Results and implications for the main intervention study

4.3.1 Acceptability of the training intervention

Both participants successfully learnt how to use both AT packages in the ten, hour-long weekly time slots allocated to them, and additional support or training from the software companies was not required. However, there were individual differences between Claire and Ella both in relation to the two AT packages, and in terms of their learning skills and preferences. These differences were illustrated by comments made during training sessions and in the post-training interviews, besides training observation notes made by the student researcher. They are briefly described below,

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firstly with reference to each of the AT software packages in turn, then with reference to their approaches to learning.

4.3.1.a Dragon NaturallySpeaking™

Claire described using Dragon Dictate™ as ‘easy but difficult.’ She said that owing to her difficulties with speaking, writing was ‘a long process’ (Claire, T3 interview). She reflected on how the software could be frustrating to use at first because its word recognition capability appeared to be inconsistent, sometimes immediately reproducing a word accurately, other times failing to recognise a word after numerous repetitions. Claire’s pragmatic solution to this was to orally attempt a word three or four times, and if it was still not produced correctly she would simply, if laboriously, type it. Mistakes rarely deterred her or slowed her down, and her standard response to these setbacks was one of amused acceptance. Over time, outlandish errors of reproduction were markedly reduced, and Claire frequently made positive remarks about the software’s capacity to recognise even proper nouns such as ‘Guggenheim’, ‘Staten Island’ and ‘Niagara Falls’. She soon discovered that using an authoritative, crisp tone of voice facilitated recognition, and consistently made use of this. It may have been of relevance that prior to her stroke, Claire had been a lawyer and an accomplished and confident public speaker.

By contrast, Ella found Dragon NaturallySpeaking™ ‘a lot more harder’ to use than she had expected; she recollected specific examples of errors (such as ‘bald’ for ‘bold’) and said that the software ‘misrepresented my work’ (Ella, T3 interview). In her training sessions, she often became disheartened by the burden of editing and correcting these errors, and in an early session remarked in frustration: ‘It would be easier to just write it!’ (Ella, training session 3). This lowering of morale in turn introduced a greater rate of error as Ella’s speaking voice became softer and more hesitant. Ella also struggled with feeling that the work she produced was not perfect and deliberated over every word, which seemed to impede her pleasure and satisfaction. Claire was more inclined than Ella to accept her

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own work as broadly satisfactory and continue to move forward with the task she had set herself.

Ella said she was unlikely to continue using Dragon NaturallySpeaking™ independently once training was completed. She was satisfied with the arrangement she had with her support worker at college, and preferred to continue writing collaborative emails with her mother, providing an idea and asking Jackie to refine it. Claire, however, intended to continue using Dragon Dictate™ independently, and was considering writing a story or a document related to her legal experience. She reported she may also be contributing to a journal paper written by a student in whose recently completed PhD study she participated.

4.3.1.b ClaroRead™

Since her reading impairments were relatively mild, Claire did not feel she needed to rely on ClaroRead™ software to check her written work. In the early stages of training, she used it to listen back to what she had written, but found its prosodic features unnatural and jarring. She soon became confident with combining rehearsing her spoken output with the microphone off, then dictating it, and finally checking it by reading directly from the screen. Ella, however, used ClaroRead™ throughout the training period, and described it as ‘good, really good.’ Though like Claire she criticised its prosody, deeming it ‘completely not realistic at all,’ she found this ‘funny’ rather than problematic, and indeed had selected ‘Australian male’ as an accent choice to heighten her amusement (Ella, T3 interview). At the end of the training intervention Ella expressed her intention to continue using ClaroRead™ to support her independent reading.

4.3.1.c Learning skills and preferences

It was evident from working with Ella and Claire that individual learning styles at a macro level were likely to influence participants’ approaches to training: for example, adopting an appropriate oral dictation style came more naturally to Claire than Ella, as did tolerance of errors. Conversely, Ella found it easier than Claire to cope with the distraction and additional

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burden of auditory processing. This was noted as a consideration for the main intervention study sessions, with the intention that these should be personalised to suit each individual; this will be returned to in detail in the intervention chapter (sections 6.4 and 6.5). Adopting a ‘coaching’ role was felt to be the most appropriate way to scaffold participants’ successful communication strategies and to tailor support to individual requirements. Participant observation was already planned, and could readily be extended to scrutiny of specific communicative behaviours such as oral dictation traits. Further, immediate written evidence of success would exist owing to the use of dictation software, which could serve to reinforce the usefulness of the strategy employed. Finally, the influence of trainer behaviour may also be captured by this approach, in a similar way to a primary conversation partner in every day conversation. This would be useful in terms of recording replicable training strategies.

These methods are somewhat analagous to those used in conversational coaching (CC) ([214], [215]) and conversation analysis (CA), ([216], [217]), though both these latter involve working with dyads rather than individuals. CC and CA offer a means of providing individuals with additional or alternative strategies for conveying information, in order to maximise their chances of being understood and to reduce frustration. The strategies suggested in these approaches are suggested based on observation of participants’ current communicative behaviours, and the outcomes of these behaviours. Practitioners engage in close scrutiny both of unhelpful habits and of areas of strength which could be further exploited, with a theoretical underpinning that by bringing unconscious behaviours to participants’ attention they can be eliminated if unhelpful, or refined and extendeded if they are beneficial. The current study takes a broadly similar approach.

