A better conversations approach for people living with dysarthria

In this chapter, the authors describe better conversations with dysarthria (BCD) therapy featuring a man living with Parkinson’s disease and his communication partner. A better conversations approach aims to help people with communication difficulties to have more enjoyable interactions. The authors outline the pre-post therapy assessment process, the intervention itself and highlight a specific outcome relating to responses to the communication partner’s turns. They also present data on the acceptability of BCD. This is the first BCD therapy case to be published and as such provides an important reference point for future work in this field

People with aphasia and their family members proposing joint future activities in everyday conversations : A conversation analytic study

Background In everyday conversations, a person with aphasia (PWA) compensates for their language impairment by relying on multimodal and material resources, as well as on their conversation partners. However, some social actions people perform in authentic interaction, proposing a joint future activity, for example, ordinarily rely on a speaker producing a multi-word utterance. Thus, the language impairment connected to aphasia may impede the production of such proposals, consequently hindering the participation of PWAs in the planning of future activities. Aims To investigate (1) how people with post-stroke chronic aphasia construct proposals of joint future activities in everyday conversations compared with their familiar conversation partners (FCPs); and (2) how aphasia severity impacts on such proposals and their uptake. Methods & Procedures Ten hours of video-recorded everyday conversations from seven persons with mild and severe aphasia of varying subtypes and their FCPs were explored using conversation analysis. We identified 59 instances where either party proposed a joint future activity and grouped such proposals according to their linguistic format and sequential position. Data are in Finnish. Outcomes & Results People with mild aphasia made about the same number of proposals as their FCPs and used similar linguistic formats to their FCPs when proposing joint future activities. This included comparable patterns associated with producing a time reference, which was routinely used when a proposal initiated a planning activity. Mild aphasia manifested itself as within-turn word searches that were typically self-repaired. In contrast, people with severe aphasia made considerably fewer proposals compared with their FCPs, the proposal formats being linguistically unidentifiable. This resulted in delayed acknowledgement of the PWAs' talk as a proposal. Conclusions & Implications Mild aphasia appears not to impede PWAs' ability to participate in the planning of joint future activities, whereas severe aphasia is a potential limitation. To address this possible participatory barrier, we discuss clinical implications for both therapist-led aphasia treatment and conversation partner training. WHAT THIS PAPER ADDS What is already known on the subject PWAs use multimodal resources to compensate for their language impairment in everyday conversations. However, certain social actions, such as proposing a joint future activity, cannot ordinarily be accomplished without language. What this paper adds to existing knowledge The study demonstrates that proposing joint future activities is a common social action in everyday conversations between PWAs and their family members. People with mild aphasia used typical linguistic proposal formats, and aphasic word-finding problems did not prevent FCPs from understanding the talk as a proposal. People with severe aphasia constructed proposals infrequently using their remaining linguistic resources, a newspaper connecting the talk to the future and the support from FCPs. What are the potential or actual clinical implications of this work? We suggest designing aphasia treatment with reference to the social action of proposing a joint future activity. Therapist-led treatment could model typical linguistic proposal formats, whereas communication partner training could incorporate FCP strategies that scaffold PWAs' opportunities to construct proposals of joint future activities. This would enhance aphasia treatment's ecological validity, promote its generalization and ultimately enable PWAs to participate in everyday planning activities.Peer reviewe

People with non-fluent aphasia initiating actions in everyday conversation with familiar conversation partners : resources for participation

Background: Conversation is central to building and maintaining relationships. Thus, it is unsurprising that people with aphasia and their familiar conversation partners often desire improved conversational ability. However, to facilitate real-world communication, focusing on improving aphasic language difficulties is not enough. We also need a comprehensive understanding of how social actions are accomplished in everyday aphasic conversation, including the means of participation people with aphasia possess. Aims: To investigate the in-situ participation of people with non-fluent aphasia by analysing how they bring up, i.e., initiate, issues of importance to them in home-based authentic conversations with their familiar conversation partners. Methodology: Using conversation analysis, we examined 6 hours of video-recorded everyday conversations of two dyads, each consisting of a person with severe/moderate Broca's aphasia and their spouse. We analysed 89 instances of the persons with aphasia initiating talk and how these initiations were produced, where in the conversation such initiations appeared, and what the initiations accomplished socially. Outcomes & Results: We identified two descriptive groupings of initiations by the persons with aphasia: formulaic initiations, and initiations striving for propositional content. Formulaic initiations were used in unproblematic ways to accomplish social actions like offerings, or to assess or summarize a topic after it has lapsed. Such initiations are considered important in building social cohesion. Most initiations strived for propositional content, i.e., entailed a content word, or an attempt to produce one. Such initiations were regularly intertwined with multimodal and material resources usually resulting in recognizable social actions like topic initiation irrespective of whether they included an identifiable content word or not. However, the achievement of topic initiation was crucially dependent on interactional work by the spouse. Finally, we discovered a difference in the sequential environment of propositional initiations between the dyads as only one of the spouses regularly provided slots for the person with aphasia to initiate talk. Conclusions: Our analysis revealed persons with Broca's aphasia participated in conversation through initiations relying on formulaic language and initiations striving for propositional content. The latter demonstrated the pronounced multimodality and interactivity of aphasic conversation. Our findings highlight the significance of the conversation partner's skills to facilitate the person with aphasia to initiate talk. Thus, our results imply the importance of providing conversation partner training to promote participation in aphasia.Peer reviewe

