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August 2009

Volume 21
Number 2

and efficient communication

difficult. AAC strategies,
tools and the training
needed to use them well
can support improved
interactions. Increasingly,
first responders and emer-
Effective communication is recog- gency personnel depend on AAC tools
nized as a priority across the health- and strategies to communicate more Clinical News
effectively with some of their patients.7 Communication access across the
care continuum because it directly healthcare continuum
affects the quality of patient care, Lack of access to auxiliary aids.
safety, medical outcomes and pa- People who rely on hearing aids, On The Web
glasses and/or AAC technologies may www.patientprovidercommunication.
tient satisfaction.1 Augmentative and not have access to them in health-re- org
alternative communication (AAC) lated situations. As a result, interac-
tions with healthcare providers may be Equipment
techniques, strategies and devices difficult. Simple assistive technologies Communication “On the Spot”
can significantly alleviate commu- can augment vision and hearing when
nication problems and barriers and glasses and hearing aids are unavail-
Advancing effective communication,
should be a major component of the able. Generic low-tech AAC displays,
cultural competence & patient-cen-
devices and strategies can also help.8-13
arsenal of communication resources tered care
available across healthcare set- Medical interventions, Medical inter- University/Research
ventions (e.g., intubation or a trache-
tings. While typically designed for ostomy) may result in a temporary loss
Evidence: Using AAC to support
patient-provider communication
people with complex communication of speech. In addition, patients may
needs (CCN), simple communication have injuries or conditions that cause EVIDAAC
displays, speech generating de- How AAC teams can benefit from
Continued on page 2 EVIDAAC
vices (SGDs), eye gaze techniques,
oped and encouraged the
special call alarms and alphabet
use of AAC devices,
boards can help many other commu-
aids and strategies.
nication vulnerable patients reduc-
Back then, we focused
ing medical errors, lessening the
primarily on school-
length of hospital stays, increasing Communication access aged children and adults with
patient safety and lowering costs.2,3
across the healthcare motor impairments (e.g., cerebral
Communication barriers in health-
care settings have many causes.
continuum palsy and motor neuron disease.)
Today, we’ve expanded our vision
Language issues. Language and Can you imagine nurses and other and AAC approaches are widely
cultural differences often underlie healthcare providers routinely using
communication problems in healthcare utilized with individuals—across
settings.4 For example, many people in simple AAC approaches as a way to
the age span—who have commu-
the U.S. do not speak English as their support all patients who experience
primary language. Also, those who nication challenges secondary to
communication difficulties? This
are deaf/hard of hearing often have cognitive, language, physical and
difficulty communicating with health- is beginning to happen. In fact, the
multiple disabilities. This article
care workers. Trained interpreters can train is leaving the station and the
help these individuals negotiate the suggests we take another step for-
AAC community should do more
healthcare system.5,6 AAC strategies ward and use AAC for anyone who
and assistive technologies can also than just sell tickets. It’s time to
is “communication vulnerable,”
help mightily. climb aboard.
i.e., struggles to communicate in a
Stress, confusion and psychiatric condi- Background particular setting. We can begin this
tions. Medically-related situations may journey in healthcare settings, where
trigger emotional responses in patients Early in the development of the
and/or in providers that make effective field, the AAC community devel- Continued on page 2

Clinical News, Cont. from page 1 and use healthcare
information to
the need is so urgent. make decisions and
follow instructions
Communication barriers for treatment.”16
Access to effective communica- Studies show that
people who have
tion is a critical component of best low-health literacy
practice and quality care across include the elderly,
the continuum of healthcare.1-3,14 minority popula-
Healthcare providers often lack the tions, immigrant
populations, low
training needed to cope with their income groups and
patients’ communication difficulties. people with chronic
Patients routinely face a wide-range mental and/or Figure 1. Communication process.
physical health Go to for animation
of intrinsic and extrinsic factors that conditions.17 AAC approaches provide AAC devices may not have access to
preclude successful interactions with supports that can increase participation these auxiliary aids during a medical
healthcare providers. and foster understanding for people emergency or while in the hospital.
wiht low health literacy. This can result in crucial communica-
Language barriers. Most healthcare
tion situations becoming even more
providers now serve people who speak Behavioral barriers. People under difficult.8-14 In addition, patients who
multiple languages, including those who stress, those with psychiatric condi- are temporarily unable to produce
rely on sign language. When patients tions, patients on medication and speech because of medical procedures
and providers do not speak/understand individuals with disabilities that influ- (e.g., intubation) need consistent access
the same language, communication be- ence cognition (e.g., dementia, autism, to alternative communication tools and
comes very difficult.4-6 AAC strategies severe developmental disabilities) may strategies.12-14
can help overcome language barriers. have difficulty comprehending and
following directions. Providers can use
Cultural barriers. People from different
AAC strategies, such as augmented
Providing communication
cultural backgrounds do not neces- access
input, to increase active and construc-
sarily share the same knowledge or
tive participation.11,18,19 Successful communication
expectations about healthcare services.
One widely discussed barrier is low Physical barriers. Patients who wear requires the joint establishment
health literacy.15 Health literacy is “an glasses, use hearing aids and/or rely on
individual’s ability to read, understand of meaning.20 Both the healthcare
provider and the patient need to
Upfront, Continued from page 1 issues. Clinical News considers
“possess the skills and knowledge
communication difficulties. Responses communication barriers and the
to medications can also interfere with required for participation within the
role of AAC across the healthcare
communication. AAC approaches may communicative interaction.”21 This
help patients participate actively in
continuum. On the Web introduces
means that successful interactions
their care and interact with family a new patient-provider communi-
are always co-constructed, involving
members and healthcare providers.11-14 cation website. Equipment high-
a constant interplay (often uncon-
Other key barriers to patient- lights communication resources for
scious) among partners. Each inter-
provider communication involve healthcare settings. Governmental
actant brings his/her unique char-
factors related to healthcare provid- discusses The Joint Commission’s
acteristics to the exchange, using
ers. Many do not know how to em- proposed standards and Univer-
aspects of the physical, social and
ploy an arsenal of simple AAC tools sity/Research spotlights research.
cultural context, prior knowledge,
and strategies when communication Finally, the EVIDAAC article ad-
shared experiences and linguistic
“isn’t working.” Additionally, AAC dresses benefits of the soon-to-be-
and nonlinguistc utterances to con-
specialists too rarely think “outside launched EVIDAAC website.
struct meaning.22
the box” or advocate for the use of Sarah W. Blackstone, Ph.D. CCC-
The icons above are meant to be
AAC as part of the arsenal of tools SP
animated in order to illustrate the
available to all patients who have dynamic nature of the communica-
difficulty communicating, across tion process between a patient and
healthcare settings. This issue of a healthcare provider. [See www.
Augmentative Communication]
News is part of an effort by an ad Initially, during an interaction, not
hoc group to increase awareness all “puzzle pieces” fit together. In-
of patient-provider communication teractants must complete the puzzle

conjointly, using various strategies, First responders and other health-
which linguists call pragmatics. Suc- care providers who know how to use
cessful communication occurs when communication tools and strategies
the pieces of the puzzle fit together.22 are likely to have an easier time
Communication in healthcare with people who are communica-
settings is particularly challenging. tion vulnerable. A growing number
For starters, the “puzzle” is often of first responders carry Tips24 [See
complex and has to be completed Figure 2. Tips for Emergency Responders Figure 2] and/or have vocabulary-
quickly. Typically, the interactants effective patient-provider communi- specific communication displays in
(patient-provider) are strangers, the cation. their vehicles [See Figure 3].25,26
situation is stressful and the stakes Currently, few community [Note: The Institute on Disabilities at
are high. When interactants don’t Temple University, with funding from
healthcare providers are aware of, the AAC-RERC, recently developed
speak the same language, or they or know how to support, the com- vocabulary and a communication
are unable to speak to, listen to or munication efforts of patients who display for use in emergency prepared-
understand each other, what begins ness. Emergency Communication 4
struggle to communicate with them. ALL—Picture Communication Aid. It
as difficult can quickly become Medical and professional schools is available in English and Spanish and
impossible. and healthcare administrators are may be downloaded for free.]25
Efforts to improve patient-pro- beginning to realize the importance Intensive care units. To sur-
vider communication, a high priority of communication training and some vive life-threatening situations and
across the healthcare continuum, provide it, albeit in often inadequate ensure the delivery of quality care,
depend on the skills and abilities doses. For example, communication barriers in ICUs
of healthcare providers as well as A video entitled “Listening” has need to be alleviated. Many health-
patients. To be successful, health- messages from patients and family
members to doctors and other medical
care providers in ICUs still struggle
care providers need communication
staff and ideas about how to communi- to communicate with patients who
training and patients need access to cate more effectively. The video aims are unable to use speech because
an arsenal of communication tools to “save lives, save money, and build of (1) medical or surgical interven-
and strategies, including some sim- value in the communities.”23
tions; (2) an illness, such as a stroke
ple, easy-to-use AAC approaches. Emergency medical care. Com- or laryngeal cancer or (3) an injury
The healthcare continuum mon entry points into the healthcare (e.g., traumatic brain injury or high
system are medical emergencies spinal cord injury). Patients who are
The continuum of healthcare re-
caused by an acute illness or injury. conscious must be able to express
flects the multiple settings in which
Stricken individuals and their family their needs and feelings and ask and
people seek and receive health
members need to be able to commu- respond to questions. Several ar-
services. It includes preventative
nicate quickly and effectively with ticles discuss how to use AAC tools
and routine care, as well as care for
first responders (police, firemen, and strategies in hospital ICUs.
acute and chronic medical condi-
emergency medical technicians) and
tions, from conception to death. 1. Costello describes the use of AAC
with doctors and nurses in emer- interventions in pediatric ICUs at Chil-
Communication difficulties run dren’s Hospital-Boston. He interviewed
gency rooms. These interactions can
rampant across the continuum. patients, family members and medical
be very difficult, not only because
Doctors offices, community staff, noting that nurses and other criti-
of critical medical issues, but also cal care providers report substantial dif-
clinics, schools, correctional facili-
due to the ambient noise, anxiety ficulty interpreting patients’ communi-
ties, etc. Doctors, nurses, communi- cation attempts. Costello advocates for
and confusion that accompany these
ty health personnel and the patients pre-operative as well as post-operative
events. Exacerbating the problem AAC interventions for surgery patients.
who seek their help face many
may be differences in language, He helps children select vocabulary in
potential pitfalls when communicat- advance and use digital voice message
cultural background, pre-existing
ing with one another. Due to time banking. Costello stresses the impor-
disabilities and the health literacy of tance of providing communication
constraints and/or a lack of training,
the patient. A lack of communica- devices and methods that are minimally
healthcare providers may direct their frustrating and maximally useful to the
tion training and skills on the part of
attention to a family member, friend patient, family and staff.27
healthcare providers can also play a
or caregiver, essentially ignoring
major role. Continued on page 4
the patient. This can short-circuit

