Who said dialogue conversations are easy? The communication between communication vulnerable people and health‐care professionals: A qualitative study

Abstract Objective To gain insight into how communication vulnerable people and health‐care professionals experience the communication in dialogue conversations, and how they adjust their conversation using augmentative and alternative communication (AAC) or other communication strategies. Methods Communication vulnerable clients and health‐care professionals in a long‐term care institution were observed during a dialogue conversation (n = 11) and subsequently interviewed (n = 22) about their experiences with the conversation. The clients had various communication difficulties due to different underlying aetiologies, such as acquired brain injury or learning disorder. Results from the observations and interviews were analysed using conventional content analysis. Results Seven key themes emerged regarding the experiences of clients and professionals: clients blame themselves for miscommunications; the relevance of both parties preparing the conversation; a quiet and familiar environment benefitting communication; giving clients enough time; the importance and complexity of nonverbal communication; the need to tailor communication to the client; prejudices and inexperience regarding AAC. The observations showed that some professionals had difficulties using appropriate communication strategies and all professionals relied mostly on verbal or nonverbal communication strategies. Conclusion Professionals were aware of the importance of preparation, sufficient time, a suitable environment and considering nonverbal communication in dialogue conversations. However, they struggled with adequate use of communication strategies, such as verbal communication and AAC. There is a lack of knowledge about AAC, and professionals and clients need to be informed about the potential of AAC and how this can help them achieve equal participation in dialogue conversations in addition to other communication strategies.

quires a two-way process (expressing and understanding) in which messages are negotiated until the information is correctly understood by both parties. 7 The present study used a broad definition of AAC, which includes formal assistive communication systems (eg voice output communication aids), conventional semiotic systems (eg handwriting), as well as commonplace objects (eg pictograms, or letters). Nonverbal communication (eg gesturing) is discussed separately. 8 Dialogue conversations can be problematic for communication vulnerable clients, since their communication difficulties make it challenging for them to be actively involved. 9 We define communication vulnerable people as people who experience difficulties communicating in particular situations. They struggle to express their needs, wishes and values, and/or to understand the information in conversations with professionals. This may be the result of mild to severe communication difficulties, related to their sensory, emotional, physical or cognitive abilities. 10 Numerous underlying aetiologies and diagnoses can lead to functional communication difficulties. Acquired brain injury can lead to aphasia, dysarthria, apraxia and paralysis, which can lead to difficulties in speech and use of language. Learning disorders can lead to difficulties in understanding, memory and concentration. And physical or sensory disabilities can lead to speaking or hearing difficulties. In line with the ICF 11 and recent developments in health care, 12 we used a top-down approach to examine communication vulnerability and the functional communication in conversations. This relates to the client's participation, and to the activities and participation levels defined in the ICF, 11 and means that we focused on the experiences of clients in functional communication in conversations, rather than on the client's diagnosis (bottom-up) 13 . It is important to acknowledge a person's experiences and elements of their environment, rather than focussing primarily on the diagnosis. 11,13 Professionals are often not aware of the clients' communication vulnerability or do not know which strategies they can use to enable clients to express themselves or to understand the professional during dialogue conversations. 10,14 Other studies have reported that professionals can experience feelings of anxiety, fear and inadequacy when communicating with people with aphasia. 15 However, existing studies on dialogue conversations have often focussed on a specific group of people with one specific diagnosis (eg aphasia) or do not provide in-depth information about the functional communication problems that both professionals and clients experience. [16][17][18] It is important to address the broad target group of communication vulnerable people, regardless of their underlying diagnosis or symptoms, 19 to be able to focus on ways of adapting communication to the specific needs of an individual client. 20 Furthermore, research about communication in clinical practice is mostly targeted at the process steps of dialogue conversations 21 or affective factors such as trust, respect and empathy, missing a focus on communication and AAC. 22

| ME THODS
A qualitative study was conducted, based on general tenets of naturalistic inquiry, focussing on communication in the natural setting of a care institution. 25 Observations were followed by semi-structured interviews with both clients and professionals.

| Setting and participants
This study was conducted in a long-term care institution for people with acquired brain injury and physical limitations in the Netherlands. The local client advisory board advised the researchers about selected sites where they could find clients with a variety of communication difficulties who required various types of support (eg medical, living, daily activities). Professionals who regularly had dialogue conversations with clients were recruited by the managers using convenience sampling. Clients were recruited by the selected professionals using purposive sampling based on the following selection criteria: being older than 18, not completely blind or deaf, able to communicate experiences (with or without AAC), having at least one dialogue conversation every 6 months with the professional, and providing more than two "yes" answers on the communication vulnerability screening list (Appendix S1).

