“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 beenservice provision to people with communication disorders and their families, their primary role isnow 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 topeople with aphasia; however, there is consensus that current practice is inconsistent with bestpracticerecommendations. Given that aphasia intervention has been identified as being central toimproved communicative outcomes, an increased capacity to effectively communicate healthcareneeds, a decrease in hospital negative events, and an increased sense of satisfaction for people withaphasia, 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 managementpractice and the factors that influence it. Specifically, the research aimed to: (a) provide an in-depthunderstanding of the current aphasia management pathway in the acute hospital setting; (b) exploreacute speech-language pathologists’ conceptualisation, experiences, and perceptions of post-strokeaphasia management, and provide a greater understanding of the factors that influence theirpractice; and, (c) understand the factors that influence acute aphasia management from theperspectives 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 twoPhases. Phase One, an interpretative phenomenological investigation, aimed to provide a deepunderstanding of aphasia management from the perspective of acute speech pathologists. Semistructured,in-depth interviews were undertaken with 15 Australian speech pathologists workingwith people with aphasia (one of which was later excluded resulting in a total n=14). Interviewswere transcribed verbatim, and data were analysed using a thematic analysis. Key themes identifiedincluded: role perception; competing priorities; the de-prioritisation of aphasia; and, the sense ofdisempowerment experienced by speech pathologists as a result of their relationship with evidencebasedpractice for acute aphasia management. In addition, a qualitative content analysis wasundertaken to describe the current aphasia management pathway. Grounded within the guidingconstruct, 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 acuteaphasia management by speech pathologists in depth, through the use of focused ethnography in asingle acute stroke unit. Three participant triads, consisting of a speech pathologist, person withaphasia, and at least one close other, were included as key informants in the research. Using avariety of qualitative research methods, including document analysis, participant reflective diaries,interviews, and observation, data collection occurred across the duration of the acute hospitaladmission 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 adiverse array of cultural factors that influence acute aphasia management and modify healthcareexperiences and outcomes.The overarching themes provide insight into the centrality that cultural and personal perceptionsand influences play on practice. They suggest that re-conceptualisation of the acute speechpathologist’s role in aphasia management, at both an individual and cultural level, is likely to bepowerful.Future research will focus on implementing knowledge transfer and exchange interventions toincrease the uptake of evidence-based recommendations in clinical settings. Interventions includeaddressing the psychological and structural empowerment of clinicians, as well as cultural levelinterventions 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 peoplewith aphasia, their families, and speech pathologists alike, the narratives and themes contained inthe 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 forpeople with aphasia, and people with aphasia and their families value the service provided byclinicians in the acute hospital. Despite this, a loud and resonating sense of dissonance regardingcurrent 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 onlyimprove service provision to people with aphasia and their families, but also to decrease the senseof dissonance for speech pathologists working in this setting.