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Exploring the emerging profession of speech-language pathology in Vietnam through pioneering eyes.

Abstract Purpose: In September 2012, 18 Vietnamese health professionals graduated as Vietnam’s first university qualified speech-language pathologists (SLPs). This study details the reflections of these pioneering health professionals at 12 months following their graduation, drawing attention to their scope of practice as SLPs and to the opportunities and challenges to progressing the practice of speech-language pathology (SLP) in Vietnam. Method: Thirteen graduates participated in small group interviews where they described their work and their perceptions of their emerging practice. Thematic analysis of the interview transcripts was employed to identify key concepts and themes within the data. Result: Four overarching themes were identified—scope of practice, establishing identity, confidence to practise and progressing the profession. Overall analysis revealed evolving professional practice characterised by new learning, fluctuations in confidence and an active forging of professional identity. Mentoring and support by international colleagues and advancing professional recognition were identified as critical to the profession’s progression and to the development of context-specific and culturally appropriate services. Conclusion: Participants’ reflections draw focus to an important role for the international SLP community as it works in partnership with colleagues to enhance awareness of and services for people with communication disabilities in under-served communities such as Vietnam.


Introduction
The first published account of the profession of speech-language pathology (SLP) in Vietnam is attributed to Pat Landis, a SLP from Maryland, USA who piloted a speech-language pathologist training program in Ho Chi Minh City (HCMC) (formerly Saigon) between March-September 1972 (Landis, 1973). Landis had travelled to Vietnam to offer ''remedial speech therapy services'' (p. 342) to children and adults undergoing reconstructive surgery for cleft lip and palate in an international hospital in HCMC (Landis & Pham, 1975). As was commonplace during that time, the hospital was staffed by international surgeons who provided reconstructive surgery to children and adults and supported the training of Vietnamese surgeons. The centre also offered teaching in related professions such as nursing, anaesthesia and data management. In a setting lacking locally trained speech-language pathologists (SLPs), Landis (1973, p. 342) noted that expanding the expertise of an international agency to include SLP was ''a logical step in development''. However, rather than services being provided by international SLPs (as had been the norm), a local professional, in this case a nurse with no prior experience in the profession, was trained. Landis concluded that it was possible for local counterparts with no previous knowledge of SLP to undertake training in the profession and that such training had the potential to foster service development and sustainability. Winterton (1998) also described the training of local Vietnamese professionals in SLP, but via a ''train the trainer'' model utilising Community-Based Rehabilitation (CBR) principles (World Health Organisation, 2010). In an organisation promoting inclusive education for children with disabilities in Hanoi Vietnam, and with an objective of establishing a sustainable model of service delivery, local staff were equipped with knowledge and skills in SLP that could be ''passed on'' to parents and the community. A resource centre for local professionals working with children who were communicatively impaired was also developed. Despite describing a number of positive outcomes from this project and arguing the validity of CBR as a means of supporting the delivery of SLP services in Vietnam, it is noteworthy that Winterton's early description of a community-based approach remains unique within the literature describing the provision of SLP in Vietnam.
The training of a local health professional as described by Landis foreshadowed future initiatives to progress the profession. Upon the opening of the country's borders in the 1990s, SLPs, often in partnership with surgical teams and non-government and religious organisations, again travelled to Vietnam (Ducote, 1998;Jones, 1997). In addition to direct client care, professional development was offered as support to Vietnamese health professionals (nurses, doctors, physiotherapists) who had commenced providing SLP as an extension of their daily work. Perhaps not unexpectedly the practice of SLP became subsumed under the auspices of these previously established health professions, a situation mirrored in a number of international contexts (Cheng, 2010) and which continues in Vietnam today.
Factors supporting the progression of SLP education in Vietnam from the somewhat ad hoc manner in which it had been provided by visiting international volunteers and undertaken by local professionals, to a 2 year post-graduate training program at Pham Ngoc Thach University of Medicine (PNTU), HCMC between 2010-2012, have been reported elsewhere (Atherton, Dung, & Nhân, 2013;McAllister et al., 2010McAllister et al., , 2013. It is not within the scope of this paper to revisit the content of these accounts; however, of particular interest to this current research are the initial reflections of the graduate therapists provided within these earlier reports. A snapshot is afforded of the graduates' professional priorities and concerns pertaining to their future professional practice; in particular, contextual challenges to practising SLP, awareness of the need for professional development but uncertainty as to how to access new knowledge, and the critical importance of promoting professional recognition and influencing policy as a means of fostering understanding of communication disabilities and sustainability of the profession (McAllister et al., 2013).
The Vietnamese graduates' early professional reflections draw attention to the experiences of new graduates globally. The uncertainty and doubt expressed by the Vietnamese graduates as to their preparedness to practice has also been reported by graduate nurses, medical interns and other allied health professionals (Duchscher, 2001(Duchscher, , 2008Gill, Deagan, & McNett, 2010;Skovholt & Rønnestad, 2003). The new graduate experience has been described as one of immense change characterised by steep learnings, challenges to confidence, and ''facing the reality'' of working as a professional. A sense of ill-preparedness to practise, of professional isolation and inadequacy when advocating for clients and the profession have all been described (Casey, Fink, Krugman, & Propst, 2004;Gill et al., 2010).
Unlike the experiences of graduates completing first degrees, however, there is a paucity of literature as to the perceptions and professional experiences of graduates completing second degrees. All of the Vietnamese graduates had prior qualifications and, whilst it might be anticipated that previous education and professional experience would positively impact graduates' sense of preparedness to practice, this is not supported in the literature. A number of authors report second degree students identifying higher levels of conflict in balancing family and work commitments, and less cohesion within their work groups (Brewer et al., 2009;Rolfe, Ringland, & Pearson, 2004). In a study of graduate nurses who completed baccalaureate and associate degree programs, Oermann and Garvin (2002) found no variance in stress levels in relation to a graduate's age, previous work experience or period of time working as a new graduate. Further, previous tertiary education has been found not to influence level of professional competency or critical thinking skills of second degree new graduates (Grey, Pearson, Rolfe, Kay, & Powis, 2001;Newton & Moore, 2013).
It was within the context of the new graduate experience and the Vietnamese graduates' early reflections that the current research was undertaken. Specifically, the aim of this research was to explore the experiences and perceptions of the graduates' practice in SLP at 12 months following graduation. It was anticipated that new insights would arise in relation to the nature of the graduates' work, including their scope of practice and factors shaping their practice. Opportunity would be afforded to identify and explore the graduates' professional priorities and consider context-specific initiatives to support the progression of the SLP profession and its practice in Vietnam.