| Data collection
Between March and July 2015, two researchers (SS, HS) observed dialogue conversations between pairs of professionals and clients.
Immediately afterwards, the client was interviewed first (to prevent problems of recalling the conversation), followed by the professional. Each interview was conducted by two trained interviewers (SS, HS) using a self-developed interview guide that focussed on experiences of communication, adaptations and AAC. The questions were formulated using the literature about communication and AAC, 5,6,10 supplemented by several additional items that emerged during the observations. The interview guide was discussed with the local client advisory board to enhance its accessibility. Different types of questions were tailored to the abilities of the clients, with or without pictograms showing several answer options, using short sentences and high-frequency words and providing sufficient time and short breaks. 24 In addition, probing questions were used and the researchers took care to note nonverbal behaviour that indicated understanding of the questions. Field notes were taken after each observation and interview.

| Data analysis
The interviews and observations were audiotaped, transcribed verbatim and analysed using conventional content analyses. 26 Two researchers (SS, HS) read the transcripts repeatedly and assigned codes to relevant fragments using the qualitative analysis software NVivo 11. Coding was derived directly from the text, focussing on experiences, adapting communication to the clients and the use of AAC. During their discussions, overarching themes emerged from the data, and the codes and themes were constantly compared between the observations, field notes and interviews. Other researchers (RD, AB, UR) took part in peer debriefing sessions where they reflected on the analysis. 25 The themes were adjusted until a final thematic structure was decided on by all researchers. After 20 interviews and 10 observations, no new themes emerged and therefore we assumed that thematic saturation had been attained; the final two interviews served to confirm and verify the content analysis.
To ensure internal validity, the preliminary analysis of the first three interviews was discussed with the client advisory board as an provided verbal consent to the professional who had recruited them, and additionally written or audiotaped informed consent to the researchers in accessible format. 24

| RE SULTS
In total, 11 observations and 22 interviews were conducted. The clients represented a heterogeneous group with considerably different scores on the communication vulnerability screening list (see Table 1). At the time of the study, none of the clients was consulting a speech and language pathologist, and only one of the clients occasionally used an AAC, namely a picto-book. The aim of the dialogue conversations differed, ranging from issues such as goal setting to the client's satisfaction with the care process.
The median duration of the conversations was 14 minutes (range 5-47).
The content analysis revealed seven key themes ( Figure 1). The results of the interviews and observations reinforced each other and are therefore presented together in the results section. Within each theme, we describe the perspectives of clients and professionals, as well as our insights from the observations.

| Clients blame themselves for miscommunications
The clients tended to take responsibility for communication problems during the conversations: they blamed their own disability.
They explained that they could not understand difficult words because of their cognitive problems or that the professional did not understand them because of their speech problems.
Interviewer: "Yes, and she did not understand it?" Peter (client): "No!" Interviewer: "OK, and why didn't she understand it?" Peter (client): Murmurs and points to himself.
The professionals did not mention this topic explicitly, but they did describe a need for adapting their communication to the client's disabilities. The question of blame was not discussed during the observed conversations.

| The relevance of both parties preparing the conversation
Both clients and professionals found it important to prepare the conversation and found it helpful to receive written information prior to the conversation. Several clients mentioned that this gave them time to think about the subject.
Some professionals prepared the conversation by preparing a fixed structure of topics to discuss. Others described supporting the clients by asking them to think about what they wanted to discuss. The observations showed that most professionals prepared the conversation, but only for themselves. The clients were not always informed about the structure or content in advance and often seemed to follow the professionals' lead. For example, in conversation 2 the professional had brought along a list of goals to evaluate, which she used as a support for herself; the client had not received this information. However, in observation 9, the structure prepared by the professional was appropriately tailored to the client who had memory problems and he could follow the structure.

| A quiet and familiar environment benefits communication
The clients and professionals expressed that a calm and quiet environment without distractions is important in conversations. The researchers also observed that the conversations in the supported living facilities mostly took place in the client's own room, which was a quiet environment, with the door closed, and no other people present. The researchers observed that time was not always used efficiently.

| Giving the client enough time
Conversations that took longer did not necessarily mean that clients had more time to express themselves. For example, while conversation 2 took 28 minutes, the professional talked fast, used long sentences, completed the client's sentences and asked multiple questions at a time. These actions meant that less in-depth information was received from the client. By contrast, the researchers observed that in conversation 5, which took only 9 minutes, the client who stuttered was encouraged to complete her own sentences and to initiate topic shifts.

| Importance and complexity of nonverbal communication
The clients stated that nonverbal communication was very important for them to express themselves, for example using gestures in combination with speech. The professionals also reported that nonverbal communication, specifically facial expressions, body language and eye contact, was important to understand the client better or to ascertain whether the client understood them.
However, the professionals also explained that the nonverbal communication of communication vulnerable clients was complex and often difficult to interpret, due to physical disabilities such as spasms. Knowing the client well helped them interpret the nonverbal communication.

