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Exploring the Opportunities & Barriers to
Communication for People with Dementia in an
Acute Inpatient Hospital Environment
2010
Word count: 4,970
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Abstract
Aim: To investigate communication barriers and facilitators for people with dementia
in an acute hospital setting.
Background: Modifications to the environment in long-term settings can improve
functioning in people with dementia. There is a lack of research on the hospital
setting.
Methodology: The researcher used qualitative and quantitative methodology. Six
people with dementia, six communication partners and six nurses in an acute
hospital were recruited.
Results and Implications: All reported communication difficulties. Communication
barriers and facilitators were identified and explored, which is vital to tailoring
person-centred Speech and Language intervention and ultimately improving people
with dementias quality of life.
Acknowledgments
It is with deep gratitude that I acknowledge all those involved in the development of
this research.
Sincere thanks to the staff in the hospital, the Speech and Language therapy
department, the staff of the specific ward, the Director of the ward and the Clinical
Nurse Manager. The excellent support and guidance the supervising Speech and
Language Therapist in the hospital continuously imparted was deeply appreciated.
Without the involvement of all the participants including the people with dementia,
their primary communication partners and staff nurses this research would not have
been possible, therefore I am sincerely grateful to them.
I wish to wholeheartedly thank my supervisor for her constant support, enthusiasm,
guidance, and advice. Her knowledge and expertise were invaluable in the
completion of this study.
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Table of contents
ContentsPage
Abstract and Acknowledgements
1
List of Tables
5
List of Figures
5
Chapter One: Introduction
1.1 Introduction
6
1.2 The Research Aims
7
Chapter Two: Literature Review
2.1 Introduction
8
2.2 Dementia Care
8
2.3 The role of the Environment in Dementia care
9
2.3.1 The Acute Hospital Environment
10
Chapter Three: Methodology
3.1 Introduction
13
3.2 Research Methodology & Design
13
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3.3 The Research Tools
14
3.3.1 The Inpatient Functional Communication Interview (IFCI)
14
3.6 Participants
14
3.6.1 The Facility
14
3.6.2 Groups of Participants
15
3.6.3 Recruitment and sampling method
15
3.6.4 Selection criteria
15
3.6.4.1 The Primary Communication Partner163.6.4.2 The Staff Nurse
16
Chapter Four: Results
4.1 Introduction
17
4.2 Which communication situations posed difficulties in the interview withthe person with dementia?17
4.3 Which communication situations did the PCP perceive the person with
dementia to have most difficulty with?
18
4.4 Which communication situations did the staff nurse perceive the person
with dementia to have most difficulty with?
19
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4.5 What barriers and opportunities to communication were identified in the
Acute Hospital Environment?
21
4.5.1 Routines in the Environment
21
4.5.2 Differences in the Environment
21
4.6 Qualitative analysis: Barriers to communication
23
4.7 Qualitative analysis: Opportunities to communication
24
Chapter Five: Discussion
5.1 Introduction
25
5.2 Hospital communication situations challenging people with dementia
25
5.2.1 Communication difficulties: Person with dementia interview
25
5.2.2 Communication difficulties identified by the PCP
25
5.2.3 Communication difficulties identified by the staff nurse
27
5.3 Communication barriers: The Environmental Checklist
28
5.4 Qualitative exploration: Barriers to communication
29
5.5 Qualitative exploration: Opportunities to communication
29
5.6 Clinical Implications
30
5.7 Methodological Limitations
30
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5.8 Future Recommendations
31
5.9 Summary
33
References
34
Appendices
Appendix 1 Ethical Considerations and Approval
Appendix 2 Validity and Reliability of the Research Tools
Appendix 3 Selection Criteria
Appendix 4 Data Collection Procedure
Appendix 5 Data Preparation for Analysis
Appendix 6 Person with dementia Information Leaflet
Appendix 7 Primary Communication Partner Information Leaflet
Appendix 8 Staff Nurse Information Leaflet
Appendix 9 The Interview Schedule
Appendix 10 The Inpatient Functional Communication Interview (IFCI)
Appendix 11 The adapted version of the IFCI
Appendix 12 The Staff Questionnaire
Appendix 13 The Environmental Checklist
Appendix 14 Transcriptions
Appendix 15 Results of interviews and questionnaire
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List of Tables
Table Title
Page
Table 2.1 Lubinskis Ten Factors of a Communication Impaired Environment
9
Table 2.2 Barriers and Facilitators to communication in long-term settings
10
Table 2.3 Assessing receptive skills and facilitating receptive difficulties
11
Table: 2.4 Assessing expressive skills and facilitating receptive difficulties
12
Table 3.1 People with Dementia participating in the Study
15
Table 3.2 Profile of PCPs
16
Table 3.3 Nurse participants
16
Table 4.1 IFCI interview scores: The communication situations posing
difficulties for the people with dementia
17
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Table 4.2 PCPs perspective: The communication situations posing
difficulties for the people with dementia
18
Table 4.3 Staff Nurses perspective: The communication situations
posing difficulties for the people with dementia
19
Table 4.4 Barriers to communication for people with dementia in hospital
23
Table 4.5 Opportunities to communication for people with dementia in hospital
24
Table 5.1 Communication facilitators suggested by a PCP
26
Table 5.2 Examples of difficulties in communication situations important for
assessment in the acute hospital setting
27
List of Figures
Figure Title
Page
Figure 4.1 Total scores in %: Person with dementia, PCP and Staff
nurse perspective
20
Figure 4.2 The person with dementias communicative ability to ask
questions about his/her care
20Figure 4.3 Average dB noise levels in all wards and the private room
22
Figure 5.3 Model of care pathway to reduce barriers and maximise
opportunities to communication in the Acute Hospital setting
32
Chapter 1
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1.1 IntroductionbyIndividuals with dementia represent the fastest growing clinical population served by
speech and language therapists (Mahendra & Arkin, 2003: 396).In Ireland there are
currently more than 44,000 people living with dementia. The number of people with
dementia is expected to be in excess of 104,000 by 2036 (Alzheimers Association of
Ireland, 2009).
