Beneficios de la Implantación de un SGA ISO 14001:2004

Gaze and bodily alignment were observed to produce the conditions for learning, by allowing the HCP to observe initiations, to indicate to the PWA that they can take a turn in the conversation, and to keep the PWA’s attention. HCP 20 was observed throughout sessions to move her bodily position to an angle where she had best view of the PWA’s face. She knelt on the floor in front of PWA 9 rather than beside her so she could notice non-verbal communication during the task. She was also observed to repeatedly lift her head if she was working with the PWA’s limbs, such as stretching the foot. Keeping eye contact with the PWA or moving their gaze toward the PWA was observed to facilitate HCPs picking up on PWA’s non-verbal initiations and cues. For example, HCP 16 moved her gaze towards PWA 3 throughout the physiotherapy task. As a result, she observed PWA 3 pulling a face and she responded by providing her with positive feedback. In contrast, when HCPs did not keep their gaze on PWA, initiations could be missed. For example, HCP 13’s gaze was fixed on the rehabilitation materials. PWA 3 opened her mouth to initiate and began

to make a groping movement with her mouth, but this was not noticed and PWA 3 gave up on her initiation.

As discussed in the materials section, gaze and bodily alignment was seen to be important during tasks and when using materials such as worksheets. HCPs often moved their bodily position to ensure that both parties could both see the material. HCP 20 moved and sat beside PWA 10 so that both parties could read the rehabilitation programme together. This also helped provide a sense of collaboration and shared control. HCP 12 also moved her body position and moved closer to PWA 5 so that he would have the worksheet in front of him as he completed a writing task, but she was able to see the material to provide tailored, timely prompts if needed. When the worksheet was too far from the HCP it was difficult for a HCP to provide feedback. HCP 22 had to stand up and look over PWA 5’s shoulders each time he wrote an answer due to poor bodily alignment at the beginning of the activity. In addition, when HCPs split their attention to write in notes while a PWA was doing an activity, this meant that initiations and opportunities to provide feedback could be missed. For example, HCP 13 missed an opportunity to provide feedback to PWA 5 when he was asking for it as he was focused on his notes. On another occasion HCP 12 missed PWA 9 shaking her fist, as she was also looking at the notes.

For some PWA it was essential for them to see the HCP’s face to facilitate their understanding. Body alignment facilitated communication for PWA 3, as she looked at people’s mouths to prompt herself.

Maintaining eye-gaze was also used to manage different stakeholders in a rehabilitation session. It was used to direct attention towards the PWA and show that the HCP was still directing the conversation towards them. For example, HCP 20 maintained her gaze to continue directing conversation towards PWA 6 when his wife was answering for him. She maintained this gaze until PWA 6 provided an answer to the question.

7.7 Summary

Data from the observation study provided detailed analysis of interactions between PWA and HCPs in routine rehabilitation. Collective influencing factors such as NHS caseload and time pressures did have an impact on how the rehabilitation sessions could take place. The structure of the sessions was for the most part consistent, irrespective of activity type or HCP. Discussion and naturalistic conversation occurred at the beginning of the activity, at the transition between activities and after the HCP closed the session. The time spent on discussions and naturalistic conversations did vary. More time was spent engaged in

discussions or naturalistic conversations with people with mild rather than severe aphasia. There were also sessions in which there was no naturalistic conversation between the PWA and the HCP. Those HCPs with a professional qualification spent more time in discussion or naturalistic conversation than APs or RAs.

The observational data allowed the researcher to see how the interview themes were enacted in rehabilitation. The environment was a facilitator for learning, providing the PWA with opportunities for salient practice and providing scaffolds for naturalistic conversation. It also allowed the HCP and PWA to identify difficulties the PWA may have had with a particular task. The only barrier to learning observed in the home environment was distractions, which had more impact on those PWA with reduced attention. Materials acted as both a barrier and a facilitator of learning. Materials could prompt a PWA and scaffold their learning. PWA were more engaged in activities where the materials were salient. Materials could also act as a barrier to learning if they were perceived as boring and repetitive, or they could shut down opportunities for conversation by distracting the HCP. Materials could signify change in activities and closing of sessions.

Although PWAs were observed taking control of the environment in some instants, control of the session was maintained for the most part by the HCPs. HCPs choose the activities for the session and maintained control of the structure of the session, deciding when activities would begin and finish. Collaboration was enhanced by placing materials where both parties could see them, explaining processes fully, being clear with directions and instruction and giving the PWA opportunities for direct rehabilitation.

Emotions were prevalent in sessions, with PWA becoming frustrated and upset. Humour, reassurance and explaining difficulties helped to negate the effects of negative emotions. Building a rapport was central to the rehabilitation activity and had a direct impact on both the HCP’s and PWA’s emotions. Rapport was built through naturalistic conversation, honest feedback and celebrating the PWA’s achievements and progress.

Finally, the importance of gaze and bodily alignment was observed in these sessions. Gaze and bodily alignment helped the HCP to provide honest feedback, to aid the PWA’s understanding and notice PWA’s initiations and respond to them appropriately. Gaze also helped to keep the PWA’s attention and to show them that the conversation was continuing.