Context of the study
In September 2012, 18 Vietnamese health professionals with previous qualifications in physiotherapy, medicine, nursing and accounting completed the newly established 2-year Post Graduate Speech Therapy 1 Training Program at Pham Ngoc Thach University of Medicine (PNTU), HCMC, Vietnam. It is within the context of these 18 graduates becoming Vietnam's first university trained SLPs that this research is situated.

Situating the author
The primary author resided in HCMC Vietnam between 2010-2012 and was the coordinator of the 2010-2012 Post Graduate Speech Therapy Training Program at PNTU. Given the teacher-student relationship that existed between the primary author and the study participants, the potential for a dependent relationship to exist is acknowledged. However, following graduation of the students in 2012, the author returned to Australia and is now known to the graduates as a colleague and researcher.

Research approach
A phenomenological approach underpinned this research project. The focus in phenomenology is to understand human experience as it is experienced by an individual or group of individuals (Creswell, 2013;Denzin & Lincoln, 1994). In this study, the research participants described their experiences of practising as SLPs in Vietnam in their first 12 months of practice and discussed their professional priorities and the future priorities for the progression of the profession in Vietnam.

Participants
In September 2013 the primary author returned to HCMC to gather feedback about the PNTU Speech Therapy Training Program so as to inform future education initiatives. Garnering graduates' reflections and insights at the 12-month stage in their professional practice was considered an important step to documenting the emergence of a new profession, and providing a ''natural occurring baseline'' from which the graduates' future professional practice could be considered. Ethics approval for the study was obtained from the University of Melbourne, Behavioural and Social Sciences Ethics Committee (#1441647.1). All 18 graduates were invited to participate in small group interviews with the primary author to explore the nature of their work. Thirteen graduates consented to participate in the interviews and for the interviews to be digitally recorded. Table I provides demographic data relevant to the research participants and that of the cohort of 2010-2012 PNTU SLP graduates.
The study participants' demographic information closely represented that of the 2010-2012 cohort with regard to primary qualification, workplace, caseload and years of professional experience. Of the 13 participants, 11 worked in HCMC in tertiary hospitals, providing inpatient and outpatient SLP services to adults and/or children. Two participants provided services within community-based organisations to children with complex disabilities-one of these participants was based in HCMC, the other in another city in Vietnam. A majority of participants had primary qualifications in physiotherapy, with nursing, medicine and accounting also represented. As per the 2010-2012 cohort there was marked variability in participants' years of professional experience, ranging from 5-28 years since primary qualification.