Clinical News, Continued from page 3 ideas, tips and strategies.
Chapters contain in-depth
2. Happ, Roesch and Garrett describe
information about how
the use of electronic speech generating
to support communica-
devices (SGDs) for temporarily non-
tion for specific popula-
speaking adult patients in ICUs. They
tions across healthcare
studied eleven critically-ill patients
settings: amyotrophic
on mechanical ventilation. Results
lateral sclerosis, aphasia,
showed these patients communicated
brainstem impairment,
more frequently when they had access
dementia, head and neck
to an SGD than they did otherwise.
cancer, Huntington’s dis-
The researchers identified five barri-
ease, multiple sclerosis,
ers to using SGDs in ICUs: (1) staff
Parkinson’s disease, pri-
unfamiliarity with the device, (2) time
mary progressive aphasia,
constraints, (3) poor device positioning,
spinal cord injury and
(4) complex message screens and (5)
Figure 3. Triage nurse with a communication board.34 traumatic brain injury.12
deterioration of a patient’s condition.28
[See volume 19#4 of Augmentative Communi-
3. In their book chapter, Garrett, Happ, tools and when healthcare providers cation News for a brief summary of some of the
Costello & Fried-Oken (2007) discuss know how to use them, successful chapters.]36
reasons why ICU staff need to provide patient-provider communication is
access to AAC technologies and 4. Balandin, Hemsley and their col-
strategies. They describe and illustrate
more likely for all patients. leagues have reported on the hospi-
the use of (1) natural communication 1. In New Jersey, nurses and other tal experiences of Australians with
signals and gestures, (2) pre-existing health care professionals are finding acquired disabilities9 and cerebral
sensory aids, (3) ways to support atten- that a two-sided communication display palsy37 who rely on AAC. For example,
tion and comprehension and (4) ways is a handy tool.33 As part of its 2007 they found that individuals with CCN
to support expression in ICUs.29 Strategic Plan to Eliminate Health Dis- experience a range of difficulties in
parities, the New Jersey Department of hospitals (discomfort, lack of participa-
4. Patak and his colleagues developed Health and Senior Services (NJDHSS) tion in their own care, frustration, feel-
the Vidatak boards (commercially distributed more than 2,200 symbol ings of isolation, increased length of
available in 17 languages and as a pic- boards to facilities across the state in an stay, etc.). They also report that nurses
ture board). Go to effort to ensure that all patients receive and caregivers8-9,38 identify a number
They report on a study of 29 patients effective medical care. By report, the of strategies healthcare providers can
in the ICU on mechanical ventila- boards are used most frequently on use to enhance communication. These
tion—70% experienced less frustration medical-surgical units and in triage include accessing and knowing how
when they had access to a communica- units. One nurse wrote: to use AAC equipment, taking time to
tion board.30 communicate, asking caregivers for tips
I remember a gentleman from somewhere in
and providing a way for patients to get
Asia who came in. He was pointing to his
5. Improving Communication in the belly. We used the board, and he pointed to the attention, etc.8-9,37-38
ICU is a concise summary of the need pictures representing the belly and using the
for communication access in ICUs. bathroom. So we could assess that he was hav- 5. Augmentative and Alternative
Written by a team consisting of a ing abdominal pain and probably diarrhea. Then Communication In Acute And Criti-
physician, nurses, researchers, policy we pointed to the picture of vomiting. He shook cal Care Settings, by Richard Hurtig
makers, as well as staff from The Joint his head no, so we were able to rule something and Debora Downey, is a 200+ page
Commission, a nongovernmental, out. When he came in, he had been looking at us “how to handbook” aimed at providing
healthcare accreditation agency, this blankly, wondering how he was going to com- protocols and implementation strategies
article specifically mentions the value municate. Then we pulled out the board, and off for using AAC approaches with people
we went.34 in acute care facilities. Written for
of using AAC approaches.31
SLPs and medical staff who work with
Acute and rehabilitation 2. Communication Matters, the United
patients who experience a temporary
Kingdom’s ISAAC chapter, has a free
hospitals. Faced with increasingly and downloadable series of leaflets.
or permanent loss of oral language,
chapters include information about the
diversified patient populations, One brochure, Communicating with
use of assistive technology, assessment
many hospitals are adding bilingual patients who have speech/language
and implementation protocols, adapted
difficulties: Guidance for medical &
staff and using telephone transla- nursing staff, helps medical and nurs-
switches, the Iowa AAC templates,
device mounting, access issues, pain
tion services to communicate with ing staff communicate more effec-
management, environmental controls
non-English-speaking patients.4,6 tively with patients who have speech,
and more. Case examples illustrate
language or communication difficul-
However, trained interpreters are not ties due to injury, illness or learning
challenges and successes in providing
always available and, while volun- AAC to non-oral patients in acute care
disabilities. General and specific tips to
teers (e.g., family members, friends, support communication are included.35
caregivers) can help, they can often Home Health. Little informa-
3. Edited by Beukelman, Yorkston
introduce additional difficulties.32 and Garrett, the book Adults with tion is available about communica-
When AAC approaches are included Acquired Disabilities includes 400+ tion difficulties that occur between
pages, CD-ROM with useful forms, patients and healthcare providers
in an arsenal of communication

