Communication Strategies Of The Nursing Team In The Aphasia After Cerebrovascular Accident^*

Estrategias De Comunicación Del Equipo De Enfermería En La Afasia Secundaria A Accidente Cerebrovascular

Abstracts

This is an exploratory, cross-sectional study of quantitative design that aimed to identify the communication strategies used and reported by the nursing staff in the care of aphasic patients after a stroke. The techniques used were the participant observation and interviews with 27 subjects of the nursing staff of neurological units in a general hospital. The most frequently mentioned strategies were gestures (100%), verbal communication (33.3%), written communication (29.6%) and the touch (18.5 %). Among the observed strategies, the gestures reached 40.7% and the touch was present in all situations, given its instrumental character essential to care. The findings show lack of knowledge of nonverbal, proxemics , kinesics and tacesics communication. No significant differences were observed among the professional categories depending on the length of experience with respect to the strategies reported by members of the nursing staff in the care for aphasic patients.


Stroke; Aphasia; Communication; Nursing, team
; Nurse-patient relations


Estudio exploratorio de corte transversal, cuantitativo, cuyo objetivo fue identificar estrategias de comunicación utilizadas por el equipo de enfermería en el cuidado de pacientes afásicos después de un accidente cerebrovascular. Se utilizaron las técnicas de entrevistas y de observación participante en 27 sujetos del equipo de enfermería de unidades de neurología de un hospital general. Las estrategias más referidas fueron gestos (100%), comunicación verbal (33,3%), comunicación escrita (29,6%) y los toques (18,5%). Entre las estrategias observadas, los gestos alcanzaron el 40,7 % y el toque estaba presente en todas las situaciones dado su carácter instrumental esencial para cuidar. Los resultados indican un desconocimiento de la comunicación no verbal, proxémica, kinésica o háptica. No se observaron diferencias significativas entre las categorías profesionales en función del tiempo de experiencia con respecto a las estrategias mencionadas por los miembros del personal de enfermería para el cuidado de los pacientes con afasia.


Accidente cerebrovascular
; Afasia; Comunicación; Grupo de enfermería
; Relaciones enfermero-paciente



Estudo exploratório, transversal, de delineamento quantitativo, cujo objetivo foi identificar estratégias de comunicação referidas e usadas pela equipe de enfermagem durante o cuidado de pacientes afásicos após acidente vascular encefálico. Foram utilizadas a técnica de entrevista e a observação participante com 27 sujeitos da equipe de enfermagem de unidades neurológicas de um hospital geral. As estratégias mais referidas foram os gestos (100%), a comunicação verbal (33,3%), a comunicação escrita (29,6 %) e os toques (18,5%). Entre as estratégias observadas, os gestos atingiram 40,7% e o toque esteve presente em todas as situações, dado seu caráter instrumental imprescindível aos cuidados. Os achados indicam desconhecimento da comunicação não verbal, proxêmica, cinésica ou tacêsica. Não foram observadas diferenças significativas entre as categorias profissionais em função do tempo de experiência com respeito às estratégias referidas pelos membros da equipe de enfermagem para cuidar do paciente afásico.


Acidente vascular cerebral 
; Afasia; Comunicação; Equipe de enfermagem
; Relações enfermeiro-paciente


Introduction

Promotion of eye health of individuals and collective integrate actions developed as part of the health system in Brazil. The growing number of individuals that present vision loss due to avoidable causes of blindness, in addition to those with low vision, reinforces the need for development of effective ways of screening and expanding access of population to consultation with an ophthalmologist and access to support services to conduct examinations, surgical interventions or rehabilitation.


However, ocular care needs mechanisms of continuity and systematization of investments(¹). Study conducted on the prevalence of use of eye care services in the past five years showed that from the total number of people interviewed, 34% did not undergo ophthalmologic consultation. The main reasons were: low financial conditions (29%), lack of time (25%) and indifference (19%). Among people seeking care, consultations were held either through health plans provided in partnership with companies or even the state or private health plan (42%), private consultation (23%) consultations on optical stores (18%) and public services (17%)(²).