Dementia is a progressive disease in which different difficulties emerge
through the various stages depending on the person. Every person who
experiences dementia does do in their own individual way, but there is usually a
decline in memory, reasoning and communication skills and a gradual loss of the
skills needed to carry out daily activities (Royal College of Speech & Language
Therapists (RCSLT), 2005: 5).
By increasing their knowledge of what it is like to be a person with dementia,
Speech and Language therapists (SLTs) and other medical professionals can offer
more person-centred intervention and learn how to facilitate communication with
people with dementia. With the personhood focus people with dementia may be
better equipped to communicate, delay their loss of interpersonal relations,
autonomy, identity, self-worth and remain at home for as long as possible (De Boeret al, 2007). The SLT can be involved in diagnosis, identifying barriers and
facilitators to communication and tailoring intervention by reducing difficulties and
maximising opportunities while monitoring the changes to communication and
language skills (RCSLT, 2005).
This researcher has both clinical and personal experience of working with
people with dementia. On clinical placement it became clear that an acute hospital
admission can be a more serious challenge for people with dementia with
communication and cognitive deficits. People with dementia often have difficulty
verbally expressing their everyday needs and when removed from their usual
environment, they struggle to cope with the complex nature of their everyday routine.
The busy acute hospital ward environment, necessitated by the nature of the care in
hospital, can often cause anxiety and agitation in a person with dementia. Sparks
(2008: 65) suggests that for people with dementia, the unfamiliar environment,
routines and caregivers coupled with decreased physical health, new medications
and procedures can increase confusion. Research has shown that while the
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environment can affect cognition and communication, modifications do appear to
improve functioning in people with dementia (Brush & Calkins, 2008).
To date, studies exploring the influence of the environment on the
communication successes, or failures, of people with dementia have been primarily
focused on the long term care setting (OHalloran, Worrall & Hickson, 2009). Many
people with dementia however spend a considerable length of time receiving medical
treatment in an acute hospital often whilst awaiting long term care placement. There
is a paucity of information on the acute in-patient hospital environment and how this
environment can increase communication disability for people with dementia
therefore it would seem advantageous to broaden the focus of this research to this
unique environment.
1.2 The Research Aims
The aim of this study is to identify the communication barriers and facilitators that
exist for people with mild to moderate dementia whilst an in-patient in an acute
hospital setting. The results will assist in identifying opportunities and methods to
disable barriers to communication in the acute setting for people with dementia so
that in the future they can be facilitated to function at their maximum capacity.
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Chapter 2
2.1 IntroductionThis chapter explores the relevant literature with regards to the research aims.
2.2 Dementia Care
Speech-language pathologists providing servicesface particular challenges when
it comes to managing the communication and memory consequences associated
with dementing illnesses (Tonkovich, 1999: 9). SLTs must face these challenges.
Potential ramifications of a lack of effective communication include medical risk to
patients they may not be able to communicate adequately about their medical
careare at risk for high levels of anxiety and frustration (Finke, Light & Kitko,
2008: 2103). According to Cummings (2004) challenging verbal behaviour such as
yelling can be a result of frustration and anxiety due to communicative difficulties.
The challenging behaviours impact on the care of the person with dementia and
ultimately their quality of life; Communication is the hallmark to quality care (Levy-
Storms, 2008: 9).
Tom Kittwoods book Dementia reconsidered: the person comes first
(Kittwood, 1997) paved the way for the notion of personhood in dementia
intervention. Personhood aims to consider the social dimension of the person with
dementia. People with dementia should receive person-centred care and services
which respect them as individuals and which are arranged around their needs
(RCSLT, 2005:8). In order to identify their needs, people with dementia must be
actively included in research on intervention strategies which ensure that those
people who have dementia are not penalized for losing their communication skills
(Cheston, 2000: 471).
OShea (2007) argues for a progressive approach to dementia care in Ireland
where a person-centred approach would facilitate people with dementia having their
voices heard (OShea, 2007: 3). In order to improve the person-centred care and
the quality of life of people with dementia it is imperative to explore the opportunities
and barriers to effective communication. A factor in the environment that assists a
persons functioning is described as a facilitator or opportunity, while a factor in the
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environment that serves to hinder a persons function is described as a barrier
(WHO, 2001).
2.3 The role of the environment in dementia care
In OSheas frameworks for dementia services in Ireland (OShea & OReilly, 1999,
OShea, 2007) he argues for environmental modification giving the accumulating
evidence on the affect of design on the well-being of people with dementia (OShea
& OReilly, 1999: 24). The modification of the environment in dementia care is an
area in the long-term care setting which in 1999 was described as being much
neglected (OShea & OReilly, 1999). In 2007 unfortunately this had not changed(OShea, 2007).
