Developing a Digital Health Intervention for Conversation Skills After Brain Injury (convers-ABI-lity) Using a Collaborative Approach: Mixed Methods Study.

BACKGROUND: People with acquired brain injury (ABI) experience communication breakdown in everyday interactions many years after injury, negatively impacting social and vocational relationships. Communication partner training (CPT) is a recommended intervention approach in communication rehabilitation after ABI. Access to long-term services is essential, both in rural and remote locations. Digital health has potential to overcome the challenges of travel and improve cost efficiencies, processes, and clinical outcomes. OBJECTIVE: We aimed to collaboratively develop a novel, multimodal web-based CPT intervention (convers-ABI-lity) with key stakeholders and evaluate its feasibility for improving conversation skills after brain injury. METHODS: This mixed methods study consisted of 3 key stages guided by the Integrate, Design, Assess, and Share (IDEAS) framework for developing effective digital health interventions. Stage 1 included the integration of current end-user needs and perspectives with key treatment and theoretical components of existing evidence-based interventions, TBI Express and TBIconneCT. Stage 2 included the iterative design of convers-ABI-lity with feedback from end-user interviews (n=22) analyzed using content analysis. Participants were individuals with ABI, family members, health professionals, and paid support workers. Stage 3 included the evaluation of the feasibility through a proof-of-concept study (n=3). A total of 3 dyads (a person with ABI and their communication partner [CP]) completed 7 weeks of convers-ABI-lity, guided by a clinician. The outcome measures included blinded ratings of conversation samples and self-report measures. We analyzed postintervention participant interviews using content analysis to inform further intervention refinement and development. RESULTS: Collaborative and iterative design and development during stages 1 and 2 resulted in the development of convers-ABI-lity. Results in stage 3 indicated positive changes in the blinded ratings of conversation samples for the participants with traumatic brain injury and their CPs. Statistically reliable positive changes were also observed in the self-report measures of social communication skills and quality of life. Intervention participants endorsed aspects of convers-ABI-lity, such as its complementary nature, self-guided web-based modules, clinician sessions, engaging content, and novel features. They reported the intervention to be relevant to their personal experience with cognitive-communication disorders. CONCLUSIONS: This study presents the outcome of using the IDEAS framework to guide the development of a web-based multimodal CPT intervention with input from key stakeholders. The results indicate promising outcomes for improving the conversation skills of people with ABI and their CPs. Further evaluation of intervention effectiveness and efficacy using a larger sample size is required.

Engaging Industry in Health Professions' Education: Benefits and Challenges.

Effective partnerships between universities and industry facilitate health-profession students' learning and work readiness. However, developing sustainable industry engagement in academic curricula remains challenging. This study utilised Social Exchange Theory (SET) to explore the benefits of and barriers to industry engagement within health-profession preparation programs. A realist evaluation framework was used to consider factors that impacted experiences and outcomes for academics and clinicians who engaged in the development and delivery of curriculum for a new health professional preparation program in speech pathology. A sequential mixed-methods design was adopted to explore factors influencing clinicians' motivation to engage with the university, using an online survey (n = 18) and focus group (n = 5). Clinicians rated "personal development" and contributing to the "future workforce" as the highest personal benefits. "Sharing knowledge" was the highest team benefit, and "staff satisfaction" was the highest employer benefit. Time and workload were perceived barriers. Academics (n = 2) and clinicians (n = 3) who collaborated in learning and teaching experiences also participated in a post-engagement focus group. Three Context Mechanism Outcome configurations were shown to facilitate engagement outcomes: engagement as opportunity, partnership, and work readiness. In accordance with SET, the nature of exchange processes and professional relationships contributed to positive engagement outcomes for clinicians, academics, and enhanced health-profession education.

Communication and Psychosocial Outcomes 2-Years After Severe Traumatic Brain Injury: Development of a Prognostic Model.

