Nurses' experiences of communicating with patients with aphasia.

AIM: This study explored nurses' experiences of communicating with patients with aphasia.
DESIGN: A naturalistic paradigm approach was adopted to describe the phenomenon of interest.
METHODS: Participants were neurological nurses employed in various neurological departments and recruited using purposive sampling. Group interviews were conducted for 1 hr and 30 min using semi-structured open-ended questions. The Consolidated Criteria for Reporting Qualitative Research checklist was followed.
RESULTS: Four generic categories were derived: "Conversations with the aphasic patients are frustrating, which leads to impatience among nurses, and they eventually dismiss the patients," "Feeling responsible for communicating with aphasic patients but also experiencing guilt for not being able to give adequate care in practice," "Concerns about communication methods with aphasic patients" and "Desire to learn ways to communicate with aphasic patients." Appropriate education and support should be given to nurses to facilitate communication with aphasic patients to ensure that they are not excluded from medical benefits because of communication difficulties.

INTRODUCTION

Approximately 180,000 cases of aphasia occur every year in the United States, with the estimated prevalence of approximately one in 250 people (National Institute on Deafness & Other Communication Disorders, 2015). Stroke is the main cause of aphasia; approximately 35%–40% of stroke patients are diagnosed with aphasia (Dickey et al., 2010). Stroke is one of the three major causes of death in South Korea (Statistics Korea, 2018). Its mortality rate has decreased significantly owing to the advancement of medical science. The number of stroke survivors have increased in Korea since the death rate has decreased by approximately 11.8% over the past decade (Statistics Korea, 2018). Reportedly, aphasia occurs in 28.8% of patients hospitalized with stroke in Korea (Chang et al., 2017).

Patients with aphasia have difficulty communicating because of damage in the speech center of the cerebrum (Saldert et al., 2013). Approximately 13% of patients admitted to the hospital with stroke have difficulty in complaining of pain on their own, which prevents them from receiving appropriate basic pain‐related interventions. Moreover, people with a higher severity of aphasia are less likely to be able to complain of pain (Smith et al., 2013). Additionally, approximately 51% of patients with aphasia encounter difficulties in completely understanding or expressing treatment‐related information during their hospitalization (O’Halloran et al., 2012). According to a study that observed conversations between stroke patients and nurses over 8 hr (Hersh et al., 2016), patients with aphasia had limited opportunities to talk with nurses compared with patients without speech impairments. Patients with communication problems are more than six times more likely to experience patient safety accidents than general patients without such issues (Bartlett et al., 2008) and also have low level of treatment satisfaction (Hemsley & Balandin, 2014). Moreover, the degree of understanding about the treatment goal differs according to the presence or absence of aphasia, even if the same treatment is given. Thus, patients with aphasia have a longer hospital stay, higher hospitalization costs and higher mortality rates than those without aphasia (Wu et al., 2020). Therefore, it is necessary to explore nurses' experiences when giving care to patients with aphasia and identify any potential difficulties in communication.

Because communication is a process that enables the sharing of information and emotions with the other party engaged in the conversation and causes changes in the behaviour of the involved parties, communication is essential for nurses to give holistic care by identifying the patient's condition or needs and comprehensively examining the situation (Barratt, 2019). This reflects the fact that communication difficulties between inpatients and nurses can cause serious problems.

Among the medical staff, nurses have the maximum communication with patients with aphasia, which has a huge impact on the patients (Hersh et al., 2016). Stroke, the main cause of aphasia, is a disease that requires collaboration and communication among various members, such as doctors, nurses, physical therapists, occupational therapists, speech therapists, psychotherapists, social workers, family members and caregivers (Gordon et al., 2009), and nurses must be the mediators who coordinate with other members to enable efficient recovery of patients (Winstein et al., 2016). In addition to screening for speech impairments and giving speech therapy interventions in daily care for patients with aphasia, nurses also play a crucial role in giving emotional support (Clarke, 2014). Because seamless communication with aphasic patients is essential to perform such high‐quality nursing (Poslawsky et al., 2010), it is necessary to understand nurses' experiences to identify the difficulties faced in communicating with aphasic patients and whether communication education is necessary.

Aim

This study explored the experiences of neurological nurses who give care to patients with aphasia when they communicate with aphasic patients.

METHODS

Design

A naturalistic paradigm approach was adopted to describe the phenomenon of interest. Accordingly, we analysed the communication experiences of nurses giving care for aphasic patients from focus group interviews using qualitative content analysis.

