[Caregivers faced with anxiety-depressive disorders in elderly people with severe dementia]

A survey of 104 caregivers in nursing homes assesses their knowledge of anxiety-depressive disorders in patients with severe dementia with aphasia and their proposed treatment. Despite a lack of training, information and tools to assess these disorders and offer adapted care, this survey highlights in particular caregivers' concern for these issues.

Autismus und Pflege. Die Gestützte Kommunikation: Bedeutung und Anwendung in der Pflege von autistischen Menschen mit schweren Handlungs- und Kommunikationsstörungen

Der folgende Beitrag sucht nach evidenzbasierten Pflegemaßnahmen bei schweren Handlungs- und Kommunikationsstörungen, wenn das Störungsbild den Kriterien für Autismus entspricht. Anhand von Beispielen werden die Auswirkungen der Beeinträchtigungen auf den Alltag beschrieben. Es ist offensichtlich, dass die Bezugspersonen der Betroffenen beständig eine sehr anspruchsvolle Pflege leisten müssen, wenn sie den Alltag bewältigen und das Zusammenleben menschlich und sinnvoll gestalten wollen. Vor dem Hintergrund dieser Ist-Situation stellte sich die Frage, wie professionelle Pflege autistische Personen versorgt, die sowohl apraktisch als auch aphasisch sind. Zur Verdeutlichung der autistischen Problematik werden die zentralen Merkmale der Störung anhand des ICD-Schlüssels beschrieben und entsprechende therapeutische Interventionen vorgestellt. Doch weder Autismustherapien noch eine Literaturrecherche nach pflegerischen Konzepten für apraktische und aphasische Menschen konnte die oben formulierte Frage beantworten. Daher untersucht die Verfasserin die Relevanz des pädagogischen Konzeptes der Gestützten Kommunikation für die Pflege. Die weit verbreitete, aber wissenschaftlich umstrittene Methode wird eingesetzt bei apraktischen autistischen Menschen, die nicht sprechen und sich nicht mimisch oder gestisch verständigen können. Praktische Alltagsbeispiele geben einen ersten Eindruck der Anwendung Gestützter Kommunikation. Anschliessend werden die historische Entwicklung, die Zielgruppe und Kernelemente der Methode dargestellt, bei der kommunikative Assessmentverfahren den Ausgangspunkt für eine gezielte körperliche, verbale und emotionale Unterstützung der Betroffenen bilden. Die Darstellung des Konzeptes endet mit der Diskussion bezüglich der Validität der Methode. Um das Wesen apraktischer Störungen besser zu verstehen und darauf aufbauend die Validität Gestützter Kommunikation angemessener einschätzen zu können, wird die Methode mit entsprechenden Erkenntnissen der Medizin und Physiotherapie in Beziehung gesetzt. Basale Stimulation und das Affolter-Konzept ähneln der Gestützten Kommunikation. Sie fokussieren ähnliche Zielgruppen und arbeiten ebenfalls mit Berührung; deshalb werden die Unterschiede und Gleichheiten diskutiert. Abschließend wird die mögliche Anwendung Gestützter Kommunikation in der Pflege im Kontext der vorangehenden Untersuchungen vorgestellt. Die «Handlungsorientierte Pflege» nach Wittneben bildet den Rahmen für die exemplarische Entwicklung eines pflegerischen Assessments und die Beschreibung pflegerischer Maßnamen für autistische Menschen mit schweren Handlungs- und Kommunikationsstörungen. Eine Darstellung relevanter Evaluationskriterien erlaubt den Pflegenden die Einschätzung der Wirksamkeit ihrer Pflege und gibt somit Anhaltspunkte, ob die praktizierte Pflege den Betroffenen tatsächlich hilft.

