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By Rosemary Musachio, Accessibility Analyst

Introduction: Nonverbal Communication in Healthcare

A hospital stay is seldom pleasant. Besides having pain and being sick, patients have to endure needle punctures a dozen times a day, beeps from medical equipment every ten minutes, and moans from other patients. When a patient is nonverbal, a hospital stay can become much worse. Although many nonverbal individuals use voice synthesizers, they usually cannot use these devices in hospital settings since they may interfere with medical equipment.

Since I am nonverbal because of cerebral palsy, I know the experience all too well. Last year I was hospitalized twice for pneumonia. The communication barrier played a major role in both hospital stays being dreadful. Although my mother and friends told doctors and nurses how intelligent I am, that I graduated from Cleveland State University, and that I work as an accessibility analyst, many of them talked to me as if I could not understand. A sign that a friend posted above my bed saying I could comprehend and the way I could communicate did not help very much.

Their presumption possibly prevented them from interpreting my gestures and vocal cues. For example, when I could not reach the call button, I would yell for someone to come. Many times my calls would go unanswered. When someone did come and asked me what I wanted, I would look at my pillow and point to it, indicating that I wanted it raised or I wanted to be lifted up. Some nurses and aides did not understand, even if my head was five inches off the pillow. Sometimes they could not even understand my “yes” and “no” responses.

Nonverbal Communication Techniques and Tools

Learning to communicate with nonverbal patients who cannot use their hands to write is as much the medical staff’s responsibility as it is that of the patient, nonverbal therapeutic communication is critical to building trust between nonverbal patients and medical staff. As mentioned above, a note or booklet that includes basic information about the individual and his augmentative and alternative communication (AAC) techniques should be placed in clear view near his hospital bed. The information also should be placed in his medical records for future reference. Additionally, a relative or friend of the nonverbal patient should consult with the medical team to reiterate his communication techniques.

As shown by my hospital experiences, however, informing a nonverbal patient’s medical team about his AAC does not always serve its purpose. While nurses in the morning shift know that the patient raises his eyes for affirmative responses, for instance, the night shift may be oblivious of this detail. Patient-nurse ratio is another factor that can undermine receiving communication cues from non-verbal patients. When a nurse or aide has 10 or more patients to attend to, taking the time to decipher a patient’s gesture can be difficult unless an interpreter or speech pathologist is there to assist.

Successful interaction between nurses and nonverbal patients also is based on the nurses’ desire to communicate with them. Despite being in a profession where they are likely to work with persons with disabilities, some nurses still may have misconceptions about them. When a patient who is nonverbal is already admitted, an assumption may be that he is deaf or cannot understand. Therefore, any attempt from the patient to communicate may be overlooked or ignored. According to a study done by Patak L, Gawlinski A, Fung NI, Doering L, Berg J. (2004), patients on mechanical ventilation have more difficulty communicating with nurses who were robotic, inattentive, and absent from the bedside. Conversely, communication becomes less frustrating for patients when nurses are kind, physically present, and informative.

Training nurses and nursing aides to understand non-verbal patients has been based on the level of pain they are in. For instance, a course is offered at Suburban Hospital in Bethesda, Maryland, where nurses learn to recognize if nonverbal patients are in pain based on facial expression, restlessness, vocal sounds, muscle tone and the ability to console. Therefore, if a non-verbal patient were in extreme pain, he would express it in one or more of the following ways:

  • Frown
  • Moan
  • Rigid limbs
  • Cannot stay still
  • Cannot accept verbal or tactical consolation

While training to recognize communication cues of nonverbal patients regarding pain is essential, the training should cover nonverbal therapeutic communication and expand to include nonverbal cues under other circumstances (i.e. the patient wants his position adjusted in bed). One of the few classes in this area is offered at University Hospital in San Antonio, Texas. After nurses and other hospital staff participated in the class, they became more aware of the need to communicate with nonverbal patients. They also tried to find communication tools for nonverbal patients to use.

Nurses can facilitate nonverbal therapeutic communications with non-verbal patients by learning to ask them close-ended questions such as “Does your stomach hurt?”, rather than “What do you feel?” Medical staff also can help patients communicate by guessing what they are trying to say. For example, if a patient points to “bed” on a word board, the nurse can guess if he wants his bed raised before he spells “raise” on the board. Additionally, practitioners can position the patient differently if he cannot reach the board or cannot gesture effectively. When patients with neurological disorders sit up, they usually have better motor control.

If nonverbal patients do not already have their own methods of communication, nurses could make simple word or picture boards. Pre-made boards also are available, such as EZ Board by Vidatak, Inc. The EZ Board has several versions, including ICU and EMS, with specific words and phases for each hospital setting. Each board also has the alphabet so patients can spell words. Since these boards are inexpensive, hospitals can purchase them to have for each floor unit.

How Effective Communication Impacts Nonverbal Patients who Use AAC

Studies have shown that effective communication by nonverbal patients can make them recover faster. For instance, according to Lindgren & Ames (2005), Henneman, Dracup, Ganz, Molayeme & Cooper (2001) & (2002), patients spend two to three days less in ICU when they can express themselves more effectively. Patients become less frustrated, which lowers blood pressure and stabilizes respiration. Their comfort level also increases since they can communicate if they are not positioned correctly in their hospital beds, for example.

Effective nonverbal therapeutic communication between hospital staff and non-verbal patients also diminishes the risk of medical errors. When nurses are aware of a non-verbal patient’s AAC cues, they can identify alert gestures such as repetitive eye gazes at an I.V. to indicate the wrong medication is being administered.

Overall, when patients who cannot speak communicate effectively with hospital staff, it makes them feel better psychologically. They feel like humans rather than medical subjects. Even if it cannot be heard, they have a voice that does not (and should not) get ignored.