Participants

Participants included Korean nurses with an experience of working in various departments, such as the neurology ward, stroke intensive care unit, neurology intensive care unit and neurology outpatient department, recruited using purposive sampling. Based on the previous literature, 6–10 participants are appropriate to conduct a focus group interview (Krueger & Casey, 2015); therefore, this study included six participants. We recruited two nurses from the ICU, two nurses from the ward, one nurse from the stroke unit and one nurse from the outpatient department. Their average age was 32.17 ± 4.88 years, the duration of their work experience at neurological units was 56.33 ± 17.99 months, and their average nursing experience was 80.33 ± 63.28 months (Table 1).

TABLE 1

Characteristics of participants

Participants	Age (years)	Gender	Marital status	Working department	Career in neurology (months)	Total career (months)	Forms of employment
1	34	Female	Married	ICU	78	90	Full‐time, permanent
2	28	Female	Single	Ward	36	36	Full‐time, permanent
3	32	Female	Married	Ward	36	39	Full‐time, permanent
4	29	Female	Single	ICU	59	61	Full‐time, permanent
5	41	Female	Married	Outpatient	74	204	Full‐time, permanent
6	29	Female	Married	Stroke unit	55	56	Full‐time, permanent

Data collection

Data were collected through face‐to‐face interviews using open‐ended questions by a nurse researcher. A researcher was female, with training in qualitative methodology, and had experienced in qualitative research. A researcher had no relationship with participants prior to the study. An interview guide was prepared before the interview. Interviews were conducted in a quiet, independent space for approximately 1 hr and 30 min by following the pre‐configured questionnaire, and the audio was recorded. Field notes were also recorded during the interview. A week later, the transcripts were returned to each participant for verification.

Ethical considerations

The Institutional Review Board of the affiliated institution reviewed and approved this study (approval number: ewha‐201911–0025–01). Before the interview, written informed consent was obtained, and participants were informed about the study's aim and that the interview would be recorded. The recorded data were transcribed within 3 days, and the audio file was deleted. At the time of transcription, each participant was given numbers instead of names, so even if the transcription was leaked, it was impossible to identify the participant. All data were stored on an encrypted computer accessible only to the researchers.

Data analysis

The collected data were analysed by all researchers using the inductive content analysis method from the qualitative content analysis methods of Elo and Kyngäs (2008). Concerning the specific analysis process, the collected data were first repeatedly read to understand the overall data, followed by the steps of open coding, creating categories and abstraction. After coding the text transcribed by the first author, the emerged codes were discussed among the first and the second authors. All authors individually grouped these codes into categories. The first author's categories were compared, contrasted and interpreted with the second author's categories. These categories have been re‐discussed, reviewed and refined by the authors several times. To secure the rigor of the study, the criteria of Lincoln and Guba (1985) were considered to establish credibility, dependability, transferability and confirmability of the study. For credibility, interviews were conducted in a quiet, independent environment, and all interviews were audio recorded. For contents with unclear meanings, the researcher clarified the accurate meaning by e‐mailing the participants, and the derived categories were confirmed by the participants. Researchers pursued to secure the credibility by repeatedly analysing and reconfirming the collected data. For dependability, the research results were described in as much detail as possible, and the statements of participants were appropriately cited. For transferability, the study results were presented to one neurological nurse who did not participate in this study and confirmed whether they agreed with it. For confirmability, the research result was confirmed by one researcher with extensive experience in qualitative research to verify whether neutrality was maintained. The Consolidated Criteria for Reporting Qualitative Research checklist (Tong et al., 2007) was used to report the requirements for qualitative research.

RESULTS

A total of 58 meaningful statements were extracted. Similar statements were collected and classified into 10 subcategories before organizing them into four generic categories (Table 2).

TABLE 2

Extraction of categories from the interviews

Generic categories	Sub‐categories
Conversations with aphasic patients are frustrating, which leads to impatience among nurses, and they eventually dismiss the patients	Frustration Felt impatient Turned away from the patient and relied on the individuals around the patient
Feeling responsible for communicating with aphasic patients but also experiencing guilt for not being able to give adequate care in practice	Felt a sense of responsibility to communicate with aphasic patients Had a sense of guilt from not being able to give sufficient nursing care
Concerns about communication methods with aphasic patients	Considered the factors that influenced the communication with aphasic patients Developed their own strategies and attempted the strategies A need to improve the system
Desire to learn ways to communicate with aphasic patients	Want to receive proper education A need for a new method to communicate with aphasic patients

Conversations with aphasic patients are frustrating, which leads to impatience among nurses, and they eventually dismiss the patients

Participants stated that frustration is the first thing that comes to mind when they think of aphasia. They complained that it was difficult to give nursing care to aphasic patients compared with other patients because accurate assessment and evaluation were difficult due to poor communication with the patient.

