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.