JCPSLP Vol 18 No. 1Mar 2016

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JCPSLP Volume 18, Number 1 2016 4
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.