to participate. Each S -L Therapist who agreed to participate was contacted telephonically in order to arrange an interview time and venue. Participants were assured o f confidentiality and o f their right to with draw from the study at any time without penalty or preju dice.

Description of participants
The sample group comprised seven female S -L Thera pists ranging in age from 26 to 52 years with a mean age o f 36 years. The number o f years work experience ranged be tween 3 and 27 years, with three participants holding Bach elor degrees and four holding Masters degrees from two universities in Cape Town. All, at the time o f data collection, worked at one o f the three tertiary hospitals in the Western Cape. Five participants had dual registration as S -L Thera pists and Audiologists while two had single S -L Therapy registration. Five o f seven participants had a predominantly paediatric S -L Therapy caseload.

Ethical considerations
Ethical approval was obtained from the School o f Health and Rehabilitation Sciences and the University o f Cape Town Faculty Research Ethics Committees. Participation in the study was voluntary. S -L Therapists who declined to participate were not contacted again in connection with the study. W ritten informed consent was obtained from each participant.
Identifying information about the participating S -L Therapists was kept confidential and participants were allo cated a number which appeared on all transcripts. Identify ing information was removed from all direct quotes without changing the meaning o f the words. As S -L Therapy de partments in the Western Cape public service are small, all correspondence between the researcher and participant was conducted via personal e-mail which is password protected.

Issues in relation to interviewing colleagues
As the researcher is herself a S -L Therapist, and in view o f the limited number o f S -L Therapists working in the Western Cape public health service, it was not possible to eliminate all S -L Therapists known to the researcher from the potential pool o f participants. Advantages o f interview ing colleagues include shared language and shared level o f education, norms, and knowledge o f the participant workculture (Holloway 8c Wheeler, 1996). A potential disadvan tage, such as lack o f trust and privacy between participating S-LTherapists and myself [the researcher], was minimised by avoiding face-to-face discussions with participating and non-participating S -L Therapists in the workplace and re questing that participants not discuss the content o f their interview with fellow colleagues. The danger o f me [the re searcher and a S -L Therapist] becoming over-involved and over-identifying with the participating S -L Therapists was minimised by formally assuring the participant that I was conducting the study from the point o f a researcher and not a S -L Therapist or colleague and that I would not be assuming or drawing on prior conversations we may have had. Continuous researcher self-reflection and bracketing (Creswell, 1998;Holloway 8c W heeler, 1996) o f presuppo sitions and attitudes, and ongoing discussion between the researcher and study supervisor contributed to maintaining the integrity o f the research process.

Research Procedure Data collection
Data were generated through seven individual in-depth interviews (approximately 90 minutes in length); the keep ing o f field notes and reflective memoranda by the research er; and seven follow-up interviews (approximately 30 min utes in length) to discuss preliminary study findings.
Each interview commenced with an initial question "I would like you to tell me as fully as you are able, and draw ing from your experience, what it is like to be a S -L Thera pist in the public health service?"This question was followed with explorative questions and reflective responses by the researcher. Phenomenological interviewing relies on skilled listening without prejudice by the interviewer, and encour aging and allowing the interviewee to describe their experi ence without interruption by questions from the interview er. As the participant is actively involved in the gathering process o f discovery and interpretation (van Manen, 1990, p. 98), and with interpretation taking place during and after the formal data gathering phase, interviews deliberately did not contain a set o f pre-formulated questions. This allowed the researcher to remain open to new and unexpected views and ideas.
Bracketing (Creswell, 1998;Holloway 8c W heeler 1996) was applied whereby the researcher's beliefs about the phe nomenon were made explicit and temporarily suspended, enabling the researcher to be open to new understandings. Interviews were recorded, dated and labelled with the par ticipant's number, and transcribed verbatim to reliably rcr fleet the interviewees precise words including non-verbal and para-linguistic communication (Hycner, 1985). | Interviews were followed by the writing o f field notes which captured the "flavour o f the interview" (Holloway 8c Wheeler, 1996, p. 70) as well as participants' behaviours, at-, titudes and non-verbal information (Mason, 1996). Reflec tive memoranda were not part o f the direct data collection process, but contributed to the analysis phase and enhanced rigour by describing the research process and capturing the researcher's views, thoughts, feelings and opinions. Individ7 ual follow-up conversations were held with each participant to clarify issues which were not clear in the original inter view. D

ata Analysis
The challenge o f qualitative data analysis is "making sense o f massive amounts o f data, reducing the volume o f raw in formation, identifying significant patterns, and constructing a framework o f communicating the essence o f what the data reveal" (Patton, 2002, p. 432). The analytic frameworks sug gested by Colaizzi (1978) and Hycner (1985) were followed