Data collection
Three small group semi-structured interviews (DiCicco-Bloom & Crabtree, 2006) comprising four participants each were conducted by the primary author in HCMC in September 2013 at venues and times convenient to the participants. An interpreter known to the graduates from the 2010-2012 PNTU training program was present at the interviews and provided consecutive interpretation in English. Consecutive rather than simultaneous interpretation was preferred so as to avoid the potential for disruption to the dialogue (Chen & Boore, 2010). One participant who was unable to attend a group interview was later interviewed by the primary author via Skype. The English proficiency of this participant was adequate for the interview to be conducted in English.
A topic guide outlining the research questions guiding the semi-structured interviews is displayed in the supplementary material. The exact wording and ordering of questions was shaped by the responses of the participants and was interspersed with questions and comments from the interviewer as a means of adding clarity to a comment and/or exploring further information in relation to a comment made.
The data obtained from the interviews was in the form of digital audio-recordings plus the field notes and reflections of the primary author made during and immediately following the interviews. Verbatim orthographic transcription of the English translated audio-digital recordings was undertaken by the primary author, thereby enabling a sense of the content and richness of the data to be developed from an early stage. Both electronic and hard copies of the associated orthographic transcripts were developed, with pseudonyms replacing the participants' names as a means of de-identification.

Data analysis
To identify and analyse the themes within the interview data, the process of data analysis as described by Braun and Clarke (2006) was undertaken. To facilitate understanding of the key themes within the entire data set, a broad analysis of the data was undertaken rather than a detailed analysis of themes within specific sections of the data.

Stage
1: Developing familiarity with the data. Multiple occasions of listening and re-listening to the original digital audio-recordings of the interviews, referring back and modifying transcripts and consulting field notes enabled the development of detailed transcripts. During the reading and re-reading of the transcripts, the primary author made notes directly onto the hard copies of the transcripts to highlight initial thoughts and impressions in response to the data. These notes were typically assigned to larger segments of the data, such as several sentences or whole paragraphs where a particular topic was being explored, for example, a participant's discussion of their professional priorities. Segments of verbatim text were also highlighted, together with the primary author's initial ideas and understanding as to the potential relevance of this verbatim text to the data set. These notes and highlights acted as ''flags'' for later reflection.
Stage 2: Developing codes and categories. An open model of data coding was implemented. Specifically, coding of data was guided by what the participants said, by the ''explicit or surface meanings of the data'' (Braun & Clarke, 2006, p. 84) rather than in relation to pre-determined codes or an underlying theoretical construct or position. The emergent codes were then related back to the research aims-for example, codes identified for data that addressed the daily professional experiences of the participants included professional identity, confidence in knowledge and professional recognition. As a means of increasing the specificity of coding (DeCuir-Gundy, Marshall, & McCulloch, 2011), a codebook was developed in which the features of each emergent code were described, examples from the data provided to illustrate the code and data NOT included in the code also described. Once initial codes were identified and further refined, they were examined for the presence of patterns and relationships, resulting in their organisation into conceptually similar categories. Through an iterative cycle of moving back and forth between the interview transcripts and the initial codes and categories, further refinement of the categories was enabled.
Stage 3: Searching for and identifying themes. To further enhance understanding of the patterns and relationships within the data, a mindmap (Wheeldon & Ahlberg, 2012) was developed. Through visual presentation of the categories and sub-categories, awareness of the relationship between the categories and the relevance of the categories to the research was heightened. Those categories considered to be conceptually related were grouped as potential themes and hierarchically arranged, with a total of six themes and associated sub-themes identified. Further review of the themes was undertaken to ensure consistency within the themes (internal homogeneity) and clear distinction between the themes (external heterogeneity). The researcher then returned to the original data to ensure the themes and sub-themes accurately represented the intent of the participants' accounts and were supported by sufficient data. Incorporating the mindmap into this final analysis stage, the themes were then re-defined, discarded and/or combined, resulting in a final four overarching themes.

Rigour.
A number of data analysis strategies were employed to enhance the trustworthiness of the data. It is acknowledged that the pre-existing relationship between the primary researcher and participants created the potential for bias, as did the researcher's pre-existing knowledge of aspects of the participants' professional practice. To address these potential sources of bias, the researcher kept detailed notes prior to, during and immediately following the interviews. Rich descriptions were kept of personal perceptions, reflections and thoughts in relation to the process of data collection. When analysing the data, observations and reflections were again made in relation to the data and their interpretation checked against notes supporting the interviews.
The presence of an interpreter also created potential for dilution of the authenticity of the data, in particular through inaccurate interpretation of the questions asked by the researcher and/or through loss of the intended or explicit meaning of the participants' reflections (Chen & Boore, 2010;Esposito, 2001). A number of strategies were employed to minimise this risk, including use of an experienced bilingual Vietnamese-English interpreter who was a native Vietnamese speaker, orientation of the interpreter to the project prior to the project's commencement and the provision of real-time interpretation which enabled the interpreter to seek clarification from the researcher and participants as required. Further, the audio-digital recordings and associated English transcripts of two of the four interviews were randomly selected for back translation (Chen & Boore, 2010) via an independent translator who verified the interpretation of the data. As a final means of enhancing the credibility or confidence in the findings, eight of the research participants were provided with opportunity to clarify the researcher's interpretation of the data.