Using Conversation Analysis to explore assessments of decision-making capacity in a hospital setting

BACKGROUND: Healthcare professionals (HCPs) have a responsibility to conduct assessments of decision-making capacity that comply with the Mental Capacity Act 2005 (MCA). Current best-practice guidance, such as the Mental Capacity Code of Practice and National Institute for Health and Care Excellence decision-making and mental capacity guidance, does not stipulate how to accomplish this in practice, for example, what questions should be asked, how options and information should be provided. In addition, HCPs struggle to assess the capacity of individuals with communication difficulties. AIMS: This study was a service evaluation that aimed to objectively analyse, using Conversation Analysis (CA), how real-life capacity assessments were conducted in a hospital setting with patients with acquired brain injury (ABI)-related communication difficulties. A second aim was to establish the feasibility of using CA to advance knowledge of the conduct of capacity assessment. METHODS & PROCEDURES: Four naturally occurring capacity assessments were video-recorded. Recordings involved speech and language therapists, occupational therapists, neuropsychologists and patients with communication difficulties as a result of ABI. The methods and findings of CA were used to investigate the interactional behaviours of HCPs and patients during assessments of decision-making capacity. The analysis was informed by our knowledge of the MCA best practice guidance. OUTCOMES & RESULTS: An overall structure of capacity assessment that enacted some of the best-practice MCA guidance was identified in one recording, consisting of six phases: (i) opening, (ii) preparation, (iii) option-listing, (iv) test, (v) decision, and (vi) close. The preparation phase consisted of two sub-components: information gathering and information giving. Variation from this structure was observed across the dataset, notably in the way in which options were (or were not) presented. CONCLUSIONS & IMPLICATIONS: CA is a feasible empirical method for exploring the structure and conduct of capacity assessments. CA identifies and provides ways of describing interactional behaviours that align with and diverge from best-practice MCA guidance. Future CA studies including a wider range of health and social care professionals and patients have the potential to inform evidence based training for HCPs who conduct assessments of decision-making capacity. WHAT THIS PAPER ADDS: What is already known on this subject The Mental Capacity Act (MCA) is poorly implemented in practice. Healthcare professionals (HCPs) find it challenging to assess the decision-making capacity of individuals with communication difficulties, and people with communication difficulties are often excluded from or insufficiently supported during capacity assessment. Research is limited to self-report methods. Observational studies of capacity assessment are required. What this study adds This is the first study to use Conversation Analysis (CA) to explore how capacity assessments are conducted in a hospital setting by HCPs with people with communication difficulties as a result of acquired brain injury. One video-recorded capacity assessment was structured in six phases that aligned with best practice MCA guidance. However, other capacity assessments deviated from this structure. One phase, option listing, varied in practice and options were not always presented. What are the clinical implications of this work? CA revealed interactional behaviours that align with and diverge from best-practice MCA guidance. Future CA studies are warranted to inform training for health and social care professionals who conduct capacity assessments

Oropharyngeal dysphagia management in cervical spinal cord injury patients : an exploratory survey of variations to care across specialised and non-specialised units

Study design: A multi-centre online survey to staff working in specialised and non-specialised acute units. Objectives: To identify clinical decisions and practices made for acute cervical spinal cord injury (CSCI) patients with respiratory impairments and oropharyngeal dysphagia. Settings: All hospital intensive care units in the UK that admit acute cervical spinal cord injury patients. Methods: Online distribution of a 35-question multiple-choice survey on the clinical management of ventilation, swallowing, nutrition, oral hygiene and communication for CSCI patients, to multi-disciplinary staff based in specialised and non-specialised intensive care units across UK. Results: Responses were received from 219 staff members based in 92 hospitals. Of the 77 units that admitted CSCI patients, 152 participants worked in non-specialised and 30 in specialised units. Non-specialised unit staff showed variations in clinical decisions for respiratory management compared to specialised units with limited use of vital capacity measures and graduated weaning programme, reliance on coughing to indicate aspiration, inconsistent manipulation of tracheostomy cuffs for speech and swallowing and limited use of instrumental assessments of swallowing. Those in specialised units employed a multi-discplinary approach to clinical management of nutritional needs. Conclusions: Variation in the clinical management of respiratory impairments and oropharyngeal dysphagia between specialised and non-specialised units have implications for patient outcomes and increase the risk of respiratory complications that impact mortality. The future development of clinical guidance is required to ensure best practice and consistent care across all units

The experiences of individuals with cervical spinal cord injury and their family during post-injury care in non-specialised and specialised units in UK

