O'Brien, Rebecca
(2019)
The development of a communication skills training intervention for healthcare professionals caring for people with dementia in the acute hospital setting: an applied conversation analytic study.
PhD thesis, University of Nottingham.
Abstract
A quarter of acute hospital beds are occupied by people with dementia. Concerns have been raised by government and carers about the quality of communication between staff and those with dementia in hospital in the UK. People with dementia may experience communication impairments such as word finding difficulties, repetitive utterances, lack of coherent speech narratives and difficulties understanding the speech of others. Since much healthcare delivery occurs through ‘talk’, healthcare professionals and hospital patients with dementia are likely to experience increased communication barriers. Consistent with this, healthcare professionals report stress and reduced job satisfaction associated with difficulty communicating with their patients with dementia.
In other contexts, communication skills training for healthcare professionals and for carers of people with dementia has been found to be effective at improving communication confidence, knowledge and skills. However, no effective training intervention has been found which addresses the specific context of communication between healthcare professionals and acute hospital patients with dementia. In addition, the existing evidence does not clearly indicate what the content of such training should be and is not based on actual interactional evidence.
This thesis presents an applied conversation analytic study which therefore sought to develop an evidence-based, deliverable communication skills training intervention by answering the following questions: what should we train, how should we train and can we train healthcare professionals to communicate more effectively in this context?
In identifying what should be trained, a systematic review of communication skills training in the context of dementia found no high quality studies demonstrating an effective communication skills training intervention for communication partners of people with dementia in the hospital setting. An empirical study was therefore embarked on to uncover what communication practices healthcare professionals could be seen to use which worked to smooth the interactional journey for both them and the person living with dementia. Video recordings were made of 41 naturally occurring interactions between registered healthcare professionals (nurses, doctors and allied health professionals) and inpatients with dementia and analysed using conversation analysis.
The analysis revealed that problems occurred frequently in two phases of the interaction: during the business phase, when patients were asked to carry out important healthcare tasks which they were frequently reluctant to do; and when interactions were difficult for the healthcare professional to close. When a patient displays reluctance or overtly refuses, the healthcare professional faces a dilemma in trying to complete a task in the patient’s best interest whilst attempting to respect the autonomy and wishes of the patient before them. The analysis described in this thesis unpacked the different ways in which healthcare professionals made their requests in terms of ‘entitlement’ and ‘contingency’ and how these could be seen to impact on the responses of patients.
The communication practices which worked best in the context of refusals and closings were identified as the ‘trainables’ and were presented along with other evidence to an expert intervention development panel for detailed consideration. The intervention design process allowed for expert considerations to inform the decision making and operationalisation by the relevant participants of ‘how we should train’.
The result was the development of ‘VOICE for Dementia’, a two day, interdisciplinary training course for registered healthcare professionals. The intervention included the use of a combination of experiential teaching methods, including conversation analytic-based video analysis and the use of specially trained simulated patients for practice development. ‘Can we train’ was tested by piloting the training intervention once with a small group of relevant professionals. Feedback from participants was gathered and used to modify the intervention, ready for testing in a feasibility study.
The findings of the study contribute to what is known about communication for people living with dementia when in hospital, and in particular to studies of patient reluctance, caregiver requesting and person-centred dementia care. The communication skills training intervention developed fits with identified training needs within the UK health service and contributes to existing knowledge about developing training based on conversation analytic findings. The implications for clinical practice, training policy and future research are discussed.
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