4.3.2 Design and development of the training intervention and materials In their post-intervention interviews, Claire and Ella made three recommendations pertaining to the second aim of the pilot study. These

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are described below, along with actions undertaken to implement them for the main intervention study.

4.3.2.a More detailed goal setting

Both participants suggested more time should be spent at the outset of the training program on exploring what activities future participants would like to undertake. Claire described how for her, while the initial intervention sessions were structured, the later ones ‘flowed’ as her travelogue took shape; often on arrival at Claire’s home during those weeks she was already working on the document and observation and note-taking were all that were required. Nevertheless, Claire felt a list of ‘options’ for writing activities would support future participants who may find it more challenging to come up with ideas (Claire, T3 interview). This was borne out by Ella’s experiences: she explained that the hardest thing for her had been coming up with ‘a concept’ and found that using Dragon NaturallySpeaking™ was difficult not only because she had to ‘re-work what I’m saying’ [when there were errors of reproduction] but also because it is even more difficult ‘thinking of the idea in my head.’ She suggested it would have been preferable to undertake a ‘project.’ (Ella, T3 interview). She initially found it difficult to describe what type of project she may have liked, but eventually thought perhaps something related to describing or reviewing television programmes she had watched.

In order to implement this recommendation, a power-point presentation was prepared for participants in the main study (Appendix 4.3), containing suggestions for both short and in depth projects. This was intended to support participants who found it challenging to conceptualise and formulate what they wanted to write about, by alleviating the burden of coming up with an idea and encouraging participants to focus on the act of writing itself, at least in the early stages of the intervention. Plans were also made to provide each participant in the main study with a folder containing a simple progress record (Appendix 4.4) in which they could indicate from a checklist, supported with pictures: tasks undertaken independently, time spent on each task, level of ease/difficulty and level of

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enjoyment. Each participant’s folder would also be updated weekly with materials from their most recent training session, recapping the main learning points in an accessible format (Appendix 4.5 contains a sample from the folder of Sarah, a participant in the main study). Finally, in the main study there would be an opportunity at the end of each session for participants to print out a record of what they have written, to enable them to monitor their weekly progress and foster a sense of achievement. It was noted that Ella’s greater preference for structure at a more micro level in the training sessions, such as needing more support not only to formulate an abstract concept but then to express it verbally in words, may also be a factor for some participants in the main intervention study. For example, they may respond more favourably to step by step procedural guidance, while those with a more loosely structured approach like Claire may prefer to learn through experimentation or trial and error, with less explicit instruction-giving from the trainer. Therefore, this too was to be considered when the sessions were personalised to suit each individual, again with broad parallels to the conversational coaching and CA literature, and will also be returned to in the intervention chapter.

4.3.2.b Extending Dragon NaturallySpeaking™ initial voice training

Ella recommended that more initial training time should be spent on improving voice recognition, in order to reduce dictation errors. In practice, the most effective way to overcome this issue is simply continued usage of Dragon NaturallySpeaking™, as Claire’s more intensive use demonstrated. Nevertheless, as a result of Ella’s comments, more care was taken to explain this explicitly to participants in the main intervention study. It was also noted that additional reading aloud tasks could be provided to supplement those in the Dragon NaturallySpeaking™ tutorial if main study participants felt this would be useful.

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4.3.2.c Mode switching between Dragon NaturallySpeaking™ editing and dictation

Despite the mechanical ease with which this can be done, Ella and Claire both found editing by voice command a challenging task, and both favoured amending their text with the keyboard. With time, they were able when encouraged to locate an error with the cursor and then delete it and correct it using voice commands, but given the choice both preferred to type. It is possible that while AT was useful for locating and deciphering the nature of an error, rectifying it conventionally felt more natural for Claire and Ella. However, this would not be a realistic option for participants with severely impaired writing and/or reading. Training in the main intervention was therefore planned to accommodate this preference where viable, and to provide more focus on mastering both modes and effectively switching between them for those unable to type either owing to physical impairment or the severity of their spelling deficits.

4.3.3 Selection of assessments to measure outcomes

The two pilot participants were compliant with the assessments, which took approximately two hours to complete at each time point. The assessments tested were acceptable to participants and most yielded appropriate data. There was no evidence of undue participant burden, which was assessed by monitoring for signs of fatigue or distress, offers of taking breaks or resuming another time which were declined in favour of continuing, and explicit enquiries as to whether levels of fatigue were acceptable for participants. Some changes to the assessment battery were made, however; these are described below, along with a brief outline of assessments which remained unchanged, which are described more fully in Chapter 5: Methodology.

4.3.3.a Language, writing and reading

The CAT was acceptable to participants and was retained for the main intervention; it is described in Chapter 5.