Result
Four overarching themes were identified in the data-scope of practice, developing identity, confidence to practise and progressing the profession. Figure 1 depicts these overarching themes and associated sub-themes conceptualising the nature of the participants' professional practice as SLPs.
Overarching theme 1: Scope of practice Participants' extensive descriptions of their typical working day have been synthesised to define their scope of practice. An expansive scope of practice was described by all participants, highlighting a diversity of clients, large caseloads and multiple professional responsibilities. Clients were described in terms of their medical and SLP diagnoses and the SLP interventions they received. Client care was predominantly 1:1; however, one of the participants, Ms Tam, described providing consultancy-based services: If the Special Education teachers have a case they need help with about language, we have a meeting with some of the teachers, and I also attend the Early Intervention Group. We read information from the teacher who has the child . . . we listen and we give advice.
To manage increasing workload demands, group therapy and harnessing the support of other professionals were utilised: For me, doing group treatment with patients with similar problems. Such as patients with puberphonia, I group them and then I see them at the same time (Ms Phuong).
At the moment I share work . . . if the teachers here don't know something, or they don't have the knowledge, then I will take care of it. But if there's a problem with the children that the teachers already know about, then I will leave it to them so that it will help reduce my workload (Ms Lac).
Professional colleagues included doctors, nurses, physiotherapists, nutritionists, audiologists, psychologists and teachers. Referrals were received from hospital and community-based doctors, physiotherapists, psychologists and teachers. A number of participants reported receipt of selfreferrals (i.e. from clients and families). Together with direct clinical services, staff management, training and staff recruitment were also undertaken. Three participants reported establishing new SLP units in the first 12 months of practice, all of which were situated in tertiary hospitals in HCMC.

Overarching theme 2: Developing identity
The over-arching theme of developing identity draws attention to participants' reflections of forging recognition in a nascent profession. This theme encompassed factors which contributed to their early professional identity-dual roles and establishing a profile.
Dual roles. All but two participants described a typical day as encompassing dual professional roles; that is, meeting the responsibilities of their primary professional roles as doctors, nurses, physiotherapists, accountant, whilst also assuming the role of SLP. Mr An described this scenario as commonplace: I think it's a common issue in Vietnam. I don't think anyone graduating from the course can work full time as a speech therapist.
The two participants' not undertaking dual professional roles worked in an organisation where a SLP unit had been established several years previously. Both of these participants identified their professional role as that of a full time SLP.
Descriptions of the challenges inherent in balancing competing demands were a common thread. Mr An described feeling pressured to find a balance: Ahhh to me, I usually work like 70-80% as a speech therapist and, for the remaining 20-30%, I do physiotherapy. And it is creating a lot of pressure on my shoulders to do both. The pressure I want to mention here is because I have to find a balance for both physiotherapy and speech therapy.
Ms Phuong and Mr Duc reported their daily professional role and responsibilities as defined by organisation-based directives: A day of my work really depends on how my boss wants me to work. Sometimes I work as a speech therapist and sometimes I work as a nurse (Ms Phuong).
My week is mixed between being a surgeon and a speech therapist. Because my boss said I only have two hands and working as a speech therapist is like using my left hand. On Monday morning I see outpatients, and on Friday afternoon I see inpatients. And the rest of the week I see patients-and I do both speech therapy and surgery (Mr Duc).
Establishing a profile. Stakeholder awareness and understanding of the profession directly influenced caseload demands, particularly the number and type of referrals received. For Ms An, who worked in an organisation which she described as having little understanding of the profession, referral numbers were limited: Not many doctors can understand our work here. Many know about working with the children with disabilities, but many doctors do not know the usefulness [of what] we do for the children so we rarely receive the referral from the doctor or from the people [the public].
Ms Bich and Ms Mai described how the limited profile of the profession resulted in a failure of professional colleagues to distinguish SLP from other health professions: When they [the SLP clinicians] ask the doctor to make the referral they have to say whether they want to have physiotherapy . . . they want a referral for physiotherapy . . . or speech therapy . . . but in the end it is just put down as physiotherapy for everything. So they say when you say physiotherapy, it means you do everything that the patient requires (Ms Bich).
Because the doctors don't separate physiotherapy and speech therapy, sometimes I help the doctors to give instructions for the family to provide the right posture for feeding or for swallowing. But in the medical record we don't write separately for speech therapy, we keep it in the same physiotherapy file (Ms Mai).
In contrast, the reflections of those participants working in organisations where an SLP department already existed and/or SLP services had been provided for a number of years highlighted better organisational understanding of their role. For these participants burgeoning caseloads were described, often within the context of demonstrating positive change in clients and developing trust: So mainly the swallowing patients I am working with. And yes, a few of them make significant progress and one time the Director of the hospital came to me and said we have you here for all the swallowing patients (Ms Ngoc).
Whilst increasing numbers of referrals were generally welcomed, for Mr An and a number of other participants this posed significant challenges in terms of staffing and workload management: Now I am gaining trust from the doctors and from other medical experts so they are referring patients more and more to me-it is only me at the moment working as a speech therapist at the hospital so I have to slow things down because I have to see patients, and then take notes, and then do case management. And the doctor of the Head of Neurology Department told me that if I like I can do an assessment of all the patients in his department who have swallowing disorders and they will be my patients, but I do not have the time and I have to slow things down and do not start that work yet because we do not have enough staff at the moment.
As means to raising participants' profiles as SLPs, both formal and informal strategies were utilised. Stakeholder education formed part of all participants' daily practice and took the form of presentations to professional colleagues, developing articles for newspapers and the workplace intranet and community-based education. Ms Giang described incorporating staff training into her weekly schedule: So, besides working at my unit, twice a week I come to the Day Care Unit to do training and to do teaching for the staff working there and for the children. And I do teaching about pictures, using pictures for communication and key word signs.
Ms An utilized daily encounters with colleagues: I also have been making connections with doctors. Maybe when we meet, I will tell them if you have any patients [that] have this and such and such problems, you can refer them to me.
Ms Tam provided a rich description of travelling to rural areas to provide education to parents and the community: At the end of last year, I have a talk, just basic information, it is the first day I have a conference in a district very far away, and I have the content and I can see parents in the village and the countryside who work as farmers. And they don't know a lot about speech therapy and what is wrong with the children at home. Because they are workers and they do not know how to work with the children.

