Speech pathologists’ experience of involving people with stroke-induced aphasia in clinical decision making during rehabilitation

Communication strategies to support decision-making by persons with aphasia: A scoping review

BACKGROUND

An individual's ability to make autonomous decisions is fundamental to self-determination. The presence of neurological pathology, for example, aphasia, and its associated difficulties with language and/or cognition, may affect an individual's capacity to make decisions, or their ability to reveal their capacity to make decisions. Decision-making by persons with aphasia (PWA) can be enhanced when communication partners are trained and if communication supports are provided, for example, supports that reduce the linguistic and cognitive demands of the task, and/or that facilitate expression.

AIMS

The main aim of this review is to identify the types of decisions for which persons with post-stroke aphasia receive support, the communication partners involved in supporting decision-making by PWA and the communication strategies implemented to support decision-making by PWA.

METHODS & PROCEDURES

A multifaceted search strategy was used. Specific keywords were used to search seven electronic databases. Hand-searches of two journals, as well as ancestral searches of the reference lists of selected articles was also performed. Through the application of predefined selection criteria, 16 journal articles, spanning from 1998 to 2021, were selected from the initial yield of 955 articles for inclusion in this review. Data pertaining to the aims of the study were extracted using a data-extraction form.

OUTCOMES & RESULTS

This review shows that most of the research to date has focused on supporting persons with post-stroke aphasia in decisions pertaining to discharge planning or accommodation, and decisions pertaining to informed consent for participation in research. The communication partners cited most frequently as supporting decision-making by PWA are speech-language pathologists and family members. A range of communication strategies, most of which are components of Supported Conversation Techniques for Adults with Aphasia (SCA™), support decision-making by PWA. The most frequently listed strategies include augmenting information with different modalities, acknowledging the competence of the PWA, thereby inviting initiation and collaboration by the PWA, and the allocation of sufficient time for the decision-making process.

CONCLUSIONS & IMPLICATIONS

This review presents research trends regarding the support of PWA in decision-making. Future research should focus on the effectiveness of the different strategies identified, and on the support of PWA in the making of a greater variety of complex decisions.

WHAT THIS PAPER ADDS

What is already known on the subject PWA have the right to be given the opportunity to participate in personally relevant decision-making through all stages of life. Research has shown that decision-making can be enhanced with trained communication partners and if supports are provided that reduce the linguistic and cognitive demands of the task, and that support the expressive abilities of PWA. What this study adds to existing knowledge This scoping review is the first to synthesize the findings of research regarding the types of decisions for which persons with post-stroke aphasia receive support, the communication partners supporting PWA in making these decisions and the communication strategies implemented to support decision-making by PWA. What are the potential or actual clinical implications of this work? Clinicians working with PWA may be sensitized to the role they can play in supporting decision-making by PWA, the current state of the literature regarding types of decisions that may need to be supported, communication partners who can provide such support and communication strategies that may be helpful in this regard.

Motivation in Aphasia Treatment: Self-Determination Theory Applied to the FOURC Model

PURPOSE

Although the importance of motivation to successful rehabilitation is frequently acknowledged in the aphasia literature, little evidence-based guidance has been provided on how to support it. The purpose of this tutorial is to introduce a well-validated theory of motivation, self-determination theory (SDT); explain its role as the foundation for the FOURC model of collaborative goal setting and treatment planning; and explain how it may be applied during rehabilitation to support the motivation of people with aphasia.

METHOD

We provide an overview of SDT, explore the link between motivation and psychological wellness, and discuss how psychological needs are addressed in SDT and the FOURC model. Concrete examples from aphasia therapy are used to illustrate main concepts.

CONCLUSIONS

SDT offers tangible guidance for supporting motivation and wellness. SDT-based practices support positive forms of motivation, which is one of the targets of FOURC. An understanding of SDT's theoretical foundation will help clinicians maximize the impact of collaborative goal setting and aphasia therapy more generally.

Barriers and Facilitators to Engagement in Rehabilitation Among Stroke Survivors: An Integrative Review

BACKGROUND

Approximately 795,000 Americans experience a new or recurrent stroke every year, and it remains one of the leading causes of disability worldwide. Patient engagement in rehabilitation and physical activity has been associated with improvements in functional outcomes during inpatient rehabilitation. There is limited knowledge of the barriers and facilitators to patients' engagement in stroke rehabilitation.