T H E L IV E D E X P E R IE N C E O F B E IN G A S P E E C H -L A N G U A G E T H E R A P IS T
to analyse the verbatim transcriptions.
The researcher read each transcript a number o f times and significant statements relating to the phenomenon were extracted. These were tabulated in an adjacent column with the statement re-written in the third person, which helped to personalise the statement (Table 1). Duplicate statements were eliminated. Next, each significant statement was coded to bring out the meaning in the description (Table 2). Next, similar codes within each transcript were grouped togeth er into clusters. Clusters were grouped across all transcripts into categories which were finally assigned to one o f five final themes. Themes and categories were checked against each original transcript to ensure that all information from the transcript was contained in the themes and vice ver sa. Findings from each theme were written as an exhaus tive thick description in paragraph form substantiating the analysis through the use o f interview excerpts, van Manen (1990) describes the identified themes as being "objects for further reflection in follow-up hermeneutic conversations in which both the researcher and the interviewee collaborate" (p. 99). This was achieved by returning the themes and a short description o f each to the participants to read, and then conducting a 3 0 -40 minute discussion where each participant was given the opportunity to comment on the findings, clarify issues and expand on the interpretation. Lastly, findings from all five themes were combined into an exhaustive description o f the phenomenon.

Rigour and Trustworthiness
In qualitative inquiry the credibility and legitimacy o f the study is dealt with under the broad framework o f trustwor thiness (Patton, 2002). Credibility (in preference to inter nal validity) refers to the truthfulness and value o f the re searcher's findings to represent the world as perceived by the participants (Maxwell 8c Satake, 2006). The research er has provided a clear description o f the study setting and participants, the research process as well as describing the researcher's personal experience o f being a S -L Therapist. Shenton (2004) recommends the "development o f early fa miliarity with the culture o f participating organisations be fore data collection takes place" (p. 64). As a S -L therapist, the researcher was 'familiar with the settings and facilities in which S -L therapist participants worked. Shenton (2004) offers further strategies for enhancing credibility: potential participants should be given the opportunity to refuse to participate, contending that this ensures that data are ob tained only from participants who are genuinely willing to take part in the study; frequent debriefing sessions between researcher and superiors/supervisors; peer scrutiny by col leagues, peer and academics; member checks (achieved by revisiting the participants after their interview to validate that the emerging categories and themes were consistent with the participants' experiences);! researcher's reflective commentary, and thick description o f the phenomenon un der scrutiny, all o f which were adhered to in this study.
Applicability/transferability is the degree to which the findings can be applied to other contexts, groups or gen eralised to the greater population although generalisability is not relevant in!many qualitative research projects (Krefting, 1991). "The results o f a qualitative study must be un derstood within the context o f the particular characteristics o f the organisation and perhaps the geographical area in which the fieldwork was conducted" (Shenton, 2004, p. 70). Participants with a range o f career experience were select ed to facilitate transferability judgments on the part o f S -L Therapists in other public service settings (Guba 8c Lincoln, 1989).
Confirmability (in preference to objectivity) shows that data are linked to their sources (Guba 8c Lincoln, 1989;Holloway 8c Wheeler, 1996). An audit trail was used to ena ble the reader to understand and evaluate how methodolog ical, analytical and theoretical decisions were made (Lincoln 8c Guba, 1985), thus ascertaining whether the findings are "grounded in the data" (Lincoln 8c Guba, 1985, p. 323). In this study the researcher kept reflective memoranda o f ideas, thoughts, feelings, opinions and difficulties experienced, e.g. the researcher's feelings during and following interviews. Included was additional information about the participants themselves such as reactions to events and comments made.
Following transcription o f each interview, the researcher's impression o f that participant's experience along with the researcher's knowledge o f that participant as a colleague was noted. This assisted to bracket out personal feelings in respect o f knowing some participants as colleagues. After each stage o f analysis progress notes were made and tables o f preliminary findings stored for comparison to the follow ing stage findings. This also contributed to the dependability (reliability) o f the research process and the findings.

Findings
Phenomenological analysis across all interview tran scripts resulted in five themes that represent the lived expe rience o f being a public health service S -L Therapist. Each theme is supported by excerpts from participants' interviews as quotes (in italics) which serve as exemplars o f the partici pants' experience.

Theme one: Expectations of practice and practice re alities
S -L Therapists begin their careers with the desire to make a significant difference to the lives o f their patients. They are motivated because "you're concerned about their speech an d lan guage"-.
". . . I think, sort o f w anting to be able to, to help people, um, you know an underlying desire to, to be able to try an d make a difference somewhere ... .you know we w ant to be able to, to help everyone make a big difference, make their lives better and, help them to cope a t school an d help them to, be a success in life, an d make their social circumstances easier... ' Working as an S -L Therapist is different to their antici pations and they soon realise that they are not able to help everyone they see. Furthermore, they feel let down as the public health system is not as organised and efficient as it was portrayed during their training, and they struggle to gain the same level o f control they had as student thera pists: ". . . I think in, in the beginning it ' s a bit harder 'cosyou, you come in into the profession an d it ' s very different to w hat you were prepared fo r as a student. As a student, I mean every thing is like in order an d you know it looks like there' s this whole system in place to deal w ith people coming in with speech problems, with hearing problems an d you know every thing looks good on paper, but when you actually start, start working. .

