JCPSLP Vol 18 No. 1Mar 2016

Methods Study 1 The data from the first study are derived from a larger study, carried out in Western Australia in 2011, that explored SLPs’ accounts and perceptions of their management decisions for people with aphasia in acute and rehabilitation settings. SLPs used a workbook, developed for the study, to record information about their management of a single person with aphasia (PWA) on their caseload. The SLPs recorded information about the individual’s medical history, the SLP goals they had for the individual, their intentions regarding the frequency with which they planned to see the person and information on each occasion of SLP service provided to the individual while they were on the SLPs’ caseload. The SLPs were asked to complete the workbook for the first person diagnosed with aphasia who was admitted to their caseload after they had consented to participate in the study. Upon completion of the workbook, the SLPs took part in an interview to confirm the details recorded in the workbook and explore points raised regarding their clinical decision making for the specific PWA. The interviews were transcribed verbatim. The current study reports on a subset of data drawn from the experiences of the eight SLPs who worked in acute hospital settings and is focused on their decision making around the goals they developed for their in-patients and the level of service delivery (length and frequency of sessions) they planned to provide for the individual with aphasia. The data is drawn from both the workbooks and the follow up interviews, analysed using thematic analysis (Braun & Clarke, 2006). A portion of the workbook data has been reported previously in Ciccone, Hersh, Armstrong, and Godecke (2013). Ethics approval for this research was granted through the Edith Cowan University HREC and the HRECs of the hospital involved in the study. Study 2 The second study (Hersh, 2003) was based on interview data with 30 SLPs collected as part of a doctoral study, analysed using a grounded theory methodology (Strauss & Corbin, 1998). Ethics approval for this research was granted through the Ethics Committee of Flinders Medical Centre, the University’s board for clinical applications in the School of Medicine, and the ethics committees of other employing institutions (three other hospitals, a rehabilitation centre, and two community health centres). One aspect of the interviews involved exploring the factors that clinicians considered influenced their decisions to keep patients or clients on in therapy or to discharge them. While a range of factors influenced decision-making, data reported for this current paper refers only to one ‘patient-specific factor’, that of motivation. All names used below from both studies are pseudonyms. Results Even though the data from these two studies were collected across states, nearly a decade apart by different researchers, and focused on clinical decisions across acute, rehabilitation and community settings, there were overlapping findings and themes (see Table 1). Motivation was considered as one of a cluster of factors influencing decisions, for example, relating to client, service-level, or wider contextual considerations. Examples of other client-level factors reported by Hersh (2003) were: age, severity of aphasia, health status, time post-onset, premorbid and current communication needs, language

role of motivation in stroke rehabilitation more broadly. Motivation is actually a poorly defined notion (Maclean & Pound, 2000), but it is often cited by clinicians as a critical factor in determining the outcome of stroke rehabilitation generally (Becker & Kaufman, 1995; Gold, 1983; Lewinter & Mikkelsen, 1995; Maclean & Pound, 2000). This has also been reflected in some aphasia-related research (Lendrem, 1994; Mackenzie et al., 1993). Becker and Kaufman (1995) reported that judgments of patient motivation were a key indicator of rehabilitation potential in the eyes of stroke clinicians. Maclean and Pound (2000) reached a similar conclusion. They highlighted the dangers of seeing motivation only as a personal trait and then “moralising” about worthiness and character in those where motivation was judged to be lacking. They cited a number of studies that suggested that: “…a moralistic approach within rehabilitation settings can have deleterious effects on patient care, and also on the quality of patients’ lives after discharge” (p. 503). In a study involving interviews with 32 members of a multidisciplinary team (although only including 2 SLPs) Maclean, Pound, Wolfe, and Rudd (2002) found that: The criteria professionals use to recognize motivation have been shown to have blurred boundaries. “Motivated” patients are expected to be proactive, but this proactivity must never manifest itself in a strong- willed rejection of therapy. Similarly, motivated patients are expected to be compliant, but this compliance must never be the total compliance associated with a lack of “intrinsic”motivation. In effect, patients walk a fine line regarding how their behavior is viewed; a delicate balance has to be struck between compliance and proactivity if the patient is to avoid being seen as unmotivated and therefore receiving a potentially damaging label. (p. 448) Professional expectations about motivation can become blinkered, for example, varying with the age of the patient (Nicholas, Rybarczyk, Meyer, Lacey, Haut, & Kemp, 1998) and can be insensitive to the sheer effort patients are expected to make in order to be regarded as motivated. Meier and Purtillo (1994) warned against labelling people as “poorly motivated”when they “may not understand the effort, pain, repetition, boredom and altered body use that is required” (p. 365). Finally, adding further to this complexity is the issue of post stroke fatigue. This may occur with depression but certainly does not have to, and therefore may not respond to antidepressant medication. It is estimated to occur in around 40% of people post stroke (Lynch et al., 2007) and may also interfere with people’s ability to manage the work demanded in rehabilitation (Morley, Jackson, & Mead, 2005). The presence of fatigue has obvious implications for the way in which clinicians predict rehabilitation potential, and it is not difficult to imagine that patients suffering from post-stroke fatigue could be viewed as too poorly motivated to participate in therapy. In the light of this review, and the particular issues facing people with aphasia, we suggest that the issue of how judgments of motivation might impact on predictions of potential in aphasia rehabilitation deserve more attention. In this paper, we draw on original data from two separate studies carried out by each of the authors to highlight examples of how judgments of motivation by SLPs influence decision-making and management of people with aphasia in post-stroke rehabilitation.

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JCPSLP Volume 18, Number 1 2016

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