Background: Participation of people with aphasia in clinical care and rehabilitation is an area of increasing research interest. Supported communication (SC) training, which aims to enhance the participation of aphasic patients, has been shown to improve conversation partner knowledge and skills. However, there is a lack of evidence for transfer of SC training to practice in post-acute rehabilitation settings. Aims: We aim to develop an understanding of causal mechanisms implicated in the transfer of SC training by examining the nature of the setting, staff perspectives, and the situated character of the action. Methods and Procedures: Twenty-eight staff from a multidisciplinary team were trained in SC. We collected detailed and varied data, including staff experiences of SC training and implementation, and video data of routine practice. Using a critical realist approach, we develop explanatory mechanisms for barriers to and enablers of transfer. Eleven team members (nursing, therapy, and assistant staff) took part in focus groups and interviews at the end of the study; 54 learning logs were collected over a 10-month period. Six aphasic patients and eight staff took part in video-recordings of therapy and care sessions. Outcomes & Results: Three main themes derived from staff experience data are linked to key components of the setting, indicating processes implicated in transfer of training, and impacting on outcomes such as perceptions of quality and staff confidence. Barriers, constraints, and problem-solving approaches in enacting SC were evidenced through patient factors, spaces and events, and time constraints. Staff flexibility and team working were key factors in problem-solving these obstacles. Staff reported responsive use of skills and resources and perceived impact of SC training, with most, but not all, staff reporting benefits, including increased confidence in interactions with aphasic patients. Activity analysis of video data illustrates how some mechanisms may be operating in practice, with evidence of rich use of interactional strategies and resources; a focus by staff on getting the work done; opportunities for patient active participation or emotional support that are realised or not; strategies for aphasia-related trouble and repair sequences. Conclusions: This model of SC training has clear benefits for staff communication practices and confidence, but transfer of training is subject to complex processes. Training should therefore address systems-level practices and be extended for staff who need more advanced skills. The values implicit in SC have the potential to create a culture of access and inclusion, encouraging and supporting active participation of all stroke patients
Background The Mental Capacity Act (MCA, 2005) and its accompanying Code of Practice (2007), govern research participation for adults with capacity and communication difficulties in England and Wales. We conducted a systematic review and narrative synthesis to investigate the application of these provisions from 2007 to 2019. Methods and findings We included studies with mental capacity in their criteria, involving participants aged 16 years and above, with capacity-affecting conditions and conducted in England and Wales after the implementation of the MCA. Clinical trials of medicines were excluded. We searched seven databases: Academic Search Complete, ASSIA, MEDLINE, CINAHL, PsycArticles, PsycINFO and Science Direct. We used narrative synthesis to report our results. Our review follows Preferred Reporting Items for Systematic Reviews and is registered on PROSPERO, CRD42020195652. 28 studies of various research designs met our eligibility criteria: 14 (50.0%) were quantitative, 12 (42.9%) qualitative and 2 (7.1%) mixed methods. Included participants were adults with intellectual disabilities (n = 12), dementia (n = 9), mental health disorders (n = 2), autism (n = 3) and aphasia after stroke (n = 2). We found no studies involving adults with acquired brain injury. Diverse strategies were used in the recruitment of adults with capacity and communication difficulties with seven studies excluding individuals deemed to lack capacity. Conclusions We found relatively few studies including adults with capacity and communication difficulties with existing regulations interpreted variably. Limited use of consultees and exclusions on the basis of capacity and communication difficulties indicate that this group continue to be under-represented in research. If health and social interventions are to be effective for this population, they need to be included in primary research. The use of strategic adaptations and accommodations during the recruitment process, may serve to support their inclusion.
Despite laudable intentions, since its inception, the Mental Capacity Act 2005 of England and Wales (MCA) has proved to be a controversial piece of legislation. The majority of legal scholarship has concentrated on the problems created by the Act in relation to the treatment of incapacitated patients. However, there is an additional and somewhat unexplored dimension to the MCA, that of research. We argue here that the research provisions of the MCA are poorly drafted and do not provide an appropriate balance between protection and empowerment. We also assert that contrasting obligations and expectations are placed on different parties in the approval process, which creates a blurred sense of responsibility and a potential chilling effect.
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