As reported by OShea (1999, 2007) research exists for the benefit of
analysing the long-term care environment. Lubinski (1995) analsyed the long-term
care setting and proposed ten factors which characterise a communication impaired
environment highlighting the barriers this environment can pose for people with
dementia (See Table 2.1).
Table 2.1 Lubinskis Ten Factors of a Communication Impaired Environment
1 Lack of sensitivity to the value of communication; people talking for persons with
dementia
2 Restrictive rules such as not talking to those with severe communication disorders
3 Few or no willing or qualified communication partners
4 Few reasons to talk
5 Individuals perceptions that they have little meaningful contribution
To their environment through communication.
6 A lack of private places for communication
7 Limited accessibility to activities and communication partners
8 Sensory confusion and deprivation in the environment
9 Social stagnation with lack of communication stimulation
10 Environment does not support the particular needs of caregivers
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Brush and Calkins (2008) also identified barriers and facilitators to communication
presented by the environment in long term care facilities (See Table 2.2).
Table 2.2 Barriers and Facilitators to communication in long-term settings
(Brush & Calkins, 2008)
Barriers Facilitators
Rooms looking the same and having
no signs: People with dementia may
get easily lost, wander, feel
frustrated and anxious.
Good signs, photographs (of the person), pictures from
home, cues and landmarks to make the environmental
features (e.g. bathroom door) more distinctive for the
person with dementia. Paint the room the persons
favourite colour, have favourite pieces of art,
personally meaningful cues. Display personal objects
outside the door so know where their room is.
Small size of signs and lack of
visual contrast.
Signs should be large, simple and have good visual
contrast with their background.
Dark lighting, light only coming from
the ceiling.
Good lighting so can see signs. Factor in some people
may just look at the floor or be in wheelchairs.
Noisy environment (e.g. mealtime). Improve the acoustics, have quiet rooms.
The environment should be designed to match the persons abilities so he/she can
perform better. This research is important as it highlights the role SLTs can
play and need for further research; we have a great opportunity to make a realdifference in residents lives by looking at and listening to what the p hysical
environment is telling us (Brush & Calkins, 2008: 25).
2.3.1 The acute hospital Environment
Patients who have communication related impairments experience difficulty
communicating their healthcare needs when they are in hospital (OHalloran et al,
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2009: 206). Ineffective communication can result in patients receiving inadequate
and inappropriate healthcare in hospital, leaving them feeling distressed and angry.
While research exists for improving care and communication in long-term
settings, there is a lack of research in the acute hospital setting (Miller, 2008). Miller
proposes techniques to improve communication with hospitalised older adults with
dementia. These techniques are based on research by Small (2003) and Perry
(2005) who analysed the effectiveness of communication strategies used by carers
of people with dementia. Millers (2008) assessment questions highlight the
impairment and barriers to communication, while the techniques propose
opportunities and facilitators for communication (see Table 2.3 & 2.4).
Table 2.3 Assessing receptive skills and facilitating receptive difficulties
(Miller, 2008)
Questions to assess
receptive skillsOpportunities/ Facilitators to difficulties
Can the patient
understand a yes-no
choice?
Verify the answers when appropriate, e.g. if the person says no
to asking them about pain but you can see it in their facial
expression, point to the site and repeat the question.
Can the patient read
simple instructions?
Use a printer or carefully write out large, bold, black letters on
white signs for legibility
Can the patient
understand simple
verbal instruction?
Identify what words and simple expressions the patient and
his/her family commonly use.
Can the patient
understand instructions
given with physical
cues?
Identify what cues the person with dementia knows and use
them to get the patients attention, use touch, reinforce all verbal
instructions with nonverbal communication e.g. demonstrate
how to use the call light and show them how you respond to it.
Can the patient make a
choice when presented
with two objects or
options?
Identify what the patient understands better and use e.g. yes/
no questions, meat versus pork, beef, ham
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Table 2.4 Assessing expressive skills and facilitating receptive difficulties
(Miller, 2008)
Questions to assess
expressive skillsFacilitating difficulties
Does the patient have difficulty
finding the correct word?
Identify any common words the patient uses, ask
him/her to describe it/point to something, recognize the
person may be frustrated with this and offer support
and time for them to answer.
Does the patient have difficulty
creating sentences or a logical
flow of idea?
Identify key concepts in the conversation and ask for
feedback. E.g. Im guessing that youre going to ask a
question about what the doctor said, is that right?
Does the patient curse, use
offensive or aggressive
language, or exhibit aggressive
or combative behaviours?
Recognise that these behaviours are usually attempts
to communicate in the only way the patient is able to
and could indicate the patient has unmet needs.
Acknowledge the feelings and provide reassurance.
Find out what conditions provoke anxiety.
Does the patient avoid
verbalization altogether or
mutter in tones that may seem
meaningless to others?
Identify if any conditions encourage this e.g. When
blood is drawn, find out if the verbalizations have
meaning.
The limitation of this article is its lack of evidence specific to the acute hospital
setting. In the Irish context OShea (1999, 2007) argues that people with dementia
should receive appropriate treatment in the acute hospital setting where he
estimates 18% of beds are occupied by people with dementia. This study therefore
aims to address the lack of research on the acute hospital environment by focusing
specifically on identifying communication barriers and facilitators for the person with
dementia in this setting.
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Chapter 3
3.1 IntroductionThe methodology of this research needs to address the questions raised regarding
the communication opportunities and barriers for people with dementia in the
hospital setting.