The importance of this discussion is based on findings that indicate that disorders affecting vision can be attributed to the natural aging process, but there are ocular disorders triggered by pathological processes of infectious and noninfectious order, such as glaucoma, cataracts, uncorrected refractive errors and diabetic retinopathy(³). 


The ophthalmologic disorders that cause visual impairment, low vision and blindness, result not only in a decrease in quality of life, occupational, economic, social and psychological restrictions, but also in inability to work, representing an onerous burden on the individual and society. Thus, early diagnosis is important, since the lack of proper decision can determine a permanent deficit. Preventive actions have great impact on health. 


In addition, there are more vulnerable groups to the development of visual problems, such as people living with HIV/aids. About 50-75% of these people develop some eye complication, most triggered by opportunistic infections and neoplasms, as a direct result of immunosuppression.


We observe, therefore, the need to ensure the extension of care beyond clinics and hospitals units, being necessary the emphasis on educational activities, with the introduction of lightweight technologies, such as brochures, booklets and manuals about the care of the eyes, through the inclusion of information about the implementation of self-care in the context of HIV/aids. It is recommended the performance of ocular self-examination that is characterized as secondary prevention without cost, safe and easily applied in large populations.


In this light, we realized the need for the development and validation of a guide on the ocular self-examination(⁴). The Guide gives advice on the performance of self-examination of the eyes by means of simple information identifying eye problems. It contains description of the technique for assessing visual acuity (near and far), external ocular structures, the visual field (peripheral vision and central vision) and eye movement. These steps aim to identify possible changes, such as reduced visual acuity, injuries, visual field loss, strabismus, diplopia, redness, among others. 


Although only an ophthalmologist can accurately diagnose an ocular problem, other professionals, such as nurses, can work in screening and empowering the population to the early identification of changes. The performance of eye self-examination alert to the existence of signs of ocular involvement that require consultation with the ophthalmologist. 


In an attempt to expand the population’s access to eye care, a virtual guide on eye self-exam was developed and validated(⁵). Its preparation comes from the high incidence of eye problems, from the lack of resources for mass production of printed material and their distribution in the health care services in the country, reinforced the need for availability on the internet. So now, there are even higher chances by the population and health professionals to use this feature, increasing the scope of the guide as the access to technology grows. 


Countless possibilities of computer use in education, especially to sensitize the user to health education in the area of ocular health, stimulated the development of the guide for the virtual environment. This research aims to describe the development process of the virtual guide on ocular self-examination.


Method

Study of virtual guide educational material development, which considers that the elaboration of an educational hypermedia must follow the steps of analysis and planning, modeling, implementation, evaluation and maintenance(⁶). In the first step, we used a guide for ocular self-examination(⁴) in which the target audience was already defined, people living with HIV/aids, the topic to be addressed, ocular health, as well as the objectives and the content to be developed, ocular self-examination. However, adaptation for internet use was necessary, considering the theoretical assumptions about distance education.


To achieve the materialization of this study, human resources and material; also financial resources from CAPES and CNPq were necessary, besides a Laboratory on Health Communication, through its physical and technological infrastructure, including a recording studio.


We opted to compose teams for its preparation, the first was the pedagogical team, composed by the authors of the printed guide and the researcher, followed by the technical team, composed of members of the Research group and Production of Interactive Environments and Learning Objects (PROATIVA), a masters in computer science, responsible for the digitization of media, and graphic design. Additionally, there was the participation of an actor and a technical specialist in filming, editing and programming. 


For the modeling step, the pedagogical and design team worked, and they were responsible for drafting an instructional script, containing the initial idea of the object, the activities, the target audience for which the material was developed for (people with HIV/aids with basic knowledge on computer use and internet access) and content, and the objectives to be achieved with the use of the material. The graphic design team was responsible for developing the visual identity and the virtual educational material interfaces, based on our instructional proposal. The development process was established after the teams composition.


In the implementation phase, the project was approved by the modeling team and the programming and digitization of media and texts, as well as adequacy of the requirements of the software used. Material resources correspond to the hardware, software and Flash software. 