OBJECTIVE: To examine predictive factors underlying communication and psychosocial outcomes at 2 years post-injury. Prognosis of communication and psychosocial outcomes after severe traumatic brain injury (TBI) is largely unknown yet is relevant for clinical service provision, resource allocation, and managing patient and family expectations for recovery. DESIGN: A prospective longitudinal inception design was employed with assessments at 3 months, 6 months, and 2 years. PARTICIPANTS: The cohort included 57 participants with severe TBI (N=57). SETTING: Subacute and post-acute rehabilitation. MAIN OUTCOME MEASURES: Preinjury/injury measures included age, sex, education years, Glasgow Coma Scale, and PTA. The 3-month and 6-month data points included speech, language, and communication measures across the ICF domains and measures of cognition. The 2-year outcome measures included conversation, perceived communication skills, and psychosocial functioning. Predictors were examined using multiple regression. INTERVENTIONS: Not applicable. RESULTS: The cognitive and communication measures at 6 months significantly predicted conversation measures at 2 years and psychosocial functioning as reported by others at 2 years. At 6 months, 69% of participants presented with a cognitive-communication disorder (Functional Assessment of Verbal Reasoning and Executive Strategies [FAVRES]). The unique variance accounted for by the FAVRES measure was 7% for conversation measures and 9% for psychosocial functioning. Psychosocial functioning at 2 years was also predicted by pre-injury/injury factors and 3-month communication measures. Pre-injury education level was a unique predictor, accounting for 17% of the variance, and processing speed/memory at 3 months uniquely accounted for 14% of the variance. CONCLUSION: Cognitive-communication skills at 6 months are a potent predictor of persisting communication challenges and poor psychosocial outcomes up to 2 years after a severe TBI. Findings emphasize the importance of addressing modifiable cognitive and communication outcomes variables during the first 2 years after severe TBI to maximize functional patient outcomes.

Impact of online learning on sense of belonging among first year clinical health students during COVID-19: student and academic perspectives.

BACKGROUND: The need to belong is a fundamental human desire that provides the basis for relationships and community; it provides a sense of security that enables growth and development. This sense of belonging is pivotal to new University students, indeed, without it, students are at greater risk of failing or withdrawing from their studies. Yet developing a sense of belonging within a new cohort is complex and multi-faceted and further complicated by a sudden shift away from in-person to online learning. Using the situated-learning framework, our study explores first year clinical health students' sense of belonging in the context of the rapid transition to online learning because of the COVID-19 pandemic. METHODS: We utilised a current mixed-method approach including a survey incorporating previously validated tools, demographic and open-ended qualitative questions. Data was also gathered from three focus groups: two dedicated student groups and one academic focus group. Qualitative data was subjected to thematic analysis whilst descriptive statistics were used to describe the quantitative data. RESULTS: 179 first year students complete the survey and four students, and five academics were involved in the focus groups. All participants were from clinical health science courses at an Australian university. Our qualitative results indicated a global theme of: Navigating belonging during the COVID-19 crisis: a shared responsibility; with four organising themes describing (1) dimensions of belonging, (2) individual experiences and challenges, (3) reconceptualising teaching and learning, and (4) relationships are central to belonging. CONCLUSION: While the rapid transition to online learning did not greatly impact knowledge acquisition of first-year students in this cohort, the lack of sense of belonging highlights the need for further research into development of this essential aspect of learning in the online domain. Although contextualised in the COVID-19 pandemic, it became clear that the findings will remain relevant beyond the current situation, as a student's need to belong will always be present in the face of challenges or change.

Cognitive and Behavioral Digital Health Interventions for People with Traumatic Brain Injury and Their Caregivers: A Systematic Review.

Traumatic brain injury (TBI) leads to cognitive linguistic deficits that significantly impact on quality of life and well-being. Digital health offers timely access to specialized services; however, there are few synthesized reviews in this field. This review evaluates and synthesizes reports of digital health interventions in TBI rehabilitation and caregiver education. Systematic searches of nine databases (PsycINFO, MEDLINE, CINAHL, Embase, Cochrane Library, Scopus, Web of Science Core Collection, speechBITE, and PsycBITE) were conducted from database inception to February 2022. Studies were included of interventions where the primary treatment focus (> 50%) was on improving communication, social, psychological or cognitive skills of people with TBI and/or communication partners. Data on participants, characteristics of the interventions, outcome measures and findings were collected. Risk of bias was accounted for through methodological quality assessments (PEDro-P and PEDro+, Risk of Bias in N-of-1 Trials) and intervention description. Qualitative data was analyzed using thematic synthesis. Forty-four articles met eligibility criteria: 20 randomized controlled trials, three single-case experimental designs, six non-randomized controlled trials, nine case series studies, and two case studies. Studies comprised 3666 people with TBI and 213 carers. Methodological quality was varied and intervention description was poor. Most interventions were delivered via a single digital modality (e.g., telephone), with few using a combination of modalities. Five interventions used co-design with key stakeholders. Digital health interventions for people with TBI and their caregivers are feasible and all studies reported positive outcomes; however, few included blind assessors. Improved methodological rigor, clearly described intervention characteristics and consistent outcome measurement is recommended. Further research is needed regarding multi-modal digital health interventions.