3.2 Research Methodology & Design
The qualitative tool of a semi-structured interview was used to gain insight into the
subjective experiences in the acute hospital of the person with dementia and their
primary communication partner (PCP), while the nurses perspective was gained
using another qualitative tool, a questionnaire. Qualitative designs are praised forgenerating rich, detailed data that leave the participants' perspectives intact and
providing a context for behaviour, however they can be criticised for being
subjective, difficult to replicate and lacking generalisation (Sarantakos, 2005).
Quantitative methodology was also used allowing for objective comparisons to
be made. A between subject design was used to compare the perspectives of the
individuals involved in this study. Quantitative researchs strength lies in its ability to
produce quantifiable and reliable data that can usually be generalised to a larger
population, however its weakness lies in the fact that it can decontextualise human
behaviour from reality and ignore the effects of variables on this behaviour
(Weinreich, 2009).
This study involved three stages in exploring:
1. The person with dementias experience
2. The experience of the PCP and staff nurse
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3. Investigating the person with dementias environment: the acute hospital
setting.
Ethical considerations for the project are examined in Appendix 1.
3.3 The Research Tools
Four tools were used in the research study:
1. The Inpatient Functional Communication Interview (IFCI) (OHalloran, Worrall,
Code, Hickson, 2004) (Appendix 6) was used to interview the person with
dementia.
2. An adapted version of the IFCI (OHalloran et al, 2004) (Appendix 7) was used to
interview the PCP and allow for comparison with the perspective of the person
with dementia.
3. The Staff Questionnaire section of the IFCI (OHalloran et al, 2004) (Appendix 8)
was used to explore the perspective of the nurse on the communication abilities
of the person with dementia in the acute hospital setting and compare with the
perspectives gathered from the person with dementia and the PCP.
4. An Environmental Checklist (Appendix 9) was specifically devised to identify any
opportunities or barriers to communication in the acute hospital setting.
3.3.1 The Inpatient Functional Communication Interview (IFCI)
The interview structure of the IFCI matched the aims of the research: The Inpatient
Functional Communication Interview...has been specifically designed to measure how
well a patient is able to communicate his or her healthcare needs in the acute hospital
setting(OHalloran et al, 2009: 440). The IFCI structure allows for replication while its
scoring system allows for comparison and generalisation. The validity and reliability of
all the research tools are discussed in Appendix 2.
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3.4 Participants
3.4.1 The Facility
One acute hospital ward in a large Irish teaching hospital was selected. Twenty-fivepatients reside in the ward where the ratio of nurse to patient is 6:1. Two SLTs and care
assistants are assigned to the ward. The ward has private rooms, two wards of 6 people
each (one male and one female ward) and one acute stroke unit with 4 beds.
3.4.2 Groups of Participants
There were three groups of participants:
1. The person with dementia.
2. The person with dementias PCP.
3. The person with dementias staffnurse.
3.4.3 Recruitment and sampling methodThe research supervisor first gained verbal consent from the director of the acute
ward. The Clinical Nurse Manager (CNM) on the ward was then given written
information on the study (Appendix 4) and invited to participate. The CNMs role was
to act as gatekeeper and assist in participant recruitment in collaboration with the
research supervisor. For Data Collection Procedures see Appendix 4.
3.4.4 Selection criteriaFrom the current nursing records, the CNM identified six people with dementia who
met the inclusion criteria (see Appendix 3). The people with dementia had mild to
moderate dementia, as defined by the Mini Mental State Examination (MMSE)
(Folstein, Folstein & McHugh, 1975). The people with dementia were the primary
group for recruitment, while the PCP and nurse were recruited following the person
with dementias consent to participate in the research.
Table 3.1 People with Dementia participating in the Study (N = 6)
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The age of participants ranged from 76 to 85 with the average age being 81. Four of
the participants were male, while two were female.
3.4.4.1 Primary Communication Partners (PCPs)
The person with whom the individual with dementia resides or sees on a daily/weekly
basis.
Table 3.2 Profile of PCPs (N = 6)
Person with
dementia ID
Gender of
PCP
Relationship of PCP to
person with dementia
PCP living with person
with dementia?
1 Female Daughter No
2 Female Wife Yes
3 Female Daughter No
4 Male Son No
5 Female Wife Yes
6 Female Daughter in law No, but close neighbour
3.4.4.2 Staff Nurse
The staff nurse was the nurse involved in the person with dementias care at the time
of data collection. Each person with dementia had a different nurse.
Table 3.3 Nurse participants (N=6)
Person with dementia Staff Nurse ID
1 N1
ID Gender Ward type Age in years MMSE score
1 Male Male ward 76 13/30
2 Male Own room 83 19/30
3 Male Acute ward 83 22/304 Female Female ward 85 14/28
5 Male Male ward 76 16/30
6 Female Female ward 84 19-23/30
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2 N2
3 N3
4 N4
5 N56 N6
For Preparation of Data for Analysis please see Appendix 5.
Chapter 4
4. 1 IntroductionThis chapter presents the results of the data collection.
4.2. Which communication situations posed difficulties in the
interview with the person with dementia?
The communication situations that pose the greatest challenges to people with
dementia when in the acute hospital setting were identified (Table 4.1).