In the evaluation phase, the texts were revised and adapted to self-instruction use, passing through media test and the necessary corrections on the text content and navigation. In the final phase of the educational material, validation was performed by six expert judges in the area of health education and distance education technologies. 


The material was previously validated by content judges(⁴). We sought to assess, at this time, the pedagogical and technical aspects of the guide. Inclusion criteria to compose the panel of judges were: work in the areas of distance health education and education technologies, have scientific production in these areas and obtain a minimum score in the sum of scores greater than or equal to 4.0 point(⁷). 


Data collection was conducted through a structured script inspired by instruments of similar studies(⁸-⁹). We used a Likert scale of four points (1 – Fully adequate; 2 – Adequate with changes; 3 – Inadequate; 4 – Not applicable). The instrument sought to evaluate the importance of content to the target audience, the contribution of technology, the encouragement of learning, the design of the material and its suitability for the virtual environment, the presentation of technology, attractiveness and ability to attract the user interest to continue browsing the site. Subjective analyzes were synthesized and organized, gathering the contributions of judges from each item evaluated. 


The study was approved by the Ethics Committee in Research of the Federal University of Ceara - UFC, under protocol number 309/09. As part of the documentation, we elaborated the Consent Form (CF). Participants were informed about the study objectives, procedures, risks and benefits. Anonymity was assured and the judges who evaluated the technical aspects were denominated as T1, T2, T3 and those who evaluated the pedagogical aspects, P1, P2, P3. 


Results

The mean age of the 27 participants of the study was 34 years ±8.4 and 55.2% of the sample was younger than 35 years. Among these, 55.5% had more than five years of experience with patients who had suffered a CVA. Regarding the time since graduation, on average it was 7.8 years ± 6.0 and the time caring for patients with CVA was 4.8 years ± 3.7.


No statistically significant differences were observed among the professional groups (p>0.05) on the mentioned strategies. The absence of reference of touching by nurses is noteworthy. The predominant type of communication were the gestures, pen and paper, and verbal communication.


It can be seen in Table 2 that the strategies reported by participants in relation to length of professional experience showed no significant differences between the more and less experienced. In both groups, the touch reached the highest frequencies, having been reported by all respondents. It draws the attention that the use of pen and paper and drawl were reported only by individuals with less experience, reaching a third of them. Low frequencies are apparent in most of these strategies.


Figure 1 displays the differences between the strategies according to the data collection techniques used and shows consistent use of nonverbal communication, based on the observation made. 


Table 1
Communication strategies reported by the nursing team professionals - São Paulo, SP, Brazil, 2010

Strategies	Professional training						p-value
	nurse technician		nursing assistant		nurse
	n	%	n	%	n	%
verbal communication	6	54.50%	2	20.00%	1	16.70%	0.151
touching	1	9.10%	4	40.00%	-	-	0.079
painful stimuli	1	9.10%	-	-	-	-	***
gestures	11	100.00%	10	100.00%	6	100.00%	***
paper and pen	1	9.10%	5	50.00%	2	33.30%	0.119
caregivers	-	-	1	10.00%	2	33.30%	0.111
nonverbal communication	-	-	1	10.00%	-	-	0.414
board	1	9.10%	2	20.00%	-	-	0.45
alphabet	-	-	2	20.00%	-	-	0.159
drawl	3	27.30%	2	20.00%	-	-	0.38
observation of the patient	-	-	1	10.00%	2	33.30%	0.111
use of terms easy to understand	1	9.10%	1	10.00%	-	-	0.732
proximity	1	9.10%	-	-	-	-	0.47

Table 2
Communication strategies mentioned by participants in relation to time of professional experience - São Paulo, SP, Brazil, 2010