Vera (professional): "At a specific moment you just no-
tice, (…) for example that she keeps adjusting the seating position of her electric wheelchair, she cannot sit still any more, yes then the conversation is taking too long." The researchers observed that clients used a lot of nonverbal communication, mainly gestures, and the professionals did pay attention F I G U R E 1 Themes relating to the experiences regarding the dialogue conversations, and the adjustments made to this. In fact, some professionals relied almost entirely on nonverbal communication. The client and professional in conversation 1 had a conversation relying only on nonverbal signs and the client's yes/no/ hmm answers. This, however, restricted the client in introducing a topic, feeling, or thought of his own.

Huub (professional): "I think I already see in your eyes
what you want to do?"

| Tailoring communication to the client
The next three subthemes describe the experiences of clients and professionals as regards tailoring the communication.

| Tailoring communication speed and complexity
The clients described that the professionals had helped them to better understand the conversation, by repeating information and speaking slowly. However, some of the clients could not always understand the professionals, because they used difficult words, talked too fast, used sentences that were too long, or gave too much information.

| Preparing a structure for both professional and client
The professionals emphasized the importance of structuring the conversation, using a predefined structure, summarizing, paraphrasing and guiding the client back to the topic of conversation. The clients did not mention the concept of structure.
The observations showed that some clients had difficulties staying on topic and following the conversation. In conversations 4, 6, 7 and 9, the professionals managed to guide the clients back to the topic while also giving them enough time to tell their story. Their strategies involved: paraphrasing, asking questions, clearly indicating a topic shift and pointing it out to them when they deviated from the topic.

| Tailoring questions to the client's needs
The professionals described that it helps the clients to ask one question at a time; the clients did not mention this strategy.
However, the observations showed that not all professionals used this strategy. In conversations 2 and 3, the professionals asked multiple questions at a time, leading to unclear answers from the clients. The professionals used both open and closed questions and reported that using closed questions could help the clients. However, the observations showed that using too many closed questions led to a lack of depth in conversations 1, 2 and 3 and that in these situations clients struggled to initiate a topic shift. During conversation 2, the professional initiated 12 topic shifts and the client none (Table 2).

| Prejudices and inexperience with regard to AAC
The clients did not know if they would like to use AAC, due to a lack of experience. Some clients thought pictograms were childish, while others found them helpful during the interview with the researchers.
Interviewer: "Do these pictograms help you?"

Mark (client): "Yes!"
A few clients explained that it is helpful to use conventional semiotic systems, such as writing, to express themselves during a conversation. The professionals explained that they did not use formal assistive communication devices or pictograms because they thought it was not necessary, it was childish, or it was for "stupid" or "crazy people". Two of the professionals indicated that clients could benefit from photos or a picto-book, but did not use this strategy during the observed conversations.
Other professionals described that written information would probably help the client to understand them, or to remember what was said. Such written information had to be adapted to the client's abilities, presenting it in large font, including only a limited amount of information, and using simple words.

Anne (professional): "Then I write it down on paper
in advance, using a larger font, so that she can read it more easily (…) No difficult words and not too much The observations showed that only one professional, Laura, used written information, by using the computer. Client and professional described that it was helpful for the client to hear as well as read the information.
Even though the use of formal assistive communication systems, pictograms, written information and writing were sometimes mentioned as helpful, the researchers observed that these were not used in the dialogue conversations.

| D ISCUSS I ON
The purpose of this study was to gain insight into how communica- showed that they mostly relied on verbal and nonverbal communication, and did not use AAC. Clients were often insufficiently enabled to express themselves, whereas client-centred care and shared decisionmaking require an active role of clients in dialogue conversations. 28 It is striking that the clients thought they were to blame for difficulties in the conversation. Clients were not aware that professionals could have used AAC to enable them to become more involved. This study showed that asking more questions appeared to be not necessarily better or worse, but that the types of question need to be tailored to the client and his or her communication difficulties.
The study by Gordon and colleagues, including people with aphasia and dysarthria, also found that nurses often controlled the topic of the conversation, while clients were limited to responding to closed questions. 16  Weaknesses of this study relate to potential bias due to sampling and socially acceptable answers. 25 The professionals could have chosen the clients who they thought were satisfied with the conversations, and the managers could have chosen professionals who they thought had good or poor communication skills. We used a preliminary member check with clients, but did not include the views of professionals. Furthermore, we cannot be sure that no socially acceptable answers were given during the interviews. The

ACK N OWLED G EM ENTS
The authors would like to thank the client advisory board of the institution for their collaboration during the sampling procedure, data collection and data analysis. We confirm that all personal identifiers have been removed or disguised so the patients/persons described are not identifiable and cannot be identified through the details of this paper.

CO N FLI C T S O F I NTE R E S T
No conflicts of interest have been declared.