Caregiver strain and caregiver burden of primary caregivers of stroke survivors with and without aphasia

Little is known about how the burden and strain of caring for stroke patients with or without aphasia affects primary caregivers. This article (a) critically examines the literature on the burden and strain of care experienced by caregivers of stroke patients and (b) examines the relationship between aphasia and caregiver burden and strain. Two literature reviews of three databases were conducted. Fourteen articles (12 quantitative articles, 1 mixed-design article, and 1 qualitative article) were found to comply with the study criteria for the first literature search. A second literature search focused on the effects of stroke survivors' aphasia on caregiving; none of the articles retrieved met the inclusion criteria. This article suggests that there is a lack of research in this area and that several key initiatives are needed, including the development of an instrument with psychometric properties appropriate for assessing the burden and strain on caregivers of stroke patients. Implications for future nursing practice and research are highlighted.

The provision of health information to stroke patients within an acute hospital setting: what actually happens and how do patients feel about it?

This preliminary study describes how health information is provided to stroke patients in an acute hospital and describes their perceptions of health information provision. A further aim was to determine if patients with aphasia were disadvantaged in their receipt of information. Seven stroke patients were observed in hospital for an average of 102 minutes each and then interviewed using a semi-structured interview. When communication occurred, only 17.5% of communication time was spent providing information. Patients with aphasia received information for less time and on fewer topics. Implications regarding approaches to information provision for patients with and without aphasia are discussed.

Finding the words

Communicating with people with aphasia can be fraught with difficulty for both the individual and nurses. A course can help make environments more 'aphasia-friendly'.

'Understanding and being understood' as a creative caring phenomenon--in care of patients with stroke and aphasia

Five care providers particularly successful at communicating with patients with communication difficulties were video-recorded together with three patients with aphasia after stroke, during morning care activities. The care providers were then interviewed immediately after the video-recordings, about their experiences of communicating with such patients. The interviews with the care providers were interpreted by means of a phenomenological hermeneutic method. Co-creating was the main theme found. Care providers invite the patient to participate in the creative act of communication. They have a communicative attitude and show interest in the patients' personal desires. The care providers encounter the patient as a presence in a caring communion. In part, care providers communicate by continuously conveying their presence to the patient and even creating availability in a close and open intersubjective relationship. A relaxed and supportive atmosphere facilitates reciprocity between care provider and patient. The communication is not technical or strategic; instead care providers share the patients' experiences in a silent dialogue. This silent dialogue involves sharing the patients' feelings and thus receiving messages from the patient.

The aphasic person's views of the encounter with other people: a grounded theory analysis

Being affected by aphasia influences the total life experience. The aim of this study was to generate a theoretical model, from a nursing perspective, of what aphasic persons (n = 12) experience in encounters with other people. Data were collected through interviews which adopted a biophysical, socio-cultural and psychological approach and then analysed using grounded theory method. Two main categories emerged, namely: 'interaction' and 'support'. Encountered experiences led to: 'a feeling of having ability'; 'a feeling of being an outsider'; and 'a feeling of dejection or uncertainty'. The feeling state was dependent on whether the interaction was 'obstructed' or 'secure' and on whether the support resulted in 'strengthened' or 'impaired' self-esteem. Therefore nurses need to give support that enhances patients' self-esteem and which results in them gaining a positive and realistic view of their aphasia, as well as involving those around them in this perspective. This then will give the possibility for the patient to turn the interaction process from an obstructed into a secure one.

Understanding between care providers and patients with stroke and aphasia: a phenomenological hermeneutic inquiry

Understanding between care providers and patients with stroke and aphasia: a phenomenological hermeneutic inquiry The present study illuminates the understanding in communication between formal care providers and patients with stroke and aphasia. Five care providers and three such patients participated in the study. Video recordings were made during conversations about pictures (n = 15), and the care providers were also interviewed (n = 15) after the video-recorded conversations. A phenomenological hermeneutic method of interpretation of the interview text was used. The findings showed that a range of conditions for 'understanding and being understood' in the communication on the part of the care providers exists. These different conditions are: lacking both knowledge and understanding; having knowledge but not necessarily accompanied by understanding; and being in understanding. Within the condition 'being in understanding', the care providers create a feeling of at-homeness in a relaxed atmosphere and thus have the opportunity to be in 'understanding and being understood' together with the patient. The condition 'being in understanding' appears in connection with the care providers' creating of a 'calm liturgy of caring' by mediating humility and calm vitality affects to the patients, and further, when needed, being present on the level of mystery, i.e. caring communion.