Overarching theme 3: Confidence to practise
The overarching theme of confidence to practise highlighted participants' reflections as to the adequacy of their training and their confidence to meet the needs and expectations of stakeholders. Confidence to practise is informed by the subthemes of knowledge and meeting expectations.
Knowledge. All 13 participants described feelings of pride and increased confidence in their knowledge and skills as an outcome of their training at PNTU. Ms Ly's comments draw focus to these feelings: Although we need to study more to update our knowledge, we feel confident and we feel proud because we have two years of training in a systematic way, and what we learned really helped to meet the needs of the children in Vietnam who have problems, and we are bringing the best we can to help them.
Mr Jach spoke of an intrinsic change in his practice: To me it has been one year since the time we graduated from the program and the first thing I would like to say is that, after graduating, I really think the thing that has been different has been my professional manner. It is really different how I work with the patients. And my confidence built up because I think I have the knowledge and I was trained in a systematic program which really helped me to build my confidence. And now I am confident to work with the patients, with their families, when I face the doctors and other medical people.
However, when referring directly to meeting the needs of clients, participants described lacking knowledge and ''knowledge gaps'' spanning all areas of SLP practice: A lack of culturally relevant norms, standardised assessment tools and other resources were identified as a significant knowledge gap. As commented by Ms An: But for some problems such as speech sound disorders it is really difficult because of the sounds that are used in English-we have no criteria norms at the moment to look up or no place to go to ask for information.
A range of formal and informal strategies were utilised to meet perceived knowledge and professional practice gaps, including accessing scholarly and online sources (including YouTube) and contacting colleagues. However, as described by Mr Duc, difficulties remained in accessing information to support practice: I don't know how other people think, but to me you know, usually speech therapy in another country has been developed for a while. So when the new graduate comes to their workplace they have people who have studied before them, people who they can ask for advice. But not here, not me, because when I come back to my hospital I was the one who decide everything and I have no-one to ask, no one to look up to. And I think that the knowledge that I learnt from the program was basic and it helps guide me, but when I work with a patient and I need more information, at that time I struggle.
A final thread identified in relation to knowledge was that international colleagues were a highly valued source of knowledge. All participants expressed desire for international lecturers and clinicians to continue to visit Vietnam to provide education in the form of lectures, workshops and clinical education. I read references from authors, but somehow I still cannot imagine it, so I really wish to have a workshop about the problem so that I can observe it (Ms Phuong).
Of note, whilst participants indicated that professional development opportunities and mentoring had been offered by international SLPs over the past 12 months, workload demands often prevented their accessing these resources.
Managing expectations. A second important component of confidence to practise was managing expectations of stakeholders. Data extracts from nine participants contributed to this sub-theme. Expectations were expressed in relation to managing increasing numbers of clients, demonstrating positive change in clients and providing evidence for interventions. Four participants spoke of a conflict between balancing the ''unrealistic'' expectations of clients and ''the reality''. As described by Ms Trang: Because most of the patients and their families when they come for speech therapy they have an expectation that the patient will be able to talk again. But we know in reality it is not going to be like that. For some patients who have severe aphasia, like global aphasia, it's going to be very tough, very difficult, but we don't want to say it is impossible for the patient to be back to normal. But if we say it straight away, immediately to the family or to the patient, they may lose hope and lose their motivation, and they don't want to do the exercise anymore.
The sub-theme of managing expectations also emerged in response to demands created by increasing recognition of the profession: I think the biggest challenge here is that there are more and more people knowing about speech therapy. We have to arrange our work so we can meet the expectations the best we can (Mr An).
Mr Jach acknowledged the expectation to treat an increasing number of clients; however, proposed education of local professionals and a decentralisation of services to meet this expectation: If we can have short courses for staff, for nurses, or for medical staff at the other provinces, where an expert from Australia, together with the 18 graduates can organise a short course for example, in the Mekong Delta. It's going to be really useful because in the other provinces at the moment we don't have any speech therapists.
Finally, an expectation from professional colleagues to develop an evidence base for assessment tools and interventions was articulated: Because in Australia speech therapy is not a new area so you have the evidence for informal tools, but when we want to develop informal tools, the medical experts or doctors will say ''Oh where did you get the evidence from? What is the evidence?'' That is one of the challenges (Mr An).

