Demetia Final

7/30/2019 Demetia Final

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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


2 Telling you what has happened to bring them tohospital

0% 17% 83%


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%



7 Understanding the implications of the currentmedical condition

33% 33% 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%


3 Asking you questions about the care 33% 0% 67%


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%



6 Understanding the implications of the current medicalcondition 67% 0% 33%

7 Telling you about pain or discomfort 67% 17% 17%





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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