Communication strategies	up to 5 years		more than 5 years		p-value
	n	%	n	%
verbal communication	2	16.7	7	46.7	0.217*
touching	2	16.7	3	20	>0.999*
painful stimuli	-	-	1	6.7	***
gestures	12	100	15	100	***
paper and pen	4	33.3	4	26.7	>0.999*
caregivers	1	8.3	2	13.3	>0.999*
nonverbal communication	1	8.3			***
board	1	8.3	2	13.3	>0.999*
alphabet	1	8.3	1	6.7	>0.999*
drawl	4	33.3	1	6.7	0.139*
observation of the patient	1	8.3	2	13.3	>0.999*
use of terms easy to understand	2	16.7	-	-	0.188*
proximity	1	8.3	-	-	***
speak up	1	8.3	1	6.7	>0.999*

Figure 1

Reported and observed communication strategies in the care of aphasic patients. São Paulo - SP, Brazil, 2010

Discussion

The results showed the use of appropriate methodological approaches for the identification of the strategies used in the care of aphasic patients. Confronting the theoretical knowledge related to the strategies of the data from interviews and comparing it with the strategies employed in healthcare has shown a troubling dichotomy in knowing/using some communication techniques and theoretical ignorance in others. However, the automatism in providing care was evident, showing few initiatives of nonverbal communication and apathy on the part of many patients.


Effective communication between patients who have suffered CVA and the care staff is often not reached due to the resistance of professionals in learning new and more effective methods. However, establishing effective measures in the interaction with these patients brings results with positive impacts in assistance. 


It was found that the strategies most reported by professionals were the gestures, verbal communication and paper and pen, with 100 %, 54.5 % and 50 % respectively. Among the observed strategies, verbal communication, touching and proximity were the most frequent. The strategy of gestures, the most reported by participants, was not frequently present during care, with a percentage of 40.7 %. These gestures exert an important role in decoding the messages received during professional or personal interactions(¹¹), and staff should receive guidance regarding its importance to facilitate the process of understanding between those who care and those who are cared for.


The body expressions and manifestations are key elements to the process of communication because of its wide use. In a study carried out with nursing graduate students about the significance of nonverbal communication, gestures and facial expression were most frequently reported symbols in human relations(¹²). Other authors claim that the tacesics communication (touching) is the most used strategy used in communication with customers, which is consistent with our observation. Although the gestures are more prevalent than touching in the opinion of the participants, the latter constitutes a tool in the observed communication process, but with relevant instrumental character. In addition to the illustrators, no other types of gestures were observed as iconic, regulators and affective.


Regarding the reported strategies in relation to the time of graduation, the gestures are also common, with a greater predominance both among those who have completed their training course within the previous five years as those with more than five years. Among the first, writing communication and drawl are also widely used strategies. Those with longer time since the end of training also use verbal communication, in addition to gestures. 


It was found that the sample included young professionals, especially technicians and nursing assistants with 7.8 years of training and 4.8 years of experience with post-CVA patients, characteristics that do not seem to affect the results of an effective communication. The literature states that there is no evidence linking the time of experience with a better communication performance(¹⁰) however, there is evidence confirming that the experience facilitates the communication with people with disabilities to communicate(⁶). This leads to the reflection that communication is a skill that is not developed and/or required in training courses of the health field. This situation tends to change, because the current emphasis is on developing this type of professional competence, given the demand for appropriate relationships with people in their various contexts of life. This ability has been included in the definition of occupational profiles and curricula, nurses in especial, a minority in the sample of this study.


The proxemics communication - present in all interactions observed among the study subjects - was reported by nursing students as the main influence of nonverbal communication during nursing care(¹³). The major use of this type of communication is justified by the need to approximate nurses and clients, which is an essential part of the interpersonal relationship in the therapeutic process(¹³). However, it has to be taken into consideration that the observed care could bias the assessment of this variable because it is impossible that the professional performs it without being near the patient. The way professionals occupy a space that, from the point of view of the territory, belongs to patients demands that they have the knowledge to avoid that the subjects of their actions do not feel inappropriately invaded(¹⁴). This is the point when the use of appropriate communication techniques can ensure the differential that nursing actions need to achieve.