Overarching theme 4: Progressing the profession
The final overarching theme of progressing the profession draws focus to the priority participants' placed upon developing the profession and forging its sustainability into the future. The sub-themes of advancing professional recognition and accessing higher education reflect this priority.
Advancing professional recognition. Data extracts from all interviews informed this sub-theme. Participants identified ''acceptance'' of the profession and the profession ''becoming official'' as key priorities: If there is one thing that I really hope for the speech therapy profession, is that it will be recognised, it will be accepted, will be official by the government. Because now we are doing speech therapy unofficially, so some times it can be tough to find help from other organizations or the government, so that's a thing I really want (Mr An).
We need speech therapy to be accepted, to be recognised, to have a code number, so that we are allowed to have . . . allowed to train more students at a Bachelor level, because if we combine both the first and second students and graduates, it is still under 40 people and that is definitely not enough to help the patients who need it (Mr Jach).
Mr Duc suggested that, whilst seeking national recognition was important, advancing recognition via way of publishing research in Vietnam about SLP was also relevant.
To me, a thing like helping speech therapy be recognised has something to do with the government, it's big. At the moment I am thinking of providing the basic knowledge-because we have the basic knowledge and we have the skill-and for the basic knowledge I would like to have an article in Vietnamese, in detail, about voice in speech.
The possibility of working collaboratively, of ''joining together'' also emerged in the transcripts. In particular, the development of an SLP ''committee'' and sourcing support from each other: I think we need to join together to help develop speech therapy. Otherwise if each of us just works at our hospitals independently the impact that we create won't be as big as when we have a committee and we help to develop speech therapy (Mr An).
Obtaining higher qualifications. A second important sub-theme to advancing the profession was that of engaging in lifelong learning and obtaining higher qualifications in SLP. A number of participants described how obtaining a higher level degree would develop their knowledge base and support their own professional practice, whilst other participants spoke of knowledge development as a means of progressing the profession's development in Vietnam: To me, I really want to keep studying. In other countries we have a Bachelor Degree and a Masters' Degree. I want to keep going with the study (Ms Phuong).
And another thing, I think I mentioned to you before is I would like to do a Masters' Degree in Australia. Because I think the visiting lecturers they bring their knowledge here, they bring their clinical skills here, but sometimes it might not cover the whole things professionally like how you were trained in Australia. That is why I would like to do my Masters (Ms Giang).
A desire to develop specialisation was also articulated: I always have a question in my mind. I study for 2 years to become a speech therapist because of course I cannot become good in every field of speech therapy. But I really want to improve more to be good in one field, at least autism (Ms Tam).
Finally, as a means of undertaking further study, Mr Jach proposed that the training of support staff in SLP would provide time for the graduates to develop the skills necessary to become ''teachers'' in speech therapy in Vietnam: We need time to study, we just don't treat patients and become good teachers, we need time to organise the lectures before coming to class. So having more staff to help us and see the patients would add to the development of speech therapy in Vietnam (Mr Jach).