in homes and group home settings. tional interactions between nursing gests using AAC systems that (1) en-
aides and their patients. Also, nursing able children to have fun and engage in
However, it is unlikely that health- familiar activities; (2) are error free; (3)
aides generalized new skills acquired in
care providers are aware of, or know the care setting to other conversational allow children to talk about a range of
how to support patients who are situations without additional training.40 topics including their feelings about dy-
communication vulnerable. Recent ing; (4) are durable and (5) can adhere
In Victoria, Australia, the state Depart- to infection control requirements.46
trends in home health services may ment of Human Services has deter-
help some because distance commu- mined that successful communication Fried-Oken and Bardach’s article
with patients with dementia is an suggests a framework for considering
nication options (email, videophone, essential component of hospital and end-of-life issues and discusses the use
instant messaging) are becoming nursing home care. Nurses report that of AAC with adults with degenerative
more available to people in rural using multimodal strategies, including conditions (e.g., as amyotrophic lateral
verbal communication, body language sclerosis and brain tumors). Included
areas, as well as those who find and written messages, is helpful. Also are comments from patients. These
traveling or speaking difficult. helpful is open communication between underscore the urgent need people have
Miyasaka, Suzuki, Sakai & Kondo healthcare providers and family mem- to communicate at the end of life.47
conducted a study in which Japanese bers to obtain detailed patient histories
doctors assessed the clinical impact and an understanding of the patient’s Summary
of a home videophone system for the cognitive deficits, sleeping patterns,
families of children receiving home re- preferred activities and supports that AAC technologies and strate-
spiratory care. Results showed a video- help the patient cope with dementia. 41 gies, and the expertise needed to use
phone system significantly reduced the them, have vast and underutilized
number of house calls by physicians,
Hospice and End of Life
unscheduled hospital visits by patients Palliative care means the active key roles to play in helping improve
and hospital admission days. Patients total care of patients whose disease the quality of healthcare and the
and health care professionals found the delivery of patient-centered care.
videophone system both acceptable and
is not responsive to curative treat-
beneficial, and researchers concluded ment. The goal of palliative care is The good news is that some indi-
that it improved the quality of pediatric achievement of the best quality of viduals, from within and outside the
home ventilatory care.39
life for patients and families. Effec- field of AAC, are pioneering efforts
Long term care facilities. Nurs- tive communication is an essential to solve or mitigate communica-
ing home residents and their health- component of palliative care.42 tion problems in various healthcare
care providers confront challenging In the European Journal of Pallia- settings, using simple, eminently
communication situations. This is tive Care, Salt, Davies and Wilkenson practical and readily available AAC
discuss the role of the speech-language tools and materials. These efforts
particularly true for patients with pathologist on palliative care teams,
dementia and for nursing aides, who noting, in one study, that 74 of 91 include practical training protocols
are rarely trained to provide com- hospice patients had communication for healthcare providers and ideas
impairments due to the progression of about how to tweak the environment
munication supports. According to their disease. They note that the use of
Michelle Bourgeois, low-tech AAC tools can support both so that patient-provider interactions
Dysfunctional interaction patterns place resi- comprehension and expression.43 are successful. The bad news is
dents at risk for an impoverished quality of life
and the staff at risk for a variety of physical and that only a miniscule percentage of
Costello stresses the need for profes-
psychiatric health effects and burnout.40
sional preparedness and involvement in those who need to know about these
In a study of seven nursing homes, providing communication options for strategies and tools are even aware
Bourgeois and her colleagues inves- children who are dying. He describes a of their existence. Current efforts to
tigated the effect of memory aids broad range of AAC approaches, e.g., a
multiple message voice output display spread the word are too often puny
on conversations between nursing
aides and residents with dementia. with personal voice-banking, a single or ineffective. Some good efforts are
Residents were given a memory book message SGD and picture communica- in their infancy, but available solu-
with autobiographical material. Aides tion displays.44 He notes that “although
there is quite a bit of research, writing tions are still far too rarely used to
received one hour of inservice training
and were then coached in the use of and ethics discussions on how to com- maximally benefit patients and their
the memory book in care settings until municate with the patient and family healthcare outcomes.
they reached 80% accuracy (an aver- in palliative care, the importance of
supporting the patient to be an active This article advocates for a
age of 8 sessions; range from 3 to 15
sessions). Two five-minute videotaped member of the team in end-of-life broader application of AAC ap-
interactions—one at baseline without discussions is just beginning to be proaches across the continuum of
recognized as an area of study.”45
the memory book; one post treat- healthcare so that patient-provider
ment session with the memory book.
Results showed that the training and
Stuart shares her experiences in provid- communication is improved for all
ing AAC as part of a palliative care patients.
memory book intervention improved team in a pediatric hospital. She sug-
the quantity and quality of conversa-

the PPC website and the comments. Current articles include
Joint Commission’s 1. Overcoming communication barriers
draft standards. [See in emergency situations.
Governmental.] 2. Communication access within medi-
cal settings.
The PPC website
www.patientprovider The goal of the PPC website is 3. Communication with patients who
have speech/language difficulties. to provide practical information to
healthcare providers, family mem- (4) Emergency Preparedness & AAC
In 2008, an ad hoc, independent
group of individuals concerned bers and patients. The site provides (5) Communication with people who
about patient-provider commu- a platform for group members to have acquired disabilities and complex
communication needs (CCN).
nication (PPC) started emailing share information and easily ac-
one another. Largely instigated by cess articles and presentations. It Annotated Bibliography.
Harvey Pressman, President of the also enables visitors to comment on Provides brief summaries of articles/
Central Coast Children’s Founda- articles and/or suggest other sources documents that relate to communi-
tion, this group has evolved into a of information and their opinions. cation barriers in healthcare settings
forum that is developing and sharing Currently, five sections are on the and how to overcome them. Many
resources, documenting communi- website. citations link directly to the article.
cation difficulties between patients Home Page. Welcomes visitors Presentations. Shares PDFs of
and healthcare providers across the to the site and announces the latest PowerPoint presentations. Current
continuum of healthcare and dis- article posted on the site. presentations include
cussing tools and strategies health- About PPC. Briefly lists partici- Call to Action: Improving Care to
pants in the forum and where they Communication Vulnerable Patients
care providers can use to ameliorate by Stronks, Patak & Costello, 2009.
these communication problems. The work.
forum includes speech-language Articles. Shares articles on vari- Improving Communication Effec-
tiveness in Health Care Settings by
pathologists, doctors, nurses, educa- ous topics related to PPC. Invites
Trautman & McBride,
tors, researchers, policy makers and Table I. Participants in the PPC forum 2009.
language interpreters, etc. who work AAC-RERC- the Rehabilitation Engineering Re-
search Center on Communication Enhancement
Frank DeRuyter, Sarah Blackstone
Meeting Patient Com-
in hospitals, universities, businesses, AAC TechConnect Debby McBride munication Needs With
nonprofit organizations, professional Evidence-Based Practice
American Speech-Language-Hearing Association Diane Brown, Steve White, Amy
by Patak, 2009.
organizations and an accrediting Hasselkus

agency. [See Table I.] Augmentative Communication Community

Barbara Collier Forum participants
maintain the site and
With a little support Augmentative Communication Inc. Sarah Blackstone

Boulder Community Hospital Juli Trautman- Pearson, Debby strive to make it current,
In 2009, the Rehabilitation McBride
relevant, useful and eas-
Engineering Research Center on Central Coast Children’s Foundation, Inc. Harvey Pressman
ily accessible to anyone.
Communication Enhancement Children’s Hospital of Boston John Costello
All comments and sug-
(AAC-RERC), Augmentative Com- Children’s Hospital-Denver Tracy Kovach, Lisa Martin
gestions are welcome.
munication Inc. and the Central Duke University Frank DeRuyter
Others enthusiastically
Coast Children’s Foundation offered Duquesne University Kathy Garrett
interested in participating
to support the development of a PPC International Connections Robert Burgener
should contact us.
Institute for Ethics at the American Medical Assoc. Matthew Wynia
website and to host monthly con- & University of Chicago Hospital
ference calls so participants could Iowa State University/Hospital Richard Hurtig, Debora Downey For additional information, to
share information, etc., contact
discuss common issues. Participants International Language Services, Inc. & National Karen Ruschke
Sarah Blackstone at sarah-
Council on Interpreting in Health Care
also formed subgroups to work Louisiana State University Health Sciences Meher Banajee or Harvey Press-
man at
on specific projects. For example, Polyglot Systems, Inc. Charles Lee Phone: 831-649-3050.
Wilson-Stronks, Patak and Costello The Joint Commission Amy Wilson-Stronks, Tina Cordera. AAC-RERC
presented a web seminar, hosted by Erica Galvez, Isa Rodriguez SPREAD THE WO R D

The Joint Commission about PPC. University of Michigan/Vidatak, Inc. Lance Patak

Others have met to discuss issues University of Southern Mississippi Tim Morris, Beverely Morris

related to emergency preparedness, VA Gulf Coast Veterans Health Care System Katy Gift

Tool Kit
The On the Spot
Tool Kit was devel-
oped to make it easier
Communication for healthcare providers to
On the Spot! access simple communication tools
to enhance patient/provider com- Figure 4. On the Spot Communication Tool Kit
The On the Spot Tool Kit and munication. [See Table II.] The kit items. The kit includes basic, low-
On the Spot Resource Book were is meant for use by medical staff cost communication aids, materials
developed at Colorado’s Boulder (nurses, aides, doctors, occupational and instructions. It offers adminis-
Community Hospital by Juli Traut- therapists, etc.) and can be housed trators a “one-stop shopping” solu-
man Pearson and Debby McBride, at the nurses’ stations and restocked tion. Table II illustrates some of the
to address a wide range of com- as needed. The items included help items included in the kit.
munication needs in healthcare to reduce communication barriers, To date, On the Spot Tool Kits
settings (i.e., emergency rooms, medical errors and other negative are being used throughout Boulder
ICUs, hospitals, acute rehabilitation, events. Community Hospital on each nurses
outpatient facilities, skilled nursing Trautman Pearson and McBride, unit (neuro, telemetry, maternity,
facilities, home health and hospice). who are speech-language patholo- medical/surgery and rehabilitation)
According to Pearson, gists (SLPs), developed the kit in with positive results. Staff report an
Communication is one of the most response to the expressed needs of increased awareness of communica-
valuable tools patients have to navigate nursing staff at Boulder Hospital
their medical care. Simple-to-use tools
tion vulnerability and applicable
can support any patient who is vulner- in Colorado. They recommend that  Purchasing policies at hospitals can complicate
nurses and other healthcare provid- the acquisition of such a range of resources
able to communication mishaps due to
from (frequently small) vendors.
difficulties hearing, reading, writing, ers receive training in the use of the
speaking or accessing a call system. Continued on page 8
Table II. Some items from the On The Spot Communication Tool Kit
PocketTalker & accessories Magnifier page Clip board Dry erase board

Amplified sound increases hearing Enlarges text so patient can read if Holds paper, communication dis- Write/draw messages. Supports com-
ability. Useful when hearing aids are glasses are unavailable. plays, forms, instructions, etc. prehension and expression.
unavailable. Has helpful tips on the back. Has helpful tips on the back (shown
Picture communication English/Spanish cards Health care communica- Vidatak EZ communication
boards: English/Spanish tion board tablet boards

Point to messages, symbols, words, 16 cards with useful words and Point to messages, symbols, Point to specific messages. Has pain
pain scale and alphabet. phrases in English and Spanish, words, pain scale and alphabet. scale, alphabet and words. Available
e.g., comfort, orientation, pain, etc. English only. in 17 languages and a picture board.