. i t ' s a lot messier than w hat I think you expect an d I think that is a bit o f a, a let down in a way, um, an d a bit fru stratin g.. . "
The abovementioned progression is described by Tryssenaar and Perkins (2001, p. 22) as the "transition stage" which is an eager "marking time" through a student's final months in training; the "euphoria and angst stage" as the therapist begins professional practice with both excitement and trepidation; the "reality o f practice stage" where thera pists struggle through sometimes "unpleasant experiences" (p. 22) as S -L Therapists come to terms with the realities o f the job.
Research conducted with health, welfare and education professionals has identified issues consistent with the ex periences o f current study participants. Curtis and Martin (1993) reported physiotherapy graduates as having had "un realistic expectations" (p. 588) on leaving student life and entering the professional world. Expectations were not al ways met or were met in an unanticipated fashion. Lloyd et al. (2002) reported that social workers have felt dissatisfied with the discrepancy between the ideals o f social work they were trained in and the reality o f day to day practice; par ticipants stated that their profession "has a very idealistic and reforming philosophy which is not met by many social workers in practice" (p. 262).
In a study by Madjar, M cM illan, Sharke, and Cadd (as cited in Chang 8c Hancock, 2003, p. 156) nurses stated that they experienced a significant gap between the theory they had learned in training and what was expected o f them in practice. School counsellors have been reported to experi ence a discrepancy between the ideal role and the role that interns (novice teachers) experience in practice (Culbreth et al., 2005). A current study participant described defining her role is a "continuous challenge".
Communication disorders are seldom as clearly diagnosed and treated as many medical conditions, and the nature o f these disorders is such that a complete recovery following intervention is often not possible or realistic. Residual defi cits may remain, and this may leave S -L Therapists feeling that their work is unfinished, unresolved and incomplete: "the nature o f language disorders, never, neverfixed, seldom, it ' s, it ' s a life-long disability... " Patients who attend the public service healthcare facility are mainly those with no medical insurance who often live in negative social contexts. For S -L Therapists this " perpetu ates the current situation" and is a barrier to progress. There are aspects o f S -L Therapists' interventions which cannot be implemented without societal change: To counteract these limitations, S -L Therapists acknowl edge the pressures their patients face and seek to use their skills and knowledge to "help people [patients] to understand how they [social elements] are related to the languageproblem"'. Through examining the environmental stressors at play in a patient's life, S -L Therapists attempt to understand fully the patient's language/speech difficulty. They dedicate their time and energy to empowering and educating their patients and families about the role they can play in bringing about last ing change in their own lives and cope with future challeng es in a positive manner.
.. um, but I think ultimately i f things in their home situa tion or community situation are affecting the specific speech an d language difficulty, one needs to address them otherwise dealing w ith the underlying speech an d language disability can be a bit o f a waste o f time... " Over time, as S -L Therapists come to terms with the re alisation that there is much that is beyond their personal ca pacity to change, they become less idealistic and more prag matic about what they can and cannot achieve. They begin to establish more realistic goals and expectations, adapting their therapy to the setting and patients: " Acceptance o f this reality enables S -L Therapists to be come more realistic about future experiences. By being less idealistic about their work, their patients and therapeu tic outcome, S -L Therapists experience less anxiety about needing to f i x " every patient's problem. No longer solely responsible for every patient's progress, and free from ideal istic expectations, S -L Therapists are better able to deal with difficulties which arise and view them as being part o f the jo b rather than crises. This adjustment to their profession is described by Tryssenaar and Perkins (2001, p Theme two: Being part of the "underdog" profession: role definition and status A great frustration for S -L Therapists' is public and fel low health professionals' misperceptions o f the profession and the nature o f their work. They feel that these attitudes and beliefs are uninformed; this makes them feel underes timated and underrated as professionals, as they know and understand their work to be far more complex and intricate than commonly understood: In a study which explored how social workers experience their work, participants stated that their role is misinter preted as "just being nice or doing the common sense things that anyone can do" (Dillon, as cited in Lloyd et al., 2002, p. 257). Occupational therapists have also reported feeling "devalued" (Hasselkus 8c Dickie, 1994, p. 147) and having their skills "unused" (p. 147) or "blocked" (p. 147) by certain team members. Current study participants described simi lar experiences, in that talking and swallowing are viewed as automatic processes that everyone can do, and are less of a priority than other more obvious impairments. This is il lustrated in the words of one participant who said " fo r many o f them, [stroke patients] it is about getting back to walking... sometimes much more than communication". The specific expe rience o f having a skill "devalued" or "blocked" is reflected on by a participant in the current study. She related an o f ten-repeated situation in which a decision regarding place ment in a rehabilitation hospital seldom takes into consider ation the opinion o f the S-L Therapist. Her experience was that, should a stroke survivor be left with both a physical and communication deficit, rehabilitation would immedi ately be recommended, however if left only with a commu nication difficulty, the referral to rehabilitation would not be automatic. Even after strong motivation, her opinion is usu ally disregarded, leaving her feeling disrespected as a profes sional.
Participants suggested that contributory factors to these misperceptions is the abstract nature of the disorders treated by S-L Therapists, the invisibility o f communication disor ders as compared with physical diseases, the historical lack of advocacy by S-L Therapists and the relatively low status of people with communication difficulties in many commu nities:

"...speech and communication disorders are not as concrete or as visible as more physical disorders, as treated by a Phys io [physiotherapist] or an Occupational Therapist, um, you know i f someone' s got a, had a stroke and one side of their body is weak, you '''can automatically see it, um, whereas speech and language is, not as visible... ''
. .people with communication difficulties as I prefer to call them whatever they are, whatever their nature, is that be cause these difficulties are not visible, they' re not well un derstood um, people, the public think that people who can't communicate properly are stupid are worthless are um, they become the butt-end of jokes... " Continually having to explain what S-L Therapists'work entails and the nature o f their role is exhausting. A further frustration is being referred to as an elocution coach or "someone who helps people to speak welt'. The ignorance sur rounding the profession is such that one study participant stated that she felt that it would have been much easier to have chosen a different career. The relative invisibility of speech, language and communication disorders means the difficulty is not well understood or acknowledged. Even within the subset of patients with different communication disorders, S-L Therapists are frustrated that more visible difficulties are prioritised. A patient is only likely to seek the S-L Therapist's help for a communication problem that is negatively affecting his or her occupation or quality of life. It is hard to accept the relative complacency o f persons with a communication difficulty; as many are content to tolerate it as long as it does not interfere too much, thus seldom seek help in the early stage of the disorder.
Patients with communication problems are also misun derstood. One participant described her experience: "the lay person' s attitude to people with communication disorders is one of ridicule" and that in her work she has often been "a recipient o f the casualties of the lay person' s attitude and actions towards them . Patients may have explored numerous options before accessing the Speech Therapy services and have often en dured teasing and ridicule.
S-L Therapists experience their work environment as nurturing, a unique community which is almost "like home" which is contrary to the perceptions of the public regarding state hospitals: .

.ja [yes], I think they, people just don't have any idea of this context even that you're working in or you know it, it, I think this hospital, it' s like a little world on it' s own, sort of a community in a way andja [yes], i f you haven't been here you don't quite understand what its like... "
S-L Therapists experience feeling secure and being nur tured by their environment which makes the tension be tween their experience and the public's misperceptions dif ficult to reconcile: "..

. .ja [yes], but it' s a home away from home sometimes in a way [laughs] now.... I think it' s, it' s, i f you've been here a long time, one, you, you know how things work here, so I think that' s just a negative perception we really have... "
Unlike physiotherapy, occupational therapy and social work, S -L Therapy services are under-represented at com munity health facility level, secondary hospital level and in mainstream education. As a result, patients' only options are to access S -L Therapy services at a tertiary level even if it is geographically and logistically very difficult to do so: "..

. often clients can receive the medical help they need at a community level, but not the rehab at a community level... " .. and I think that' s, that' s an area of, where our profession really needs to be to be working at is at a level of, um... com munities, but also educators, doctors... ''
Within the Western Cape, the hospitals with skilled and available medical personnel are geographically some dis tance from the majority of their patients. This negatively af fects patient attendance and increases S-L Therapists' frus tration. While certain S-L Therapy services require medical support which is offered by the hospital, a large proportion o f the services S-L Therapists offer to both adults and chil dren are not suited to this setting and would be " fa r more effective i f offered at a community level or in mainstream class rooms". S -L Therapists are left feeling detached from their patients and misplaced as health professionals who provide decontextualised services.
The lack of S-L Therapy services at community level ex acerbates the pressure to get through the large case load in a limited time, which, when added to the associated adminis tration, can result in reduced productivity and less time and energy to focus on each individual patient. The lack of suf ficient time for patient care is a consistent finding in other human service profession research. Occupational therapists are reported to feel unable to serve clients adequately when coping with a large caseload (Hasselkus 8c Dickie, 1994) and to experience excessive paperwork and statistics as a major source of stress (Bailey, 1990;Freda, 1992;Pringle, 1996). The physiotherapy literature reveals similar findings in that "during periods o f high demand for physical therapy" (Deckard 8c Present, 1989, p.116) therapists felt pressured and complained about inadequate time in which to provide all their patients with adequate treatment. Physiotherapists in the above study reported feeling "torn between providing service to everyone" (p. 116) which decreased the quality of care and amount of time they were able to devote to each treatment. Theme three: Being connected S-L Therapists engage in a broad range of relationships with others. Intervention is a collaborative process between S-L Therapists and patients and their families and involves " a tremendous amount of give and take". They place the pa tients and their families at the centre of the intervention process, giving them permission " to state their priorities and expectations o f therapy". S-L Therapists recognise them as important and useful resources for change and strategically look at what their patients and families are able to contrib ute to the treatment/rehabilitation process.
S-L Therapists'relationships with their patients are com plex and interactive (Holland, 2001). Current study partici pants described a real sense of connectedness to their pa tients as they are intimately involved in a dynamic two-way helping relationship fuelled by a desire to help, remediate and improve the presenting communication or swallowing difficulty. Worrall 8c Frattali (2000) described S-L Thera pists' involvement with their patients as "entering into peo ple's lives in a very real way and becoming involved in issues of human living" (p. 193). All therapeutic endeavours occur in cultural context with cultural factors demanding aware ness and sensitivity (Holland, 2001).
The importance of personal relationships is reflected in a person's choice to enter the profession of S-L Therapy, for which helping other people is a primary motivation (Byng et al., 2002). In line with the abovementioned two-way helping relationship, Egan (2002, p. 7) presents two princi pal goals of helping: the first being to help clients manage their problems in living more effectively and develop unused resources and missed opportunities more fully; and the sec ond being to help clients become better at helping them selves in their everyday lives. He further states that due to the nature of helping others, helpers "are only successful to the degree to which their clients, through the client-helper interaction are better able to manage specific problems and develop specific unused resources and missed opportunities more effectively" (p. 7).
Collaborative partnerships with the healthcare team help S-L Therapists offer more effective and holistic manage ment and reduces the pressure and expectation that they feel to try to meet all their patients' needs: .