Background: Individuals with acute cervical spinal cord injury require specialised interventions to ensure optimal clinical outcomes especially for respiratory, swallowing and communication impairments. This study explores the experiences of post-injury care for individuals with cervical spinal cord injury and their family members during admissions in specialised and non-specialised units in the United Kingdom. Methods: Semi-structured interviews were undertaken with individuals with a cervical spinal cord injury and their family member, focussing on the experience of care across units. Eight people with spinal cord injury levels from C2 to C6, were interviewed in their current care settings. Six participants had family members present to support them. Interviews were audio-recorded and transcribed with data inputted into NVivo for thematic analysis. Results: The study identified six themes from the participant interviews that highlighted different experiences of care in non-specialised and specialised settings. A number of these were related to challenges with the system, whilst others were about the personal journey of recovery. The themes were titled as: adjustment, transitions, “the golden opportunity”, “when you can’t eat”, communication, and “in the hands of the nurses and doctors”. Conclusions: Whilst participants reported being well cared for in non-specialised units, they felt that they did not receive specialist care and this delayed their rehabilitation. Participants were dependent on healthcare professionals for information and care and at times lost hope for recovery. Staff in non-specialised units require training and guidance to help provide support for those with dysphagia and communication difficulties, as well as reassurance to patients and families whilst they wait for transfer to specialised units

Giving Voice to People With Dementia and Their Carers: The Impact of Communication Difficulties on Everyday Conversations

People living with dementia are an under-served group, whose voices are often excluded from research studies due to their speech, language and communication difficulties. As part of a larger study into language processing in dementia, we invited five people with dementia and their carers to tell us about how dementia impacts on their everyday conversations. We also wanted to gain insights into their views on communication strategies to circumvent these difficulties. Aware of the limitations of a standard focus group methodology for this population, we adapted this approach to provide people with dementia the opportunity to be active research participants. To amplify their voices and to enable carers to be as open as possible we ran the groups separately. Each was facilitated by a speech and language therapist. Both groups used communication accessible materials, to create an inclusive environment that valued contributions from all participants. The topic guide remained the same for all participants, ensuring equity in posing the same core questions. Focus groups were video recorded and transcribed. Reflexive thematic analysis was selected as the most appropriate method to ensure overarching themes identified were based in the data. In our analysis the main theme was sense-making; participants experienced and tried to make sense of dementia through the lens of interaction. Four subthemes were also identified, 1. It’s a journey, 2. You have to make the most of things, 3. Ask the right questions and it just flows-strategies in conversation, and 4. Dealing with people. Multimodal adaptations to a focus group methodology have given voice to people with dementia as well as their carers. They characterise dementia and identify useful strategies based on observations of what changes for them in everyday conversations

Exploring the conversation of speakers with agrammatic aphasia: some rehabilitative implications

This presentation applies Conversation Analysis (CA) to the phenomenon of agrammatic aphasia. Although mainstream research has done much to characterise the nature of the underlying disorder in agrammatism, most studies have analysed elicited, task-based data by applying the theoretical concepts of a standard grammar. As a result, little is known about the grammar that people with agrammatism use in everyday interaction with habitual conversational partners. There is evidence in the CA literature to suggest that conversational grammar may not mirror the grammar of elicited language samples (Heeschen & Schegloff, 2003). This presentation will investigate the notion that conversation and task-based data do not necessarily reveal the same grammatical phenomena, and will explore the implications for rehabilitation

Development of fidelity of delivery and enactment measures for interventions in communication disorders

OBJECTIVES: This study was part of a process evaluation for a single-blind, randomized controlled pilot study comparing Better Conversations with Primary Progressive Aphasia (BCPPA), an approach to communication partner training, with no speech and language therapy treatment. It was necessary to explore fidelity of delivery (delivery of intervention components) and intervention enactment (participants' use of intervention skills in the form of conversation behaviours comprising facilitators, that enhance the conversational flow, and barriers, that impeded the flow of conversation). This study aimed to: (1) Outline an adapted methodological process that uses video observation, to measure both fidelity of delivery and enactment. (2) Measure the extent to which the BCPPA pilot study was delivered as planned, and enacted. DESIGN: Observational methods were used alongside statistical analysis to explore the fidelity of intervention and enactment using video recordings obtained from the BCPPA pilot study. METHODS: A 5-step methodology, was developed to measure fidelity of delivery and enactment for the BCPPA study using video-recorded data. To identify delivery of intervention components, a random sample of eight video recorded and transcribed BCPPA intervention sessions was coded. To examine the enactment of conversation behaviours, 108 transcribed 10 -min-video recorded conversations were coded from 18 participants across the control and intervention group. RESULTS: Checklists and guidelines for measurement of fidelity of treatment delivery and coding spreadsheets and guidelines for measurement of enactment are presented. Local collaborators demonstrated 87.2% fidelity to the BCPPA protocol. Participants in the BCPPA treatment group increased their use of facilitator behaviours enacted in conversation from a mean of 13.5 pre-intervention to 14.2 post-intervention, whilst control group facilitators decreased from a mean of 15.5 to 14.4, over the same timescale. CONCLUSIONS: This study proposes a novel and robust methods, using video recorded intervention sessions and conversation samples, to measure both fidelity of intervention delivery and enactment. The learnings from this intervention are transferable to other communication interventions