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Turn up and tu
Several people kindly shared their experience in offering training to homes, including the headaches in setting it up and getting people to attend, and ideas on what to include. This information helped us compose a bid to the local Primary Care Trust for consortium funding for a project offering training on acquired communication disorders - and we were successful! The project ran from October 2001 to October 2002. The funding enabled the two of us to plan and run six free half day training courses in a variety of locations in Bedfordshire, and also covered administrative support.

Participative and enjoyable

Niki and Karen

IF YOU WANT TO IMPROVE COMMUNICATION ENVIRONMENTS BID FOR PROJECT FUNDING TARGET HARD TO REACH SERVICE PROVIDERS

Elderly people with acquired communication disorders who live in nursing and residential homes depend on care workers to support their everyday conversation. But how do the carers develop the skills to do this? Karen Booth and Niki Freedman recount a training project in Bedfordshire which had promising results - for those who attended.

For the content, we devised a PowerPoint presentation of clinical theory and included plenty of thought-showering opportunities, practical activities and videos of real people with real communication disorders. The videos were a combination of our own patients who had consented to appear in training material, and published videos (Lock et al, 2001; Murphy & Scott, 1997; Parkinsons Disease Society, 1994). We intended the training to be participative and enjoyable, giving delegates the opportunity to discuss the types of problems some residents have. The course format is in figure 1. Figure 1 Course format
We started the session with questions such as What is communication? Why do we communicate? How do we communicate? What do we need to be able to communicate? Then we looked at the communication process, considering the difference between speech and language, the communication environment and nonmedical reasons for communication breakdown. Next we covered the theory - we explained medical conditions that can cause communication disorders, including Parkinsons disease, Multiple Sclerosis and other neurological conditions, with particular emphasis on stroke. A lot of time was spent defining dysarthria, dyspraxia and aphasia, with videos and discussion on real patients known to the staff members. We then looked at general communication strategies, and gave specific ideas on how to alter their own language and the communication environment - and what to do if it all goes wrong. We planned practical activities looking at normal and disordered communication. One activity involved backto-back picture description in pairs to simulate speech only, with no non-verbal communication. In another, the group tried to elicit a message from one of the course members who was role-playing someone who could only eye-blink. They had to work out how to communicate with the patient and how to modify the environment and their own communication to ensure that they successfully received the message.

WE INTENDED THE TRAINING TO BE PARTICIPATIVE AND ENJOYABLE, GIVING DELEGATES THE OPPORTUNITY TO DISCUSS THE TYPES OF PROBLEMS SOME RESIDENTS HAVE.
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hen visiting nursing and residential homes, we often found some staff had very little knowledge and experience of acquired communication disorders. This made it hard for them to carry out therapy advice and also to manage everyday conversation with residents. We felt this had to be tackled to make progress with this client group. We decided to plan a project for improving staff communication with their residents. This would involve training to increase staff understanding of speech and language disorders, with practical activities to teach strategies and improve confidence in communicating with the residents. Firstly we needed to know if this had been done before. We looked through past editions of the Bulletin (Royal College of Speech & Language Therapists), and submitted a clinical query. This yielded several detailed responses, and referred us on to some published research. Buckwalter (1988) looked at improving nurse communication with residents. She found improved initiation and participation after staff improved their interaction and spent regular time chatting with residents. Jones (1991) wrote about student nurse education, summarising a project run in Scotland. Students were given theoretical and practical training on aphasia. This improved use of strategies and success of communication. It confirmed that both theoretical and practical training are essential.