From burden to benefit: a multi-site study of the impact of allied health work-based learning placements on patient care quality.

Allied health clinical placements take place within an increasingly overstretched health care system where demand for services often exceeds availability of resources. Within this environment, student placements are often perceived as an additional burden to an already overwhelmed workforce. This study explored whether the quality of patient care was enhanced when services were re-designed using a collaborative partnership approach to more purposefully integrate students into delivery of care. Using an embedded multiple case study design, data were collected through focus groups and interviews, patient experience surveys, and secondary administrative data sources. Cases were across physiotherapy and occupational therapy in six different hospital settings. Perception of care provided by students was viewed positively by all stakeholders, including patients. Perceived health outcomes of faster improvement of health condition, improved mobility and function identified through our qualitative findings were supported by quantitative service delivery markers such as increased therapy sessions, more patients being discharged home instead of to other care facilities and reduced length of stay. Health care providers and students alike perceived improvements in service efficiencies whilst maintaining high quality care. This study has provided preliminary evidence towards improved patient care when a partnering approach is adopted whereby students are intentionally integrated into services that otherwise might not have been delivered. Furthermore, it has shifted the associated narrative from students as additional burden to students as benefit.

Clinical educators can supervise students without increased stress: a study of interacting factors using insights from complexity theory.

Supervising students in healthcare settings is complex and can be stressful for clinical educators. However, it is unclear how to design student placements without clinical educator stress. Using complexity theory as a lens, fuzzy set Qualitative Comparative Analysis (fsQCA) was used to explore factors associated with no increased stress for clinical educators during speech pathology (SP) placements. Factor selection was informed by the Demand- Control- Support model and existing literature. No single factor was necessary for clinical educators to experience no increased stress. Varied combinations of all factors were found in 10 paths to no increased stress. These combinations often had passing student(s); however, multiple paths included other factors that could be adjusted by clinical educators prior to placement. For example, having more than one workday per week without students was a factor in four paths to no increased stress despite other potential challenges such as a higher caseload throughput. More experienced educators, who had other supporting factors (e.g. lower caseload throughput or workplace engagement such as support from colleagues and managers), also perceived no increased stress in four paths. Student placements without increased stress for clinical educators require consideration of multiple interacting factors. Principles of complexity theory provide insight into how clinical educators uniquely respond to their individual circumstances, resulting in different experiences of student placement impact even within similar workplaces. FsQCA has highlighted practical ways clinical educators supervise students without increased stress. However, any changes for an individual clinical educator need to be considered in combination with other factors given the complexity of clinical education and healthcare settings.

Psychosocial Outcomes of Severe Traumatic Brain Injury in Relation to Discourse Recovery: A Longitudinal Study up to 1 Year Post-Injury.

Purpose The interrelationship between psychosocial outcomes and discourse after severe traumatic brain injury remains largely unknown. This study examines outcomes relating to work, relationships, and independence within the context of discourse recovery across the 1st year post-injury. Method An inception cohort comprising 57 participants with severe traumatic brain injury was assessed at 3, 6, 9, and 12 months post-injury. Outcomes were measured with the Sydney Psychosocial Reintegration Scale-2 (Tate et al., 2012; Tate, Simpson, Loo, & Lane-Brown, 2011), and discourse was evaluated with Main Concept Analysis of a narrative retell. Correlation and linear regression analyses were utilized. Results Significant correlations were found between psychosocial outcomes reported by relatives and discourse performance across the 1st year. The 6-month discourse scores significantly predicted the 12-month psychosocial outcomes reported by relatives. Initial discourse severity and recovery pattern also informed outcomes. Conclusions Discourse disorders have a strong relationship with everyday outcomes relating to work, relationships, and independence as reported by relatives. Six months post-injury is a beneficial time for assessment, education, and service planning. Age, years of education, and aphasia may mediate recovery and outcomes. A clinical decision tree is offered to support goal setting. Supplemental Material https://doi.org/10.23641/asha.9755444.

