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1. REVIEW
A systematic review of the effectiveness of nurse communication with
patients with complex communication needs with a focus on the use of
augmentative and alternative communication
Erinn H Finke MS, CCC-SLP
PhD Candidate, Department of Communication Sciences and Disorders, The Pennsylvania State University, University Park,
PA, USA
Janice Light PhD
Distinguished Professor, Department of Communication Sciences and Disorders, The Pennsylvania State University,
University Park, PA, USA
Lisa Kitko MS, RN, CCRN
PhD Candidate, School of Nursing, The Pennsylvania State University, University Park, PA, USA
Submitted for publication: 10 August 2007
Accepted for publication: 4 January 2008
Correspondence:
Erinn H Finke
Department of Communication Sciences and
Disorders
The Pennsylvania State University
308 Ford Building
University Park
PA 16802
USA
Telephone: (814) 863 2279
E-mail: enh109@psu.edu
FINKE EH, LIGHT J & KITKO L (2008)
FINKE EH, LIGHT J & KITKO L (2008) Journal of Clinical Nursing 17, 2102–
2115
A systematic review of the effectiveness of nurse communication with patients with
complex communication needs with a focus on the use of augmentative and alter-
native communication
Aims and objectives. To systematically review the research regarding communi-
cation between nurses and patients with complex communication needs (CCN).
The research was reviewed with respect to the following themes: (a) the
importance of communication; (b) the barriers to effective communication; (c)
the supports needed for effective communication; and (d) recommendations for
improving the effectiveness of communication between nurses and patients with
CCN. Augmentative and alternative communication (AAC) strategies that can be
used by nurses to facilitate more effective communication with patients with
CCN are discussed.
Background. Effective nurse-patient communication is critical to efficient care
provision. Difficulties in communication between nurses and patients arise when
patients are unable to speak. This problem is further complicated because nurses
typically receive little or no training in how to use AAC to communicate with
patients with CCN.
Design. Systematic review.
Method. This paper reviewed the published research focusing on the perspectives
of nurses, patients with CCN and their caregivers regarding the challenges to
effective communication between nurses and patients with CCN. Further, specific
strategies (i.e., using AAC) that nurses can use to improve and facilitate com-
munication with patients with CCN are provided.
2102 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd
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2. Conclusions. Communication between nurses and patients is critical to providing
and receiving quality care. Nurses and patients have reported concern and frustration
when communication is not adequate. Using AAC strategies will help nurses and
patients better communicate with each other when speech is not an option.
Relevance to clinical practice. Communication with all patients is very important
to the provision of quality nursing care. Communication cannot always be
achieved using the speech modality. Nurses need to have tools and skills that will
allow them to communicate with all of their patients whether or not they can
speak.
Key words: augmentative and alternative communication, complex communica-
tion, nurses, nursing, systematic review
Introduction
Nurses work in a variety of settings including hospitals,
schools, doctor’s offices, emergency rooms, forensic and
correctional facilities, acute care facilities, long-term care
facilities, health care agencies, community clinics, govern-
ment agencies, hospice, research labs, universities and private
practice offices (Utica College Department of Nursing).
Within these varied places of employment nurses work with
an equally broad spectrum of individuals with a wide variety
of illnesses and disabilities (e.g., Yorkston 1992, Beukelman
et al. 2007). Regardless of the employment setting, or the
populations of individuals who are cared for, there is general
consensus in the nursing field that effective communication
with patients is integral to good practice.
The need for effective nurse-patient communication is
obvious. Effective communication is defined as a reciprocal
interaction, involving both a speaker and a communication
partner (Romski Sevcik 1993). Consequently, when
considering effective (i.e., efficient and accurate) nurse-
patient communication, it is important to consider the
communication skills of both the nurse and the patient. For
communication between these individuals to be effective,
both the nurse and the patient need to possess the skills and
knowledge required for participation within the communi-
cative interaction.