“Really, frustration comes to my mind a lot. We are the people who must communicate. For example, we have to educate them. I really do not know what to do and often feel that this is really difficult and frustrating.” (Participant 5)

Participants also stated that they felt impatient when communicating with aphasic patients who required longer care, especially when they are busy performing duties with insufficient manpower.

“The staff are so few and I need to quickly attend to other patients too so it is hard to care for patients who cannot speak one‐on‐one. More than anything, the staffing is a major issue. Because I am feeling impatient, I repeat ‘come on, come on’ to myself in my mind.” (Participant 5)

Accordingly, the participants said that they eventually ask and educate the people around the patients, such as guardians or caregivers, rather than directly assessing and educating patients with poor communication.

“Actually, I do end up asking with the guardian or the caregiver when I'm giving medications, checking for symptoms, or assessing the input and output. Because we really are busy. Then we do end up looking at the caregiver first, rather than the patient.”(Participant 6)

Feeling responsible for communicating with aphasic patients but also experiencing guilt for not being able to give adequate care in practice

Participants had a sense of responsibility and recognized that they were the principal points of communication with aphasic patients.

“I really do know that patients with aphasia improve if they talk more so I tell the patients to consistently speak and I know that we need to talk to them and listen to them, but we do not have the time for that. I cannot tell them to talk to themselves. ” (Participant 2)

The participants also experienced a sense of guilt because aphasic patients would be pushed down the priority list for patient care because they required more time and because it was difficult to understand the patients' intentions, which prevented the provision of holistic care in addition to giving emotional support.

“It may not be what I think it is, really. They could just be anxious or there may be another factor involved, but I could not care for them specifically. That would frequently come back to my mind.” (Participant 2)

“I should have allowed them to talk together or listen to them but I did all the talking. I feel sorry when I think about it.” (Participant 5)

Concerns about communication methods with aphasic patients

Participants said that they regarded the characteristics of nurses who were good at communicating to improve their communication with aphasic patients.

“Obviously, when working, there are some nurses who catch on quite well and some nurses who cannot, and patients would think ‘that nurse understands me perfectly but this nurse…’ (laughs).” (Participant 5)

Participants searched and implemented strategies for communication based on their experiences to give care for patients with aphasia. However, there were cases in which the attempted strategies were less effective than expected.

“I used to think about it for a long time and made a picture board. There were pictures on toilet or ‘I'm thirsty’ on A4 paper. However, we did not have time to use it, so we would just assume they wanted to use the toilet and say ‘no toilet.’ That's what we end up saying.” (Participant 2)

Participants stated that a system that can share information about the patient's language problems with other healthcare providers was necessary to improve communication between aphasic patients and healthcare providers.

“I've been thinking about it for a long time ago, but I think it will be solved only when the system is improved. Even among nurses, we share information mainly on drugs and tests, but not on the patients' verbal symptoms. If we know a little bit of information in advance and see the patient, we will be able to gain better understanding, but there is no such system and no one says to do it…” (Participant 2)

Desire to learn ways to communicate with aphasic patients

Participants expressed their desire to receive an education if there was a proper communication method because they had no formal training on communicating with aphasic patients.

“We have received education primarily based on pathophysiology, but it would be nice if we could systematically receive education regarding communication. We just encounter the patients and try this or that when continuously looking after them, and if something feels okay, then we just use that. So, I wonder if this is the right way to do things.” (Participant 4)

Participants wanted to know about new methods, such as devices, media and universally recognized agreements, to facilitate communication with patients with aphasia.

“If education on things like universally recognized gestures, perhaps, could be provided as education for everyone, then it will be good for us all to use.” (Participant 1)

DISCUSSION

Nurses stated that despite understanding the importance of communicating with aphasic patients (Bennett et al., 2016), conversations with aphasic patients consumed a lot of time, which made them feel frustrated and impatient, and they eventually dismissed the patients. Similarly, healthcare providers stated that communicating with aphasic patients was challenging because of their busy schedules, including clinical, administrative and teaching duties (Carragher et al., 2020). The most neglected activity when nurses were busy was the act of communicating with the patient (Ball et al., 2014). Moreover, even when nurses have conversations with aphasic patients, their conversations focus only on obtaining information rather than trying to establish social relationships (Hersh et al., 2016). Additionally, if nurses have negative experiences, such as encountering difficulties in conversing with aphasic patients when the workload is heavy, it becomes a potential opportunity to avoid communicating with aphasic patients (Carragher et al., 2020).