Patterns of early conversational recovery for people with traumatic brain injury and their communication partners.

PRIMARY OBJECTIVE: To investigate whether the degree of participation by people with severe Traumatic Brain Injury (TBI), and the degree of support by their communication partners (CPs) changes in conversation during subacute recovery. METHODS AND PROCEDURES: Seventeen pairs of participants with TBI and their CPs were video-recorded during a 10 min casual conversation at 3 and 6 months post-injury. Communication behaviors were rated using the adapted Measure of Participation in Conversation (MPC) and the adapted Measure of Support in Conversation (MSC) at both time points and compared. RESULTS: Inferential analyses showed that there was no significant change in the degree of participation in conversation by participants with TBI and the degree of conversation support by their CPs from 3 to 6 months post. Comparison of qualitative field notes revealed that specific conversational behaviors changed over time, including better turn-taking and topic maintenance. CONCLUSION: Documenting early communication recovery is a complex and challenging endeavor. The lack of change in conversational effectiveness during the sub-acute period using global rating scales highlights the need for social communication tools that are sensitive to communication recovery following severe TBI.

Discourse recovery after severe traumatic brain injury: exploring the first year.

OBJECTIVES: Although much is known about discourse impairment, little is known about discourse recovery after severe traumatic brain injury (TBI). This paper explores discourse recovery across the critical first year, controlling for pre-injury, injury and post-injury variables. DESIGN AND METHODS: An inception cohort comprising 57 participants with severe TBI was examined at 3, 6, 9 and 12 months post-injury and compared to a cross-section of matched healthy control participants. A narrative discourse task was analyzed with main concept analysis (MCA). A mixed linear model approach was used to track recovery controlling for pre-injury, injury and post-injury variables. RESULTS: An upward trajectory of recovery was observed, with peak periods of improvement between 3-6 and 9-12 months and all time points were significantly below controls. Years of education and PTA duration were significant covariates in the recovery model. Presence of aphasia also influenced the recovery model. CONCLUSIONS: Individuals with TBI typically improve over the first year, however many will continue to have discourse deficits at 12 months. Years of education, PTA duration and aphasia should be considered when planning services. The 3-6- and 9-12-month periods may offer optimal periods for discourse recovery and increased supports may be beneficial between 6-9 months.

Cognitive-communication and psychosocial functioning 12 months after severe traumatic brain injury.

OBJECTIVE: Cognitive-communication deficits after severe Traumatic Brain Injury (TBI) may contribute to poor psychosocial functioning, however, the possible nature of this relationship remains unclear and warrants investigation. The current study explored the variance and correlations of a measure of cognitive-communication with a measure of psychosocial outcome in adults 12 months following TBI. METHOD: 36 adults with severe TBI evaluated at 12 months post-injury. Cognitive-communication skills were evaluated with the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES), Sydney Psychosocial Reintegration Scale-2 (SPRS-2) Form A - Informant version assessed psychosocial functioning. Multiple regression analyses were used to investigate association between cognitive-communication and psychosocial outcomes. RESULTS: Two measures of cognitive-communication assessment (Accuracy and Rationale of the FAVRES) contributed significantly to total psychosocial outcome (SPRS-2). Multiple regression analyses revealed these variables accounted for 29.1% of the variance. Cognitive-communication variables accounted for 24.0% and 28.6% of the Work/Leisure and Relationship domains of the SPRS-2. CONCLUSION: Cognitive-communication ability was significantly related to psychosocial functioning at 12 months post-TBI. Findings suggested continued speech pathology involvement in the post-acute stages of recovery may improve social, vocational and overall psychosocial functioning. The FAVRES is a promising cognitive-communication assessment for identification of treatable factors impacting psychosocial outcomes.