Discussion
This study explored the professional practice of Vietnam's first university trained SLPs at 12 months following graduation. Viewed collectively, the accounts afforded rich insights into the nature of the participants' early practice and their perceptions as to the challenges and opportunities available to them to progress their practice and the profession of SLP in Vietnam. Analysis of interview transcripts revealed four overarching themes conceptualising their work-scope of practise, confidence to practice, establishing identity and advancing the profession.
A number of the themes identified in this study were not unexpected. Participants' extensive scope of practice mirrored that defined by professional associations governing the practice of SLP internationally (American Speech-Language-Hearing Association, 2007; Speech Pathology Australia, 2015). Further, the delivery of services as described by a majority of participants reflected a medical model approach, with disability viewed as a consequence of illness, injury or disease and intervention provided in the form of individual treatment by professionals (World Health Organisation, 2002). These findings were anticipated given early global conceptions of disability as a health issue (World Health Organisation, 1980) and the key drivers supporting the introduction of the profession to Vietnam . However, the work practices of several participants also encompassed community education and training, namely travelling to rural areas to offer education and targeted training to local health professionals and teachers, community groups and parents of children with communication disabilities. In doing so the work of these participants reflected aspects of a CBR model of service delivery (World Health Organisation, 2010), with focus shifted from impairment alone to factors within an individual's environment which may contribute to disability. The World Report on Disability (World Health Organisation & The World Bank, 2011) draws specific focus to contextual factors promoting disability, including availability of and ease of access to essential services and societal understanding of and attitudes towards disability. Utilisation of CBR as a strategy to promote inclusive development for people with disabilities is supported by Vietnamese government policy (Government of The Socialist Republic of Vietnam, 2010) and has been described in relation to the education and training of multi-skilled professionals, volunteers and community and family members in Vietnam (Jones, 1997;Ngo et al., 2014;Sharma & Deepak, 2001). It is note-worthy that, within the Vietnamese government's recently-released ''Resolution No: 4039 QD-BYT National Plan for Rehabilitation Development 2014-020'' (Ministry of Labour, Invalids & Social Affairs: MOLISA, 2014) CBR is again highlighted as a key development strategy and explicit reference made to ''[the] promotion of training on different forms, levels of rehabilitation and community-based rehabilitation according to the needs of society'' (p. 6). The reflections of participants in this study highlight a need for further exploration of the utility of broad-skilled generalist health, education and other workers within a CBR framework and to the role of community in supporting the development and provision of services for people with disabilities that are culturally appropriate, context specific and sustainable.
The adoption of dual professional roles and challenges to establishing a professional profile, such as defining scope of practice, raising the profile of a ''new'' profession and providing services in the absence of culturally relevant norms and resources have been previously described in contexts where the profession is in a nascent stage (Aron, Bauman, & Whiting, 1967;Cheng, 2010;Georgieva et al., 2014; The emerging profession of SLP in Vietnam 117 Topbas, 2006). Participants' in this study highlighted their active engagement in progressing their identities through assuming the title of SLP, sourcing opportunities to practise as SLPs, and promoting the profession to stakeholders. By doing so the participants not only draw attention to their commitment to meeting the inherent challenges in their daily practice, but also to their early engagement in the process of ''professional socialization'' (Ajjawi & Higgs, 2008;Toal-Sullivan, 2006), defined as a period during which new professionals acquire the values, skills, knowledge, and identity of a profession. Whilst it is unclear whether the concept of ''professional socialisation'' is found in the Asian literature, the notion of ''professional'' has been explored in the Vietnamese context and found to reflect similar Western constructs of professionalism, such as altruism, identity and values (Nhân, Violato, An, & Beran, 2014).
Challenges to accessing knowledge and professional support have the potential to impact knowledge development and translation, an additional component of professional identity (Ajjawi & Higgs, 2008;Davis, 2006). The self-doubt and anxiety expressed by participants in relation to their work, including reduced confidence in clinical decisionmaking, particularly when confronted with novel or unfamiliar situations, and limited autonomy in sourcing knowledge to meet perceived knowledge gaps, have been reflected in the experiences of other new graduates (Casey et al., 2004;Duchscher, 2008;Dyess & Sherman, 2009;Gill et al., 2010;Hoben, Varley, & Cox, 2007;Kuiper & Pesut, 2004;Tryssenaar & Perkins, 2001). An extensive body of literature supports new graduates' access to experienced mentors and professional colleagues as means of guiding practice, encouraging development of critical reflective skills and contributing to professional development (Davis, 2006;Hoben et al., 2007;Newton & Moore, 2013). However, the emerging state of the profession in Vietnam and logistical challenges to accessing support from international colleagues pose significant threats to this support being realised. Further, as communicated by the participants in this study, workload demands and competing priorities limit opportunity to engage in these activities.
The final three findings of this research relate to the personal professional priorities of the participants and their perceptions as to the priorities for the profession in the next 12 months. In keeping with the overarching theme of confidence to practice, participants' desire for continuing professional development was anticipated. A desire to complete higher degrees was also anticipated, both as means to advancing personal knowledge and to advancing the profession. The completion of Masters and Doctoral degrees to support development of the profession has been reported in other Majority World 2 contexts, with local graduates returning home after completing their studies in international settings to establishing university based programs in SLP (Crowley et al., 2013;Karanth, 2002;Lian & Abdullah, 2001). Outcomes from these initiatives indicate this to be a successful means of advancing education in and awareness of the profession in education, community and health sectors.
Closely tied to the desire for higher qualifications was participants' prioritisation of recognition of the profession at an ''official level'', for the profession to be provided with its ''own code''. Professional recognition by government has also been described in other international contexts as a driver of change, not only in terms of funding for new SLP programs, but also as a means of financial support to universities seeking to send local professionals overseas to undertake training in SLP. Whilst participants considered this to be a long-term goal, it is note-worthy that, within Resolution No: 4039 QD-BYT (MOLISA, 2014), the strengthening of capacity of current and future rehabilitation therapists and professions, including SLP, is identified as a priority. Participants' engagement with community and civil society, including grass roots organizations supporting and representing people with communication disabilities will also be a priority as they seek government recognition.
The acquisition of new knowledge and skills via way of further education is also seen as a means to support participants' interest and engagement in research. Participants identified numerous areas of interest in relation to research in SLP; however, the development of culturally relevant norms and resources was highlighted as an area of pressing need, not only to inform practice of SLP in Vietnam, but also to bring legitimacy to the profession and advance recognition. To this end a number of participants described developing resources and engaging in research projects to develop the knowledge base for contextually relevant information, but perceived knowledge gaps were identified as barriers to doing so. Once again, as throughout all the interviews, access to further education and skill development is highlighted.

