Daily life on an acute stroke ward: Seminar

Apasia Seminar: Observing daily life on an acute stroke ward for people with aphasia: A videoethnographic study.

D. Hersh et al.

I recently attended a seminar given by Deborah Hersh. Here are some of my notes/reflections:

·   D. Hersh is currently completing a project on goals and aphasia.

The Environment

·   Ulrich(1984) found that patient’s recovered faster/needed less analgesia when they had a window overlooking greenery.

·   Hersh’s ethnographic study involved observing 9 patient’s with aphasia and 10 without (for over 7 hours) and recording these observations of their life on the stroke unit.

·   The use of video allowed for subtle observations to be picked up and allowed the researchers to analyse and repeat recordings.

Comparison of Apasic vs non-aphasic

·   Those without aphasia talked 1.5 times more than those with aphasia.

·   Families and nurses spoke less to those with aphasia

·   Patient’s with aphasia spent significantly more time alone and significantly less time communicating.

Nurses interactions

·   Clips of the ethnographic study showed variable communication styles of nursing staff.

·   Nursing communication tended to be around physical care and tended to be impersonal.

·   Ball et al 2014 – questioned nurses about care activities left undone and found that 66% of nurse respondents reported talking/comforting patients and after this a high proportion cited giving information to patient’s as left undone.

·   NHS campaign ‘the 6 C’s’ – care, compassion, competence, communication, courage, and commitment’

Observations of a successful interaction

·   The nurse knew personal information about the patient and asked a few personal questions e.g. ‘why would you want to go?’

·   Humour was used

·   Eye contact with the patient – even when his family spoke for him

·   The patient was given time to respond to comments/questions.

Patient experience on the ward

1.     Need for rest VS Being in someone’s workspace (pseudo privacy)

2.     Boredom VS Business (busy ward)

3.     Uncertainty (not knowing what is happening) VS Need to make major decisions

4.     Managing major change VS Seeking normality

Aphasic patients need to manage all of these contradictions whilst coping with a communication disability.

Focus points

·   Points which broke a period of boredom e.g. a meal, observations, visitors, therapy, daily paper……

·   Patients found these to be very important and structured their day around them/ liked to know when they would occur so that they could look forward to them.

·   Therefore – timetables are important.

Analysis of results

·   Theory: Lack of interaction and experiences of communication breakdown may lead to learnt non use of communication.

·   Less turn taking and less natural communication exchanges were observed with aphasic patient’s.

Reflections/ summary

·   Provide as many opportunities as possible for communication e.g. family pictures/ information for hospital staff on the patient and their interests/ preferences.

·   Nursing staff used few repair strategies – model these strategies for them, encourage them to make communication interactions more personal for those with aphasia.

·   Communication passports – making information on aphasia accessible to all e.g. domestic staff/ HCA’s spend more time with patient’s than the therapists – want to reinforce communication success and therefore the availability of resources. Personalised aphasia communication resources for patients may be useful, even if this is just a pen and pad.

·   Clips of communication on the ward would be a useful training resource – getting nurses/ staff members to reflect on communication and how small changes/ strategies can have a large impact.

·   Communication opportunities were low: as SLT’s we have a duty to provide these opportunities and to provide information e.g. i-pads, communication books, diaries, magazines/papers…..

Palliative care - reflection

Think of a recent therapy session or event.

• palliative care client with end stage liver cancer, independent up until a month ago, now bed bound and coughing on fluids.
• Presented with reduced breath support, muscle weakness (globalised) affecting the cranial nerves, behaviours – very fast drinking, large sips – not responding to prompts to slow down. Having oral intake in a semi-lying down position due to preference + drinking from a beaker and tipping head back.
• Recommended syrup thick fluids from a cup, upright for oral intake, pillows behind head to prevent tilting head back.
• On review a week later – put on custard thick fluids due to signs of aspiration on syrup – syrup thick when drinking from a spoon.
• Patient had slured speech + reduced breath support – able to understand 1-2 stage commands and follow instructions.

What did this session make you feel?

• I felt that I was calm and able to improve the patient’s quality of life by reducing his distressing coughing on fluids. In retrospect I felt that I did not take enough professional responsibility for ensuring that the patient was able to make a decision in regard to his feeding if he deteriorated.

What would you want to change, and why?

• I would discuss oral feeding with the patient in my first session i.e. assess their capacity to understand information about feeding tubes and make a decision about artificial feeding if they deteriorated and were unable to eat orally.
• I would ask about medications – i.e. whether they could swallow their pain medication and contact their GP to discuss this and a decision on feeding.
• I would give the patient's family information on what foods are the least effortful to eat and how to downgrade the patient If they are having increasing difficulties with eating. I would plan for deterioration.

What do you need to learn or find out before the next event?

• Cancer and dysphagia -  further information.
• Read up on the procedures for recording end of life decisions and capacity assessments.