Getting comfortable with "comfort feeding": An exploration of legal and ethical aspects of the Australian speech-language pathologist's role in palliative dysphagia care.

PURPOSE: With an ageing population, speech-language pathologists (SLPs) can expect to encounter legal and ethical challenges associated with palliative and end-of-life care more frequently. An awareness of the medico-legal and ethical framework for palliative dysphagia management will better equip SLPs to work effectively in this area. METHOD: This narrative review examines a range of legislation, legal, ethical and SLP literature that is currently available to orient SLPs to legal and ethical palliative dysphagia management in the Australian context. RESULT: Relevant legal and ethical considerations in palliative and end-of-life care are described. CONCLUSION: SLPs have a role in palliative dysphagia management, however, this can involve unique legal and ethical challenges. The legal position on provision and cessation of nutrition and hydration differs between Australian States and Territories. Decisions by the courts have established a body of relevant case law. This article introduces SLPs to some of the important considerations for legal and ethical palliative care, but is not intended to be directive. SLPs are encouraged to explore their local options for ethical and medico-legal guidance. It is hoped that increasing SLPs awareness of many of the concepts discussed in this article enhances the provision of high-quality patient-centred care.

Quality of life improves for tracheostomy patients with return of voice: A mixed methods evaluation of the patient experience across the care continuum.

OBJECTIVES: A tracheostomy tube can profoundly impact ability to communicate. The impact of this on patients' self-esteem and quality of life in the care continuum from the intensive care unit to after decannulation has not been reported. Therefore, the aim was to investigate the patient-reported experience regarding change in communication function, communication-related self-esteem and quality of life. RESEARCH DESIGN: A mixed methods approach was utilised. Quantitative data were obtained using validated measures of self-esteem related to communication-related quality of life and general health. Data were measured before return of voice, within 48 hours of voice return and six months after tracheostomy decannulation. Qualitative data were collected through structured interviews six months after tracheostomy. RESULTS: Seventeen participants completed the study. Four themes emerged from the interviews: It's hard communicating without a voice; What is happening to me?; A storm of dark emotions and More than a response…it's participating and recovering. Significant positive change occurred in six items of self-esteem related to communication from baseline to return of voice. Overall, positive changes in quality of life scores were observed. CONCLUSIONS: Voice loss with tracheostomy significantly affected participants' abilities to effectively communicate their care and comfort needs. Restoration of voice occurred in conjunction with patient-reported improved mood, outlook and sense of recovery.

Procedural discourse performance in adults with severe traumatic brain injury at 3 and 6 months post injury.

BACKGROUND: There is limited research on communicative recovery during the early stages after a severe traumatic brain injury (TBI) in adults. METHODS AND PROCEDURES: In the current study 43 people with severe TBI described a simple procedure at 3 and 6 months post injury and this was compared to the description provided by 37 healthy speakers. Linguistic productivity and the presence of macrostructural discourse elements were analysed. MAIN OUTCOMES AND RESULTS: No change occurred in productivity in the TBI group between the two time points. There was increased use of relevant information (macrostructure) over time for the TBI group, reflecting improvement. People with TBI differed from controls in speech rate and in two out of three macrostructural categories at both time points, indicating difficulties even after 12 weeks of recovery. CONCLUSIONS: Overall, the quality, rather than the quantity of discourse was disordered for participants with TBI. Findings indicate that procedural discourse is sensitive to discourse deficits of people with TBI and can be used to map recovery during the sub-acute phase.

Exploring the relationship between cognition and functional verbal reasoning in adults with severe traumatic brain injury at six months post injury.

OBJECTIVE(S): This study aims to determine the association between cognitive impairment and functional verbal reasoning in adults with severe traumatic brain injury (TBI), at six months post-injury. METHOD(S): 38 participants with severe TBI were assessed using the four tasks on the Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES) [1] and a battery of neuropsychological tests at 6 months post injury in a cross-sectional observational study. RESULTS: Overall performance on the FAVRES [1] was strongly associated with overall performance on the neuropsychological battery (rho = 0.60). FAVRES Task 2 and FAVRES Task 4 had the most significant positive associations with the cognitive indices of Attention and speed of processing, Memory and Executive functions. There was one weak significant association between the Task 1 Accuracy score and the Total Cognitive index (rho = 0.46). CONCLUSIONS: Performance on the FAVRES [1] is positively associated with cognitive processes. Participants with stronger verbal reasoning skills which may be required for activities in work, home and social contexts also had higher scores on tests of cognitive functioning. These findings may inform clinical practices for speech pathologists and other health professionals, in the assessment and treatment of cognitive communication disorders during early stages of recovery in people with severe TBI.