. when we run multidisciplinary clinics we provide a much better service fo r a patient because it's one-stop-shop, it's less timefor them, it's less schlepping [walking] around less wait ing, less stress... everyone' s in one place, so that we work to gether at the same time with the parent and the child and we can give them feedback together and we have one plan... which is just a more efficient way o f doing things... "
In the hospital setting, patients often require interventions in addition to that offered by S-L Therapists. The multidis ciplinary team is a source o f information and support. This illustrates the team's role in producing better quality serv ice and comprehensive approach than its individual mem bers working as solo practitioners. The professional is able to increase productivity and has a sense o f accomplishment (Benierakis, 1995). Current study participants described ex periencing great willingness from team members to work collaboratively, making their own work day more enjoyable. This is consistent with a study o f occupational therapists who reported that job satisfaction is derived from being part of a multidisciplinary team and that good communica tion and co-operation among team members increased their sense o f fulfilment (de Wesley 8c Clemson, 1992).
Despite this positive experience o f teamwork, ignorance and misperceptions about S-L Therapists' professional roles continue to exist among colleagues. Study participants de scribed feeling "side-lined' compared to professionals from seemingly better-understood professions, and described not being recognised as equal members of the team. For one par ticipant in particular, remarks and actions of medical doctors in particular make her feel "stupid' and that her interven tion techniques are not sufficiently academic. An Australian study in the occupational therapy profession found that the underlying ignorance and misperception of the profession is seen in both an absence o f referrals or inappropriate referrals to the profession (Moore et al., 2006a).
Current study participants spoke of poor collaboration with some educators, certain healthcare professionals, and some privately employed S-L therapists. This makes effec tive management very difficult and creates a barrier for the development and maintenance o f good working relation ships: "..

Theme four: The holistic nature of the Speech-Lan guage Therapist's practice
The therapy process involves much more than direct therapeutic intervention. S-L Therapists need to conscious ly engage with their patients in order to better understand their needs. They need to "...really get to know them beyond the superficial level, to just go a bit deeper... but it' s also about hearing them, it' s about having the humility to hear them with out judging them.,. " S-L Therapists focus on more than the presenting com munication disorder and take a holistic approach to patients and families, placing high value on the way their patients use speech and language functions, rather than individual grammatical structures, to gain communicative power. The aim is to assist their patients to use language as a tool for everyday life and to facilitate successful social integration:

". . . I mean I think one of the most important things is not only focussing on sort o f specific language things but looking at more lifestyle communication and pragmatic skills which are going to help them later on in life as opposed to being able to say something that's syntactically correct! or whatever, and you know it might be more of apriority to deal with, get them coping at a certain level which is functionally going to be use fu lfo r them as opposed to what would be perhaps ideal... "
The presence of a communication difficulty is the reason for the consultation, yet S-L Therapists' primary focus is on the 'person' and their role requires that they consciously ad dress their patients' salient needs with the same respect and rapidity as they do their communication difficulty: .. it feels like you're giving more than just that [therapy]...

but you end up having to, to just make, make their lives neat and tidy from other aspects so you can actually -you know, i f all that is in a mess then somehow the therapy is not, they cantfocus on therapy because they too stressed about blah blah blah and something else, so it' s almost like you have tofocus on all the little bits and pieces as part of like a like a holistic sort o f management that you're doing... "
S-L Therapists understand how speech and language are used in the daily interactions between their patients, their patients' significant others and community, and the severely limiting impact of the communication difficulty on their pa tient's ability to interact effectively with his or her world: .

