The relevance of stroke care for living well with post-stroke aphasia: a qualitative interview study with working-aged adults

How do speech and language therapists enact aphasia psychosocial support in Ireland? A cross-sectional online survey informed by normalization process theory

BACKGROUND

Supporting psychosocial well-being in aphasia is necessarily person-centred, interdisciplinary and coordinated. Shortcomings in such support are described in Ireland and elsewhere. Speech and language therapists (SLTs) are integral; and describing current practice and barriers they experience is important for enhancing service delivery.

AIMS

To understand how SLTs enact, and are supported to enact, aphasia psychosocial care in Ireland.

METHODS & PROCEDURES

This is a cross-sectional, online, self-administered clinician survey targeting SLTs working minimally 1 year post-qualification with persons with aphasia of any aetiology in Ireland. The survey questions were charted against key constructs of the implementation science framework, normalization process theory (NPT), and descriptive statistics were applied.

OUTCOMES & RESULTS

A total of 54 eligible datasets were included. SLTs believed psychosocial support to be part of their role, but perceived multiple barriers in enacting it. These included a lack of training, clinical supervision, management support, role recognition, and access to and joint working with mental health professionals and services.

CONCLUSIONS & IMPLICATIONS

SLTs in Ireland face a range of individual and structural barriers, including care coordination and resourcing. There is a clear need not only for training, upskilling and mentorship, but also for wider changes around access to mental health professionals and clarity around the processes of referral, coordination and integration of aphasia care across settings. These findings comprise preliminary insights into current practices. Further research is needed as well as clarity on best-practice pathways for different aetiologies of aphasia. Articulating current practices using NPT may have utility for developing empirically informed and principled interventions to improve service delivery.

WHAT THIS PAPER ADDS

What is already known on this subject People with aphasia of all aetiologies are at risk of psychosocial problems. Shortcomings in access and the availability of appropriate support have been documented both internationally and in Ireland. To address this issue, an important first step is to understand how SLTs in Ireland currently enact and are supported to enact aphasia psychosocial care. What this study adds to the existing knowledge The findings describe the potential levers and barriers to progressing aphasia psychosocial care in Ireland. A range of individual, team and structural factors were identified. These were locally contextualized but similar issues are reported in other countries. Linking attitudes with NPT constructs provides a first step for further principled implementation projects. What are the practical and clinical implications of this study? Addressing psychosocial problems is perceived as a legitimate part of the speech and language therapy role. SLTs in Ireland enact a range of therapeutic approaches but may need opportunities for formal training and supervision, and for better coordination and integration with other mental health services and disciplines. Understanding differences in care pathways across the range of aphasia aetiologies is additionally important given the emphasis on post-stroke aphasia in the literature.

Distinctions and blurred boundaries between qualitative approaches and public and patient involvement (PPI) in research

Purpose: International health and social care policy increasingly draws on stakeholder experiences and opinions. The distinctions between various approaches to researching "insider" perspectives are contentious. This article explores features (e.g. philosophy, ethics, and power dynamics) of qualitative approaches and public and patient involvement (PPI) in communication disorder research and explicates the blurred boundaries between them.Method: We use two case studies involving PPI contributors with aphasia - an Irish mixed methodologies study and a Danish qualitative study - to illustrate PPI in research and thus demonstrate how researchers can bridge the gap between theoretical considerations and research implementationResult: There are important distinctions between PPI in research and qualitative approaches (e.g. origins, roles, and reimbursement) and many blurred boundaries (e.g. inclusion, openness to mutual learning and "insider" perspectives). A key difference is that PPI contributors take an active role at project level and more flexibility in roles is required in PPI research. These flexible and varied roles reflect the shared decision-making powers between lay and professional researchers.Conclusion: PPI can add innovation to qualitative and mixed methods communication disorder research as illustrated in both case studies. However, researchers wishing to include PPI must embrace and respond to the evolving and flexible nature of PPI relationships and processes. Flexibility, negotiation and continuous reflection on methodological approaches, power dynamics, roles and co-created knowledge will impact and transform the field of research in communication disorders.

Regulating emotional responses to aphasia to re-engage in life: a qualitative interview study

BACKGROUND

People with post-stroke aphasia (PWA) are more likely to experience serious mood disorders compared with those without. Emotional regulation may be important for influencing life participation after stroke. Understanding emotional regulation in the context of aphasia is important for promoting personally defined recovery, psychological well-being and life participation.

AIMS

To explore how individuals experience and regulate negative emotional responses to aphasia as part of re-engaging with life.

METHODS & PROCEDURES

In-depth semi-structured qualitative interviews with 14 PWA were conducted. The focus and design were developed with public and patient involvement contributors. Reflexive thematic analysis was applied.

OUTCOMES & RESULTS

Analysis generated three themes, which captured inherent diversity across participants in terms of emotional experiences, responses and regulation strategies: (1) emotional upheaval at all stages of recovery; (2) regulating emotional upheaval; and (3) discerning possibilities for life participation. Emotional regulation occurred both within and without the context of formal support services.