Table 4.1 IFCI interview scores: The communication situations posingdifficulties for the people with dementia
Mostdifficultsituation
ranking
Communication situation in theacute hospital setting
Successfulcommunication
Partialsuccessful
communicationUnsuccessful
communication
1 Understanding the medical diagnosis or reasonfor admission
0% 17% 83%
2 Understanding descriptions (delayed recall) 0% 33% 50%
3 Understanding the implications of the currentmedical condition
17% 33% 50%
4 Understanding descriptions 17% 33% 33%
5 Telling you about any current medical concerns 17% 67% 0%
6 Following instructions 17% 83% 0%
7 Telling you about preadmission medical history 33% 67% 0%
8 Gaining the patient's attention 50% 50% 0%
8 Telling you what has happened to bring them to
hospital
50% 50% 0%
8 Telling you about pain or discomfort 50% 50% 0%
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8 Asking for something 50% 50% 0%
9 Asking you questions about the care 67% 33% 0%
10 Calling for a nurse 67% 33% 0%
11 Expressing feelings 83% 17% 0%
12 Telling you what they do or do not like 100% 0% 0%
This table shows that the 6 people with dementia all had communication difficulties
understanding the medical diagnosis or reason for admission. Although 17% could
give a partial indication, 83% did not communicate it at all. However all 6 people with
dementia did successfully communicate what they did and didnt like.
4.3 Which communication situations did the PCP perceive the
person with dementia to have most difficulty with?
The perspective of the PCP on the communication situations that are difficult for
people with dementia are detailed in Table 4.2.
Table 4.2 PCPs perspective: The communication situations posing difficultiesfor the people with dementia
Mostdifficultsituationranking
Communication situation inthe acute hospital setting
Successfulcommunication
Partialsuccessful
communication
Unsuccessfulcommunication
1 Telling you about preadmission medical history 0% 0% 100%
2 Telling you what has happened to bring them tohospital
0% 17% 83%
3 Understanding descriptions 0% 67% 33%
4 Asking you questions about the care 17% 0% 83%5 Understanding descriptions (delayed recall) 17% 17% 67%
5Understanding the medical diagnosis or reasonfor admission 17% 17% 67%
6 Following instructions 17% 50% 33%
7 Telling you about any current medical concerns 33% 33% 33%
7 Understanding the implications of the currentmedical condition
33% 33% 33%
8 Expressing feelings 50% 0% 50%
8 Calling for a nurse 50% 0% 50%
9 Gaining the patient's attention 67% 33% 0%
10 Asking for something 67% 0% 33%
11 Telling you about pain or discomfort 83% 0% 17%11 Telling you what they do or do not like 83% 0% 17%
N.B.: N= 60% Successful Communication = no person with dementia interviewed communicated successfully in thissituation100% Successful Communication = all 6 people with dementia communicated successfully in this situation
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This table shows that the PCPs reported that none of the 6 people with dementia
could tell you about preadmission medical history. However they did report that 83%
of the people with dementia could successful tell if they had a pain or discomfort and
what they do or do not like, the later of which agrees with the person with dementias
scores in what the least challenging communication situation is for the person with
dementia while in hospital.
While the PCPs did report 67% of the people with dementia have difficulty
understanding the medical diagnosis or reason for admission, they reported greater
difficulty with telling you about preadmission medical history, what happened to bring
them into hospital, understanding descriptions and asking questions about the care.
4.4 Which communication situations did the staff nurse perceive
the person with dementia to have most difficulty with?
The perspective of the staff nurse on the communication situations that are difficult
for people with dementia are detailed in Table 4.3.
Table 4.3 Staff Nurses perspective: The communication situations posingdifficulties for the people with dementia
Mostdifficultsituationranking
Communication situation in acute hospital setting Always Sometimes Never
1 Understanding the medical diagnosis or reason foradmission 0% 50% 50%
2 Telling you about preadmission medical history 20% 40% 40%
3 Asking you questions about the care 33% 0% 67%
4 Calling for a nurse 50% 0% 50%
4 Telling you what has happened to bring them to hospital 50% 0% 50%5 Telling you what they do or do not like 50% 33% 17%
5 Telling you about any current medical concerns 50% 33% 17%
5 Understanding descriptions 50% 33% 17%
6 Understanding the implications of the current medicalcondition 67% 0% 33%
7 Telling you about pain or discomfort 67% 17% 17%
7 Asking for something 67% 17% 17%
8 Expressing feelings 67% 33% 0%
9 Gaining the patient's attention 100% 0% 0%
9 Following instructions 100% 0% 0%
Understanding descriptions (delayed recall)
not
asked not asked
not
asked
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This table shows that the nurses reported that none of the 6 people with dementia
could always understand what their medical diagnosis or reason for admission was
which agrees with what the person with dementia was reported to have the most
difficulty with. However the nurses did report that all the people with dementia always
followed instruction and paid attention, which differed from both the PCPs
perspective and the interviews with the people with dementia.
Figure 4.1Total scores in %: Person with dementia, PCP and Staff nurse perspective
As per Figure 4.1 the scores on the communication difficulties and success of the
person with dementia in the hospital setting differed from the person with dementia,
the PCP and the nurse. One situation which differed remarkably for the researcher
was the discrepancy between the three perspectives regarding the person with
dementias communicative ability to ask questions about his/her care while in
hospital. The difference in scores can be seen in Figure 4.2.