Strengthening the quality of longitudinal research into cognitive-communication recovery after traumatic brain injury: A systematic review.

PURPOSE: (i) To systematically review longitudinal and prognostic studies relating to the trajectory of cognitive-communication recovery after TBI and (ii) to provide recommendations to strengthen future research. METHOD: Thirteen health literature databases were accessed up until July 2014. MAIN MEASURES: Articles were screened systematically against pre-determined inclusion and exclusion criteria. Quality reviews were performed on the selected articles using a modified Downs & Black Rating Scale. Two independent reviewers performed the reviews. RESULT: Sixteen longitudinal and prognostic articles met the inclusion criteria. There was evidence of either maintenance or improvement of cognitive-communication skills during the first 3 years post-injury. However, the studies did not provide detailed recovery trajectories, by failing to evaluate numerous data points over time. No studies evaluated recovery beyond 3 years post-injury. Injury severity, lesion location, brain volume loss and conversation skills may predict specific cognitive-communication outcomes. There was high variability in study characteristics and measures. CONCLUSION: There is currently scarce evidence regarding cognitive-communication recovery and prognosis. People with TBI may recover or maintain pre-morbid cognitive-communication skills during the early rehabilitation stage. Further research detailing the recovery trajectory with a view to evaluating predictive factors is strongly indicated. Guidelines for future research are provided.

Conversational topics discussed by individuals with severe traumatic brain injury and their communication partners during sub-acute recovery.

PRIMARY OBJECTIVE: To investigate the nature and patterns of conversational topics discussed by individuals with severe TBI and familiar communication partners at 3 and 6 months post-injury, and to examine changes occurring in conversational topics during sub-acute recovery. RESEARCH DESIGN: Qualitative content analysis was used to explore the nature of topics and generate conversational themes. Topic analysis provided an understanding of conversational topic management by identifying patterns of topic initiation and maintenance. METHODS: Twenty-two people with severe TBI and a familiar communication partner engaged in a 10-minute casual conversation on self-selected topics at 3 and 6 months post-injury. MAIN OUTCOMES AND RESULTS: Three main conversational themes were identified: connecting; re-engaging; and impacts of injury. The nature of topics related to these themes changed over time to reflect participants' sub-acute rehabilitation experiences. Most conversational dyads maintained similar conversational and topic patterns during sub-acute recovery. CONCLUSIONS: Qualitative analysis provides a new insight into the conversational topics of individuals with severe TBI. Many participants engaged in appropriate conversations and discussed mutually important topics with familiar communication partners. Findings may inform speech-language pathology intervention in sub-acute recovery to improve conversational discourse abilities of individuals with severe TBI and support their communication partners.

Food Culture, Preferences and Ethics in Dysphagia Management.

Adults with dysphagia experience difficulties swallowing food and fluids with potentially harmful health and psychosocial consequences. Speech pathologists who manage patients with dysphagia are frequently required to address ethical issues when patients' food culture and/ or preferences are inconsistent with recommended diets. These issues incorporate complex links between food, identity and social participation. A composite case has been developed to reflect ethical issues identified by practising speech pathologists for the purposes of illustrating ethical concerns in dysphagia management. The case examines a speech pathologist's role in supporting patient autonomy when patients and carers express different goals and values. The case presents a 68-year-old man of Australian/Italian heritage with severe swallowing impairment and strong values attached to food preferences. The case is examined through application of the dysphagia algorithm, a tool for shared decision-making when patients refuse dietary modifications. Case analysis revealed the benefits and challenges of shared decision-making processes in dysphagia management. Four health professional skills and attributes were identified as synonymous with shared decision making: communication, imagination, courage and reflection.