Nurses were aware of the importance of communicating with patients and felt responsible; however, they also felt guilty about not being able to give adequate care. A study by Carragher et al. (2020) stated that nurses shift their responsibilities and have a bystander effect because speech pathologists have better conversations with patients, which is contrary to the present study. The difference may be that the speech pathologist does not intervene in the patient's daily life in the ward, except during the designated rehabilitation times in Korea. Nurses felt responsible and guilty because they could not afford enough time to care for aphasic patients compared with other patients. This is similar to the results of a previous study (Bridges et al., 2013), which stated that nurses working in acute settings who lack time could not form sufficient therapeutic relationships with patients due to limitations in the work environment, which caused negative emotions such as distress. Unclear communication also induces anxiety because nurses lack confidence in giving nursing care (Pound & Jensen, 2018), and unsuccessful conversations threaten the sense of identity by causing a sense of guilt, frustration and helplessness (Nystrom, 2009).

Because nurses do not have opportunities to specifically learn about effective communication strategies with aphasic patients (Carragher et al., 2020), nurses who give care for aphasic patients have confessed that they have been struggling for a long period to communicate effectively using their communication experiences. Even though some nurses developed and used their own communication strategies, they felt a sense of despair because the strategies were ineffective. Therefore, nurses with more extensive experiences in communicating with aphasic patients had better communication (O’Halloran et al., 2012), and they used the personal experiences gained by caring for patients with communication disorders as the primary source of knowledge in communicating with aphasic patients (Cheba et al., 2014).

Nurses gave care to patients with aphasia based on their personal experiences but were unaware of effective communication strategies (Bennett et al., 2016). Therefore, the participants of this study stated that they were unsure about their nursing care and expressed a desire to learn effective communication methods, which was similar to other studies (Carragher et al., 2020; Radtke et al., 2012), which revealed the demands for receiving education on communication methods with aphasic patients. More specifically, nurses wanted to learn about communication aids that could be used in the ward. Furthermore, they expressed a desire to learn about conveniently usable assistive devices drawing on the latest technology (Radtke et al., 2012). The study participants also expected that the use of the latest technology might improve the efficiency of communication. Organizational support not only directly affects the nurse's work environment but also induces positive feelings from nurses (Sharif et al., 2021). Thus, strengthening organizational support is necessary.

In summary, participants had difficulties communicating with aphasic patients because of a lack of in‐depth knowledge about aphasia and the methods that could assist in communicating with them. Therefore, it is necessary to increase nurses' awareness by giving knowledge about caring for patients with aphasia and giving education on special communication strategies to overcome the discomfort of communication and deliver effective nursing care.

This study is significant in the sense that it highlights the need for special education to facilitate communication with aphasic patients based on the communication experiences of nurses who give care to aphasic patients. However, this study is limited in the sense that the external validity may have been restricted because of the purposive sampling of participants, which included six nurses working in neurology or neurosurgery department in one district. In addition, different forms of employment may offer different experiences to nurses (Gan, 2020); however, this study is limited in the sense that all participants were full‐time nurses.

CONCLUSION

Nurses who gave care to patients with aphasia experienced frustration during their conversations with aphasic patients, which led them to dismiss them because of impatience. They felt responsible for communicating with aphasic patients but also experienced guilt for not being able to give adequate care in practice. Moreover, nurses were concerned about their communication methods with aphasic patients and reinforced their desire to learn ways to communicate with aphasic patients. Therefore, developing and giving an appropriate communication education for nurses is necessary.

RELEVANCE TO CLINICAL PRACTICE

Patients with aphasia have difficulties in communicating with nurses. Communication with patients plays a crucial role in nursing, but a patient with aphasia requires some special conversation. Our findings may be relevant to a wider global clinical situation, especially when giving care for patients with aphasia. Many clinical settings do not give special communication training for nurses. Therefore, they struggle to appropriately communicate with a patient with aphasia. A customized conversational training is required for nurses to alleviate their difficulties and prevent healthcare inequalities for patients with aphasia.

CONFLICT OF INTEREST

The author(s) declare(s) that there is no conflict of interest.