39%
43%
18%
36%
19%
46%
59%
17%
24%
0%
20%
40%
60%
80%
100%
Percentage of total
asked
Person with
dementia
PCP Staff Nurse
Three perspectives
Total communication situation scores: Person with Dementia, PCP and
Staff Nurse perspective
Unsuccessful communication
Partial communication
Successful communication
33%
0%67%
17%
0%
83%
Staff nurse perspective PCP perspective
Person with dementia
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Figure 4.2 The person with dementias communicative ability to ask questions about his/hercare.
4.5 What barriers and opportunities to communication
were identified in the Acute Hospital Environment?
The Environmental Checklist was conducted in the male and female wards, one
private room and one acute ward setting.
4.5.1Routines in the Environment
The routines for all people with dementia were the same for mealtimes:
8:00 - 8:10am for breakfast
12:00 - 12:15pm for lunch
5:00 - 5:15pm for tea
Medication was distributed at mealtimes. Rehabilitation was variable for all and
visiting times were between 2:00 - 4:00 pm and 6:30 - 8:30pm.
4.5.2 Differences in the Environment
As per the researchers opinion lighting in the wards was adequate for all of the
people with dementia. However, the person with dementia in the private room did not
have adequate light at his bedside for reading the newspaper. No signage for the
toilet was visible in any of the wards or the private room. This was particularly
noticeable in the private room which had its own bathroom but no sign on its door to
indicate this was the bathroom. The person with dementia and the PCP commented
on the confusion this caused the person with the dementia. There were no signs for
the dining area or exits in the wards or the private room.
Orientation cues in the wards and the private room differed. While there was a
clock above the door in each of the six person wards and in the private room there
was no clock in the acute ward. No personal watches or calendars were present and
33%
0%
67%
Successful
communication
Partial successful
communicationUnsuccessful
communication
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newspapers were only by the beds of two people with dementia interviewed.
However they commented that they had been left in by visitors.
Noise levels in the ward, the acute ward and the private room were recorded
as per Figure 4.3.
Figure 4.3 Average dB noise levels in all wards and the private room
There was no significant difference in decibel levels between the general ward and
bedside for each person with dementia. The lowest averages were found in the
private room; however the highest dB levels were recorded in the acute ward which
was expected to be the quietest area.
Average dB noise levels: All wards & private room
47.5
43
58.7
47.5
52.5
47
40
42
44
46
48
50
52
54
56
58
60
1 2 3 4 5 6
Person with dementia ID
AveragedB
leval
General Ward Area
Person's bedside
ID Ward type
1 Male ward
2 Privateroom
3 Acute ward
4 Femaleward
5 Male ward
6 Femaleward
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4.6 Qualitative analysis: Barriers to communication
Four key themes arose in the qualitative analysis of the interviews, questionnaires
and Environmental Checklist which highlighted the barriers to communication for a
person with dementia in an acute hospital setting. The themes are environmental
factors, communication partners, hospital procedure and external communication
aids. The extracted sub-themes were grouped under each of the four key themes as
per Table 4.4.
Table 4.4 Barriers to communication for people with dementia in hospital
Themes Sub themes Illustrative quotes
Environmentalfactors
- A lack of signage for e.g. thetoilet
- The noise in the wards causedby visitors and other patients
P2:youd want (to be) a really a tough guy tofind your way (to the toilet)
P5: I would have a lot of trouble sleeping fromthe NOISE
Communicationpartners
- Lack of time to interact withstaff in the hospital
- The use of complex commands- The use of complex and
lengthy language- A lack of understanding of the
communication difficulties of aperson with dementia e.g. wordfinding difficulties, recall
difficulties, hallucinations, pastmemories
P6: talking you find in hospital is only whenpeople come and visit
P3:some of them (doctors) you tell them whatis wrong use certain sentenceslongsentences
5/6 PCPs reported: person with dementia hasdifficulty with following complex command. In
contrast Staff nurses reported all persons withdementia to always have ability to followsimple and complex commands.
Hospitalprocedure
- Lack of explanation ofinformation taking account ofthe person with dementia
- Lack of written information- Delays- Lack of explanation of hospital
facilities e.g. the remote- Lack of counseling for
expression of feelings
5/6 persons with dementia said they receivedno written information, 1/6 said she did butdidnt know what it was5/6called the nurse by calling nurse anddidnt know they could use the remote to callthe nurse or for the radioP1:they (the nurses) arrive for about half anhour later and thats the sometimes I donteven call them at all
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diagnosis, implication ofmedical condition
- Routine, familiarity
with allPCP: Printouts would help
Externalcommunication
Aids
- Use of hearing aids,glasses and dentures
- Use of visualcommunicative aids
P4: she commented that it would help if I(researcher) spoke louder due to her
hearing difficulty and lack of hearing aid.Researcher: Visual modeling was usedeffectively in the research to explainquestions.
Chapter 5
5.1 Introduction
The results presented in the previous chapter are discussed in relation to the
research aims.
5.2 Hospital communication situations challenging people
with dementia
The study confirmed that the acute hospital setting poses serious challenges to the
communication effectiveness of a person with dementia. When analysing the total
results, difficulties were reported in 13 communication situations for the people with
dementia, 14 by the PCP and 13 by the nurses. The severe challenges of the acute
hospital environment to people with dementia correspond with arguments by Sparks
(2008), OHalloran (2009) and Miller (2008).