. speech and language is a part o f interaction which is a part o f the child' sfamily, which is a part of their society... "
There are times when S-L Therapists' roles entail not do ing anything, but just being there for their patients and con sciously assuming the role of supporter, advisor, or counsel lor. One participant described how she regards herself as a committed friend a!nd support to her patients and families, needing to operate from a place o f " enormous empathy".

".. .just to be supportive, I think it' s kind of to acknowledge what you'refeeling, it is a process, it does take time... and cer tainly with my adults i f I cry with them, Ijust think it adds a dimension, they do know that you feel, and why should I hide it? I f I ' m going to cry andfall apart and I can't help him, that' s a different story, but i f you're helping him andfeeling fo r him... "
S-L Therapists make personal investments into the lives of their patients and families by offering themselves and their skills in the therapeutic process, with their own needs subservient to the greater needs o f their patients. They are fully present in sessions with their patients and conscious ly focus their minds, thoughts, attention and energy during that time, not allowing themselves to become distracted: "..

. it' s like, you know a child comes running, smiling and you've got to, you've just pull out what you need and you know deliver the goods!... and sometimes that's a natural thing, other times you dig deep!...''
The therapeutic process involves more than specific activ ities; there is an emotional component to the therapy. Help ing professions such as S-L Therapy involve more than just helping, but require "an investment of knowledge and skill blended with facilitating interpersonal qualities to effect change in another individual" (Lubinski 8c Frattali, 2001, p. 189). Regardless of personal feelings and circumstances and day-to-day pressures, participants described how the patient always comes first. S-L Therapists are emotionally drained after a day of making such intense investments into the lives o f their patients. A day at work is described by one participant as " much more than just a job". The responsibility of managing patients with serious communication difficul ties is onerous. The management of even uncomplicated pa tients is like "trying to eat spaghetti" in that it is "hard to man age". As they interact with their patients on a deeper level, an emotional bond develops with expectations o f them as therapists: "..

. they come to you with all this hope and I think because we are in a profession that gives people a little more time it' s not you know quick consultations, they have a lot o f one on one time with you and because it' s -it' s not just so medi cal but so -therapeutic -there' s a lot of counselling and stuff that goes on, that, I think it doesn'tjust affect the patient, you know somehow you also become involved, in their lives..., in what it means fo r them... you know it becomes your, your problem as well... "
S-L Therapists share in the emotional journey of their patients and families. One study participant described how in the past she had "hoped with the family" that test results would not return as suspected. Other participants described the emotional journeys they have taken with patients and families as together they express grief and disappointment at the birth of a disabled child, the diagnosis of a terminal illness or life-altering procedure. Taking on the responsibili ty of managing patients with serious medical conditions and chronic disabilities requires emotional maturity and stami na. One participant described her experiences as requiring " staying power which takes more maturity than your years".
The repeated exposure to illness and suffering can make S-L Therapists hardened, no longer as sensitive as they were to the shocking reality of their first experience. Certain sights, sounds and smells become so much a part of their daily activities that they no longer have the impact they once did. They easily lose their sense of what is regarded as normal, see disorders as the norm, and thus seldom ex pect anything more. They lose hope that miracles do hap pen and that recoveries can occur. S-L Therapists may find themselves approaching their patients from the perspective of "deficit", thinking only about what they cannot do, instead of what they are still able to do: Healthcare professional [S-L Therapists] have have to deal with occupational stressors that are not part of most other occupations in that they deal with people in situations involving death and suffering that have a profound effect on them (Payne 8c Frith-Cozen, 1987). For this group of S-L Therapists, the repeated exposure to illness and suffering with the common sights, sounds and smells makes it easy to become hardened to seeing people suffer "with even the most experienced professional feeling awkward and help less" (Arbore, Katz, Therese 8c Johnson, 2006, p. 17). Seeing disorders as the norm and seldom expecting anything more was also described by Arbore et al. (2006, p. 25) who state that in such cases, the professional is often left to feel that there is nothing he or she can do for the patient except to be with the patient in the situation. Health professionals re act in different ways to seemingly hopeless situations. They either become over-or under involved, which is described as unconscious countertransference feelings (Arbore, et al., 2006, p. 22). One participant described her shock and sur prise at patients who, against all odds, make unbelievable recoveries. This makes her aware o f how pragmatic and mat ter-of-fact she has become.

