It is a person’s right to communicate about his or her own healthcare, and better communication improves care and safety in healthcare settings. These tips on ‘communication with people who have little or no speech in healthcare settings’ are based upon recent research by the author and are provided as general information only and not taken as specific recommendations for any individual. Ask the person themselves, their significant communication partners, and a speech pathologist and occupational therapist for guidance and help in determining how a person with no speech might communicate in the healthcare setting. These tips are not intended as an exhaustive guide to interacting or communicating with people who do not speak.
1. INTERACTION TIPS
GAINING ATTENTION: Check that the person who cannot speak has a way to gain your attention to interact.
PROXIMITY: ‘Stop’ and get in closer – attention and proximity helps when trying to understand a person who struggles to talk.
ATTITUDE: Adopt an open attitude to successful communication – ‘having a try’ affords a person the opportunity to attempt communication. Let the person know if you have not understood, and try again.
COMPETENCE: Just because a person cannot speak, does not mean they cannot understand speech or gather something from tone of voice. Realise that even if a person does not understand words, he or she may take a lot of meaning from your tone of voice, body gestures, and facial expressions.
ASSISTANCE: Ask for help from someone who knows the person or has worked with him or her before – they might be able to give you some tips or ‘demonstrate’ successful communication. Ask the person who cannot speak to show you how they communicate: start with yes/no, and find out how they communicate to ask or answer other questions.
2. MULTIMODAL COMMUNICATION TIPS. There are many ways to communicate in addition to speech. No one communication method or system will meet a person’s every communication need, in every situation. Therefore, support all of the following methods of communication as far as you can.
SPEECH – the person with very poor speech may use parts of words, vocalisations or grunts/groans to communicate with meaning. Listen carefully to their vocal responses when you do things and talk – check out your interpretations with them. Some people use ‘speech interpreters’ who are more familiar with their speech and can ‘interpret’ what they say to other people.
GESTURE/SIGNING – people who cannot speak may try to point, make natural gestures, mime, or use a formal ‘signing’ or ‘gestural’ system. If you do not know what their gestures mean, look at the context – and ask others for help. Ask the caregiver what gestures mean and ask for a ‘photo sheet’ to show the gesture, the meaning, and what to do when it is used.
LOW TECHNOLOGY COMMUNICATION BOARDS – these are picture or alphabet or word boards that are readily available by searching on the web – there are also many available as listed on http://www.patientprovidercommunication.org. The trick with using these boards is making sure the person has a way to point to or look at the pictures, and a communication partner who will check and confirm which picture or letter is being selected. Successful use of a board relies upon many skills of the communication partner.
HIGH TECHNOLOGY COMMUNICATION SYSTEMS – these are ‘talking machines’ that the person may use outside of the hospital. Some hospitals are now providing high technology systems to patients to use, particularly in high dependency care settings where many patients cannot speak. Devices include ‘dedicated’ speech generating devices and ‘generic’ or mainstream technologies such as tablet mobile touch screen technologies (e.g., IPAD, Samsung Galaxy). Ask the person if they have a speech device and explore the possibility that it be brought to the hospital for use at the bedside.
BEHAVIOURS. Some people do not understand the meaning of pictures and words and also cannot speak. They might rely upon interpreting meaning from the ‘situation’, what is happening, what is going on, the context, and other peoples’ behaviours and actions in the environment. Being aware of the person’s body responses, behaviours, and movements can help staff in realising ways to help the person to be comfortable in the situation and included with dignity in interactions. Use your own movements and behaviours to convey important messages when interacting with the person who does not understand words or pictures.
3. TIMING TIPS
TAKE THE TIME TO COMMUNICATE: Communication with little or no speech can take a little longer than direct communication by speech. Take the time to communicate, as it may save time in care.
WAIT FOR THE PERSON TO RESPOND – people who have little or no speech report the ‘timing’ of their communication attempts often fails, and they miss the opportunity to have a ‘turn’. Waiting for a response gives them a chance to have a turn, and will help you to understand their needs.
EQUALIZE THE SPEAKING TURNS – attend to how often you have a turn, and try to ‘equalize’, giving the person every opportunity to have a turn to talk. Natural speakers often ‘dominate’ conversations and give the person no opportunity except to say ‘yes’ and ‘no’. Ask some open ended questions as well as the person might have something else to add.