Goalsetting Performa for Patients

Here is a goalsetting performa i have created for patient's. I feel that often my patient's don't have as much ownership of their goals as i would like and feel that it is an area of my practice i would like to improve. I have also noticed that patient's tend to keep hold of their goals if they have written them and if they have a copy at the end of the goalsetting session (not me typing them) I will start by:

1. Always attempting to involve patient's/ family members in goal setting.
2. Providing a visual goalsetting form for patient's to keep their goals on.
3. Considering what motivates my patients e.g. their greatest hopes may not be achievable but may be motivating.

Goals/ Hopes

Greatest Goal/Hope

Steps needed to achieve my Hope/Goal.

Coaching and Mentoring Training

Today I attended a training course on coaching and mentoring in preparation for supervising a therapy assistant. I found the course inspiring and motivating and thought I would note down the key take home messages before they are forgotten.

Personal performance

·   Interrogate you’re successes – what are you good at, what has gone well, why?

·   1%’s - Improve the most important areas of you’re work by small amounts e.g. the top 5 areas by small amounts. E.g. the British cycling team take pillows with them to improve their sleep – small improvement – large impact.

·   Happiness – workforces are proven to be more effective if happier – therefore spread positive energy. 10:5 – if within ten feet of a colleague give eye contact and smile, 5ft – eye contact smile and say hello. Tell patient’s/families your name.

·   Act as if……. – Act as if you are the best form of yourself e.g. in an interview act as if you are an SLT with 3 years experience not as if you are an interviewee with 4 hours experience. This is based on the psychological principle that you always become the way you act. Therefore approach things with a positive inner voice

·   G.O.B’s – Glimpses of brilliance – record your successes i.e. glimpses of brilliance and refer back to these when acting as if… Record what you saw, what happened and what this made you feel.

·   Avoid mood hoovers – people who are negative and bring your enthusiasm/ the teams enthusiasm down.

Model for achieving goals

·   You need skills, knowledge, desire and confidence.

Coaching – facilitating people to empower themselves. Use the GROW model.

GOAL -  ask why? Five times to get to the true motivations of the person. Visualise/be specific.

REALITY – where are you now?

OPTIONS – how can you achieve this? G.O.B – when have you achieved something similar.

WHATNOW/NEXT – SMART goal

Tips for using this model

·   Have the person you are coaching write down their goals in their own words in order to take ownership of them.

·   Managing involves telling others what to do, coaching involves facilitating others to gain self awareness and structure their goals.

·   Trust – you need to gain the persons trust (relationship building) and show that you care enough to want to help them.

·   G.O.B’s – find examples of them demonstrating key behaviours e.g. being assertive with their children – then relate that to being assertive at work and have them Act as if…

·   Learn what people’s motivators are.

Reflection on the training day

I felt empowered by the training day. I felt that I was familiar with the skills and tools taught but needed reminding of why we use them and how to motivate myself and others. I felt that I really took away how the way that you feel about a task/ the way that you approach it really affects the potential outcome. I also felt that I need to record, memorise and analyse my successes so that I can replicate and extend them.

Student Placements: Positives

What has worked well and why?

Good outcome	Reasoning
Sandwich feedback – one good, one constructive, one good comment.	Motivating, built up the students self belief and self efficacy, directs CPD.
Timetable for the whole placement with meetings, supervisions, and joint sessions (SLT/OT/PT) organized for the first week.	Modeled timetabling skills and facilitated the students to book their own sessions. Structured their placement.
Careful caseload planning – choosing three patients for the student’s caseload who they will do individual sessions with and the student shadowed the SLT with other patients.	This allowed the student to focus their planning and readings and develop therapy resources.
Contacting IT and RIO early on	Allows the patient’s to have an NHS email, Rio access and computer access earlier on.
Providing journal articles/ direction for readings	Facilitated the student’s self efficacy.
Creating an introduction pack with tasks.	Prevented me from omitting any important information. Gave the student an activity to complete during down time.
Allowing the student to lead a structured session early on in their placement e.g. dysphagia history/ structured therapy task. Also stepping in to support them to have a successful session.	Student reported that she felt less pressure/ stress if I stepped in occasionally during sessions to support/ direct her.

Journal Review: apraxia of speech

Reference: Aichert, I and Zeigler, W. (2013) Segments and syllables in the treatment of apraxia of speech: An investigation of learning and transfer effects.

Background information

·   Isolated phonemes are often used as targets in the treatment of severe AOS.

·   Isolated phoneme’s however occur rarely in natural speech and do not play a role in language acquisition (bablling is based on syllabic units).

·   The syllable is assumed to be the basic unit of articulatory programming in speech.

·   Levelt et al (1999) – Phonetic level – there is a long-term store of motor patterns for frequently occurring syllables.

·   AOS – syllable structure and frequency impact on production accuracy.

·   Hypothesis: In AOS patients have access to a mental syllabary but the motor programs stored there are partially destroyed.

Study Question

·   Which out of segments or syllables (both phonological units) can be more efficiently trained in patient’s with severe AOS.

·   Learning effects and transfer effects into larger units were analysed.

Methods

·   4 patients used with AOS diagnosis (diagnosed by looking at spontaneous speech and repetition) + associated aphasia.

