Let Nonverbal Patients Communicate
A hospital stay is seldom pleasant. Besides having pain and being sick, patients have to endure needle punctures a dozen times a day, beeps from medical equipment every ten minutes and moans from other patients. When a patient is nonverbal, a hospital stay can become much worse.
Since I am nonverbal because of cerebral palsy, I know the experience all too well. Last year I was hospitalized twice for pneumonia. The communication barrier played a major role in both hospital stays being dreadful. Although my mother and friends told doctors and nurses that I am intelligent, that I graduated from Cleveland State University and that I work as an accessibility analyst, many of them talked to me as if I could not understand. A sign that a friend posted above my bed saying I could comprehend and the way I could communicate did not help very much.
Their presumption possibly prevented them from interpreting my gestures and vocal cues. For example, when I could not reach the call button, I would yell for someone to come. Many times my calls would go unanswered. When someone did come and asked me what I wanted, I would look at my pillow and point to it, indicating that I wanted it raised or I wanted to be lifted up. Some nurses and aides did not understand, even if my head was five inches off the pillow. Sometimes they could not even understand my “yes” and “no” responses.
Communication Techniques and Tools
In general, effective interpersonal communication means the exchange of information between two or more persons in which it is understood. Technically speaking, one individual encodes information verbally while another decodes it.
Encoder: “I’m pregnant”
Decoder: Faints (He got the message clearly.)
Effective communication between a non-verbal patient and a medical professional involves more, According to the U.S. Joint Commission (formerly the Joint Commission on Accreditations of Health Organizations) it entails:
“the successful joint establishment of meaning wherein patients and healthcare providers exchange information, enabling patients to participate actively in their care from admission through discharge, and ensuring that the responsibilities of both patients and providers are understood”
In January 2011, the Joint Commission mandated The Patient-Centered Communication Standards for Hospitals. They will become effective in July 2012. Some of these standards that relate specifically to patients with communication disorders are as follows:
• Identify a patient’s communication needs
• Inform the patient’s assigned medical staff about these needs
• Include the patient’s communication needs in his medical records
Patients who cannot talk due to a disability, such as cerebral palsy or a stroke, try to exchange information through augmentative and alternative communication (AAC) methods. They include picture/word boards, hand gestures facial expressions, and eye movements.
Learning to communicate with nonverbal patients who cannot use their hands to write is as much the medical staff’s responsibility as it is that of the patient. As mentioned above, a note or booklet that includes basic information about the individual and his AAC techniques should be placed in clear view near his hospital bed. The information also should be placed in his medical records for future reference. Additionally, a relative or friend of the nonverbal patient should consult with the medical team to reiterate his communication techniques.
As shown with my hospital experiences, however, informing a nonverbal patient’s medical team about his AAC does not always serve its purpose. While nurses in the morning shift know that the patient raises his eyes for affirmative responses, for instance, the night shift may be oblivious of this detail. Patient-nurse ratio is another factor that can undermine receiving communication cues from non-verbal patients. When a nurse or aide has 10 or more patients to attend to, taking the time to decipher a patient’s gesture can be difficult unless an interpreter or speech pathologist is there to assist.
Successful interaction between nurses and nonverbal patients also is based on the nurses’ desire to communicate with them. Despite being in a profession where they are likely to work with persons with disabilities, some nurses still may have misconceptions about them. When a patient who is nonverbal already is admitted, an assumption may be that he is deaf or cannot understand. Therefore, any attempt from the patient to communicate may be overlooked or ignored. According to a study done by Patak L, Gawlinski A, Fung NI, Doering L, Berg J. (2004), patients on mechanical ventilation have more difficulty communicating with nurses who were robotic, inattentive, and absent from the bedside. Conversely, communication becomes less frustrating for patients when nurses are kind, physically present, and informative.
Training nurses and nursing aides to understand non-verbal patients has been based on the level of pain they are in. For instance, a course is offered at Suburban Hospital in Bethesda, Maryland, where nurses learn to recognize if nonverbal patients are in pain based on facial expression, restlessness, vocal sounds, muscle tone and the ability to console. Therefore, if a non-verbal patient were in extreme pain, he would express it in one or more of the following ways:
• Rigid limbs
• Cannot stay still
• Cannot accept verbal or tactical consolation
While training to recognize communication cues of nonverbal patients regarding pain is essential, the training should expand to include nonverbal cues under other circumstances (i.e. the patient wants his position adjusted in bed). One of the few classes in this area is offered at University Hospital in San Antonio, Texas. After nurses and other hospital staff participated in the class, they became more aware of the need to communicate with nonverbal patients. They also tried to find communication tools for nonverbal patients to use.
