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.

Hospital transport: Reflection

Reflective Log

1. Think of a recent therapy session or event.

- I booked ENT appointment for a patient with locked in syndrome who’s only communication method was speech.

- Ambulance crew called to say he needed to be ready 2 hours before they picked him up, which was an hour before his appointment.

- The patient told the crew and his wife he didn’t want to go because of pain from sitting but they took him anyway.

-the patient refused to have FEES done and was upset at his family and wife for bringing him.

- I apologised and explained to the patient that the ambulance crew had needed to come early. He was very agitated but this calmed him.

3. What did this session make you feel?

- I felt guilty and upset that I had not researched hospital transport further.

-I thought that I had prepared well since I had spoken to the lead LST in the ENT clinic to handover communication guidelines and I had talked to the aptient extensively about the procedure. This made me feel disappointed since my plans did not work out.

-I felt that I had broken the trust I had developed with my patient.

4. What would you want to change, and why?

- I would request the ENT appointment information so that I could attend the session with the patient

- I would explain the full procedures for the hospital appointment to the patient i.e. when he would get out, waiting times etc.

- I would consult OT/PT regarding how long the patient could sit out for.

- I would consider alternative forms of transport e.g. family members/ dial-a-ride…

Nursing Home Working - Reflection

Think of a recent therapy session or event.

Nursing home staff frequently did not position a patient upright enough for oral intake and did not adhere to guidelines I had set when feeding the patient. The patient’s family also frequently fed them inappropriate foods/drinks, resulting in the patient being re-referred due to having frequent chest infections. The patient also had cognitive impairments affecting her dysphagia and making her ability to swallow variable.

What did this session make you feel?

I felt that I was not being productive when I assessed the patient time after time. I also felt frustrated that I could not prevent the patient having chest infections and frustrated at the communications between the nursing home and the patient’s family.

What would you want to change and why?

I would want to communicate more clearly with the patient’s nursing home and family from the off. I would explain how the patient’s cognitive impairments meant that their ability to swallow was variable and would put plans in place to deal with their variability.

What has this session taught you?

This experience really tought me that I need to educate other health professionals more on dysphagia (causes, strategies to reduce the risk of aspiration, hypothesis for dysphagia….) and facilitate staff to be able to use their own judgements when working with patient's who have variable swallowing abilities.

What will you do next time?

·   Liaise closely with patient’s family regarding their mealtime recommendations, goals and therapy input.

·   Take a picture of the patient when they are positioned optimally and put this on their bedside wall.

·   Explain to nursing home staff/ the patient’s family why the person has dysphagia and why some foods/drinks are more difficult for them to swallow.

·   Create a plan for patient’s whose swallowing is variable e.g. downgrade to puree if they appear fatigued/ have an infection.

·   Request skilled carers/ contact the manager of the nursing home to handover recommendations.