FATIGUE – keep in mind that the person with little or no speech may be making extra efforts to communicate without speech. You may need to give them a break or a rest between their turns. Watch for signs of fatigue and give them a chance to relax for their next turn.
BE AWARE OF ‘FLOW’ – Sometimes a conversation can become ‘disjointed’ as both parties try to clarify their messages and establish shared meaning. You might move onto topic B, while the person is still thinking about or talking about topic A. This can get confusing to both parties as each tries to clarify and re-establish meaning. Checking regularly if you are on the right track and giving the person a chance to respond helps keep both parties in a ‘flow’ together on establishing mutual understanding.
4. ALPHABET BOARD TIPS
IT’S NOT AS EASY AS IT LOOKS – Using an alphabet board is sometimes the first strategy people try, when it might actually be the most difficult. Keep this in mind when you try it.
SPELLING: sometimes even spelling the first letter of a word can help you understand a person’s speech. Not all people who cannot speak have strong literacy skills, and some only use it to ‘add’ to their speech for clarity.
USING FULL WORDS: Having some words on a communication board, along with the alphabet, may be helpful. Some common communication needs in hospital are yes/no/don’t know; pain/location/severity; hot/cold; hungry/thirsty; food/drink; toilet/shower; comfort/position; nausea; caregiver/home.
START AGAIN/THAT’S NOT RIGHT: Pointing to a ‘start again’ square means ‘that’s not right, start spelling again’. You or the person using the board might have selected/understood the wrong letter. It is important to know this as soon as it happens, and to ‘start again’.
SAY IT BACK OR WRITE IT DOWN: As they spell each letter, say the letter out loud. This means they can hear if you have understood the right letter. If it is a longer message, write it down. The person’s spelling might not be perfect, or fatigue might set in, so this helps in deciphering some messages.
5. COMMUNICATING WITH CARERS TIPS
CLARIFY ROLES in supporting communication. How would you like the carer to help you communicate with the person who cannot speak? what care roles do you expect or hope that the carer might take up in the healthcare setting?
WRITE DOWN what the caregiver tells you about the person’s care and communication. It is not always easy to include all information in a verbal handover, from shift to shift, so writing it down saves time in re-establishing successful communication.
TALK TO THE PERSON WITH DISABILITY even when caregivers are present. Natural speakers have a tendency to prefer to interact with other natural speakers – it can be easier and faster. Talking directly to the person with little or no speech helps build rapport that can help with care, and gives the carer an opportunity to give communication tips to ‘bridge’ communication if it breaks down.
REMIND the caregiver to bring any communication aids to the hospital that will help hospital staff to communicate with the person who cannot speak. Keep it in reach of the person and ask him or her to show you how it is used.
IT’S EXHAUSTING – family caregivers in particular report that providing constant support in hospital settings is stressful and exhausting. Paid carers report that they are often not given the same breaks from caregiving roles as they might be in their usual employment settings. Give caregivers regular breaks and reassure them that you can provide adequate care to the person with disability. Carers may also feel anxious and/or guilty when away from the bedside. Two things may help them – knowing that the person has a way to gain attention, and knowing that the person can indicate a basic care problem (e.g., pain, hunger, thirst, discomfort, nausea). Ask the carer to show you a way to communicate with the patient, and give it a try in front of the carer.
Hemsley, B., & Balandin, S. (2004). Without AAC: The Stories of Unpaid Carers of Adults with Cerebral Palsy and Complex Communication Needs in HospitalAugmentative and Alternative Communication, 20 (4), pp. 243–258.
Hemsley, B., Balandin, S., & Togher, L. (2007). Narrative analysis of the hospital experience for older parents of people who cannot speak. Journal of Aging Studies 21 (2007) 239–254.
Hemsley, B., Balandin, S., & Togher, L. (2008). ‘We need to be the centrepiece’: Adults with cerebral palsy and complex communication needs discuss the roles and needs of family carers in hospital. Disability and Rehabilitation, 30(23): 1759–1771.
Hemsley, B., Balandin, S., & Togher, L. (2008). Professionals’ views on the roles and needs of family carers of adults with cerebral palsy and complex communication needs in hospital. Journal of Intellectual & Developmental Disability; 33(2): 127–136.