What Does the Patient Want? To truly put patients in the center of their own care, we need to ensure they can effectively communicate with providers and loved ones—and vice versa. Our professions are integral to making this happen. Features
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Features  |   March 2016
What Does the Patient Want?
Author Notes
  • Sarah W. Blackstone, PhD, CCC-SLP, is president of Augmentative Communication Inc., in Monterey, California. She is an affiliate of ASHA Special Interest Group 12, Augmentative and Alternative Communication. sarahblack@aol.com
    Sarah W. Blackstone, PhD, CCC-SLP, is president of Augmentative Communication Inc., in Monterey, California. She is an affiliate of ASHA Special Interest Group 12, Augmentative and Alternative Communication. sarahblack@aol.com×
Article Information
Professional Issues & Training / Features
Features   |   March 2016
What Does the Patient Want?
The ASHA Leader, March 2016, Vol. 21, 38-44. doi:10.1044/leader.FTR1.21032016.38
The ASHA Leader, March 2016, Vol. 21, 38-44. doi:10.1044/leader.FTR1.21032016.38
How do we ensure effective patient-centered communication across settings? And how, especially, do we do this when patients face communication challenges?
The authors of a recently published book—“Patient-Provider Communication: Roles for Speech-Language Pathologists and Other Health Care Professionals”—tackle these questions and offer advice to make sure we put even the most communication-vulnerable patients at the center of their own care.
The first article (below), by one of the book editors, lays out the basics. The next two articles “Simulating Patient Communication Strategies” and “Words of Preparation for Patients,” by other contributors examine how we can more effectively train providers to put patients first and how we can better prepare patients for medical encounters.
All three articles emphasize that communication sciences and disorders professionals are critical to interprofessional practice in health care settings and as advocates for patient rights, value-based care and patient-centered care.
Katie sustained serious injuries to her spine and neck in a car accident. At the scene and in the ambulance, she spoke to responders, providing personal and contact information for family members. At a regional trauma center, staff diagnosed her with a cervical (level 4) spinal cord injury and intubated for her respiratory support so she could undergo surgical procedures on her neck and back. After surgery, Katie remained intubated for 48 hours, during which time she was unable to speak or write (because of her limb paralysis). She communicated with nurses using head movements to signal “yes” and “no.”
Although yes/no communication, mouthing words and relying on gestures are better than nothing, these are quite limited, unidirectional strategies. Luckily, when Katie’s relative, a speech-language pathologist for a rehabilitation facility, arrived, she immediately used a simple eye-gaze strategy so Katie could spell messages (see graphic below).
Katie quickly learned to use the strategy, easing her stress levels and bolstering the accuracy and efficiency of her communication. Katie could then ask about her legal power of attorney and the whereabouts of her cellphone and glasses.
Most of our experiences aren’t typically as severe as Katie’s, but we all have been, are or will be “patients.” Most of us can recall an interaction with a health care provider that didn’t go so well. And we’ve all heard stories from friends or loved ones about difficult experiences communicating with health care professionals—where there was no related SLP to help.
Such breakdowns are not surprising.

Effective communication is … “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.” —The Joint Commission

Most medical encounters are time-limited. They involve people who don’t know each other very well (or at all), and they take place under stressful conditions. In fact, research reviewed in “Patient-Provider Education” confirms that effective patient-provider communication is not easily achieved, especially when patients have a communication disability. Few physicians, for example, are prepared to deal with patients who have significant communication disabilities. Even when providers are aware that communication problems exist, many do not know how to “fix” or adjust to them.
There may not necessarily be lasting harm, but there can be. As indicated by my own and others’ research (see sources below), ineffective communication between patients and health care providers can lead to some serious problems:
  • Sentinel events that are unexpected and involve serious physical or psychological injury or death (or the risk of these).

  • Negative health outcomes.

  • Increased costs.

  • Lack of adherence to provider recommendations.

  • Longer stays in intensive care units (ICUs).

  • Increased hospital readmissions.

  • Reduced patient satisfaction.

Most medical encounters are time-limited. They involve people who don’t know each other very well (or at all), and they take place under stressful conditions.

A changing culture
At the trauma center where Katie was treated, an SLP completed a swallowing assessment when her intubation tube was removed. There were no orders to assess or address her communication issues during those first 48 hours, which points to a lack of patient-centered, communication-supportive care, as called for in recent health care law, policy and regulations.
Why this emphasis on patient-centered care? Successful patient-provider communication correlates positively with patient safety, patient satisfaction, positive health outcomes, adherence to recommended treatment, self-management of disease and lower costs (see sources below). It is also key to addressing health disparities across populations—another important national health policy goal. The Patient Protection and Affordable Care Act of 2010 and other laws strongly encourage health care stakeholders to address communication skills.
Patients need to be able to call nurses and communicate effectively with medical personnel and family members. Yet this often doesn’t happen, according to a University of Iowa Hospitals and Clinics study conducted over several weeks by Lauren Zubow and Richard Hurtig and published in ASHA Special Interest Group 12’s Perspectives on Alternative and Augmentative Communication. In it, of the 91 patients (daily average) who were conscious and older than 3 years, 33 percent were unable to access the nurse-call system, 33 percent were unable to use their speech, and 19 percent could do neither. In non-ICUs, of the 386 patients (daily average) who were conscious and over the age of 3 years, 14 percent were unable to access the nurse call, and 7 percent were unable to use their speech.