The tacesics communication was present in all observed activities and equally occurred because it is related to the implementation of procedures. This type of communication involves the use of hands and if properly used, it allows a more humanized care(¹³). As already expressed in this study, the use of this communication during care can be classified as instrumental touch because it was the kind of touch required for the development of techniques, not objectifying other purposes. This fact implies that professionals have implemented the resource without awareness of its importance and indication on the client-professional relationship, which is in agreement with the study that observed predominance of instrumental touch over the instrumental-affective and affective(¹⁵). The authors of the mentioned study attested that nursing professionals should understand that the process of care is also a form of nonverbal communication. Despite these data, in another observational study(16) it was found that practitioners are aware of the importance of the touch to provide a quality care, in contrast to the findings of this research, in which this was reported by less than one-fifth of the subjects.


The differences observed between the data from semi-structured interviews and field observation may be related to the fact that verbal communication is not important in the conception of professionals and also because they do not have knowledge based on communication, since they reported not having received this particular content during their professional development. In a recent study on factors that influence the communication between patients with communication disability and health professionals, the knowledge about the issue and communication skills were mentioned. Thus, the lack of concern and knowledge of non-verbal communication strategies make it impossible to establish effective communication with these patients(¹⁷).


These aspects are important because the complexity imposed by the care to aphasic patients implies in support to professionals. These professionals need special attention from academic and health care institutions when facing difficult situations in providing the care. The knowledge and development of skills are needed in these situations, as well as the support and existence of institutional policies and processes(¹¹). Offering an environment conducive to therapeutic communication associated with training, family involvement, an appropriate physical environment, and attitudes of professionals is essential to establish a proper communication(¹⁸). A research carried out with people with aphasia showed that they communicate better with professionals who have been properly trained(¹⁹).


This study had some limitations that may have influenced the results. The first was that the researcher was not part of the studied nursing team, which may have influenced the data collection during the observation period. Although the study objectives were very clear to the participants and they seemed secure and apparently available in the answers during the interview, they also seemed bothered by the fact of being watched. This might have led them not to use resources that they habitually use in their daily practice. 


It is suggested that further studies are carried out, including the observation of professional-patient interaction in times of referrals for exams, preparation for discharge and other non-routine situations. In addition to studies with greater availability of time of researchers and associating difficulties with the degree of injury, neurological deficit, type of aphasia and evaluation of the emotional state of the patient after the CVA.


Despite the aforementioned limitations, this study provided an opportunity to reflect on the role of nursing professionals regarding the lack of instrumentation on communication techniques. The difficulty in communicating with patients with aphasia after a CVA reflects the lack of training and education programs for health professionals.


Although considered a basic tool of nursing, communication should be seen as a capacity to be developed by nurses, regardless of their area of expertise. Through this ability it is possible to identify, understand and contribute to solve the problems of patients and their families.


Conclusion

No significant differences were observed between occupational categories depending on the length of experience in relation to the strategies mentioned by members of the nursing staff in the care for aphasic patients. The observed strategies are opposed to those reported in frequency and quality, having noted a diversity of resources that facilitate communication in the interviews (although at low frequencies), but its use has not been observed in practice.


The tacesics and proxemics nonverbal communications were observed because the nursing care required instrumental touching and proximity to patients, which makes the evaluation of its use complex and debatable.


Communication strategies used by nursing staff with aphasic patients are applied informally, without proper knowledge of professionals and without efforts to achieve a more therapeutic communication.


• *
  Article extracted from the Master thesis "Communication strategies of the nursing team in aphasia after cerebrovascular accident"

