Improving Patient-Provider Communication: A Call to Action

Patients who are communication impaired are at greater risk of medical error and poorer outcomes. Contributing factors that perpetuate ineffective patient-provider communication include the lack of a systematic method for nursing assessment, evaluation, and monitoring of patient-provider communication needs and interventions; and a lack of standardized training of health care providers. We propose a call to action for nursing administrators to position patient-provider communication as a patient safety-care quality priority within the healthcare organization and incorporate bedside practices that achieve effective patient communication, especially with those most vulnerable to impaired communication. Effective patient-provider communication is an essential component of patient care; and in order for communication to be effective, the information must be complete, accurate, timely, unambiguous, and understood by the patient (1). By formally implementing the assessment of patient communication needs into routine care, nursing administrators will create a sense of accountability among bedside nurses to meet the needs of patients who are communication-vulnerable.

A patient's right to effective patient-provider communication is supported by accreditation standards (2), regulatory guidelines (3, 4), and patient rights declarations (5, 6). Patients have the right to be informed about the care they receive, make educated decisions about their care, and have the right to be listened to by their providers. However, patient communication needs often go unmet or are addressed inappropriately (7-10). In the case of non-English speaking patients, language access services such as the provision of in-person, telephone, or video interpreters and translated documents are either not available or infrequently used (8-11). Many health care institutions rely on ad hoc interpreters such as family, friends, or administrative and custodial staff to communicate and facilitate patient-provider communication, despite the fact that research has shown that the use of ad hoc interpreters can lead to miscommunication and medical errors (12).

For critically-ill or nonspeaking patients, nonverbal behaviors, such as mouthing words, gestures, and head nods, are the principal means of communication; however these methods have been shown to be ineffective, fatiguing and inciting frustration (13-18). Often communication is attempted by simply asking yes/no questions and more appropriate communication interventions are not employed. Limiting the patient's communication to yes/no answers restricts the patient's responses to predictable messages only or messages that meet the a priori expectation of the patient's need as determined by the clinician.

The absence of effective patient-provider communication has been cited as a significant factor contributing to adverse outcomes (19, 20). In a 2007 public policy paper focused on health literacy, The Joint Commission recommended that health care organizations “make effective communication an organizational priority to protect the safety of patients” and to “incorporate strategies to address patient's communication needs across the continuum of care” (21). Effective patient-provider communication is a vital component of this transformation and must be prioritized to improve patient safety.

Call to Action

Conduct an Assessment

Patient communication assessment should include a thorough initial assessment of literacy, linguistic, cultural, behavioral and physical barriers (e.g., patient wears glasses or uses hearing aids) at the point of care. It should also include referrals to communication specialists for selection of appropriate interventions when immediate resources at the point of care fail to achieve effective patient communication. (To view a daily patient centered rounds goals' form, see Supplemental Digital Content 1)

Evaluate the Intervention

An evaluation of the effectiveness and outcomes of communication interventions will determine whether further interventions are necessary.

Monitor and Document Effective Communication

It is imperative that the effectiveness of communication interventions be monitored, as a decline in patient communication may indicate a change in the patient's health status or suggest an alternative intervention is needed. There are several methods for documenting communication-related information (22-24); and, for systematic implementation, Table 1 presents a sample assessment and documentation tool incorporating a methodological sequence of symptom management. This assessment tool was designed to be incorporated into computerized charting menus to assist nurses in selecting drop down items which corresponded to their patient communication assessment, intervention, and evaluation process. (See the overview table depicting an extensive menu of assessment and intervention features, Supplemental Digital Content 2)

Table 1. Patient Communication Assessment Tool.

