PLORAS Interaction Aid Online Guide

Welcome to the online guide for using the PLORAS Interaction Aid.

The PLORAS Interaction Aid is a dynamic visual tool designed to facilitate the first stage of the consent process. We post the Aid to you in booklet form. This online guide provides a resource to help you use it, with instructions and short demonstration videos for all sections.

You can refer back to this online guide at any time.

Who is it for ?

• The Interaction aid supports obtaining informed consent for the initial steps of taking part in PLORAS (Consent Form Part I).
• It is aimed particularly at participants with moderate to severe aphasia, who need more support than the standard documents
• The aid is for CRN use only (not intended to be given to participants).

How does it work ?

• It opens up like a book in front of you and the participant, with instructions and model phrases on the left, and images on the right
• It is designed to complement “Supported Conversation Strategies” – you can learn these practical skills through our E-Learning.
• Practice by yourself or with a colleague first, to get used to this style of communication.

You need the following:

• pens and blank paper
• the ‘Interaction Aid’ (which you should have received by post)

Printed extra pages for each participant:

• ‘PLORAS Participant First Stage Summary’ sheet’ (to give to the participant)
• ‘Participant Consent Form’ (for signing and CRN records)
• ‘Initials’ page (for explaining and practicing the initials)

For your convenience, we have included three extra page holders at the back of the Interaction Aid for storing spare copies of these documents.

Model phrases

• Bold font indicates key words.
• These words should be emphasised using intonation in your voice
• Say the word whilst pointing to the corresponding image or page title simultaneously.
• Sometimes, you will need to gesture simultaneously

For example

Do improvise gestures according to what feels natural to you in the moment

The key is that any gesturing has meaning corresponding to the word you are saying out loud simultaneously

Supporting conversation

Other factors may impact conversation outside of and in addition to aphasia.

Before you begin using the Interaction Aid (or any interaction with someone with aphasia), set yourself up for success by being mindful of those that you can address.

• The primary goal is to make the person with aphasia feel valued and respected, even in the midst of a busy and challenging environment.
• These suggestions will maximise your chances of success in your interaction. Consider:
  • The environment
  • The person
• We understand challenges in a busy ward setting, a quiet room is often not available. Just try to do what you can.
• Your efforts to create a supportive interaction space, no matter the constraints, will be appreciated.
• A handy reminder checklist is located at the back of the interaction aid

Setting up the environment

Sit side by side
Sit side by side Ideally, you will be on the participant’s left* so that you can see the model phrases (left page) while they can see the page with images (right page). *You may need to adapt this as needed if the participant has neglect, hearing impairment or other considerations.
Minimise visual distractions
	Clear table and area of other objects or visual distractions. If a separate area is not feasible, draw curtains around the bed Lights should be on
Make regular eye contact, read facial cues
Observe to assess comprehension (facial expression/eye gaze, body posture, gesture). Attend to clues the participant gives you to get their message out. Allow the participant to see your facial expressions, gestures, and body language clearly. This gives them the best chance of understanding what you are trying to say.
Limit group size
	One close visitor can often be an asset to supporting interaction. More will make it difficult, so limit people at the bedside
Minimise background noise
close doors turn off TVs, radios, etc choose a quiet room (if possible), is there any area that is quieter remove/mute any noise-emitting equipment (if safe to do so) ask neighbouring patients to assist by: turning off/down TVs, radios, etc taking conversations elsewhere or being mindful of noise A sign to request quiet may assist
Use quiet times
	Try to schedule interactions during quieter times. Mealtimes and ward rounds may be noisier Immediately after medication rounds may be quieter

Set up the person

Set yourself up for success by being mindful of factors that affect communication outside of aphasia. Some may seem obvious, but it is easy to forget to ask or check these simple and effective ways of optimising communication

Dentures
Ensure they have their dentures (if applicable) and are wearing them. Check they fit well
Visual aids (glasses)
	The person needs to be able to see clearly: your facial expressions picture supports words for reading
Hearing aids
The person needs to be able to hear you clearly Ensure they have their hearing aids and are wearing them Check they are on and charged
Interpreter
	Book an interpreter in the appropriate language
Fatigue
You may need to return when they are more alert Take several smaller sessions if needed
Memory / Cognition
	Repeat essential information as needed Use visual aids Break information down into accessible points Encourage note taking
Mood
Demonstrate empathy, understanding and acknowledgment Provide space when necessary Re-engage when and if appropriate

Communication Strategies

Once you have set up the conversation for success, you can start to support communication. You may already have an idea of the extent of the person's aphasia before entering the conversation or you may discover the support needed as you encounter communication breakdowns.

It is important to gradually build up the strategies you use according to the amount and type of support the person needs.

In practice most people with aphasia will benefit from a dynamic use of a variety of tools to support their understanding.

Our e-learning breaks down each of these strategies one by one. At the back of the interaction aid you’ll find a handy reminder checklist.

It is imperative that you attempt these strategies with people with aphasia even when you may not feel proficient in them. With each attempt, every success will reinforce use, while each breakdown will help with honing your skill set.