Equipment, Continued from page 7 tions can access an alerting system.
resources. Patients are participating Physical access strategies: Keyguards
more fully in their care. The SLP de- for letter boards, modified pointers,
partner assisted scanning, eye move-
partment has also noted an increase ment systems (eye gaze system, eye
in consults for AAC assessments. link) and a Yes/No Topic Book.
[Note: Boulder Community Hospital was
recently recognized by The Joint Commission 5. BEDSIDE RECOMMEN-
and the Commission on Accreditation of Reha-
bilitation Facilities (CARF) for its excellence in
DATIONS. Easily copied, posted
addressing communication needs.] and given to anyone who needs to
communicate with a patient.
Resource Book Instructions: How to use Partner As-
The 106 page On the Spot Figure 5. On the Spot Resource Book sisted Scanning, a Yes/No Topic Book,
an Eye Gaze System such as Eye Link.
Resource Book is meant primarily healthcare settings with instructions
to help SLPs in healthcare settings on how to make a communication Writing Strategies: How to help
who do not necessarily know much book of meaningful images using someone with arm weakness or limited
control communicate via writing.
about AAC. It provides resources to photo books and/or a velcro file
help them support patients, nurses folder. Communication Recommendations:
(for Aphasia): How to use key words.
and family members when tempo- Images: Maps, calendars, emotions. Ways to indicate Yes/No.
rary, chronic or changing speech Yes/No indicators and pain scales.
and/or language difficulties occur. Adaptive Tools: How to use all the
Commercially available picture tools a person has to foster successful
The book has six clearly illustrated boards: Critical Communicator Picture communication.
sections with easy-to-implement Board, Daily Communicator (Pocket
sized) and Health Care Communication 6. PAPERWORK. For SLPs.
ideas. Board. Easy-to-complete forms to docu-
Modified pictures: Includes var- ment what was tried with patients
For literate patients. Twenty plus ied symbol types, sizes (smaller vs. and implemented successfully. Can
pages with low-cost, easily acces- enlarged pictures) and contrasting
become part of a more compre-
sible tools and instructions. backgrounds.
hensive assessment by a speech-
Writing boards: Simple dry erase 3. BOARDS IN DIFFERENT language pathologist/audiologist if
boards and clipboards for writing, with
valuable writing strategies on back.
LANGUAGES. For people who communication difficulties persist.
don’t speak English. Commer-
Letter boards: Easily copied direct cially available boards in different Case Examples**
selection and scanning communication
boards. Landscape or portrait view with languages (highlighting those in 1. The medical team was preparing to
ABC and/or QWERTY layouts and Spanish), including the EZ Commu- extubate Mr. K. from the ventilator.
contrasting backgrounds. Also, boards An ICU nurse felt he’d have increased
nicator, Critical Communicator and intent to communicate as his sedation
for partner-assisted scanning arranged
according to most frequently occurring Daily Communicator boards. wore off, so she pulled the Vidatak
letters. 4. MODIFICATIONS. Twenty- Communication Board and the Picture
Communicator from the Tool Kit.
two pages of ideas and strategies Once Mr. K. was conscious, his nurse
Word boards: Easily copied topic and
phrase boards. Instructions on how to about how to provide voice output, reviewed both boards with him. Mr.
use an EZ Communicator; a Word Pow- amplification and magnification to K. immediately pointed to a board to
er OnBoard and a pocket-sized Daily improve communication access, as communicate that he was thirsty and
Communicator. Also includes how to his mouth tasted awful. As a result, the
determine text size for a patient. well as various ways to access call nurse used a suction toothbrush and
bells. applied a mouth moisturizer to relieve
The Writer: How to use a typing his discomfort.
device without speech output, but with Voice Output: The Go Talk, Talking
word prediction. Photo Album. 2. Ms. S. was rushed by ambulance
to the ER because of chest pain. Once
2. PICTURES/SYMBOLS. Amplification strategies: PocketTalker
her condition was stable, the staff gave
(hearing), Chattervox (voice), Sprint
For persons with cognitive and/or Relay (phone use).
her multiple forms to complete and
language difficulties who are less read. However, she had left her reading
Enhancing vision: Magnifying glass glasses at home. She might have decid-
successful using traditional letter ed to “just sign on the dotted line,” but
or page.
boards. Thirty-five pages of easy to she asked a nurse if he had time to read
copy and use materials relevant to Call bells: Examples of modified call ** Thanks to Juli Trautman Pearson for these
bells so patients with physical limita- informative and illustrative case examples.

all of the information to her. Instead, the SLP to identify some tools and strategies Summary
nurse gave her a magnifier page and she that could facilitate his communica-
was able to read and complete all paper- tion. These included a dry erase board, The On The Spot Tool Kit and On
work independently. a communication book (with words The Spot Resource Book provide
and pictures copied from the Resource
3. Ms. A. was receiving a treatment for Book), as well as the use of key words practical, easy, low-tech solutions
lung cancer that involved the use of and the Written Choice Communication for communication problems that
ototoxic medications. At baseline, Ms. Technique. Also, bedside recommenda- occur during medical interventions,
A. did not have hearing aids, although tions were copied from the Resource
her hearing was not very good. Due to Book and posted at his bedside. acute injuries and acute/chronic
respiratory distress after a lower lobec- illnesses. These tools also can ad-
tomy, she was intubated in the ICU. The 5. Mr. A. had a brainstem stroke and was dress language and cultural differ-
noise from the pump, combined with her in an acute rehabilitation facility with
ototoxic meds, made it difficult for her severe-profound spastic dysarthria. He ences when trained interpreters are
to fully participate in conversations with could finger point with limited accuracy. not available. Trautman Pearson
her doctor, family or hospital staff. A His yes/no responses were accurate, and McBride join an increasing
nurse provided her with a Pocket Talker although holding his head up was dif-
amplifier. Her communication partners ficult, and when he got emotional, he number of AAC specialists who
helped her put on the earphones and then was unable to nod his head. The Assess- daily demonstrate the value of AAC
talked into the amplifier’s microphone so ment Hierarchy and Evaluation Form and speech language pathology in
she could hear what was being said. allowed the SLP and Mr. A. to determine
his strengths and consider his com- healthcare settings. Their resources
4. Mr. W. had a left CVA, aphasia, a munication options. He decided to use are useful for anyone who confronts
right hemiparesis and difficulty commu- a keyguard over a white-on-black letter
nicating. His yes/no response appeared
communication barriers in health-
board (from the Resource Book) and
accurate (for basic questions) and he spell messages. He also used a topic/ care settings, from first responders
could recognize familiar/common words. phrase book (copied from the Resource to hospitals, rehabilitation, hospice,
Although he couldn’t say where he lived, Book) to select topics. Then, he would home care and all points in between.
he pointed to his hometown when given wait for his communication partner to For more information, contact AAC Tech Connect
a choice of four cities. He could point flip to the tab of the category he wanted at or 866-482-2279.
to, or trace in the air, the first letter of and scan through individual messages On The Spot Communication Resource Book
a word using his non-dominant hand, using partner-assisted scanning. Bedside $99 (Introductory Price); On The Spot Tool Kit
but he could not spell. The Assessment recommendations were also posted. $699. Go to to order
Hierarchy and Evaluation Form in the and check out other options.
On the Spot Resource Book allowed the

as part of its Hospitals, tive communication is more than

Language, and Cul- a patient’s right, it is essential to
ture: A Snapshot of the patient safety and quality of care. As
Nation study.*** The the Joint Commission staff stud-
draft standards provide ied how culture and language can
baseline expectations impact communication in diverse
Advancing effective for hospitals accredited by The Joint patient populations, they recognized
communication, cultural Commission in regard to care sys- there are other communication
competence & patient- tems that are responsive to patients’ “vulnerabilities” that may impair
centered care by Amy unique needs. It is hoped that when effective patient-healthcare provider
Wilson-Stronks finalized these standards will be ad- communication. These include diffi-
opted for inclusion in accreditation culties with speech, hearing, vision,
The Joint Commission, a non-gov- requirements for hospitals. physical disabilities, disease and
ernmental healthcare accreditation medical procedures that interfere
agency, recently released a set of Background
with effective communication.
draft standards aimed at advancing The Joint Commission has ad-
Commission staff also recog-
effective communication, cultural dressed patient’s rights in its ac-
nized that individual and institution-
competence and patient-centered creditation standards for decades.
al factors can affect communication.
care practices in hospitals.** These Within these standards has been the
The draft standards highlight, both
standards build on ongoing research patient’s right to effective communi-
while leaving institutions the flex-
conducted by The Joint Commission cation. However, as is clear through
ibility to create systems that meet
the review of sentinel event data
 Formerly known as The Joint Commission on their unique needs.
Accreditation of Health Care Organizations and a voluminous literature, effec-
** This project is funded by The Commonwealth *** This study is funded by The California Continued on page 10
Fund. Endowment.

