Adjunct Professor / Postdoctoral Fellow The George Washington University Washington, District of Columbia
Abstract Text: The purpose of this project is to uncover implicit interactional and linguistic practices among healthcare practitioners and patients during the administration of clinical assessments. Clinical assessments, such as the Coma Recovery Scale – Revised (CRS-R), measure neurobehavioral responses of persons in disordered states of consciousness (DOC) to particular sensory stimuli and use specific guidelines to interpret responses. The CRS-R stimuli include command prompts and questions that test motor function, verbal ability, communication, and arousal. These explicit prompts can be understood as scripts for the practitioner to follow. However, in preparing the patient for these stimuli, practitioners must embed this formal script in less formal language that initiates and orients the conversational interaction. Furthermore, sociological research has shown that there are interactional and linguistic assumptions made when using such assessments. These ‘unnoticed’ assumptions may provide evidence for neurobehavioral competencies that are not specifically addressed by the formal assessment. We closely examined a 12-minute video-recorded interaction with a patient in DOC and a speech language pathologist practitioner in order to identify competencies that are not directly captured by the assessment. Because current literature suggests that up to 40% of patients in DOC are classified to an incorrect state of consciousness, we believe that by identifying and analyzing these implicit and unnoticed conversational competencies, our approach may help improve accuracy of diagnosis, treatment, and outcomes for patients in DOC by understanding and enriching the clinical assessment process.
We employed the approaches of Discourse Analysis and Speech Act Theory to closely examine conversational interactions in the video. We transcribed the video using the conventions of Conversation Analysis, noting the sounds, gestures and movements that occur within each participants’ turn of talk. We examined the transcript as a whole and categorized sections into discrete patterns of interaction, each of which exhibit characteristic forms of speech, gaze, and gesture. In addition to categorizing verbal structures, we studied the timing of pauses between turns, documented accompanying gestures and body movements, and tracked the focus and gaze of each participant. This approach allowed us to unpack the explicit and implicit conversational competencies exhibited by the participants.
In the video, the patient in DOC demonstrates multiple conversational competencies, some (but not all) of which are acknowledged by the practitioner, and most of which are not directly addressed by the assessment scoring criteria. The patient shows an ability to follow the unspoken rules of conversation by acknowledging the end of a turn of talk, anticipating responses, responding appropriately to shifts in focus, and correctly interpreting a variety of complex speech acts that differ from the more direct language of the assessment script. Because the patient cannot converse verbally, he participates in the conversation primarily through the direction of his gaze, using it to answer questions, indicate acknowledgement, and signal his availability to interact. In some cases, the patient fails to correctly respond to CRS-R prompts related to situational awareness, which would adversely affect his score in a formal assessment. He nevertheless demonstrates implicit and unacknowledged conversational competencies during those turns of talk that initiate and frame these scripted prompts.
Our purpose was to unpack the explicit and implicit conversational competencies that occur during the administration of standardized assessments of neurobehavioral function, such as the CRS-R, and which serve as an important source of data to inform clinical decision making and care planning. Specifically, we demonstrate that a person in DOC may display conversational competencies not captured by the CRS-R scoring criteria. We identified clearly observable, reproducible, and describable conversational competencies that may suggest a higher level of consciousness than would be detected by the CRS-R sensory stimuli alone. Conversational competence is rarely, if ever, evaluated in determining recovery of consciousness, where the focus is usually on vocalization. Yet our analyses demonstrate that such conversational competencies are clearly observable, even when the patient cannot vocalize. This approach provides important new ways of considering content for assessments of neurobehavioral function that are absent from current approaches, presents new insights in the challenges of standardized assessments, and holds potential for facilitating greater diagnostic accuracy for persons in DOC.
Keywords: Consciousness Disorders, Neurological Rehabilitation, Needs Assessment, Neuropsychological Tests, Mental Status and Dementia Tests, Linguistics, Body Language, Caregivers, Outcome Measurement Error