METHODS

An integrative review with a systematic approach was conducted to explore the current available literature on barriers and facilitators to patient engagement in stroke inpatient rehabilitation.

RESULTS

Twenty-five studies were included in the final review. Four major themes described the identified barriers and facilitators: (1) stroke impact, (2) self-efficacy, (3) therapeutic relationship, and (4) motivating factors. Individualized patient-centered goal setting was a commonly studied intervention found to successfully increase engagement.

CONCLUSION

Engagement in stroke rehabilitation is associated with improved patient outcomes. Using the identified themes from this review, nurses can develop focused interventions aimed at reducing barriers and increasing stroke patient engagement.

Decision Making by People With Aphasia: A Comparison of Linguistic and Nonlinguistic Measures

Purpose Decision making involves multiple cognitive and linguistic processes. The extent to which these processes are involved depends, in part, on the conditions under which decision making is assessed. Because people with aphasia (PWA) have impaired language abilities and may also present with cognitive deficits, they may have difficulty during decision-making tasks. Yet little research exists on the decision-making abilities of PWA. Thus, the purposes of this study were to investigate the performance of PWA on linguistic and nonlinguistic decision-making measures and to explore the relationship between decision making and cognitive test performance. Method A quasi-experimental design was used to compare the performance of PWA (n = 16) and age- and education-matched control participants (n = 16) on three decision-making tasks: Making a Decision subtest from the Functional Assessment of Verbal Reasoning and Executive Strategies (linguistic decision-making task), Iowa Gambling Task (nonlinguistic decision-making task with ambiguity), and Game of Dice Task (nonlinguistic decision-making task without ambiguity). Participants also completed assessments of language, working memory, and executive functions. Scores on the three decision-making tasks were compared between groups, and cognitive influences on decision-making performance were examined using correlation analyses. Results PWA differed significantly from control participants on linguistic decision making, particularly when required to verbalize their rationale for making their decision. PWA and control participants did not differ significantly on measures of nonlinguistic decision making. Performance on multiple cognitive measures was correlated with performance on the linguistic reasoning task, as well as one of the nonlinguistic tasks (Game of Dice Task). Conclusions Decision-making tasks that are heavily dependent on language, such as those used in capacity assessments, may disadvantage PWA. Assessments of decision-making capacity should include communication supports for people with acquired communication disorders; further investigation in the areas of decision making and aphasia is needed.

What do speech-language pathologists describe as most important when trying to achieve client participation during aphasia rehabilitation? A qualitative focus group interview study

Purpose: The aim of this study was to investigate what speech-language pathologists describe as most important when trying to achieve client-oriented participation during aphasia rehabilitation. Method: A qualitative study including semi-structured focus group interviews with 11 speech-language pathologists. Interviews were analysed with the use of systematic text condensation. Result: Four main themes emerged from the analysis. (1) It is important to take the vulnerability of the client group into account. (2) It is important to address the client's process of realisation by navigating around unrealistic wishes and goals. (3) It is challenging to involve clients when the evidence-base for clinical practice is limited. (4) It is crucial to make therapy meaningful to the client. Conclusion: This study showed that speech-language pathologists perceived prediction of a clinical course in aphasia rehabilitation as challenging due to the vulnerable client group and the perceived need to guide the clients through the rehabilitation process. They talked about how unrealistic client goals, and the lack of a solid evidence-base to guide their clinical practice, made collaborative goal setting and treatment planning challenging. Due to these barriers, the speech-language pathologists struggled to achieve client participation, and thereby aphasia rehabilitation could not be described as fully client-oriented.

Collaborative Goals for Communicative Life Participation in Aphasia: The FOURC Model

Purpose Collaborative goal setting is at the heart of person-centered rehabilitation but can be challenging, particularly in the area of aphasia. The purpose of this clinical focus article is to present a step-by-step model for forming a collaborative partnership with clients to develop an intervention plan that follows the client's lead, addresses communicative participation, and integrates multiple treatment strategies. Method We introduce the rationale and core features of a 4-step and 4-pronged process (the FOURC model) and illustrate its application through 3 cases of people with aphasia who were treated in outpatient rehabilitation. Conclusions The model invites client initiative in a clinically feasible manner while supporting the clinician's role in guiding the intervention based on professional expertise and growing familiarity with the case. Outcomes observed in case studies include strengthened motivation and improved real-life communication.