“Communication is taking a back seat”: An exploration of aphasia management in acute hospital settings

Abstract

While in the past the focus of speech pathologists working in the acute hospital setting has been service provision to people with communication disorders and their families, their primary role is now in dysphagia. In the limited literature regarding aphasia management in acute hospital settings,there is a lack of consistency regarding the type and amount of intervention being provided to people with aphasia; however, there is consensus that current practice is inconsistent with best practice recommendations. Given that aphasia intervention has been identified as being central to improve communicative outcomes, an increased capacity to effectively communicate healthcare needs, a decrease in hospital negative events, and an increased sense of satisfaction for people with aphasia, this is of concern. Little is known about the reasons underlying this evidence-practice gap.The overall aim of this thesis was to provide an understanding of current acute aphasia management practice and the factors that influence it. Specifically, the research aimed to: (a) provide an in-depth understanding of the current aphasia management pathway in the acute hospital setting; (b) exploreacute speech-language pathologists’ conceptualisation, experiences, and perceptions of post-stroke aphasia management, and provide a greater understanding of the factors that influence their practice; and, (c) understand the factors that influence acute aphasia management from the perspectives of speech pathologists, people with aphasia, and their close others, through a culturallens.In order to address the research aims, the empirical aspects of this research were conducted in two Phases. Phase One, an interpretative phenomenological investigation, aimed to provide a deep understanding of aphasia management from the perspective of acute speech pathologists. Semi Structured,in-depth interviews were undertaken with 15 Australian speech pathologists working with people with aphasia (one of which was later excluded resulting in a total n=14). Interviews Were transcribed verbatim, and data were analysed using a thematic analysis. Key themes identified included: role perception; competing priorities; the de-prioritisation of aphasia; and, the sense of disempowerment experienced by speech pathologists as a result of their relationship with evidence based practice for acute aphasia management. In addition, a qualitative content analysis was undertaken to describe the current aphasia management pathway. Grounded within the guiding construct, First contact with the profession, the findings represented the significant diversity in the pathways of care for people with aphasia and their families in the acute hospital setting. Overall,analysis revealed the complex, diverse, and multi-faceted nature of the phenomenon.Phase Two was designed based on the findings of Phase One. It examined the culture of acute aphasia management by speech pathologists in depth, through the use of focused ethnography in a single acute stroke unit. Three participant triads, consisting of a speech pathologist, person with aphasia, and at least one close other, were included as key informants in the research. Using a variety of qualitative research methods, including document analysis, participant reflective diaries,interviews, and observation, data collection occurred across the duration of the acute hospital admission of the person with aphasia. Data were analysed using an inductive thematic approach.Findings suggest that the central theme of Creating a positive experience is contributed to by a diverse array of cultural factors that influence acute aphasia management and modify healthcare experiences and outcomes.The overarching themes provide insight into the centrality that cultural and personal perceptions and influences play on practice. They suggest that re-conceptualisation of the acute speech pathologist’s role in aphasia management, at both an individual and cultural level, is likely to be powerful.Future research will focus on implementing knowledge transfer and exchange interventions to increase the uptake of evidence-based recommendations in clinical settings. Interventions include addressing the psychological and structural empowerment of clinicians, as well as cultural level interventions targeting the creation of a stronger ‘communication culture’ in acute hospitals.In conclusion, whilst the experiences of aphasia in the acute hospital setting are unique for people with aphasia, their families, and speech pathologists alike, the narratives and themes contained in the findings of this study offer a positive message for all stakeholders in aphasia management.Speech pathologists strive to provide evidence-based practice that creates a positive experience for people with aphasia, and people with aphasia and their families value the service provided by clinicians in the acute hospital. Despite this, a loud and resonating sense of dissonance regarding current service provision persists. If, societally, value is placed on the management of aphasia in the acute hospital setting, then change needs to occur. Such change has the potential to not only improve service provision to people with aphasia and their families, but also to decrease the sense of dissonance for speech pathologists working in this setting.