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Two substantive changes to the battery of writing and reading assessments were made. Firstly, the use of the WRAT4 was discontinued because there were factors which made it an ineffective measure of the skills targeted by the training intervention. The WRAT was not created specifically for an aphasic population, but designed to assess reading comprehension and single word spelling in both children and adults in order to identify specific learning disabilities; the original assessment also tests numeracy but that sub-test was not used.

The three WRAT4 tasks which pilot participants were originally required to complete were single word reading, single word written spelling to dictation, and written sentence comprehension (where comprehension was deemed successful if the participant could successfully provide a missing word orally). The last task was particularly problematic for the pilot participants, and it was concluded it could not offer a true measure of sentence comprehension for participants with aphasia owing to the potentially confounding effect of their word-finding difficulties. The WRAT4 was therefore replaced by selected subtests of the Psycholinguistic Assessment of Language Processing in Aphasia (PALPA) [17], as described in more detail in Chapter 5. Most of these were to be used diagnostically, while a small subset was to be administered at all time points, in conventional pen and paper format only. This subset would monitor for potential remediatory effects of the intervention, for example as a result of improved confidence, or intensive practice with/increased exposure to the written word. Secondly, as a result of deciding not to use the WRAT, the Gray Oral Reading Test 4 (GORT-4) [218] was introduced to ensure that narrative reading comprehension was sufficiently assessed and monitored in the main study.

In addition to these two changes, a minor adjustment was made to the constrained writing task in order to ensure that it was truly reflective of functional writing skills. The instructions regarding the topic of this task were amended to emailing a friend inviting them to meet, arguably a more natural task than writing to the student researcher. Further, the pilot

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participants indicated that the original topic would not be easy to fulfil for those who had not engaged in any recent writing activity. Nevertheless, the constrained writing task appeared to be sensitive to change, with both participants able to produce more written narrative with AT than with pen and paper.

4.3.3.b Cognition, quality of life, mood and social participation

The CLQT, the SAQOL-39g, the GHQ-12 and the SNA were all found to be acceptable to participants and were retained in the main intervention; they are described in Chapter 5. Use of the SSNS was discontinued owing to the high degree of overlap with SNA. The SSNS is a questionnaire-based measure which captures the number of people from five subgroups - children, friends, relatives, neighbours, interest groups - with whom the interviewee is in contact, the frequency of this contact, and a rating scale for satisfaction with frequency (though not quality) of contact for each group, from which an overall rating can be obtained. Scores range from 0 to 100, with higher scores indicating a stronger social network. The pilot participants expressed a preference for SNA owing to the pictorial accessibility of the diagram and instructions, and the way in which each individual member of their social network, rather than simply subgroups such as friends, relatives or neighbours, could be discussed, thereby capturing change in participants’ social relationships in finer detail. Furthermore, Claire pointed out that any dissatisfaction she felt with regards to her social network tended to stem not from frequency of contact, but the quality of that contact, which she felt was impeded by her aphasia. However, there were useful elements of SSNS which were missing from SNA, namely satisfaction levels with frequency and type of contact with members of the network, membership of groups, and experience of loneliness. In the main study, the first aspect could readily be incorporated into SNA, and the latter two were to be covered with more specific probing in the in-depth, semi-structured interviews.

119 4.3.3.c Qualitative data

The topic guides created for pre- and post-training intervention yielded rich information relating to functional reading/writing, social participation and engagement with technology pre- and post-stroke, and as a result were not amended before the main study, though as with all semi-structured interview guides they were not an exhaustive question battery; rather, they were to be treated flexibly throughout the main study and adapted as appropriate whenever novel and relevant topics were introduced by participants.

A highly useful finding of the pilot study was that the combined use of video-recording and observation note taking for participant training sessions was more illuminating than was anticipated at the design stage. Not only was it acceptable to participants, but - besides fulfilling its original purpose of recording and monitoring progress – the video recordings and observation notes additionally captured numerous instances of participants discussing many of the phenomena covered in the in-depth interviews. Sometimes this occurred when participants cited a training experience as representing a specific example of something they had described in general terms during interview, whether procedural, such as struggling to find a word or forgetting the steps required to start a computer programme, or psychological, such as feeling frustrated or mourning the loss of their employment. At other times, additional disclosures were made which related to interview topics but which participants had not previously mentioned, perhaps owing to the intimacy of one-to-one training and increased trust as the weeks passed. Furthermore, as noted above, observation data would be very useful for scrutiny of specific communicative behaviours and recommendation of successful strategies, as described in the conversational coaching literature.

As a result of this finding, the emphasis on observation in the main intervention was increased, and the literature on participant observation (PO) in interventions was therefore consulted at the end of the pilot study; this literature is briefly summarised below. It revealed that the additional

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insights yielded by observation described above were indeed a justification for its continued use: observation data is often used for interview triangulation, to ‘provide a check on what one is told for reasons of impression management’ [219] (page 532). In other words, in interviews participants may, consciously or otherwise, give responses they believe interviewers may find favourable; however, they are less likely to be able to sustain a stance they do not genuinely hold over longer periods of observation during which they are concentrating on an additional activity