5.2.1 Communication difficulties: Person with dementia interview
The lack of effective communication impacts on the person with dementias activity in
decision making, self-esteem and quality of life. This is reflected in the reported
inability by all people with dementia to understand the medical diagnosis or reason
for admission. If they dont know whats wrong how can they take an active role in
their medical care? The impact is also highlighted in the signs of frustration among
the people with dementia where 50% were described as crying in response to their
difficulties with one being described by his PCP as getting upset when he couldnt
get the words out.
The people with dementia did identify barriers to communication as 50%described noise as a difficulty. Three people with dementia commented on the lack
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of time and interaction and the use of lengthy complex language. By engaging the
people with dementia in this study, they were observed to be empowered (e.g. all
could express likes and dislikes and 83% successfully expressed feelings). The
immense value of their unique insight into their own situation in hospital and
identifying their needs corresponds to current research engaging the person with
dementia in the research process (De Boer et al, 2007), the notion of Personhood
and person-centred care (Kittwood, 1997).
5.2.2 Communication difficulties identified by the PCP
The interviews with the PCP confirmed how well they know the person with
dementia, the communication challenges they perceive in the acute hospital setting
and the important and unique knowledge they can impart which is essential for
developing individualised care plans (Robinson et al, 2007). The majority of the
PCPs recognised the ability of the people with dementia to tell you what they did or
did not like, which illustrates how well the PCP knows the person.
The information from the PCP was important in highlighting the differences in
communication in the home environment versus communication in the hospitalsetting. For example one PCP described how the person with dementia would tell
him if she had pain but would not tell a nurse. One PCP also described how the
person with dementia got very frustrated about his medical concerns.
It was interesting to note in the interviews with the PCPs their own
identification of communication barriers and opportunities in the acute hospital
setting. One PCP reported noise and lighting in the shared ward to hinder
communication. She identified difficulties with using the remote control for calling the
nurse and going to the toilet. However she also suggested communication facilitators
as per Table 5.1.
Table 5.1 Communication facilitators suggested by a PCP
- Move to a private room if possible
- Label buttons on the remote control
- Have large colourful signs indicating the toilet and exit
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- Have one large tree shaped board displaying pictures and names of the
nurses in large font
- Use notebooks and daily newspapers to remember important information and
dates
- Give routine instructions
- Allow the person with dementia more time to answer or follow commands.
5.2.3 Communication difficulties identified by the staff nurse
The nurses perspective can be effectively compared to that of the PCP and person
with dementia in order to analyse how the hospital setting differs from the home
environment. The study reveals that staff in the hospital face communication
challenges in caring for the person with dementia. The person with dementia, the
PCP and the nurse all reported difficulties in vital case history and assessment
communication situations such as in Table 5.2:
Table 5.2 Examples of difficulties in communication situations important for
assessment in the acute hospital setting.
Difficulties were also reported in understanding the implications of their medical
condition and descriptions which could negatively impact on multidisciplinary medical
intervention (e.g. Physiotherapy).
The fact that all nurses reported that they could gain the attention of all people
with dementia and that all people with dementia could follow their instructions
- Telling you about preadmission medical history
- Telling you about any current medical concerns
- Understanding the medical diagnosis or reason for admission
- Telling you about pain or discomfort
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highlights their communication skills. This suggests they have had experience or
training in this area. The SLT department in the hospital where this research took
place has a strong active presence in this ward.
However only 50% of nurses reported that the people with dementia could
always express what they like and dislike. This contrasts with all people with
dementia expressing this in their interviews. This could suggest that a barrier to
communication is a lack of awareness of the person with dementias signals of
communication needs.
Such a communication barrier could act as a barrier to the implementation of
patient-centred care by caregivers (Robison et al, 2009). The nurses reported that
only 33% of people with dementia were able to ask questions about their care and
the PCPs believed 17% could. In the interviews this was remarkably contrasted in
that 67% of people successfully asked questions about their care (e.g. are my toes
covered?, more heat, will I get a wheelchair?) when the researcher facilitated this
by giving time, using repetition and rephrasing of questions as recommended by
Miller (2008).
5.3 Communication barriers: The Environmental Checklist
The Environmental Checklist revealed barriers to communication which agreed with
comments by the PCP or person with dementia. One PCP noted the difficulty in
using the hospital procedure for calling the nurse i.e. press the button on the
remote control. Only one person with dementia mentioned this as a way to call for a
nurse, all others reported calling out loud for the nurse. One person with dementia
mentioned his difficulty in finding his way around, particularly with regards to the
bathroom. His PCP discussed the complexity of the remote control and how the lack
of signs particularly for the bathroom caused him further confusion and increased his
wandering difficulties.
Three of the people with dementia described the environment to be noisy
which Brush and Calkins (2008) proposed as a barrier to communication. The sound
level meter measurements indicated noise levels to be averaging at 49.3dB. The
American Speech-Language-Hearing Association (ASHA, 2009) classify 40dB-50dB
to be moderate (e.g. the sound of moderate rainfall) and 60bB to be very loud. Five
out of six people with dementia reported hearing difficulties strongly indicating noise
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as a barrier to communication in the hospital environment, especially in the acute
stroke ward. It was noted by the researcher that speaking louder in the interviews
with the people with dementia facilitated communication.
5.4 Qualitative exploration:
Barriers to communication
The sub-themes of noise and signage were identified in the qualitative analysis;
which have already been discussed as barriers to communication. The remaining
sub-themes identified will therefore be discussed.
