Supporting communication for people with aphasia in stroke rehabilitation: transfer of training in a multidisciplinary stroke team

Abstract

Background: Participation of people with aphasia in clinical care and rehabilitation is an area of increasing research interest. Supported communication (SC) training, which aims to enhance the participation of aphasic patients, has been shown to improve conversation partner knowledge and skills. However, there is a lack of evidence for transfer of SC training to practice in post-acute rehabilitation settings.

Aims: We aim to develop an understanding of causal mechanisms implicated in the transfer of SC training by examining the nature of the setting, staff perspectives, and the situated character of the action.

Methods and Procedures: Twenty-eight staff from a multidisciplinary team were trained in SC. We collected detailed and varied data, including staff experiences of SC training and implementation, and video data of routine practice. Using a critical realist approach, we develop explanatory mechanisms for barriers to and enablers of transfer. Eleven team members (nursing, therapy, and assistant staff) took part in focus groups and interviews at the end of the study; 54 learning logs were collected over a 10-month period. Six aphasic patients and eight staff took part in video-recordings of therapy and care sessions.

Outcomes & Results: Three main themes derived from staff experience data are linked to key components of the setting, indicating processes implicated in transfer of training, and impacting on outcomes such as perceptions of quality and staff confidence. Barriers, constraints, and problem-solving approaches in enacting SC were evidenced through patient factors, spaces and events, and time constraints. Staff flexibility and team working were key factors in problem-solving these obstacles. Staff reported responsive use of skills and resources and perceived impact of SC training, with most, but not all, staff reporting benefits, including increased confidence in interactions with aphasic patients. Activity analysis of video data illustrates how some mechanisms may be operating in practice, with evidence of rich use of interactional strategies and resources; a focus by staff on getting the work done; opportunities for patient active participation or emotional support that are realised or not; strategies for aphasia-related trouble and repair sequences.

Conclusions: This model of SC training has clear benefits for staff communication practices and confidence, but transfer of training is subject to complex processes. Training should therefore address systems-level practices and be extended for staff who need more advanced skills. The values implicit in SC have the potential to create a culture of access and inclusion, encouraging and supporting active participation of all stroke patients.

Keywords:

• aphasia
• supported communication
• multidisciplinary
• post-acute stroke rehabilitation
• training transfer
• critical realism

Disclosure statement

The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR, or the Department of Health. No potential conflict of interest was reported by the authors.

Acknowledgements

We would like to acknowledge the contributions of all members of the SCIP-R research team, Trial Steering Committee, and study sponsor to the project from which this paper is drawn. Great thanks go to all staff and patient participants, and to the Norfolk Conversation Partners and aphasia experts from Cambridge for their invaluable contributions.

Additional information

Funding

This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme [grant reference number PB-PG-0609-17264].