Speech language pathologists at a community hospital in Boulder, Colorado developed the “On The Spot Communication” toolkit. Acting like a First Aid kit for patient communication, it contains such tools as:
• Word and picture boards in different languages
• Adapted call bell for patients who cannot reach or press standard call bells
• Writing boards for patients who cannot talk but who can write
• Items to help patients who are hearing implied (i.e. pocket talker amplifier)
The toolkit is available nationwide through the AAC Connect Store with the hopes that as many hospitals as possible will purchase it. Once nurses and other medical professionals have the toolkit, they should store it where they have easy access to it so using it will become habitual.
If nonverbal patients do not already have their own methods of communication, nurses could make simple word or picture boards. Pre-made boards also are available, such as EZ Board by Vidatak, Inc., which happens to be in the “On The Spot Communication” toolkit. The EZ Board has several versions, including ICU and EMS, with specific words and phases for each hospital setting. For instance, the ICU boards include words describing a patient’s state (i.e. cold, scared) and desires (i.e. to sit up). ICU boards also include a Pain Chart that includes words for pain levels, discomfort types, and personal hygiene. Each board also has the alphabet so patients can spell words. Since these boards are inexpensive, hospitals can purchase them to have for each floor unit.
Although many nonverbal individuals use voice synthesizers, they usually cannot use these devices in hospital settings for several reasons. The device may be mounted on a motorized wheelchair, which can be bulky to enter in a hospital room. Because of its custom position on the chair, the exact position possibly cannot be duplicated in the hospital bed.
Thanks to the tremendous popularity of iPads and other types of tablets, however, non-verbal patients can have access to electronic word boards and voice synthesizers. Because these devices are compact and adjustable, patients can use them in bed. Dozens of augmentative communication apps are available for specific age groups, disability types, and linguistic ability. For instance, Phrase Board is an iPad app is like the EZ Board with scrollable options and a chart of the human body. The app also lets patients draw with their fingers if they cannot find specific words. Medical professionals and speech pathologists also can develop apps to meet a patient’s specific needs.
To help non-verbal patients use manual or electronic boards more effectively, nurses can guess what the non-verbal patient wants to say while she spells it out. For example, if a patient points to “bed” on a word board, the nurse can guess if he wants his bed raised before he spells “raise” on the board. Additionally, practitioners can position the patient differently if he cannot reach the board or cannot gesture effectively. When patients with neurological disorders sit up, they usually have better motor control.
Nurses can facilitate communications with non-verbal patients by learning to ask them close-ended questions such as “Does your stomach hurt?”, rather than “What do you feel?” Medical staff also can help patients communicate by guessing what they are trying to say. If nurses or other medical staff cannot decipher or develop communication methods, they could ask the residential speech pathologist for assistance.
Effects of Nonverbal Patients who Use AAC
Studies have shown that effective communication by nonverbal patients can make them recover faster. For instance, according to Lindgren & Ames (2005), Henneman, Dracup, Ganz, Molayeme & Cooper (2001) & (2002), patients spend two to three days less in ICU when they can express themselves more effectively. Patients become less frustrated, which lowers blood pressure and stabilizes respiration. Their comfort level also increases since they can communicate if they are not positioned correctly in their hospital beds, for example.
Effective communications between hospital staff and non-verbal patients also diminishes the risk of medical errors. When nurses are aware of a non-verbal patient’s AAC cues, they can identify alert gestures such as repetitive eye gazes at an I.V. to indicate the wrong medication is being administered.
Persons with communication disabilities may face similar barriers in any medical environment, not just hospital rooms. Communication techniques and strategies that have been discussed in this paper can apply also at the doctor’s office, dentist’s office, radiology, physical therapy, and laboratory.
Overall, when patients who cannot speak communicate effectively with medical professionals, it makes them feel better physiologically. They feel like humans rather than medical subjects. Even if it cannot be heard, they have a voice that should not be ignored.