A lack of time for interaction with staff was identified by two people with
dementia as a barrier to communication which agrees with Lubinskis (1995)
research. Complex language was reported by another person with dementia. A lack
of understanding of their diagnosis, reason for admission, implications of the current
medical condition and descriptions were observed and reported for the majority ofpeople with dementia. This corresponds to research by Miller (2008) who identified
complex language as a barrier to communication in the acute hospital setting. The
lack of written information and explanation of hospital facilities acts as a barrier to the
person with dementia understanding and potentially creates further confusion. The
absence of hearing aids, glasses and dentures also acted as barriers of
communication for the majority of people with dementia in both their understanding
of information and expressive skills.
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5.5 Qualitative exploration:
Opportunities to communication
One PCP suggested bright signs for bathrooms and exits, lights, personal pictures,
calendars, clocks, newspapers and less noise as facilitators which Brush & Calkins
(2008), OShea & OReilly (1999) and OShea (2007) all argue. One person with
dementia mentioned how familiarity facilitates communication and this was
supported by one PCP describing the benefit of routine instructions. Miller (2008)
supports this by proposing the use of functional common words as a facilitator for
communication in the acute hospital setting.
Miller (2008) also proposed the use of nonverbal communication, yes/no
questions, repetition and rephrasing to facilitate communication in the hospital. The
researcher found these strategies along with a slowed rate of speech to facilitate
communication. For example one person with dementia did not follow the request to
move his hand until this was demonstrated by the researcher. Successful
communication was also facilitated by giving more time to the interaction. The
majority of interviews with both the person with dementia and the PCP were longer
than the estimated time proposed by OHalloran et al (2004). The researcher also
found elements of validation therapy (Feil, 2002, Tondi et al, 2007) and reminiscence
therapy (Norris, 1986) to facilitate communication especially when one person with
dementia was explaining a hallucination he had and another person with dementia
continually expanded answers to include information from almost 30 years ago.
Communication could be facilitated by medical staff breaking down
information into manageable chunks (Robinson et al, 2009). Written information
summarizing information could facilitate this. The use of hearing aids, glasses anddentures in the hospital setting is a practical and immediate facilitator of
communication. Although not mentioned in any of the data, training of staff as
argued by Miller (2008) would be recommended to enable staff to facilitate
communication in this environment.
5.6. Clinical Implications
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The promotion of environmental modification for people with dementia was put
forward as a priority focus area by OShea and OReilly (1999) and again by OShea
in 2007. The first step in environmental modification is the identification of the
communication barriers and opportunities for people in their environment which this
study undertook. This study revealed how communication can be severely
challenged in the acute hospital setting for people with dementia and how by
identifying the barriers and opportunities to communication, proposals can be made
as to how effective communication in the acute hospital setting can be facilitated.
5.7 Methodological Limitations
Time and resource constraints dictated the small sample size of this study, which
does not allow for generalisation of the findings. Noise levels were only recorded at
one time of the day perhaps not fully illustrating the average noise levels in the
setting. The staff questionnaire was advantageous to use in that it was a brief
interruption to the nurses schedule, however its briefness and limited answers
(Always, Sometimes or Never) restricted the nurses ability to answer
comprehensively.
5.8 Future Recommendations
Future recommendations by the researcher include research into the barriers and
opportunities for communication for people with dementia in other acute hospitals.
As there is a strong SLT presence in the hospital researched, it would be beneficial
for contrastive purposes to research acute hospitals where there is little or no SLT
input.Noise levels should be recorded at different stages of the day (e.g. at
mealtimes and visiting times) to obtain a more accurate measure of the noise levels
in the setting. A modified version of the IFCI should be developed in order to
comprehensively collect data from the nurse. Training intervention which breaks
down the communication barriers identified and maximises the opportunities
revealed should be developed based on the findings of this and future research.
A proposed model of care pathway in facilitating communication in the
hospital setting is outlined in Figure 5. 1.
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Accident & Emer enc De artmentDischarge
Acute bed
Communication AssessmentPrimaryCommunicationPartners e.g.family, routine athome
Person with dementia EnvironmentalChecklist
Staff e.g.nurse,doctors, careassistant
Identify communication barriers and opportunities
Personalised Communication Care Plan: Communication Interventione.g. Reminiscence therapy
Reduce barriers & maximise o ortunities to communication
Needs based assessment units
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Figure 5.1 Model of care pathway to reduce barriers and maximise opportunities to
communication in the acute hospital setting
5.9 Summary
This study addresses a gap in the literature by providing an insight into exploring the
opportunities and barriers for communication for people with dementia in the acute
hospital setting. The research found that the acute hospital setting poses serious
challenges to people with dementia. Barriers to communication can be identified in
order to target them and maximize opportunities to communication.
The exploration of the communication barriers and opportunities with this
population was found to be aligned to barriers and opportunities identified in the
long-term care setting (Brush & Calkins, 2008). However, the results of this
explorative research indicate a lack of awareness of the barriers and opportunities to
communication in the acute hospital setting. The application of environmental
modification to facilitate communication in the care of the person with dementia
offers a potential tool to serve a number of person-centred goals in speech and
language intervention with the person with dementia.
Environmentalfactors: Realityorientation e.g.clocks, calendars,signs, noise levels,pictures, familiarity
Communicationpartner traininge.g. staff, familyand volunteers
Explain hospitalprocedures e.g.use writteninformation, routine,visual aids
Use ofexternalcommunication aidse.g. hearing aids,visual communicationaids
Review communication barriers and opportunities regularlyto ensure client needs are person-centred
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