Governmental, Continued from page 9 promote equity, respect and inclu- ASHA on Health Literacy
A series of government and sion. Because communication can The American Speech-Language-Hear-
healthcare studies and policies over be impaired by a multitude of fac- ing Association has initiated an effort to
the past nine years have helped tors, The Joint Commission does not make written materials more accessible to
shape The Joint Commission’s claim that addressing these issues is the general public. Adhering to the prin-
ciples of plain language and addressing
understanding of effective commu- an easy task. However, several new health literacy issues, ASHA is revising
nication, cultural competence and requirements, if included in the stan- its pamphlets and website so they are
patient-centered care, as well as in- dards, could improve the quality and more readable, user friendly and targeted
creased the level of attention paid to safety of care provided to patients. for the general public. Check out:
1. Tips for talking to your audiologist or
healthcare disparities and the quality Sixteen issues are addressed in the speech-language pathologist: www.asha.
of healthcare. [See Table III.] draft standards. org/public/talkingwithaudorslp.htm.
Staff training on cultural sensitivity. 2. Questions to ask about new products or
Issues addressed Staff and licensed independent practitioner treatments:
training on the use of communication tools. consumerqa.htm.
Areas addressed in the draft Use of population- and patient-level
standards include (1) the collection demographic data. The ASHA Leader published 3 articles
Identification of the patient’s communication by Amy Hasselkus, Associate Director of
and use of demographic data for needs. Health Care Services in SLP. She says,
both service provision and strate- Address communication needs across Health literacy is not just a problem for the
the care continuum. patient, client or family. Healthcare provid-
gic planning, (2) assessing patient Provision of language access services and ers also have a responsibility to be sensitive
communication needs and providing auxiliary aids. to a client’s cultural needs and provide
Assessment of patient understanding. appropriate and understandable health
resources to meet those needs and Inclusion of health literacy needs in learning information.48
(3) developing systems of care that needs assessment.
Contact Amy Hasselkus at ahasselkus@asha.
Table III. Chronology of events shaping The Joint Commission’s Access The ASHA Leader articles at
proposed standards (1)
2001 Office of Minority Health releases National Standards for Culturally and Linguistically Ap- archives/2009/ 090120/090120d.htm;
propriate Services (CLAS) (2)
archives/2009/ 090210/090210c.htm;
Institute of Medicine releases its Unequal Treatment Report identifying racial and ethnic health (3)
and health care disparities. archives/2009/090324/090324e.htm
The Joint Commission begins to evaluate its standards against the CLAS standards and recom- Collection of patient-level demographic data.
mendations in the Unequal Treatment Report. Gaps are identified, but the field is not yet ready Documentation of need for mobility assistance.
2003 to implement suggested strategies. The Joint Commission decides not enough is known about Documentation of the use of language access
the capacity of health care organizations to adopt culturally/linguistically appropriate services. services and auxiliary aids.
The Joint Commission receives a generous grant from The California Endowment to study how Accommodation of patient’s cultural and
hospitals across the nation are addressing issues related to language, culture and health dispari- personal beliefs.
ties. Technical advisory panel convened; project advisors appointed to assist with research. Accommodation of patient’s religious and
spiritual practices.
2003 Hospitals, Language, and Culture: A Snapshot of the Nation study is conducted. Findings show Non-discrimination in care.
to much is being done to address language, culture and health disparities, but efforts are not always Inform patients of right to receive language
2006 consistently implemented. Awareness of recommended practice and legal supports for language access services.
access is limited. Unlimited access to designated patient advocate.
Hospitals, Language, and Culture: A Snapshot of the Nation, Exploring Cultural and Linguistic The impact
Services in The Nation’s Hospitals: A Report of Findings is released in March.
Although it is not yet clear which
2007 The Joint Commission completes pilot study investigating relevance of Limited English Profi-
ciency to adverse events in Hospitals. Language proficience and adverse events in US hospitals: proposed standards will be ap-
A pilot study published in the International Journal for Quality in Health Care. Demonstrates proved, final standards will be avail-
that language barriers appear to increase risks to patient safety.
able in January 2010 for implemen-
2008 One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations, the second
report from the Health, Language, and Culture study is released. It provides promising practices tation by the field in January 2011.
and a framework for action to improve care for diverse patients. An implementation guide that will
Aug The Joint Commission receives grant from The Commonwealth Fund to develop standards to help hospitals meet the new stan-
2008 advance effective communication, cultural competence and patient-centered care in hospitals.
dards will include information about
Standards build on the work of the Health, Language, and Culture study. Expert panel estab-
lished to guide the development of the standards. the use of AAC tools, strategies and
May Draft standards to advance effective communication, cultural competence and patient-centered technologies.
2009 care in hospitals released for public comment. Amy Wilson-Stronks, Principal Investigator of
the Hospitals, Language and Culture study, can
Aug Revision of draft standards based on analysis of public comments, expert opinion and pilot test- be reached at awilson-stronks@jointcommis-
2009 ing. Implementation guide under development to help hospitals meet the standards. sison. org. To access publications, go to www.
Final standards will be available in January 2010 for implementation by the field in January 2011.

ers. Researchers identified Some current research
what participants defined
as barriers to communica-
tion in hospitals, as well Several researchers around the
as what strategies helped
them overcome these
world are addressing issues that aim
barriers. [See Table IV.] to improve patient-provider commu-
Evidence: Using For example, barriers included nication across healthcare settings.
nurses not having knowledge about a
AAC to support variety of communication supports or
The following are some examples.
patient-provider access to tools that could help them University of Iowa, USA. Rich-
communication interact successfully with patients. ard Hurtig describes work underway
Also, nurses reported overly rigid time at the University of Iowa Hospitals
This article highlights some sources constraints. Success was more likely
when nurses were willing to ask for and Clinics, a 500+ bed medical
of evidence that address the use of assistance, spend time with patients and facility. Recognizing the importance
AAC by healthcare providers across share information with other staff about of communication and the chal-
settings. These sources, as well as how to communicate with a patient.
Being familiar with a range of commu- lenges patients who don’t speak
current research initiatives described nication tools and strategies also made English or who have temporary or
here, may serve to broaden minds a difference. permanent communication impair-
and help the AAC community advo- Researchers concluded that these fac- ments face, he and doctoral students
cate for all patients who struggle to tors can improve patient-provider com- Debora Downey and Lauren Zobow
communicate in healthcare settings. munication: (1) availability of AAC are conducting studies designed to
tools and strategies, (2) quiet environ-
1. A narrative review article. A ment, (3) smaller case loads for nurses support patient-provider communi-
systematic review of the effectiveness of
nurse communication with patients with
and (4) presence of family/friends.11 cation in acute care settings.
complex communication needs with a 2. Books on the use of AAC in health- Downey is developing and testing an
focus on the use of augmentative and care settings. online introductory tutorial for nurses
alternative communication by Erinn Augmentative Communication Strate- and other healthcare providers by
Finke, Janice Light and Lisa Kitko. gies for Adults with Acute or Chronic educating them about AAC so they can
Reviews evidence from 1990-2007 Medical Conditions (2007)12 and Aug- provide communication supports to
regarding nurse-patient communication mentative and Alternative Communica- patients.
and AAC in the Journal of Clinical tion in Acute and Critical Care Settings
Nursing.11 The authors completed Zobow is identifying professional and
(2008).13 Described on page 4 of this
an extensive literature search, which institutional barriers to the delivery of
issue, these books offer a plethora of
revealed 23 articles, of which 12 met AAC services in hospitals by con-
research findings, practical ideas and
their criteria (i.e., appeared in a peer-re- ducting initial interviews with target
strategies for supporting patients across
viewed journal, written in English and groups. From these, she will develop
the continuum of healthcare. While
used primary research methodologies). a survey, administer it nationally and
aimed at speech-language pathologists,
Participants in selected studies were pa- analyze the results.
other healthcare providers will find por-
tients with CCN, nurses and unpaid car- tions highly useful. In addition, Hurtig is working with
Table IV. Communication barriers and supports: Nurses and patients with CCN11 hospital administrators to embed
What are barriers to communication? What helps? questions about patient communi-
1. Most interactions are task-focused, nurse-con- 1. Prior training and experience working with cation in hospital-wide electronic
trolled and focus on physical needs and medi- people with disabilities. charting protocols. Sample ques-
cal/care procedures.
tions include
2. Interactions often do not result in needs being 2. Looking for nonverbal cues to make sure
met. patient understands. Can the patient communicate effec-
tively and efficiently? Does the patient
3. Nurses lack knowledge about AAC. 3. Sharing information with other medical staff.
require the use of glasses? Hearing
4. Some nurses feel that providing communication 4. Following written directives of patient/family aids? Does the patient use any assistive
tools is “not my job.” about how to communicate with the patient. technology? Can the patient use a call
5. It takes more time to care for and communicate 5. Willingness to take time and be persistent until button? and so on.
with patients who are communication vulnerable. the patient’s message is understood.
Because this is part of a hospital-
6. Nurses lack access to communication tools. 6. Being familiar with/using AAC approaches.
wide database, the SLP Department
7. Patients often don’t have a way to gain the 7. Asking family, speech-language pathologist,
staff’s attention. etc. to make suggestions. can identify patients who have dif-
8. When a nurse is not assigned to care for the 8. Sharing information with other nursing staff ficulty communicating throughout
same patient over several days, the continuity of (e.g., shift changes) about what communication the hospital at any time.
care may be compromised. supports work with a patient.
9. Presence of family members. 9. Asking for help when communication is dif- Continued on page 12