Because of their medical conditions, many individuals are
not able to participate verbally in communicative interactions
(i.e., using the speech modality; Beukelman et al. 2007).
Therefore, these patients are considered to have severe
communication impairments in addition to their primary
medical diagnosis (e.g., traumatic brain injury, CVA, etc.).
Severe communication impairment is defined as a condition
‘where speech is temporarily or permanently inadequate to
meet all of the individual’s communication needs and the
inability to speak is not because of a hearing impairment’
(ASHA 1991). Many patients who require nursing care are
permanently or temporarily unable to speak because of
physical, developmental, or acquired disabilities (e.g., York-
ston 1992, Beukelman et al. 2007). Patients with severe
communication impairment and complex communication
needs (CCN) of this nature generally require augmentative
and alternative communication (AAC) tools and strategies to
facilitate communication (Beukelman Mirenda 2005).
These AAC tools and strategies and their implications for
promoting effective communication between nurses and
patients with CCN, will be further explained in the discussion
section.
Despite acknowledgement of the need for effective com-
munication between nurses and patients, a general concern
exists over the impact of: (a) the severe communication
impairment of the patient and (b) the inherent demands of the
nursing job on this communication process in daily interac-
tions (Ashworth 1984, Connolly Shekleton 1991, Fried-
Oken et al. 1991, Hemsley et al. 2001). Potential ramifica-
tions of a lack of effective communication include medical
risk to patients with CCN, permanent or temporary, in that
they may be unable to communicate adequately regarding
their needs/concerns about their medical care (Hemsley et al.
2001). They are also at risk for high levels of anxiety and
frustration if communicative attempts with nurses are
unsuccessful (e.g., Ashworth 1984, Connolly Shekleton
1991, Fried-Oken et al. 1991). To determine the current state
of effective communication between nurses and patients
with CCN, a systematic review of the relevant research is
justified.
Goals of the review
The goals of this review were to (a) review systematically the
research on communication between nurses and patients with
CCN; (b) examine the outcomes of this research; and (c)
discuss implications for improving communication between
nurses and patients with CCN.
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3. Methodology
Inclusion criteria
Inclusion criteria for this systematic review were: (a) pub-
lished in a peer-reviewed journal between 1990–2007, (b)
published in English, (c) published with use of primary
research methodology (i.e., the authors of the study collected
the data analysed in the study) to undertake an examination
of at least one of the following: (i) the importance of
communication between nurses and patients with CCN
(hereafter referred to as ‘patients’); (ii) the barriers to
communication between nurses and patients; (iii) the sup-
ports for communication between nurses and patients; and
(iv) the recommendations for how to improve communica-
tion between nurses and patients. Excluded from the review
was any material that described nurse-patient communicative
interactions without use of primary research methodology or
without data reported as a result of the investigation.
Search procedures
A range of search methods were used to locate the studies
reviewed in this paper. First, general purpose electronic
databases [specifically ProQuest Nursing Journals, ProQuest
Psychology Journals, PsycINFO and PubMed (Medline)]
expected to contain publications relevant to the topic of this
review (Schlosser et al. 2005) were searched using a combi-
nation of keywords. The keywords ‘nurse-patient communi-
cation’, ‘severe communication impairment’ were searched in
combination with each of the following terms: ‘CCN’,
‘voicelessness’, ‘AAC’, ‘hospital’, ‘nurse’, ‘patient’, ‘carers’,
‘caregivers’ and ‘communication’. All possible arrangements
of the terms were searched. Finally, the reference sections of
located articles were reviewed for additional sources that
were not defined during the online database searches.
Review parameters
Search procedures identified a total of 23 papers. Of these 23
papers, 11 did not meet the inclusion criteria listed above
(Ashworth 1984, Dowden et al. 1986, Connolly Shekleton
1991, Horsfall 1998, Costello 2000, Kruijver et al. 2000,
Happ 2001, Casbolt 2002, Dickerson et al. 2002, Schmidt
2003, Alasad Ahmad 2005). The 12 studies that met the
inclusion criteria were based on the perspectives of one of
three stakeholders. The first stakeholder was the nurse and
his/her perspective regarding communication with patients
(Bergbom-Engberg Haljamäe 1993, Leathart 1994, Hall
1996, Baker Melby 1999, Happ 2000, Hemsley et al.
