Abstract
Background
Traumatic brain injury (TBI) incidence rates are rising significantly across all age groups, often requiring complex and expensive medical care. Common causes of TBI include motor-vehicle accidents, violence, sport injuries and falls. For some individuals, inpatient rehabilitation (IPR) is used as a care pathway to provide intervention(s) for the physiological, psychological, neurobehavioural and cognitive-communication sequelae of a TBI.Many patients with a TBI will also experience dysphagia, an impairment or disorder of deglutition (swallowing). Dysphagia affects hydration, nutritional intake, respiration and can significantly impact an individual’s quality of life. It has been identified as a contributing factor in the mortality and morbidity of patients in many hospital care settings.
In the Province of Ontario, patients with dysphagia concomitant with a TBI often receive inpatient rehabilitative care by a Speech-Language Pathologist (SLP). Successful outcomes for dysphagia are best achieved when the patient, independently whenever possible, and the family when it is not possible, have been educated and counselled to know which foods they can and cannot safely consume and why this is important. This requires that the SLP enact education and counselling with the patient who has a cognitive-communication disorder related to the TBI and their family in an effective way to provide critical and understandable information about the assessment results and the risks and benefits of the various management choices under consideration. It is also considered part of the SLP’s scope of practice to ensure that all members of the interdisciplinary IPR team are aware and understand the assessment results, management recommendations and know how to recognize and respond to signs and symptoms that reflect a risk of harm.
As a Speech-Language Pathologist (SLP) working in an IPR setting for over 20 years with patients who have a TBI and dysphagia,I have recognized that there is a lack of accessible, evidence-based, comprehensive methods that are patient and family-focused for SLPs to use to enact education and counselling within this practice context.
Therefore the objectives of this thesis were to: (1) conduct a scoping review of the literature to better understand how SLPs enact education and counselling with patients who have dysphagia and a TBI, especially within the context of inpatient rehabilitation settings; and (2) use qualitative hermeneutic inquiry to understand how SLPs enact dysphagia education and counselling with patients who have a TBI and are in inpatient rehabilitation settings in Ontario.
Methods
This research started with a scoping review of the literature followed by a qualitative study using a philosophical hermeneutical perspective and semi-structured interviews with twelve SLPs working in IPR settings with individuals who have dysphagia and a TBI. Participants also provided for consideration the materials they used when enacting education and counselling with their patients.
Results
The scoping literature review helped to reveal important parts of the enactment of education and counselling, especially as it relates to the numerous people and groups of people within the inpatient practice context who must be part of the education and counselling conversations. The results of the hermeneutic inquiry revealed important information about the complexities and constraints of practice and provided evidence of how SLPs continually try to mitigate the risks within this environment to keep their patients safe. These important conversations also revealed that SLPs generated practice-based knowledge and used innovation(s) around education and counselling primarily due to the lack of guidance around education and counselling currently available within guideline documents.
Conclusion
This thesis project provided a useful framework for examining the individual accounts of the SLPs and bringing these together in a thematic manner to generate important information for SLPs, educators, policy makers, and health care administrators. It advanced our understanding of how SLPs enact dysphagia education and counselling for patients with a TBI within IPR settings in Ontario