University/Research, Cont. from page 11 way, Cummins is interviewing AAC how widespread publication of such systems
stakeholders and nurses to develop would be of benefit, and further research in this
Another project is the evaluation these modules and will then evaluate area is urgently needed.49
and use of the IOWA Protocol. The their usefulness as training modules in
Over the next four years, Hemsley,
aim is to enhance patient-caregiver hospitals in Scotland and Norway.
Balandin and Linda Worrall are col-
communication for all non-oral pa- Prior’s study aims to create “add on” laborating on a Communication in
items to the electronic patient records Hospital project with hospitalized
tients and patients who do not speak adults who have developmental dis-
of people with CCN. Items will address
the language of healthcare provid- basic care needs, cognitive levels and abilities and CCN. In Phase I Hemsley
ers. Goals are to put AAC solutions communication needs. In focus groups, is interviewing paid carers, hospital
quickly in place at the bedside and adults who have CCN and some cogni- nurses and adults with development
tive impairment identified information disability and CCN in the hospital. In
to train SLPs and other providers to they wanted in their hospital records. Phase II she will observe interactions
use AAC strategies with patients. To ascertain the perspectives of doc- between individuals with CCN and
Typical interventions include call tors, Prior held a forum theater session hospital healthcare providers. She is
whereby two adult actors who rely also involved in a set of projects, Chil-
button modifications, environmental on AAC and two professional ac- dren Communicating in Hospital: The
controls and communication tem- tors enacted scenarios based on real Path to Better Health Care, looking at
plates designed for specific units. life experiences. The scenes depicted ways children with CCN communicate
problems that occur when doctors are in hospitals and what barriers and strat-
Dundee, Scotland. Annalu egies to communication exist for them
not fully aware of the medical histories
Waller and doctoral students Kath- of patients with CCN and/or how they and their healthcare providers. This
leen Cummins and Suzanne Prior communicate. The audience, com- work extends her previous research
prised of newly qualified doctors, were with adults.
are conducting research on patient-
asked what information they might
provider communication issues in need to access in a patient’s electronic
Robyn O’Halloran at LaTrobe Univer-
sity has developed a functional com-
hospitals. Earlier, Judson, Waller, record. Based on these results, Prior is
munication measure for patients with
and others worked on the ICUTalk, developing a software program for use
acquired communication disability in
in hospitals. She notes, not surprisingly,
a device designed to meet the needs that perspectives of adults with CCN
acute hospital settings. Previously, she
of patients in the ICU. documented the numbers of patients
and doctors are quite different.
unable to communicate their needs
The Dundee team followed a user-cen- in acute hospital stroke units and the
tered methodology to develop a simple- Australia. Researchers at the multiple factors that influence their
to-use AAC device with a pre-stored, University of Queensland and ability to communicate with healthcare
vocabulary of 200 items (8 categories) Latrobe University in Australia providers.
and an alphabet. Vocabulary items
were selected on the basis of patient continue to work on patient- Norway. Susan Balandin at
and nurse interviews and observations. provider communication issues. the University College Molde in
Researchers introduced the ICUTalk They have previously noted that
to patients at Ninewells Hospital
Norway continues her collabora-
and collected data for one year via individuals with developmental tion with researchers in the UK and
questionnaires and automated logging. and acquired disabilities and Australia. A current interest is the
Results suggested that patients learned CCN are hospitalized more
to use the device after about 5 minutes
transition from pediatric to adult
of training. Two problems were noted: frequently than people without healthcare services for young people
the size of the device and patients’ disabilities, particularly as they with CCN. She and her Norwegian
difficulty accessing desired vocabulary. get older. colleagues are currently working
Today, a decade later, Ninewells Hospi-
tal staff reportedly continues to use the Bronwyn Hemsley, a post doctoral with Telemed Norway to develop a
ICUTalk. (Researchers concluded that fellow at the University of Queensland, series of lectures by people who use
the device is not a viable commercial continues to investigate the communi- AAC about their healthcare interac-
product, but are making the software cation experiences of people with life-
available as opensource on the Oatsoft long disability who are in the hospital. tions. She will explore the use of
Portal In her Ph.D. studies, Hemsley worked
icutalk/) with Profs. Susan Balandin and Leanne  She recommends Beyond Words Book Series,
full-colour picture books addressing problems
Togher to develop an Information Kit
Currently, Cummins is studying bar- children and adults who are not literate may
for Family Carers of Adults with Cere- face. Sample titles are: Going into hospital,
riers between nurses and people with bral Palsy and CCN in Hospital. The Going to the doctor, Looking after my breasts,
CCN who are hospitalized and use Kit incorporates information, tips and Getting on with epilepsy. Go to www.intellectu-
AAC. She is developing online training strategies aimed at supporting patient- beyond_words.htm
modules for nurses so they can better provider interactions using various
address the communication difficul- AAC approaches. She says,
ties experienced by their patients, thus
Since there is no research literature that tests
improving the hospital experience for
the usefulness of generic low-tech systems on
all. Working with Annalu Waller, Thilo the ward, it is not possible to say whether or
Kroll and Susan Balandin in Nor-
3. Once located, to deepen and advance the use of
articles need to be
read to determine
evidence informed practices.
which are relevant The international EVIDAAC
Evidence in Augmentative and Alternative Communication
to the clinical team consists of
questions being
Ralf Schlosser, Northeastern Univer-
sity, Patricia Dowden, University of
How AAC teams can 4. Finally, someone needs to evaluate Washington and Sarah Blackstone,
benefit from EVIDAAC the selected articles according to their Augmentative Communication Inc.
relevance to a particular client and [USA]; Jeff Sigafoos, Victoria Uni-
with Ralf Schlosser
his/her circumstances and determine versity-Wellington [New Zealand];
whether conclusions are valid and reli- Pammi Raghavendra, Novita Childrens
Suppose a clinician and the family able and therefore, trustworthy. To do Services, [Australia] and Gunther
of a young child with autism are so, research designs and methodologies Eysenbach, University of Toronto,
considering the use of the Picture must be carefully evaluated using pre- [Canada].
determined criteria. This step not only
Exchange Communication System takes time but, for many clinicians, is
(PECS) as a beginning communica-
The EVIDAAC process
beyond their level of expertise.
tion strategy. Both the clinician and The EVIDAAC team searches
the family are interested in know- What is EVIDAAC? for and appraises existing evidence
ing whether there is any research In October 2009, EVIDAAC in the area of AAC and then pub-
evidence to suggest that PECS is will launch its website [www.evi- lishes their results on the EVIDAAC
indeed effective in helping young] and the field of AAC will website in a form that is easy for
children with autism make requests have an accessible and usable data- clinicians, individuals with CCN
and comments. Despite the best of base of appraised research evidence. and family members to access. The
intentions, most augmentative and Thus, AAC team members will be process is as follows:
alternative communication (AAC) able to go to a single source, type in Selecting clinical questions. The
teams simply do not have the time a few keywords or select from a list EVIDAAC team identifies clini-
to find existing evidence or the ex- of clinical questions, to initiate an cally-relevant questions based on
pertise to appraise its reliability and online search of relevant evidence. available research evidence. Once a
validity. Current options for finding For example, a team might select potential question is identified, team
and appraising evidence in the area “autism” as the population of inter- members begin to search for further
of AAC remain limited for several est, and “child” as the age range. evidence.
reasons: The team could see immediately Locating evidence. The EVI-
1. As a field, we lack a large database that both single articles and review DAAC team regularly conducts
of individual, peer-reviewed, meth- articles are available. Rather than electronic database searches fol-
odologically sound research studies lowing the guidelines set forth in
on topics of interest to clinicians who having to begin reading individual
work in AAC, family members and studies, the team can decide to begin Schlosser, Wendt, Angermeier, &
individuals who use AAC. The popula- by requesting abstracts of the review Shetty (2005). They use the follow-
tions who rely on AAC approaches are ing databases:
diverse and small in number and the articles and as well as EVIDAAC’s
field still has too few researchers and/or appraisal ratings for each article. Cumulative Index of Nursing and
master clinicians worldwide who Allied Health Literatures (CINAHL),
This enables them to assess (1) Educational Resources Information
conduct and publish clinically-oriented
research in peer-reviewed journals.
which review articles are most Center (ERIC), Language and Lin-
relevant to a particular child and guistics Behavior Abstracts (LLBA),
2. Finding existing studies and review Medline, PscyINFO, Scirus, and Web
his/her environment and (2) which of Science.
articles is tedious and time consuming.
For example, one has to search for ar- review articles appear to be most
ticles using general-purpose databases trustworthy methodologically. In addition, they may conduct hand
(e.g., ERIC, PsycINFO) or web-based Together with the AAC team searches of selected journals and
search engines such as Google Scholar. search reference lists in relevant
Because AAC-related articles are members’ knowledge of the client
published in many different journals, and his/her circumstances, their books.
multiple databases and other sources sound clinical judgement and the Selecting articles to appraise.
must be searched.
preferences of the family and person The following criteria determine
with complex communication needs whether the EVIDAAC team will
 While ERIC and Google are freely accessible
on the Internet, PsycINFO requires a subscrip- (CCNs), EVIDAAC offers a way Continued on page 14

