In the intensive care unit (ICU) at Harborview Medical Center, the stakes are high and often depend on critical, fast-paced conversations for patient care. For patients with spinal cord injuries (SCI), those conversations play a central role not only in their medical care, but also in how they begin to understand what has happened to them and what comes next. But making those conversations work for everyone is not always easy.
Alissa Smith, a speech-language pathologist (SLP) and doctoral student in the Rehabilitation Science PhD Program at the UW School of Medicine, is studying these interactions as part of her dissertation. Using ethnography, a qualitative research approach based on in-depth observation, Smith examines how communication between patients, families, and clinicians shapes the experience of care in the trauma ICU for SCI patients. She joins patients at their bedside to observe interactions among patients, doctors, physical therapists, occupational therapists, and other healthcare providers. Her goal is to understand how patients with new SCIs and their healthcare teams communicate during the earliest days after injury, and how these interactions shape patients’ perspectives and rehabilitation.
Professor Carolyn Baylor, PhD, CCC-SLP is a speech-language pathologist and Smith’s dissertation committee chair. According to Dr. Baylor, patients with communication disabilities have more difficult experiences in the healthcare setting because of the communication challenges.
“Spinal cord injury doesn’t always cause speech changes, but many of these patients may also have a traumatic brain injury which can impact speech, language, and cognitive function. Or they could be on a ventilator, which impacts their ability to talk. Any of these make communication difficult,” says Dr. Baylor. That’s where Smith’s work becomes important.
“After a spinal cord injury, many people spend time a long time in the ICU,” says Smith. During this early phase, care focuses on medical stabilization while patients and families begin to make sense of major changes. The ICU can be unfamiliar and overwhelming, and patients are often learning new information while adapting to changes in their bodies, routines, and expectations. “Ethnography gives us a way to look closely at what it’s like to receive and provide care during this time,” Smith says. “I’m trying to understand the culture of the ICU and how communication fits into that.”
Smith’s dissertation shows how multidisciplinary clinicians and researchers in the Department of Rehabilitation Medicine collaborate on research to advance both knowledge and patient care. Smith’s collaborative team grew naturally out of the Department where she connected with physiatrist and Assistant Professor Heather Barnett, MD who specializes in the management and treatment of patients with spinal cord and other neurologic injuries at Harborview Medical Center. Barnett serves as Smith’s point person on the medical team at Harborview, helping Smith integrate into the unit for observation.
“It is complicated to observe the clinical environment and figure out the best ways for her to plug herself in both physically and considering different dynamics of the teams and the locations. A lot of it was figuring out what's feasible in a clinical environment for an ethnographic study,” says Dr. Barnett.
“I’m trying to be a sponge,” says Smith, who has been observing interactions between patients and healthcare providers real time, and then interviewing patients and providers separately to learn about how communication is experienced from different perspectives. “My goal isn't to assume something needs to be changed, but to understand what it’s like to be in a relationship with patients, providers, and families at a critical time in their lives.” Nevertheless, Smith’s research has led to opportunities for reflection on the part of providers.
“Hearing some of the things that she collected from patients made us realize the [communication] barriers that we see regularly. People feel like they're not being heard. Bringing attention to improving the communication is important for ongoing care,” adds Dr. Barnett.
Supported by research mentor Dr. Baylor and SCI specialist Dr. Barnett, Smith continues her work on her dissertation to convey her findings to the broader community. “I want to create a realistic picture so that, down the line, we can create supports that actually work,” adds Smith.