Baseline Communication Method/Special Needs Verbal Writing (Pen & Paper) Communication board Electronic communication device Speaking valve Gesturing Mouthing/lip reading Hearing aids Glasses Language interpreter needed Family facilitated Sign language/interpreter needed Other (document explanation)	Interventions At Point of Care Comfort measures Music Sitter Communication device (document explanation) Phone Speaking valve Calm spoken voice Give patient time to communicate Released restraints Glasses Hearing aid Call light Interpreter Other (document explanation)
Assessment	Re-Assessment
Patient's reported level of distress with communication [scale (0-5)]*	Patient's reported level of distress with communication [scale (0-5)]*
0) Not at all	0) Not at all
1) A little bit	1) A little bit
2) Somewhat	2) Somewhat
3) Quite a bit	3) Quite a bit
4) Very much	4) Very much
5) No response	5) No response
Current Barriers Hostility Withdrawn/depressed Delirium Agitation Confusion Impaired LOC Illiterate Orally intubated Tracheotomy Foreign language Sedated Restrained Surgery History of stroke Weakness Vision impairment Hearing impairment Visitation restrictions Other (document explanation) None	Evaluation/Effectiveness Patient reports being satisfied Family reports being satisfied Patient reports being unsatisfied Family reports being unsatisfied Patient responds appropriately with intervention Necessary information is obtained from and provided to the patient Patient demonstrates understanding Other (document explanation)
	Referral Yes (document explanation) No

^*Adapted from MSAS Short Form with permission (30).

Expanding the Multidisciplinary Team and Making Appropriate Referrals

Readily available resources to aid in communication should be present on all patient care units for managing patient communication needs at the point of care. In the event such resources are ineffective, a referral to communication specialists (speech language pathologists, audiologists, and professional health care interpreters) may lead to a more comprehensive assessment where the best feature match to a patient's needs can be determined, especially when the communication process remains dynamic throughout the nonspeaking condition (25).

Standardize Training for Health Care Providers

Patient communication strategies, particularly those used to assess and communicate with communication-vulnerable patients, have historically been neglected in medical and nursing education (26). It is important for health care organizations to provide and elevate training on patient-provider communication as an essential component of staff continuing education and development. Recently, commercially available communication boards have been developed and implemented specifically to facilitate commonly used messages with both critically ill and non-English speaking patients (27, 28). Physicians, nurses, therapists from various disciplines and other staff who interact directly with non-speaking and non-English speaking patients need to be trained on how to work effectively with these communication aids and with interpreters. Additionally, nurses should be trained to be sensitive to signs of communication distress and made aware of the process for obtaining appropriate referrals to communication specialists, such as a speech language pathologist. Samples of communication boards can be seen in Supplemental Digital Content 3, 4, 5, 6, 7, and 8.

• Supplemental Digital Content 3, illustration of front of a picture board

• Supplemental Digital Content 4, illustration of back of a picture board

• Supplemental Digital Content 5, illustration of front of an English language picture board

• Supplemental Digital Content 6, illustration of back of an English language picture board

• Supplemental Digital Content 7, illustration of front of an Arabic language picture board

• Supplemental Digital Content 8, illustration of back of an Arabic language picture board

Summary

An assessment of communication needs should be done for every patient to determine if patients are able to communicate effectively with healthcare providers or require an intervention (i.e., communication resources). This should be followed by monitoring for changes in the patient's assessment or changes in the effectiveness of the intervention. The interdisciplinary team should consult with professionals who are trained in specific communication interventions. Health care organizations need to have supportive systems in place to help meet patient communication needs; and accreditation and regulatory bodies need to increase attention to this important safety issue as a means to inspire organizations to act. Nursing administrators play a key role in helping to ensure that assessment of communication needs is an integral component of patient care. Improving communication can enhance patient safety and nurses can serve to champion initiatives to promote patient-provider communication and make a difference in patient outcomes.

Supplementary Material

1. Supplemental Digital Content 1.

form displaying daily patient centered rounds goals

2. Supplemental Digital Content 2.

Table depicting an extensive menu of assessment and intervention items

3. Supplemental Digital Content 3.

illustration of picture board front

4. Supplemental Digital Content 4.

illustration of picture board back

5. Supplemental Digital Content 5.

illustration of English language picture board front

6. Supplemental Digital Content 6.

illustration English language picture board back

7. Supplemental Digital Content 7.

illustration Arabic language picture board front

8. Supplemental Digital Content 8.

illustration Arabic language picture board back