Communicating healthcare needs

Hospital patients with suspected aphasia should receive assessment by a speech pathologist to determine the patient’s ability to communicate their healthcare needs.

Reference: Bartlett et al., 2008; Hemsley et al., 2013; O'Halloran, Grohn, & Worrall, 2012.
NHMRC level of Evidence: IV

Rationale: Approximately 50% of stroke inpatients have difficulty communicating their healthcare needs in hospital (Hemsley, Werninck, & Worrall, 2013).  The incorporation of patient needs and values in healthcare decision making is a key component in the delivery of evidence-based care (Straus, Richardson, Glasziou, & Haynes, 2011).  Patients who are therefore unable to communicate their healthcare needs are at risk of not receiving evidence-based healthcare. Patients with aphasia who are unable to communicate effectively with healthcare providers may receive inadequate and inappropriate health care in hospital and experience feelings of distress and anger (Hemsley et al., 2013; Susie Parr, Sally Byng, Sue Gilpin, & Ireland, 1997).  Additionally, people with communication difficulties, including people with aphasia, are six times more likely to experience an adverse event in hospital (Bartlett, Blais, Tamblyn, Clermont, & MacGibbon, 2008). Adequate assessment of the functional communication abilities of each person with suspected aphasia is therefore imperative in ensuring adequate support for all stroke patients.

Acknowledgements:
This section was written by Alexia Rohde (The University of Queensland).

Why do I need to determine a patient’s ability to communicate their healthcare needs?

• To clarify the communicative strengths and weaknesses of each patient to determine the areas of communicative independence and areas requiring support (O’Halloran, Worrall, Toffolo, Code, & Hickson, 2004)
• To provide strategies and support required to optimise communicative abilities (O’Halloran et al., 2004) (e.g. provision of AAC devices, communicative strategies and techniques (Kagan, 1998)
• To enable appropriate education and support for family members to optimise communicative interactions (O’Halloran et al., 2004)
• To minimise miscommunications and potential adverse healthcare events (Bartlett et al., 2008).
• To optimise each patient’s ability to contribute to their healthcare decision making in line with evidence based practice standards (Straus, 2011).

How do I know if a patient is able to communicate their healthcare needs?

• Discuss the patient’s communicative functioning with the different members of the multidisciplinary team (e.g. nursing staff, occupational therapist). 
• Determine if there are any potential medical factors which may influence a patient’s ability to communicate their basic needs (e.g. drowsiness, cognitive level, delirium)?
• Ask the patient’s perspective. What difficulties are they having getting their message across? Do they feel they have any difficulties getting their message across?
• Ask family members if the client’s communicative needs are being met?
• Observe how the patient responds in a variety of different communicative situations.  For example: Can they use the bells to ask to go to the toilet?  Are they able to use the menu effectively to choose their own meals? Does the patient respond appropriately to questions about their environment or personal questions? (e.g. Are you in hospital?) Is the patient able to follow instructions regarding their basic care? (e.g. Can you roll to your left while I move this pillow). Does the patient ask for help if they need it? Does the patient seek clarification or demonstrate when they do not understand something? (O’Halloran et al., 2004).

Inpatient Functional Communication Interview (IFCI)

The Inpatient Functional Communication Interview (IFC) is a resource specifically designed to describe a patient’s ability to communicate in a typical hospital environment (O’Halloran, 2004). The IFCI is a structured interview administered by a speech pathologist (30-45 min in length).  The interview aims to determine a patient’s functional communication abilities in the acute hospital environment; provide communicative strategies and also identify communicative situations which may benefit from direct intervention.   A staff questionnaire is also included when can be used by other staff to identify potential communication difficulties.

How can I support a patient who is having difficulty communicating their healthcare needs?

• Directly address any questions, concerns and any potential misunderstandings that may have occurred.  Discuss the communicative situation with the patient and family members.  Alert any relevant health care professionals and discuss any potential breakdown in communication and resolve any misunderstandings that may have occurred (O’Halloran et al., 2004).