Limitations
A number of the methodological limitations to this study have been described earlier. The previous teacher-student relationship existent between the researcher and the participants and the researcher's pre-existing knowledge of aspects of the participants' professional practice create the potential for bias. In a study investigating collaboration in learning within a Vietnamese context, Vietnamese students were described as ''see [ing] the teacher as a moral figure who is always right'' (Phuong-Mai, Terlouw, & Pilot, 2006, cited in Phuong-Mai, Terlouw, Pilot, & Elliot, (2009. Further, when meeting or working in groups, Phuong-Mai et al. (2009) report Vietnamese students to favour a hierarchical relationship among group participants and the appointment of a group leader who will provide ''formal directive leadership'' (p. 868). As a majority of the data within this study was obtained via small group interviews, consideration must be given to the influence of group hierarchy and leadership upon the data.
Whilst the demographic data of the study participants closely represented that of the 2010-2012 student cohort, it is possible that the five graduates who did not participate in this study may have done so for reasons that could have influenced the themes identified. Finally, the influence of translation upon the authenticity of the data is again acknowledged.

Conclusion
To the authors' knowledge, this study is the first to describe the practice of SLP in Vietnam by locally trained SLPs. Findings from this study highlight a number of significant challenges faced by Vietnam's pioneering SLPs and the need for specific initiatives to support their practice, including regular and targeted professional development and access to higher education. Further, timely access to experienced mentors would provide support in terms of skill development, clinical problem-solving, reflective practice and the development of professional identity. A role in supporting participants advocate for the profession and for persons with communication disabilities and consider alternate forms of service delivery is also highlighted.
Future research exploring the profession's emergence in Vietnam will enhance insight into factors shaping the profession and will create an opportunity for exploration of context-specific and culturally relevant initiatives to support the development of and access to the services required by people with communication disabilities in Vietnam. Whilst seeking to avoid a ''one size fits all'' approach to the process of new service development in communities such as Vietnam, the findings of this and earlier studies may suggest a set of ''generic challenges'' arising throughout this process. An exploration of existing literature within and outside health and of the experiences of pioneering practitioners and of persons with communication disabilities, has the potential to inform understanding of these challenges and create opportunity for the development of contextually relevant strategies to support service development and access to services in resourcelimited contexts such as Vietnam.