We also had some practical planning to do. We needed a method of evaluating the course, so we devised a questionnaire to be filled in before and after attending. This looked at

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une in
understanding of the different acquired communication disorders, and asked staff to gauge their ability to maximise their residents communication environment and to modify their own communication and use of strategies to aid residents in communicating. We sent a letter to 26 nursing / residential homes, specifically excluding homes for elderly people with a mental illness, as staff supporting such residents would need a different training package. We offered free half day training courses, with a choice of six dates over a five month period, in a variety of accessible locations. When staff were booked for a specific date we sent the questionnaire with a stamped addressed enveloped to be returned prior to the course. If they hadnt returned it they were asked to complete it on arrival for the training. We used our PowerPoint presentation as the course handout, and gave an attendance certificate. So, did it work? Unfortunately, attendance proved to be the biggest problem (figure 2). Figure 2 Attendance statistics
No. of courses Accepted places Attendance Failed to attend Cancelled Average attendance per course Average non-attendance per course 6 86 43 41 2 7.16 6.83

Good contributions
We felt the course was well-received and there were good contributions from delegates. Staff members showed significant improvement in their understanding of the theory and in their own confidence in maximising the communicative environment and using strategies to improve communication. A few of the homes had a high percentage of elderly mentally ill residents and this made the course less useful for them. However all of the homes had some relevant residents that they could discuss and think about as they learned the theory. Staff were keen on the idea of the speech and language therapy service being able to provide individual communication advice on specific clients. One of the activities in the course was to attempt to communicate with a partner using specific communication strategies. Delegates reported this was very helpful. The very poor attendance rate was our biggest cause for concern. Because we had received funding for the project, the course was free. We felt in hindsight that attendance may have been better if the homes had had to pay, as the managers would have been more committed and enforced attendance. A year later we wrote to the nursing and residential homes in the county offering the course again, to be charged at 20 per head to cover costs only (hall hire and refreshments, two speech and language therapists for one session, two hours administration per session, paper, ink, stamps, envelopes and photocopying). We followed up the letter with phone calls. Unfortunately, again the uptake was poor and, despite repeated phone calls, two dates were cancelled. We ran one course for 10 members of staff, all of whom attended. Again the questionnaire results show significant improvement after training (figure 4). Again the course was popular with the delegates and everyone contributed enthusiastically. Figure 4 Questionnaire Results (second course)
Average Average pre-training post-training

STAFF WERE KEEN ON THE IDEA OF THE SPEECH AND LANGUAGE THERAPY SERVICE BEING ABLE TO PROVIDE INDIVIDUAL COMMUNICATION ADVICE ON SPECIFIC CLIENTS.

Fortunately the questionnaire results showed significant improvement. Using a scale of 0 (not at all) to 5 (fully), results are in figure 3. Figure 3 Questionnaire results (first courses)
Average Average pre-training post-training How well do you feel you understand: Aphasia Dysarthria Dyspraxia Could you explain the difference between speech and language? Depending on your resident, could you modify the communication environment?

How well do you feel you understand: Aphasia Dysarthria Dyspraxia 1.22 0.78 0.78 4.11 3.67 3.78

3.01 2.02 2.23

4.34 4.27 4.27

Could you explain the difference between speech and language?

1.67

4.22

2.95

4.40

Depending on your resident, could you modify the communication environment? 1.56 Depending on your resident, could you use appropriate communication strategies? 1.67

4.22

4.22

2.66

4.70

Depending on your resident, could you use appropriate communication strategies? 3.08

4.42

Uptake was still poor, despite the charging factor (which did seem to eliminate the non-attendance issue). The costs were small so we do not feel this was a deterrent. It seems that staffing issues may have meant that several homes were unable
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resources
to send staff. Perhaps advanced notification would give homes sufficient time to plan staff rotas / holidays and so on? We will probably try once more, particularly as there would now be minimal preparation and course fees would cover any expenses. For future courses it may be useful to follow up on the changes previous participants have made to the environments in their homes and their communication with residents. Further research and courses attended by the speech and language therapy team have also led us to consider increasing the practical component of the course. This could include inviting people with communication difficulties, and perhaps focusing on teaching supported communication.

For more resources see page 28.

Free demo TROG-2

The TROG-2 (Test for Reception of Grammar 2) is now available in an electronic format for Windows. The complete kit includes the TROG-E CD ROM, manual, users guide and a free one year licence (210 + VAT). For a free demo disk, contact Lucy Do, Harcourt Assessment, 1 Procter Street, London WC1V 6EU, tel. 020 7911 1975, e-mail lucy.do@harcourt-uk.com.