·   Diagnosis (Zeigler 2008): 1. Presence of phonemic errors (e.g. substitutions/omissions) 2. Inconsistent occurrence of phonetic distortions 3. Dysfluency due to: inter/intrasyllabic pauses, phoneme lengthenings, groping/repairs.

·   Screening lists of syllables + consonants were administered (target+control syllables/consonants).

Therapy

·   Four 45 minute sessions a week.

·   Segments/syllables presented orally and visually in a repetition + reading aloud format.

·   Feedback was given regularly e.g. auditory stimulation, visual cues (therapists mouth shape), and tactile/kinesthetic cues were given.

·   Syllables were always trained as a whole.

Results

·   Only one patient did not improve – they were the only patient to demonstrate severe perseveration.

·   Clear advantage of syllable training rather than segmental training. ¾ patients improved on target syllables, 2/4 showed transfer effects compared to ¼ and 0/4 for segmental training.

Key discussion points

·   Communicative expressions with single vowels/dipthongs/consonants which do constitute natural speech units e.g. sh, mm, ah, ai = good candidates to facilitate first speech sounds in patients with severe AOS.

·   The coarticulation of consonants with vowels (this occurs in syllables) is likely to be in the speech motor plan that needs to be re-learned. This has been found in several studies.

·   Transfer effect was noted form single syllables – two syllable words.

·   Perseveration may be due to disinhibited speech motor programs, when defective phonetic encoding fails to generate new motor patterns.

·   Different treatment protocals could be chosen for patient’s who perseverate.

Criticisms

·   Small cohort.

·   Multiple factors such as degree of aphasia could impact on the results.

·   Segments and syllables tend to be trained together and embedded in words.

Learning Outocomes

·   Perseveration – negative prognositic indicator – consider a different treatment protocal e.g. more participation based.

·   Train syllables rather than phonemes and try to use communicative individual segments to begin with e.g. mm, ah, ai…..

Locked in syndrome case study

Diagnosis – multiple brainstem strokes due to basilar artery thrombosis

Presentation – Severe dysarthria and dysphonia (<10 % intelligible), severely limited body movements (only able to oppose fingers on his right hand inconsistently).

Diagnostic assessments – FEES + VF – moderate oro-pharyngeal dysphagia, reduced strength + coordination of oral manipulation, reduced base of tongue to posterior pharyngeal wall approximation. Decreased vocal fold approximation/adduction and some evidence of overcompensation.

Therapy in hospital – consistent yes/no response via head nodding/ no movement was established + use of an AEIOU alphabet chart (listener assisted) utilising the yes/no response.  The patient disliked the use of AAC and predominantly attempted to communicate via speech.

Communication Guidelines

Understanding

·   T can understand what you are saying.

·   T can find it harder to understand if he is tired or upset.

·   On these occasions you may need to slow down your speech/ repeat yourself.

Speaking

Following his stroke T has:

·   Dysphonia- a difficulty with using his voice and vocal cords effectively and consistently.

·   Dysarthria – a difficulty using his mouth, tongue and lips to articulate clearly.

T finds it difficult to speak loudly and clearly. You can use these tips to help him maximise his communication:

·   Listen carefully and watch T’s lips when he is talking.

·   Prompt T to break words up; if he says one word at a time it is easier to understand him.

·   Remind T to exaggerate sounds.

·   If you are stuck on a word ask T to spell it out aloud.

·   If you are really stuck ask T to take a break and try again in a while.

Communicating

T is able to use strategies to aid communication when speaking is too hard to understand.

·   Ask him yes/no questions and get him to shake or nod his head clearly.

Goals

To improve consistency of strategy use to increase intelligibility with mouthing. Strategies 1. Break up the words and syllables 2. Over-articulation 3. Respond to forced choices.

To improve reliability of low tech AAC use.

Tasks

·   Based around T’s interests and family in order to keep him motivated/engaged.

·   Practicing breaking family names into syllables, getting T to count the syllables. Breaking down short phrases into words.

·   Practice spelling of words using the alphabet board e.g. places he has visited

Goals

To improve timing, depth and consistency of in-breath and out-breath.

To increase the frequency of voicing. Within task and conversation.

Tasks:

1.     Head and neck mobilisation and relaxation

Ø  Head and neck stretches and relaxation exercises.

2.     Breathing

Ø  Support T to put a hand on his abdomen and upper chest for feedback. Practice diaphragmatic breathing exercises, blowing exercises (blowing tissue/ imaginary candle/ imaginary letters/ blow on a mirror).

3.     Voice

Ø  Yawn/sigh, ‘h’ words (turning voicing on and off).

Ø  Blah blah blah app on ipad – saying ah and maintaining the sound

4.     Conversation

Ø  Pracice strategies within a conversation about one of T’s interests. Aim is to understand 3 keywords/ phrases.

Outcomes

Ø  T became around 65 % intelligible at a single word level and 50% intelligible at a short phrase level.

Ø  Inconsistent voicing but consistent controlled exhalation for short phrases.

Ø  T was able to participate in conversations with his family.