Successful patient-provider communication correlates positively with patient safety, patient satisfaction, positive health outcomes, adherence to recommended treatment, self-management of disease, and lower costs.

What about our clients with acute, chronic or degenerative conditions like aphasia, dysarthria, traumatic brain injury, cerebral palsy, autism, amyotrophic lateral sclerosis, Down syndrome, laryngectomies or severe hearing impairments? Are their rights to communicate being addressed across medical settings? Are professionals in the community encouraging all clients (and/or family members) to plan for more successful communication during future medical encounters? Are SLPs and audiologists advocating on their behalf?
Making a difference
Certainly, SLPs and audiologists have the skills to support patients with communication vulnerabilities, train staff and advocate for communication access across health care facilities. ASHA’s vision statement—“Making effective communication, a human right, accessible and achievable for all”—underlies our standards of practice, pre-professional and continuing educational programs, Code of Ethics, and certificates of clinical competency.

SLPs and audiologists can help provide clients and patients with “communication curb cuts” or “communication ramps” before medical treatment. We can also periodically provide training to other facility staff.

Here’s what can happen when we help our clients prepare for medical treatment episodes and empower them to be self-advocates:
Jamie was born with cerebral palsy and severe dysarthria. He is functionally literate and has mild cognitive disabilities. He uses low- and high-tech augmentative strategies, gestures and signs, as well as his limited speech to communicate. Jamie has worked with SLPs all his life, has a job, lives in a supported living facility, and is active in his community.
At 35, Jamie required orthopedic surgery. As soon as surgery was scheduled, he contacted his favorite SLP, called the hospital’s Speech and Hearing Department, and sent a list of questions and required communication accommodations to the hospital admissions office and his doctor (see suggestions on page 44). For example, he made sure he could activate an adapted nurse-call button and that ICU staff knew how to use partner-assisted scanning. As he progressed, he used his personal communication boards and speech-generating device to connect with staff, friends and family.
SLPs and audiologists can help provide their clients and patients with these sorts of “communication curb cuts” or “communication ramps” before medical treatment. We can also periodically provide training to other facility staff. We can take other steps to support better patient-provider communication:
  • Participate in interprofessional rounds, generate more referrals for communication supports, advocate that information about communication be included in electronic health records, and encourage practices that require immediate reporting of communication problems.

  • Encourage clients and/or their family members to prepare in advance for medical emergencies, outpatient appointments and inpatient admissions.

  • “Walk the walk” as well as “talk the talk.” For example, teach-back is an effective method designed to ensure that patients understand what a provider is saying by asking them to repeat key points of the provider’s instructions (see sources below). It is easily adaptable using visual supports for clients with diverse communication disorders.

We, as communication sciences and disorders professionals, are critical to interprofessional practice in health care settings and as advocates for patient rights, value-based care and patient-centered care.
Resources Available for Person-Centered Care in Audiology

Looking for guidance on providing client-centered care in audiology?

ASHA audiologists have compiled a collection of resources to help you look beyond physical symptoms and consider psychological, social and environmental factors in treating patients. The resources include information about working collaboratively with families, other professionals and patients themselves.

Example of an eye-gaze system that can be used for partner-assisted scanning.
Image Not Available
Questions to Ask Health Care Providers
  • Who are my communication partners likely to be (e.g., providers, care staff, family members, housekeeping, dietary)?

  • Will nurses and doctors know how to communicate with me?

  • Will professionals with expertise in speech-language pathology and audiology be available if needed?

  • How will I be supported in communicating basic needs reliably and successfully: pain, eating, drinking, sleeping, toileting, skin care, hygiene?

  • Will I be able to access a nurse call button at all times?

  • Will I be able to bring and use my personal assistive technologies (hearing aids, glasses, communication devices/displays)?

  • Will there be signage in the room to explain how I communicate?

  • How are safety concerns addressed (infection control, privacy, storage of equipment, etc.)?

  • What is the knowledge and attitude of the facility’s staff regarding my communication disability and how I communicate?

  • Does the facility have a policy regarding communication access for people who have difficulty speaking with and/or understanding the staff who care for them, as well as for patients who require interpreter services?

Sources
Bartlett, G., Blais, R., Tamblyn, R., Clermont, R., & MacGibbon, B. (2008). Impact of patient communication problems on the risk of preventable adverse events in the acute care setting. Canadian Medical Association Journal, 178(2), 1555–1562. [PubMed]
Bartlett, G., Blais, R., Tamblyn, R., Clermont, R., & MacGibbon, B. (2008). Impact of patient communication problems on the risk of preventable adverse events in the acute care setting. Canadian Medical Association Journal, 178(2), 1555–1562. [PubMed]×
Blackstone, S. W., Beukelman, D. R., & Yorkston, K. M. (Eds.). (2015a). Patient-provider communication: Roles for speech-language pathologists and other health care professionals. San Diego: Plural Publishing Inc.
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Blackstone, S. W. & Pressman, H. (in press). Patient communication in health care settings: New opportunities for augmentative and alternative communication. AAC Journal.
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March 2016
Volume 21, Issue 3