CONCLUSIONS & IMPLICATIONS

Individuals may be differently (en)abled in responding positively, with implications for aphasia psychological support and self-management interventions. The findings may inform future interventions to optimize well-being and personally meaningful outcomes for PWA.

WHAT THIS PAPER ADDS

What is already known on the subject PWA experience significant psychosocial upheaval and are at risk of mood disorders. Emotional regulation may be important for influencing one's emotional state, social participation and relationships after stroke. There is a need to better understand the ways in which PWA experience and regulate their emotions to develop better support for personally defined recovery. What this paper adds to existing knowledge PWA may experience significant and pervasive mood disorders in the long term after stroke. This may be compounded by worries for their children's well-being. Some, but not all, regulate emotions by drawing on positivity, determination, gratitude or stoicism. Having (supportive) opportunities to experience the impact of aphasia is important for discerning helpful strategies and participation opportunities. What are the potential or actual clinical implications of this work? Confronting altered abilities requires supportive, responsive opportunities sensitive to emotional responses. Opportunities for peer support and/or meaningful emotional support and compassion from family and friends are important therapeutic targets. Therapeutic input should pay attention to any familial and parenting concerns that may be compounding low mood. Although emotional regulation and recovery may occur without formal support, mental health services must be organized in such a way that PWA can access as needed.

Communicative and Supportive Strategies: A Qualitative Study Investigating Nursing Staff's Communicative Practice With Patients With Aphasia in Stroke Care

This study aimed to provide detailed descriptions of the influences on the nursing staff’s communicative practices with patients with aphasia in the context of usual stroke care interactions, and secondly to explore the nursing staff’s use or non-use of supportive techniques, including the SCA^TM method. A qualitative design was chosen, combining field observations and semi-structured interviews. Inductive and deductive qualitative content analysis was used. The results showed that the nursing staff’s interactions with patients with aphasia were influenced by organizational and environmental influences, nurses’ roles and functions and supporting patients with aphasia in communication. The role of the nursing staff in caring for the psychosocial well-being of patients is deprioritised in favor of other tasks. If there is no time or culture for prioritizing time for conversing with patients and supporting their psychosocial well-being, communication-partner training like SCA^TM is likely hindered.

A Visual Interactive Narrative Intervention (VINI) for aphasia education: Can digital applications administer augmented input to educate stroke survivors with aphasia?

OBJECTIVE

Persons with aphasia (PWA) face additional barriers to proper healthcare due to inadequate patient education by health professionals unequipped to use augmentative and alternative communication (AAC). The current study examines a digital application that evokes and sustains health information processing through AAC specifically aimed at increasing comprehension with augmented input (AI).

METHODS

A digital application designed to educate PWA about their health condition was compared to a video-recorded doctor providing oral-only education. Sixteen PWA received both education interventions in a crossover manner. Health information processing was assessed through heart rate (HR) and skin conductance levels (SCL), which were collected continually during each administration of education interventions.

RESULTS

PWA demonstrated greater cognitive processing of health information via HR and SCL indices during the digital application compared to the typical oral-only education intervention. The oral-only intervention led PWA to disengage with health information.

CONCLUSION

By combining visuographic materials and adapted language into a customizable narrative structure, digital applications can utilize AI to educate PWA about basic health information (i.e., diagnosis and prognosis).

PRACTICE IMPLICATIONS

The current study's AAC requires minimal training and can be used as an aided support in conjunction with other techniques that increase PWA's access to health information.

'I hated being ghosted' - The relevance of social participation for living well with post-stroke aphasia: Qualitative interviews with working aged adults

Background

In the context of increasing incidence of stroke in working aged adults, there is a specific need to explore the views of working aged adults with post‐stroke aphasia, whose communication difficulties may result in restricted social participation, loss of employment and changed relationship and parenting roles. This study aimed to explore the perspectives of working aged adults with post‐stroke aphasia in relation to social participation and living well with aphasia (LWA).

Design and participants

We conducted qualitative interviews with 14 people with post‐stroke aphasia (PWA). Data were analysed following principles of reflexive, thematic analysis.

Patient or Public Contribution: A Public and Patient Involvement aphasia advisory group inputted into the study design and interpretation of data.

Results

Social participation spanned 5 themes: Relationships and roles; Social support; Peer network, Aphasia awareness; and Employment and training. Meaningful, interesting social participation for LWA is individually defined. Working aged PWA may require flexible support with parenting, accessing a diverse social network and finding opportunities for meaningful social connection, training and employment.

Conclusions

The findings extend knowledge of social participation in the context of LWA for working aged adults by elucidating the individually defined nature of meaningful participation and how PWA may need flexible support with parenting, accessing a diverse social network and training and employment. For aphasia research, policy and services to be relevant, it is crucial that working aged PWA are meaningfully involved in setting the aphasia agenda.