[Variability in the delivery of care in stroke units: analysis of the protocols]

In spite of the existing guidelines, the strategies and behaviours adopted in the care of the patients admitted to stroke units may vary widely across centres. The aim of this study was to quantify and quality the degree of real variability of the protocols enforced a sample of 13 of such units. There is no uniform behaviour for the monitoring of patients admitted with a stroke: vital signs are collected with different range intervals, i.e. blood pressure 15 for the first 6 hours, from every 15 minutes to 2-3 hours. The assessment of dysphagia can be performed with the swallow test or having the patient drink a spoonful 10 ml of water, or 50 ml without stopping. The variability of behaviours is not, per se, a negative characteristic but it becomes a potential and unacceptable risk when solid evidences of effective practice are available. In the absence of clear cut recommendations the protocols should be defined trying to find a balance between effectiveness of the behaviours recommended and workload for nurses.

The meaning of skilled care providers' relationships with stroke and aphasia patients

Little is known about the reciprocal influence of communication difficulties on the care relationship. To illuminate care providers' lived experiences of relationships with stroke and aphasia patients, narrative interviews were conducted with providers particularly successful at communicating with patients. A phenomenological hermeneutic analysis of the narratives revealed three themes: Calling forth responsibility through fragility, restoring the patient's dignity, and being in a state of understanding. The analysis disclosed caring with regard to the patient's desire, which has its starting point in intersubjective relationship and interplay, in which nonverbal communication is essential--that is, open participation while meeting the patient as a presence. Thus, care providers prepare for deep fellowship, or communion, by being available. They described an equality with patients, interpreted as fraternity and reciprocity, that is a necessary element in presence as communion. The works of Marcel, Hegel, Stern, and Ricoeur provided the theoretical framework for the interpretation.

Communicating with people with stroke and aphasia: understanding through sensation without words

To illuminate the phenomena of 'communicating with people with stroke and aphasia without words', 10 care providers particularly successful at communicating with stroke and aphasia patients who were working at a stroke rehabilitation ward narrated their experiences of communicating with such patients. A phenomenological hermeneutic approach, inspired by Ricoeur's philosophy, was used in the analysis. Two main themes were found: facilitating openness and being in wordless communication. The care providers sensed the feelings of the patients and experienced similar feelings themselves, thus, the communication is guided by the shared feelings between the care provider and the patient, i.e. communion. For this 'communication through sensation' to take place, the following factors were found to be necessary: creative closeness in combination with protective distance; striving for satisfaction and against exhaustion and desperation; meeting the patient halfway to gain understanding; exhibiting attention and accessibility to the patient; and trust and confidence for both care providers and patients. The findings were interpreted and discussed in the light of works by Levinas, Lögstrup and Stern.

[Care of persons with aphasia--a review of the literature]

What patients suffering from aphasia experience was examined by Helmbold et al. (1998). The course of the illness was described and divided into six stages. Other models of recovery processes do not take into account the fact that patients who have suffered a stroke are very often confronted with the problem of speech impairment which leads to a delay in recovery. If patients cannot talk to or interact with friends and relatives or professional carers they find it almost impossible to grasp their own clinical symptoms and ultimately to accept them. Nurses working in general hospitals rarely centre their attention on the individual needs of the patients, with the result that there is little or no interaction between patients with aphasia and their carers. This leads to isolation and depression. Interventions have shown that communication is possible even when there is serious speech impairment. In all attempts to encourage communication however the care and attention shown by nurses to aphasic patients is of decisive importance.

Screening by nurses for aphasia in stroke--the Ullevaal Aphasia Screening (UAS) test

PURPOSE

In Norway, the speech therapist is responsible for the assessment of language impairment after stroke, but many hospitals have no speech therapist. This study therefore developed and evaluated a simple method to be used by nurses to detect aphasia in the acute stage of stroke; the Ullevaal Aphasia Screening (UAS) test.