Medical spell checker

A UK version of medical and pharmaceutical spelling software checks for accurate spelling of medical and surgical terms, procedures, diseases, drug names, acronyms, eponyms, medical devices, abbreviations, Greek terms and diacritical markings. Spellex is 70 for single users and 348 for a ten user licence. www.spellex.co.uk

Karen Booth and Niki Freedman are speech and language therapists with Bedfordshire Heartlands Primary Care Trust. Karen is based at Bedford Hospital, tel. 01234 792275 and Niki at Luton & Dunstable Hospital, Luton, tel. 01582 497049.

New from Contact a Family

Contact a Family has several new publications. 1. Parent Participation in health settings is a practical guide to involving parents in shaping service delivery. It provides examples from a variety of settings and has fourteen case studies including producing information on local services and establishing parents forums. 2. Finding medical information on the internet contains a checklist of questions parents should ask when reading medical websites. It has been written in response to concern that parents are getting wrong information and being encouraged to spend large sums of money on unnecessary treatment. 3. Making a Difference: the NSF and parents of disabled children is a guide for individual parents to help them make sense of the childrens NSF. 4. Making a Difference: how parent groups can use the Childrens NSF to influence local services. All can be ordered from Contact a Family on Tel: 020 7608 8700 or e-mail: info@cafamily.org.uk . In addition, the charity has updated its directory entry for Landau-Kleffner syndrome, see www.cafamily.org.uk/Direct/l12.html.

References
Buckwalter, K.C., Cusack, D., Beaver, M., Sidles, E. & Wadle, K. (1988) The behavioural consequences of a communication intervention on institutionalized residents with aphasia and dysarthria, Archives of Psychiatric Nursing 2(5), pp. 289-295. Jones, C. (1991) Student nurse education. Bulletin of the College of Speech & Language Therapists, May.

Training guide
The developer of speech recognition software Dragon Naturally Speaking v8 has produced a CD-ROM based video training guide to its use. 115, see www.keytools.com

Resources
Lock, S., Wilkinson, R. & Bryan, K. (2001) SPPARC (Supporting Partners of People with Aphasia in Relationships and Conversation): A Resource Pack. Bicester: Speechmark. Murphy, J. & Scott, J. (1997) Talking to people with severe communication difficulties: An introductory training video. University of Stirling, Department of Psychology. Parkinsons Disease Society (1994) Face to Face: facial animation made easier. Parkinsons Disease Society of the United Kingdom.

Text-tospeech
NextUp Talker 1.0 is text-to-speech software designed for people with medical conditions affecting their ability to talk. $99.95, free 30 day trial at www.talkforme.com/.

Brain injury book

A review in Encephalitis Today describes Deborah Wearings book Forever Today: A memoir of love and amnesia as a must read. It charts the journey of Deborah and her partner Clive, a musician whose memory is lost by Herpes Encephalitis. The reviewer says the book is educational, emotional and documents changes in brain injury services over the last 20 years. www.encephalitis.info

Acknowledgements
Thank you to Danny Scott, Greater Glasgow Primary Care Trust, and Rosemary Lester, St Georges Hospital, Sheffield for sending us ideas and references. This was a great help in providing a framework and getting us started.

REFLECTIONS ON TRAINING
DO I FIND OUT ABOUT AND LEARN FROM WHAT HAS BEEN DONE BEFORE? DO I FOLLOW IT UP TO ASSESS THE IMPACT ON CLIENTS? DO I ALLOCATE TIME TO LOGISTICS AS WELL AS CONTENT?

Changes at Vocal Process

Vocal Process, which promotes vocal expertise through training and educational programmes, has changed its web address to www.vocalprocess.co.uk. The companys publishing arm has transferred to Voicesource Limited, see www.vppl.co.uk.

Self-management
Stepping Stones to Success: An Implementation, Training and Support Framework for Lay Led Self-management is a booklet from the Expert Patients Programme and the UK voluntary sector to support the development of good practice in recruiting, training and supporting volunteers to deliver lay led self-management programmes. www.expertpatients.nhs.uk/

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