appraise a study or review article: Table V. Designs and appraisal scales
1. The study or review article has to fall
within the realm of AAC based on the Design and Appraisal Scale Description of Design
2002 ASHA definition. See below.** Randomized Controlled Trial (RCT) An RCT compares at least two treatments (one of which can
Adapted PEDro scale be a no-treatment control or a wait-list control condition) with
2. The study or review article must (maximum points possible: 12) random allocation (participants are randomly allocated to
examine the efficacy, effectiveness or groups for either the treatment being studied or control/placebo
efficiency of one or more interventions. using a mechanism, such as coin toss, random number table,
Studies related to assessment, diagno- or computer-generated random numbers) and compares the
sis, prognosis, as well as surveys and outcomes. Pseudo or intended-to-be-RCTs are also included in
qualitative studies are not included. this category wherein participants are allocated to groups for
treatment or control/placebo using a non-random method (such
3. Individuals with disabilities and/or as alternate allocation, or by odd or even client numbers).
their communication partners are the Non-RCT A non-RCT is similar to an RCT in that it compares at least
focus of the intervention study. [Re- Adapted PEDro Scale two treatments (one of which can be a no-treatment control or
search with non-disabled participants (maximum points: 10 ) a wait-list control condition). However, participants are not
is not appraised because it requires randomly allocated to groups. Rather, they are selected based
replication with disabled participants on disability or outcome. Then information is obtained about
in order to inform evidence-based previous exposure to a treatment or other factor being studied.
Case series Case series refers to a group(s) of participants who are exposed
4. The study/review is published in Adapted PEDro Scale to one treatment. Outcomes are measured before and after
(maximum points: 4 ) exposure to the treatment.
a peer-reviewed journal in English.
[Note: Other languages are a future Single-subject experimental designs SSEDs use repeated measurement of a dependent variable
possibility.] (SSEDs) – evaluating effectiveness of and demonstrate experimental control through manifestations
one intervention of experimental effect at different points over time (a) within
Appraising study and review EVIDAAC Single-Subject Scale a single participant (within-subject replication) or (b) across
articles. At least two members of (maximum points: 10) different participants (between-subject replication). SSEDs
may involve only one participant or several participants. Each
the EVIDAAC team and/or EVI- participant serves as his/her own control.
DAAC Editorial Board appraise and SSED – comparing effectiveness of Comparative SSEDs compare the effectiveness, efficacy,
independently rate each study or re- two or more interventions efficiency of two or more interventions. The scale uses a com-
view article. They reconcile any dif- EVIDAAC Comparative Single-Sub- bination of items from the SSED scale, as well as other items
ject Design Rating Scale that apply only to comparative acquisition designs.
ferences before ratings are posted. (maximum points: 19)
Appraisal scales. Scales are Systematic reviews Systematic reviews “…adhere closely to a set of scientific
selected according to the type of EVIDAAC Systematic Review Scale methods that explicitly aim to limit systematic error (bias),
(maximum points: 16) mainly be attempting to identify, appraise and synthesize all
research design used in the study or relevant studies (of whatever design) in order to answer a
review article, as shown in Table V. particular question” (by Petticrew & Roberts, 2006, p. 9).
The higher the score derived from Systematic review and meta-analysis Systematic reviews that employ statistical means for the analy-
the scale, the more solid the research EVIDAAC Systematic Review Scale sis of pooled data from multiple studies.
(maximum points: 20)
evidence and the more trustworthy
the researchers’ conclusions. relate to clinical questions, such as References
Final steps. When the appraisal What are the effects of: American Speech-Language-Hearing Association.
(2002). Augmentative and alternative com-
process is complete, the team posts 1. AAC interventions on natural speech munication: Knowledge and skills for service
the title, abstract and results of the production? delivery. ASHA Supplement, 22.
appraisal on the EVIDAAC website. 2. Manual sign intervention on speech Petticrew, M. & Roberts, H. (2006). Systematic
production? reviews in the social sciences: A practical
Summary guide. Oxford: Blackwell Publishing.
3. Manual sign intervention on manual Schlosser, R., Wendt, O., Angermeier, K., &
The EVIDAAC site, when sign production? Shetty, M. (2005). Searching for and finding
launched in October, will contain evidence in augmentative and alternative com-
information about approximately 40 4. Functional communication training munication: Navigating a scattered literature.
on challenging behavior? Augmentative and Alternative Communication,
studies and 20 review articles that 21: 233-255.
5. PECS on expressive communication? Schlosser, R. & Raghavendra, P. (2004).
** AAC refers to an area of research, clinical and
Evidence-based practice in augmentative and
educational practice, and involves the study 6. Treatment packages that involve the alternative communication. Augmentative and
of and, when necessary, compensation for, use of SGDs on requesting behaviors? Alternative Communication, 20: 1-21.
temporarily or permanently, the impairments,
activity limitations and participation restric- 7. Milieu and naturalistic teaching on EVIDAAC is funded by a Grant from the National Institute on
tions of individuals with severe disorders of
production/expression? Disability and Rehabilitation Research (NIDRR), U.S. Depart-
speech-language production and/or comprehen- ment of Education (H133G070150-08). The opinions herein are
sion, including spoken and written modes of those of the grantee and do not necessarily reflect those of the
communication. (ASHA, 2002) U.S. Dept. of Education.

Resources competence: A framework for understanding Clark, H. (2005). Pragmatics of language