METHOD

The study was carried out among 37 stroke patients admitted to an acute stroke unit. They were assessed by nurses using the UAS, while the results of a comprehensive assessment by a speech therapist acted as the 'gold standard'.

RESULTS

The predictive value of a positive test was 0.67 and that of a negative test 0.93; only two out of 28 who screened negative on the UAS were diagnosed with mild aphasia by the speech therapist. The weighted kappa coefficient of agreement was 0.83, indicating a strong agreement between the nurses' and speech therapists' scoring. The screening took 5-15 minutes to complete.

CONCLUSION

The Ullevaal Aphasia screening test seems to be a short and valid screening instrument for aphasia in the acute stage of stroke, but further studies would be needed to substantiate the efficacy of the UAS test.

Pragmatics: right brain communication

Neuroscience nurses as well as other health care providers are called upon to assess and implement intervention strategies to assist clients and family members and significant others to communicate in the presence of communication deficits. Language, high level language skills and speech are frequently addressed in presentations and in the literature but pragmatics which includes prosody, attitude, emotions and gestural behaviors is rarely addressed. Pragmatic competence mediated by the right hemisphere, is an equally important and essential component of human communication. An understanding of pragmatics permits the neuroscience nurse to identify and evaluate pragmatic deficits so interventions to facilitate communication can be undertaken. Specifically prosody, that is melody, pause, intonation, stresses and accents, affective tone, subtle grades of meaning and varied emphasis; its components; and aprosodia (lack of prosody) will be discussed. Kinesics, that is limb, body and facial movements, and referred to as pantomime and gestures, will be examined also as will facial expression. Suggestions for pragmatic assessment and therapeutic nursing interventions will be given.

Stroke. Communication difficulties

This paper highlights the problem of non-fluid dysphasia and provides an overview of the complex physical, psychological and social dimension to consider when caring for this client group.

Aphasia: a care study

Aphasia is a term used to describe any deficit in the production or comprehension of speech. Damage to various parts of the brain can give rise to aphasia. The communication problems experienced by patients with aphasia present a unique challenge to the nurse. It is vital that all patients receive a proper assessment of their needs. A holistic approach is required. Nurses should be non-judgmental in their approach and remember the person behind the aphasia.

The Peyote way: implications for Culture Care theory

The development and provision of culturally sensitive and meaningful nursing care is a challenging yet essential element in our rapidly changing health care environment. This article describes the use of the theory of Culture Care to assess, understand, and plan care for an aphasic Navajo man who followed very traditional ways. It is an example of how nursing praxis can be applied to a clinical setting. A description of a Navajo peyote ceremony serves to illustrate the importance of incorporating traditional healing practices into nursing and collaborative care for individuals from diverse culture backgrounds. It also describes how the participation in the Native American Church benefitted the client and his family. By using the Culture Care theory, the authors were able to make predictions about the influences of a culture specific expression, the peyote ceremony, had on the client's care.

Psychological responses in aphasia: theoretical considerations and nursing implications

Patients experiencing aphasia from brain damage due to cerebrovascular accident or craniocerebral trauma manifest psychological and behavioral changes resulting from communication deficits. Although literature is controversial regarding the etiology of the psychological responses, the major determinant of these responses depends upon the premorbid personality. Specific nursing diagnoses focusing on communication, knowledge deficits and grieving are presented with suggested interventions.

Guidelines for treatment of chronic depression in the aphasic patient

This article defines the language disorder of aphasia and the motor speech disorders of apraxia of speech and the dysarthrias. Discussion includes depression and the five definable sets of behaviors related to the phenomenon: motor-expressive behaviors, affective, cognitive, motivational, and somatic, and the relationship of self-concept to both depression and visual and verbal thought. Detailed discussion of treatment of chronic depression inpatients with non-organic reactive factors is presented. These include positive reinforcement of desirable behaviors, avoidance of verbal punishment, labeling the disorder for the client and family, and time structuring or scheduling to assist in motivation. In addition, implementation of support from family, friends, and social relationships, tolerance of expressions of frustration and anger by the client, and environmental manipulation are considered therapeutic interventions.