Always Acknowledge Competence
No matter how unsuccessful the transaction of information might be for whatever reason, we can always make efforts to make the conversation feel good, help the person with aphasia feel respected.
Use an adult tone of voice. “I know you know” Acknowledge frustrations Deal openly with limitations Make the conversation feel good – use humour and connect Attribute breakdowns to yourself as a communicator
Make your Message Clear: Adjust your speech
When using strategies to support communication, use short, simple sentences and an expressive voice. Observe the participant to assess comprehension and modify, layering your hierarchy of techniques to support your talking.
	Slow down Simplify words Short, simple sentences Emphasize key words Use intonation Use repetition
Help the person understand
As you are talking, use gestures that the participant can easily understand, write key words or the main idea in large bold print. Use pictures–focus on one at a time.
Use meaningful gesture Write key words Use pictures Use drawings New idea, new page
Help the person to express
When using strategies to support communication, use the right type of questions. These could be yes/ no questions, asked in a logical sequence from broad to specific. You might offer a series of choices, and always remember to have a ‘something else’ option. Encourage the person with aphasia to help you by finding ways to give you clues, and get creative with what resources you might have to hand that could help with providing the person with a way to respond. Go through each topic one at a time and allow plenty of time for responding. Observe the participant to attend to body language, facial expression and cues.
	Provide fixed choices Ask yes or no questions One thing at a time Ask for a clue Get creative Allow extra time for the participant to respond
Always double check (verify)
So far you have set your conversation up for success, supported understanding and supported expression. Now comes a critical step – verification. You need to check and make sure that YOU have understood the person with aphasia correctly. Reflect back what the participant has told you in that moment and overall throughout the conversation. Expand by adding what you think the participant may be trying to say. ‘Expanding’ on what the person with aphasia gives you really helps to move from the superficial to a more complex and satisfying conversation. Summarize by pulling things together at the end of a longer discussion. Slowly and clearly, outline what you think the participant is trying to say, e.g. … “so let me make sure I understand. …”. When you summarize, it’s a good idea to write down the key words for the participant to keep. Something written enables them to refer back or ask questions related to that conversation. We’ve also provided a summary page with visuals designed to be kept for reference after a supported conversation about the PLORAS study.
Reflect Expand Summarise

Demonstration Videos

There are 6 Sections in the interaction aid. We have included 12 demonstration videos that correspond to different pages of the interaction aid. We hope you find them useful.

1. Understanding first stage of study (30s each)
   
   • About aphasia
   • Brain scans
   • Medical records
   • Ask you questions
   • PLORAS
   • Send information
   • Contact you
2. Summary
3. Questions
4. Ask someone else
5. Consent
   • Taking consent
   • Consent pages (Full demonstration)
   • Signing the consent form
6. Initialling

Unlike the videos in our E-Learning , which focus on strategy-specific approaches, the videos here are literal demonstrations of each section of the Interaction Aid.
These videos are intended to provide step-by-step guidance and a true representation of how to use the Interaction Aid from start to finish.

About aphasia

Brain scans

Medical records

Ask you questions

Contact details

PLORAS

Send information

Contact you

Summary

You’ll notice throughout the interaction aid we emphasize an important principle in supported conversation: “new idea, new page”

It’s also important to ‘summarize’ your interaction. This gives the person with aphasia the opportunity to highlight any misunderstandings and to ensure we are on the same page.

We have prepared a summary page for you.

Print a summary page for each participant. Overlay it as shown in the video.

It is important to give this to the person with aphasia so they have it available to refer back to at a later stage, if they have further questions, or wish to tell another person about the content of this interaction.

Questions

Participants may have questions, but their aphasia may pose a barrier to them expressing these.

You may need to be creative in getting their message ‘out’.

Pay close attention to clues they give you. This could be gestures, facial expressions, or other creative solutions.

We have provided a page in the interaction aid that offers some picture support and fixed choice support for possible questions.

When they indicate a question, get confirmation from them, and when you are confident you have understood their question, answer it.

A simple spoken response may be sufficient, however if more support is needed to understand the question, you can use a separate piece of paper to write the key words and draw symbols/pictures.

There is a something else option for the participant to choose if none of these options apply to what they’d like to ask.

You could then write or draw other options you might think of, on a separate piece of paper.

Ask someone else

There will be occasions when available skills to support communication access are not sufficient in revealing the capacity of the person with aphasia. The flowchart highlights using the ‘Someone else’ page. This step is crucial in acknowledging the participant’s competence and our limitations as communicators.

Initialling

Additional Resources

Further aphasia/communication skills training

• Better Conversations with Aphasia: free e-learning resource to improve access to conversation therapy for SLTs, people with aphasia and their families, and healthcare workers and medics who interact with people with aphasia.
• STARs online training: Stroke Training and Awareness Resources (STARs) online training modules. See Module 13 ‘Communication following stroke’.
• Aphasia etiquette video: short video on how to communicate with someone with aphasia.
• Communication Access UK: online training in communication difficulties. Potential for individual/site accreditation.

Guidance on including people with communication difficulties in research

• ASSENT project guidance: guidance on including adults who may lack capacity and/or may have communication difficulties in ethically sound research.
• Consent Support Tool: A tool to facilitate involvement of people with communication difficulties in research.
• Collaboration of aphasia triallists resource: downloadable resource pack for researchers working with people with aphasia.

Other resources

• Communication tools for stroke survivors: Stroke Association communication resources to use with people with aphasia.

Thank you

A huge thank you for taking the time to help people with aphasia give informed consent for participation in research. We acknowledge this effort takes significant time, in addition to your regular workload. People with aphasia appreciate you making the effort at having a meaningful interaction, even if no concrete information is exchanged by the end of the conversation.

It feels daunting at first even for experienced speech and language therapists, but everyone can develop the skills to support conversation. Before approaching a person with aphasia, practising (with a colleague, or by yourself) can be hugely beneficial to your confidence and success in using this new style of communication.

Practice and develop your skills through trial and error with participants. Please do not hesitate to reach out for help – from your colleagues, your local SLT team, or to us at PLORAS. We are all here to support one another in doing our best for people with aphasia.

E-Learning ("PLORAS E-Learning Resource")

Please note CRN staff members supporting participants with aphasia, also have access to our E-Learning, "PLORAS E-Learning Resource." This is tailored training of knowledge and skills to improve your confidence in interacting with people with aphasia and the consent processes within the PLORAS study, including strategy-specific content.