• Provide education and strategies to the multidisciplinary team and family members and friends (O’Halloran et al., 2004).  Information and education about aphasia and strategies for enhancing communication have been shown to be effective in optimising patient care.  Legg, Young & Bryer, (2005) in a randomised controlled group study found that medical students who were trained using supported communication strategies (Kagan, 1998) demonstrated significant improvement in their skills in obtaining information from case history medical interview and also establishing rapport.  These findings suggest that increased communicative competence within the multidisciplinary team can have significant implications for improving patient’s involvement in their healthcare. More information on communication partner training. 
• Identify specific communication situations where interactions may benefit from additional support (O’Halloran et al., 2004)  A patient may benefit from the use of supportive communication devices.  AAC strategies and devices have been shown to be effective for supporting communication for people with aphasia (Fox & Fried-Oken, 1996, Garrett & Beukelman, 1998).  AAC devices can enable people with aphasia to be more independent and communicate functional needs more specifically (Garrett & Beukelman, 1998; Hopper & Holland, 1998) (AAC communication board link in resources section below).
• Identify any factors in the hospital environment which may be preventing effective communication (O’Halloran et al., 2004)  One potential barrier may be difficulties in accessing written resources such as patient information handouts (O’Halloran et al., 2004).  Aphasia friendly information has been shown to assist people with aphasia to comprehend written information (Rose, Worrall, & McKenna, 2003).  More information on support materials for people with aphasia.  

 RESOURCES:

1. Inpatient Functional Communication Interview (IFCI): O’Halloran, R., Worrall, L., Toffolo, D., Code, C. and Hickson, L. (2004). The Inpatient functional communication interview (IFCI). Oxon: Speechmark
2. Communication board to assist functional communication in acute hospital settings
3. Aphasia friendly resources
4. Accessible Information Guidelines: 'Making information accessible for people with aphasia' booklet. 
5. Assessment for Rehabilitation Pathway and Decision-Making Tool. This tool was designed to ensure fair and accountable decision making when assessing patients in stroke units for rehabilitation. Unfortunately, many people are not assessed for rehabilitation or if they are there is great variability between assessors. As we cannot predict with confidence how much function can be recovered after stroke, it is best practice to have expert assessment for all stroke survivors using a consistent tool. This tool provides a comprehensive method of assessment and was developed by the Australian Stroke Coalition Rehabilitation Working Group and the South Australian Stroke Network Rehabilitation working group.

    

References:

1. Bartlett, G., Blais, R., Tamblyn, R., Clermont, R. J., & MacGibbon, B. (2008). Impact of patient communication problems on the risk of preventable adverse events in acute care settings. CMAJ : Canadian Medical Association journal 178(12), 1555-1562. doi: 10.1503/cmaj.070690
2. Fox, L. E. & Fried-Oken, M. (1996). AAC aphasiology: Partnership for future research. Augmentative and Alternative Communication, 12, 257-271.
3. Garrett, K. L., & Beukelman, D. R. (1998). Adults with severe aphasia. In D. R. Beukelman & P. Mirenda (Eds.), Augmentative and alternative communication: Management of severe communication disorders in children and adults (2nd ed., pp. 465–499). Baltimore, MD: Paul H. Brookes.
4. Hemsley, B., Werninck, M. & Worrall, L. (2013).  “That realy shouldn’t have happened”: people with aphasia and their spouses narrate adverse events in hospital, Aphasiology, 27,6, 706-722.
5. Hopper, T., & Holland, A. (1998). Situation-specific training for adults with aphasia: An example. Aphasiology, 12, 933-44.
6. Kagan A.: Revealing the competence of aphasic adults through conversation: a challenge to health professionals. Top Stroke Rehabil 1995; 2: 15-28
7. Legg, C., Young, L. & Bryer, A. (2005). Training sixth-year medical students in obtaining case-history information from adults with aphasia, Aphasiology, 19,6, 559-575.
8. O'Halloran, R., Grohn, B., & Worrall, L. (2012). Environmental factors that influence communication for patients with a communication disability in acute hospital stroke units: a qualitative metasynthesis. Archives of Physical and Medical Rehabiliation, 93(1 Suppl), S77-85. doi: 10.1016/j.apmr.2011.06.039
9. O’Halloran, R. Worrall, L. & Hickson, L. (2012).  Stroke patients communicating their healthcare needs in hospital: a study within the ICF framework, Int J Lang Commun Disord, 47(2), 130-43.
10. O’Halloran, R., Worrall, L., Toffolo, D., Code, C. and Hickson, L. (2004). The Inpatient functional communication interview (IFCI). Oxon: Speechmark.
11. Parr,S. Byng, S. Gilpin, S. & Ireland, C., Talking about aphasia, Open University Press, Berkshre, England. 2003.
12. Rose, T.A., Worrall, L.E., McKenna, K. (2003). The effectiveness of aphasia-friendly principles for printed health education materials for people with aphasia following stroke. Aphasiology, 17(10), 947–963.
13. Straus SE, Glasziou P, Richardson WS, Haynes RB. Evidence-based medicine: how to practice and teach EbM. 4th edition. Edinburgh: Churchill Livingston Elsevier, 2011.