Theme five: Erosion or promotion
The public service setting presents many challenges for S-L Therapists: time pressure to complete their work, high patient caseloads, time-consuming reports, insufficient staff complement, changes in promotional possibilities (the abol ishment of rank promotion based on work experience) and no financial incentives other than their monthly salary: "

. I think i f there was time you could sort it out better; um, but you in a bit o f a hurry too, to sort out all the loose ends sort o f move on so it does, I think the time and the pressure on, on numbers and things like that does, does affect how much you can actually do..." "... now money' s an issue, but in the past the salaries were ad equate um, as the cost of living increased so the salaries didn't keep pace, but in the beginning it wasn't as shocking a salary as it is now... ''
A large caseload results in less time and energy to fo cus on each individual patient, especially with the time-consuming referrals and report writing: I think it also depends

on your, your workload um, I think i f you' re really working hard you have less o f thatfor each patient... ''
Despite the many challenges which make S -L Therapists question their decision to stay in the public service, this is countered by the predictability and security they experience in this setting. A guaranteed stable salary and benefits, rea sonable administrative support and a high level o f predict ability in the nature of their work makes them feel settled, grounded and in control: S-L Therapists receive consistent and predictable admin istrative support which enables them to focus on service de livery rather than on administrative duties. Their familiarity with the way their environment functions, whether positive or negative, defuses much of their frustration over everyday challenges. They are prepared for the common challenges of a public health service and able to manage these.

". . . I mean I 've always had a job, I ' m, I ' m in quite a secure environment, which is maybe also why I ' m staying
Security, permanence of employment, regular salary, pension benefits, together with, flexibility o f vacation leave and clearly defined sick leave benefits contribute towards the stability of their roles. Similar findings were reported in the responses of participants from a study of Occupational Therapists working in the British National Health System who stated that they regarded themselves as having a job "for life" and reported valuing their pension and good con ditions of service (Pringle, 1996, p. 405).
The diversity of S-L Therapists' caseloads provides them with opportunities to grow and develop as therapists. This enables inexperienced therapists to develop a sound clinical foundation as they work in the tertiary service infrastruc ture and support networks. One participant described how the freedom she had to "find her feet" is rarely available in other settings, in which providing services to paying clients is the priority:

"...Initially you're pretty much finding your feet in the pro fession, you' re doing, a little bit o f everything, figuring out what you like, what you do better, what you don't do so well, so there' s that initial kind o f just almost testing the waters kind of thing... "
Working in a training hospital offers S-L Therapists var ied patient exposure and the opportunity to manage patients with a wide variety of communication disorders including those with multiple and / or rare conditions. This makes S-L Therapists' experiences dynamic, stimulating and challeng ing. It stretches them in terms of the knowledge, clinical skills and expertise they require and demands flexibility, cre ativity and a sound knowledge and understanding of dif ferent treatment approaches. The three tertiary hospitals! in this study are teaching hospitals, with the ethos o f learning, teaching, research and clinical advancement. They have ac cess to academic resources and staff which offers them edu cational and clinical development opportunities. The teach ing environment is stimulating, rewarding, and a source of significant job satisfaction.
. This expectation o f exposure to valuable learning op portunities in specific contexts is common to other health professions. In a study looking at career choice, 55 percent of newly qualified Canadian physiotherapists reported hav ing chosen a public service hospital setting due to the per ceived learning opportunities and the anticipation o f it be ing an appropriate environment to start as a novice therapist (Ohman, Solomon, 8c Finch, 2002). In another study novice physiotherapists chose the hospital setting because of the learning opportunities they believed it would offer them (Miller, Solomon, Giacomini, 8c Abelson, 2005). The hos pital setting, which facilitated the grounding of their clini cal experience, was viewed as a "stepping stone" (p. 148) to other practice settings. This viewpoint was not described by current study participants; rather it was their belief that this THE L IV E D EXPERIENCE OF B EIN G A S P E E C H -L A N G U A G E T H E R A P IS T was the opinion of S-L Therapists in private practice. Study participants described privately-employed S-L Therapists to most definitely have the perception that " you start off in the public sector when you don't know very much, learn as it' s a very good place to start, and then graduate to private practice!".
Even after many years of working in the public service health setting, the opportunities that initially attracted S-L Therapists to the public service continue to keep them mo tivated to stay: S-L Therapists who are socially motivated to work in this setting or who chose it because of the role they wished to play in this context, experience it very differently to S-L Therapists who did not have these same sentiments. Even after years in this setting, those who described themselves to have "chosen it" are still committed to the public service.
Despite the ups and downs o f S-L Therapists' clinical work, the positive experiences and job satisfaction play a major role in their decisions to be a part of the service: ".. S-L Therapists feel enriched by being exposed to the wide variety of people around them and have learned to accept others more, judge them less, and understand them more deeply. Engaging with patients and families on a daily ba sis requires them to go beyond a superficial level to "know ing where they're coming from " and "really understand the peo ple you're working with". The daily interaction with people from diverse cultural and socio-economic groups enriches and deepens their understanding of humanity:

". . . i f I hadn't worked here, I would never have known much, as much about people who are not different, I mean we're all the same basically,\live in different circumstances, have grown up differently, got\different priorities perhaps um, I think it' s made me more tolerant o f people, more understanding of dif ferent ja \yts\just o f different belief systems and culture... "
Being a part of their patients'journeys towards recovery and rehabilitation is an enriching and validating experience. There is a sense of accomplishment as they see their patients become empowered to succeed beyond the therapy setting. Victory for a patient is translated into renewed passion for what S -L Therapists do and why they do it: ".. .1 love it when I have a 'happy client'. W hen I've been able to make a difference... .. .my patients actually, because o f the, the, the type of pa tients I see, I 'm humbled by them, I'm, they, they, they make me feel good on a daily basis..." S-L Therapists' patients' successes are a personal victory, not because of the role they have played, but due to the deep connection they feel to their patients and their rehabilita tive journeys: .. S-L Therapists in this setting are greatly affected by their patients. Two participants expressed their feelings: " Ilove my patients", " I love working with them" and "7 have had won derful experiences with patients". Working and interacting with them on a daily basis humbles the S-L Therapist. S-L Therapists'experiences of crying with patients, talking about their progress, how they have grown, or being thanked for help they have given, are all rewarding and affirming experi ences. A study investigating the satisfaction of occupational therapists (Moore et al., 2006a) reported that patient con tact and working with patients was a highly fulfilling part o f their work. One participant stated, "I don't think there's anything I'd rather be doing" (p. 22). Other participants described their relationships with patients as being mean ingful and rewarding. Current study participants described feeling humbled by, and privileged to listen to the life sto ries and experiences of their patients, their past experienc es and thoughts of the future. As S-L Therapists' patients share their experiences, their dreams, fears and reflections, therapists feel honoured that they choose to allow them to enter their reality. S-L Therapists feel enriched and validat ed as they realise the contribution they have made in their patients' journeys. Social workers, nurses and occupational therapists reported the opportunity to develop relationships with patients and see them progress as being a frequent source of satisfaction (Reid et al., 1999). For a current study participant, seeing patient achievements renew her passion for her work. S-L Therapists experience patients' successes as almost a personal victory, not because of the role they played in it, but because of the deep connection they feel to their patients and their rehabilitative journeys. A n occupa tional therapist stated, in a study by Moore, et al. (2006a), how the role she is able to play in a patient's life gives her a sense of achievement and validates her as a person. S-L Therapists describe their relationship with patients as being full o f "ups and downs", being as joyful and fulfilling as lim iting and challenging and as "leading them to unexpected places" (Byng et al., 2000, p. 93).

Limitations of the Study
The researcher is a S-L Therapist at one of the tertiary hospitals from which participants in the study were drawn. Although there is a risk of over-involvement and over-iden tification, especially in the interviewing phase, studying col leagues is also viewed as an advantage (Holloway 8c W heel er, 1996). Qualitative research calls for the researcher to "immerse and involve him or herself in the setting and the culture under study" (Holloway 8c Wheeler, 1996, p. 3) and to have a "close" (p. 3) relationship with participants. In or der to minimise this limitation, the researcher kept reflective memoranda throughout the process and tried as far as pos sible to ask participants for clarification of their ideas and not assume to have a full understanding of what participants said before clarifying it with them.
A criticism of qualitative research is that studies with small samples (such as this one) prevent the research from being generalisable to the general population. From the out set current findings were not anticipated to be generalisable. The nature of the clinical work and the predominance of paediatric S-L Therapists in the study may mean that the experiences of S -L Therapists who work in other fields may not be fully described. The present study findings reflect the description and analysis of a reality experienced by S-L Therapists in this specific setting, taking into account the conditions and context.

Recommendations
The absence o f S-L Therapy services at community health centre level is a significant barrier to the provision of services to people who most require these. Speech Therapy departments from established hospitals should consider ini tiating outreach projects in the community i.e. district hos pitals. Partnering with, and developing a good relationship with an outreach site, offers the opportunity to develop a much needed service and could lead to the establishment o f a permanent service, in line with the objectives of the Healthcare 2010 plan for the Western Cape public service.
Participants' perceptions o f the public's appreciation of professional role and function of the S-L Therapist have highlighted the need for further development. Marketing strategies which are sustainable and adequately portray the benefits o f S-L Therapy and services need to be considered. For S-L Therapists working with children in particular, there is a need to strengthen relationships and referral be tween educators and S-L Therapists. Outreach programmes and information sessions to schools could facilitate this.
The education and training of S-L Therapists requires continual curriculum development to prepare and support new therapists in their role in a rapidly changing health service. S-L Therapists will need to be pro-active, market their profession, lobby for the development of appropriate, affordable and accessible services for underserved commu nities, and be creative in offering these within the budgetary constraints of the public health service.

Conclusion
This study has explicated the lived experience of being a S-L Therapist in the public service health setting, in a inquiry in which there is minimal published research. Al though the public service is only one area in which the S-L Therapist may practise, the study highlights issues specific to this context as well as to the profession o f S-L Therapy in general.
The lived experience o f being a S-L Therapist in a pub lic health service is one of challenge, opportunity, security, predictability and connectedness through diverse and com plex relationships. The profession of S-L Therapy and the holistic nature of the work impact on the therapist's entire being -physical, mental and emotional. The joy of helping is contrasted with the exhaustion and despair where S-L Therapists do not feel that they make a difference. Despite this, however, S-L Therapists are committed to their chosen profession and to the clients and patients who need them.