References

• ¹
  Bejot Y, Benatru I, Rouaud O, Fromont A, Besancenot JP, Moreau T, et al. Epidemiology of stroke in Europe: geographic and environmental differences. J Neurol Sci. 2007;262(1-2):85-8
• ²
  Bonita R, Beaglehole R. Stroke prevention in poor countries: time for action. Stroke. 2007;38(11):2871-2
• ³
  Falcão IV, Carvalho EMF, Barreto KML, Lessa FJD, Leite VMM. Acidente vascular cerebral precoce: implicações para adultos em idade produtiva atendidos pelo Sistema Único de Saúde. Rev Bras Saúde Matern Infant. 2004;4(1):95-102
• ⁴
  Hilari K, Needle JJ, Harrison KL. What are the important factors in health-related quality of life people with aphasia? A systematic review. Arch Phys Med Rehabil. 2012;93(1 Suppl):S86-95
• ⁵
  Engelter ST, Gostynski M, Papa S, Frei M, Born C, Ajdacic-Gross V, et al. Epidemiology of aphasia attributable to first ischemic stroke: incidence, severity, fluency, etiology, and thrombolysis. Stroke. 2006;37(6):1379-84
• ⁶
  Pontes AC, Leitão IMTA, Ramos IC. Comunicação terapêutica em enfermagem: instrumento essencial do cuidado. Rev Bras Enferm. 2008;61(3):312-8
• ⁷
  Caron OAF, Silva IA. Parturiente e equipe obstétrica: a difícil arte da comunicação. Rev Latino Am Enferm. 2002;10(4):485-92
• ⁸
  Lam JM, Wodchis WP. The relationship of 60 disease diagnoses and 15 conditions to preference –based health-related quality of life in Ontario hospital-based long term care residents. Med Care. 2010;48(4):380-7
• ⁹
  Schneider CC, Bielemann VLM, Sousa AS, Quadros LCM, Kantorski LP. Comunicação na unidade de tratamento intensivo, importância e limites- visão da enfermagem e familiares. Cienc Cuid Saúde. 2009;8(4):531-9
• ¹⁰
  Schneider CC, Bielemann VLM, Sousa AS, Quadros LCM, Kantorski LP. Comunicação na unidade de tratamento intensivo, importância e limites- visão da enfermagem e familiares. Cienc Cuid Saúde. 2009;8(4):531-9
• ¹¹
  Silva LMG, Brasil VV, Guimarães HCQCP, Savonitti BHRA, Silva MJP. Comunicação não verbal: reflexões acerca da linguagem corporal. Rev Latino Am Enferm. 2000;8(4):52-8
• ¹²
  Santos CCV, Shiratori K. A influência da comunicação não verbal no cuidado de enfermagem. Rev Bras Enferm. 2005;58(4):434-7
• ¹³
  Silva MJP. Percebendo o ser humano além da doença: o não verbal detectado pelo enfermeiro. Nursing (São Paulo). 2001;4(41):14-20
• ¹⁴
  Prochet TC, Silva MJP. Proxêmica: as situações reconhecidas pelo idoso hospitalizado que caracterizam sua invasão do espaço pessoal e territorial. Texto Contexto. 2008;17(2):321-6
• ¹⁵
  Pinheiro EM, Rocha IF, Silva MCM. Identificação dos tipos de toque ocorridos no atendimento de enfermagem de um serviço ambulatorial. Rev Esc Enferm USP. 1998;32(3):192-8
• ¹⁶
  Gala MF, Telles SCR, Silva MJP. Ocorrência e significado do toque entre profissionais de enfermagem e pacientes de uma UTI e unidade semi-intensiva cirúrgica. Rev Esc Enferm USP. 2003;37(1):52-61
• ¹⁷
  O’Halloran R, Grohn B, Worrall L. Environmental factors that influence communication for patients with a communication disability in acute hospital stroke units: a qualitative metasynthesis. Arch Phys Med Rehabil. 2012;93(1 Suppl):S77-85
• ¹⁸
  O’Halloran R, Worrall L. Environmental factors that influence communication between patients and their healthcare providers in acute hospital stroke units: an observational study. Int J Lang Commun Disord. 2011;46(1):30-47
• ¹⁹
  Simmons-Mackie NN, Cristie CO, Kagan A, Huijbregts M, McEwen, Willems J. Communicative access and decision making for people with aphasia: implementing sustainable healthcare systems change. Aphasiology. 2007;21(1):39-66

Publication Dates

• Publication in this collection
  Apr 2014

History

• Received
  03 Sept 2013
• Accepted
  22 Jan 2014