language barriers in health care. Journal of performance. In L.R. Horn & G. Ward (Eds.).
Sincere and hearty thanks to my colleagues for General Internal Medicine. 22:368-370. Handbook of pragmatics. Oxford: Blackwell
their help with this issue. Publishing. 365-382.
The Interpreter’s World Tour: An Environmental
John Costello, Dir., AAC Program, Children’s Scan of Standards of Practice for Interpreters. 21
Finke, E., Light, J. & Kitko, L. (2008). Op.cit.
Hospital Boston, Boston, MA. Prepared for the National Council on Interpret- 2103. ing in Health Care. (2005). 22
Blackstone, S. & Wilkins, D.W. (2009). Meet
Susan Balandin, Prof., Department of Health and 7
Blackstone, S. & Warrick, A. (2008). World di- me more than half way and then some: AAC
Social Sciences, University College, Molde, sasters and humanitarian emergencies: Unheard and pragmatics. Invited presentation at the
Norway. voices. Augmentative Communication News. ASHA’s Special Interest Division on AAC.
Kathleen Cummins, Ph.D. student, University of 19:4, 1-3. Maryland, February, 2009.
Dundee, Dundee, Scotland, 8
Hemsley, B. & Balandin, S. (2004). Without 23
Listening. (2008). Video produced by the Texas AAC: The stories of unpaid carers of adults Medical Institute of Technology.
Amy Hasselkus, Assoc. Dir.. Health Care Services with cerebral palsy and complex communica- 24
Tips for Emergency responders for seniors,
in SLP. ASHA, Rockville, MD. tion needs in hospital. Augmentative and Alter-
People with service animals, People with native Communication. 20:4, 243-258.
mobility impairments, People who are mentally
Bronwyn Hemsley, Postdoctoral Fellow (Public
Balandin, S., Hemsley, B., Sigafoos, J., Wallace, ill, People who are blind or visually impaired,
Health). The University of Queensland, C., Forbes, R. & Parmenter, T. (2001). Com- People who are deaf or hard of hearing, People
Queensland, Australia. municating with nurses: The experiences of 10 with cognitive disabilities. The University of
individuals with an acquired, severe commu- New Mexico’s Center for Development and
Richard Hurtig, Professor & Starch Faculty Fel- nication impairment. Brain Impairment. 2:2, Disability.
low, Dept. of Comm. Sciences & Disorders, The 109-118. html#tips (Accessed on 8/18/09).
University of Iowa, Iowa City, IA.
Murphy, J. & Cameron, L. (August 2006). 25
The acute hospital experience for adults with e4all.shtml (Accessed on 8/18/09).
Debby McBride, Pres., AAC TechConnect, Ever- complex communication needs. Communication
green, CO.
Matters. 20:2, 7-11.
(Accessed on 8/18/09).
Lance Patak. M.D., University of Michigan 11
Finke, E., Light, J. & Kitko, L. (2008). A
Health System, Ann Arbor, MI.
Costello, J. (2000). AAC intervention in the
systematic review of the effectiveness of nurse intensive care unit: The Children’s Hospital
communication with patients with complex
Boston model. Augmentative and Alternative
Juli Trautman Pearson, Clinical SLP, Boulder communication needs with a focus on the use of
Community Hospital, Boulder, CO. augmentative and alternative communication.
Journal of Clinical Nursing. 17, 2102-2115.
Continued on page 16
Harvey Pressman, Pres,, Central Coast Children’s
Beukelman, D., Garrett, K. & Yorkston, K.
Foundation, Monterey, CA 93940. (Eds.) (2007). Augmentative Communication Strategies for Adults with Acute or Chronic
Medical Conditions. Baltimore, MD: Paul H.
Suzanne Prior, Doctoral student. University of Brookes Publishing Company.
Dundee, Dundee, Scotland. sprior@computing.
Hurtig, R. & Downey, D. (2008). Augmentative
and Alternative Communication in Acute and Augmentative Communication News
Annalu Waller, Senior Lecturer, School of Critical Care Settings. San Diego, CA: Plural
Computing, University of Dundee, Dundee, (ISSN #0897-9278) is published
Publishing, Inc.
Scotland. quarterly. Copyright 2009 by Aug-
Patak, L., Wilson-Stronks, A., Costello, J., mentative Communication, Inc., One
Amy Wilson-Stronks, Proj. Dir., The Joint Com- Kleinpell, R., Henneman, E., Person, C. &
mission, Oakbrook Terrace, IL. Happ, M.B. (in press). Improving patient- Surf Way, Suite 237, Monterey, CA provider communication: A call to action. The 93940. Reproduce only with written
Journal of Nursing Administration. consent.
References 15
Mehallow, C. (2006). Tips for effective patient- Author: Sarah W. Blackstone
Stewart, M. (1995). Effective physician-patient provider communication. Monster Health Care. Technical Editor: Carole Krezman
communication and health outcomes: A review.
Canadian Medical Association Journal. 152: 9,
Managing Editor: Harvey Pressman
Provider-Communication-Tips.pdf (Accessed
1423-1433. on 8/18/09).
One Year Subscription: Personal
Wilson-Stronks, A., Lee, K., Cordero, C., Kopp,
check U.S. & Canada = $50 U.S.;
A. & Galvez, E. (2008). One size does not fit (Accessed on 8/18/09).
Overseas = $62 U.S.
all: Meeting the healthcare needs of diverse Institutions, libraries, schools, hospi-
Nielsen-Bohlman, L., Panzer, A. & Kindig, D.
populations. Oakbrook Terrace, IL: The Joint
(Eds). (2004). Health Literacy: A Prescrip-
tals, etc.: U.S. & Canada=$75 U.S.;
Commission. Overseas = $88 U.S.
tion to End Confusion. Committee on Health
Bartlett, G., Blais, T., Tamblyn, R., Clermont, Literacy. Washington, DC: The National Single issue rate = $20. Special rates
R. & MacGibbon, B. (2008). Impact of patient Academies Press. for consumers and full-time stu-
communication problems on the risk of prevent- php?record_id=10883 (Accessed on 8/18/09).
able adverse events in the acute care settings. dents. Periodicals Postage rate paid
Canadian Medical Association Journal.
Bourgeois, M., Dijkstra, K., Burgio, L. & Allen- at Monterey, CA. POSTMASTER
178:1555-62. Burge, R. (2001). Memory aids as an augmenta- send address changes to Augmenta-
tive and alternative communication strategy
Jacobs, E., Shepard, D., Suaya, J. & Stone, E. for nursing home residents with dementia. tive Communication, Inc., 1 Surf
(2004). Overcoming language barriers in health Augmentative and Alternative Communica- Way, Suite 237, Monterey, CA 93940.
care: Costs and benefits of interpreter services. tion,17:3, 196-210. Telephone: 831-649-3050;
American Journal of Public Health. 94:5, 866-
Mirenda, P. & Iacono, T. (Eds). (2008). Autism FAX: 831- 646-5428.
Spectrum Disorders and AAC. Baltimore, MD: email:
Gregg, J. & Saha, S. (2007). Communicative Paul H. Brookes Publishing Company.

Augmentative Communication News
1 Surf Way, #237
Monterey, CA 93940

Address Service Requested.

References, Cont. from page 15 patients communicate ailments to nurses. augmentative and alternative communication Gannett Healthcare Group: New strategy for nursing home residents with demen-
Communication, 16:3, 137-153.
Jersey. tia. Augmentative and Alternative Communica-
Happ, M., Roesch, T. & Garrett, K. (2004). dll/article?AID=/20071217/NATION- tion,17:3,196-210.
Electronic voice output communication aids for AL02/312170014/-1/frontpage (Accessed
temporarily nonspeaking patients in a medical
Improving the admission and discharge prac-
August 18, 2009).
intensive care unit. Heart and Lung. 33:1, tices of acute and sub-acute care facilities in
Ibid, p. 1. relation to people with dementia. (2003). 52-58.
Communicating with Patients who have Speech/
Garrett, K., Happ, M.B., Costello, J. & Fried- rep.doc (Accessed on 8/18/09).
language Difficulties: Guidance for Medi-
Oken, M. (2007). AAC in the ICU. In D.
cal & Nursing staff. Communication Matters 42
Pollens, R. (2004). Role of the speech-language
Beukelman, K. Garrett, & K. Yorkson, (Eds.)
publication. Available from www.communica- pathologist in palliative hospice care. Journal of
Augmentative Communication Strategies for Palliative Medicine. 7:5, 694.
Adults with Acute or Chronic Medical Condi-
cus_on.html (Accessed on August 18, 2009)
tions. Baltimore, MD: Paul H. Brookes Publish- 43
Salt, N, Davies, S. & Wilkinson, S. (1999).
ing Company. 36
Blackstone, S. (2007). Augmentative Communi- Communication. The contributions of speech
cation News. 19:1, 1-16. and language. European Journal of Palliative
Patak, L., Gawlinski, A., Fung, I., Doering, L.,
Berg, J., & Henneman, E. (2006). Communi- 37
Balandin, S., Hemsley, B., Sigafoos, J. & Green, Care. 6:4, 126-9.
cation boards in critical care: patients’ views. V. (2007). Communicating with nurses: the 44
Costello, J. (2004). AAC, life threatening illness
Applied Nursing Research: 19:4, 182-190. experiences of 10 adults with cerebral palsy and and communication at end-of-life. The ASHA
complex communication needs. Applied Nurs- Leader. 9:15, 99.
Kleinpell, R., Patak, L., Wilson-Stronks, A.,
ing Research. 20:56-62.
Costello, J., Person, C., Henneman, E. & Happ, 45
John Costello (August 7, 2009). Personal com-
M. (2009). Improving communication in the 38
Hemsley, B., Sigafoos, J., Balandin, S., Forbes, munication.
ICU: Tools and strategies exist to help caregiv- R., Taylor, C., Green, V. & Parmenter, T. (2001). 46
Stuart, S. (2004). AAC and pediatric palliative
ers understand patients unable to express them- Nursing the patient with severe communica-
care. Perspectives on Augmentative and Alter-
selves. Advance for Respiratory Care & Sleep tion impairment. Journal of Advanced Nursing.
native Communication. 13:4, 2-16.
Medicine. http://respiratory-care-sleep-medi- 35:6, 827-835. 47
Fried-Oken, M. & Bardach, L. (2005).
Miyasaka, K., Suzuki, Y., Sakai, H. & Kondo,
rial.aspx?cc=202912 (Accessed on 8/18/09). End-of-life issues for people who use AAC.
Y. (1997). Interactive communication in
Perspectives on Augmentative and Alternative
Wilson-Stronks, A., Galvez, E. (2007). Hospi- high-technology home care: Videophones for
Communication. 14: 15-19.
tals, language, and culture: A snapshot of the pediatric ventilatory care. Pediatrics: Official
nation. Exploring cultural and linguistic servic- Journal of the American Academy of Pediatrics, 48
Amy Hasselkus (August 13, 2009). Personal
es in the nation’s hospitals: A report of findings. 99:1, 1-6. communication.
Oakbrook Terrace: The Joint Commission. 40
Bourgeois, M., Dijkstra, K., Burgio, L. & 49
Browyn Hemsley (August 15, 2009). Personal
Thompson, L. (2007). Picture boards help Allen-Burge, R. (2001). Memory aids as an communication.