2001). The second stakeholder was the patients’ perspectives
on communication with nurses (Fried-Oken et al. 1991,
Robillard 1994, Happ 2000, Balandin et al. 2001, 2007,
Buzio et al. 2002) and the third stakeholder was the family
members and unpaid caregivers and their perspectives on
communication between nurses and patients (Happ 2000,
Hemsley Balandin 2004). These studies are summarised in
Tables 1, 2 and 3 respectively.
Results
Studies that met the inclusion criteria were analysed for
patterns of results in the following areas: (a) importance of
communication between nurses and patients with CCN; (b)
barriers to communication between nurses and patients; (c)
supports for communication between nurses and patients; (d)
recommendations for improving communication between
nurses and patients.
Importance of nurse-patient communication
Nine of the 12 studies analysed in this review reported
information related to the importance of communication
between nurses and patients. Across these studies, perspectives
from all three groups of participants; nurses, patients and
unpaid caregivers, were represented. Three of the six studies
with nurses as participants (Bergbom-Engberg Haljamäe
1993, Baker Melby 1999, Hemsley et al. 2001), five of the
six studies with patients as participants (Fried-Oken et al.
1991, Robillard 1994, Balandin et al. 2001, 2007, Buzio et al.
2002) and one of the two studies with carers as participants
(Hemsley Balandin 2004) generated results indicating the
importance of communication between nurses and patients.
One of the most consistently represented perspectives was
the potential impact on quality of care if communication
between nurses and patients was lacking. Nurses reported
that lack of communication between nurses and patients
could affect overall patient recovery and the length of the
patients stay in the hospital (Hemsley et al. 2001), while
patients reported feelings of frustration, lack of control/self-
determination, physical discomfort and overall effects on
recovery when unable to communicate with nurses (Fried-
Oken et al. 1991, Robillard 1994, Balandin et al. 2001, 2007,
Buzio et al. 2002). The patient participants in Buzio et al.
(2002) stated that their communication with nurses was
rarely successful, even when information about how to
communicate was provided in writing to nurses and hospital
staff prior to their entering the hospital. Further, in many
instances they felt that even their basic care needs remained
unmet. Finally, unpaid caregivers reported feeling fearful that
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4. Table 1 Summary of studies with patients with CCN as participants
Study n Participant population Design Summarised results
Balandin et al. (2001) 10 (8M, 2W) Patients with acquired
severe comm. impairment
QI Patients reported that:
relatives or close friends assisted them and supported them during their period in the hospital
the variability in the nurses’ skills and communicative behaviors affected the overall
communication experience
the experience was more positive when nurses were humorous and had the patience to interact
the lack of success in communicating with nurses led to frustration and feelings of isolation
they felt depressed, stressed, or confused
they were physically uncomfortable due to an inability to communicate
and that they had difficulty participating in decisions about their own care
specific strategies used by nurses increased communicative success
they thought nurses should know about AAC
they should realise that communication is important to recovery and should know about
the effects of lack of communication on relationships and emotional status
nurses should take enough time to talk to the patient and not be in a hurry
Balandin et al. (2007) 10 (5M, 5W) Patients with CP QI Patients reported that:
they encountered some difficulties in making themselves understood by the nurses
they received no support from the hospital staff to use their usual communication
system in the hospital or to develop a functional communication system for use
during their hospital stay
their CCN resulted in barriers to communicating with nurses when necessary
the lack of an effective communication system limited their ability to successfully
initiate a message when they wanted or needed to communicate with nurses
some nurses did not take time to listen or look at the patients’ own written
information
nurses did not have time to stop and communicate with the patient
gaining the nurse’s attention was a common difficulty encountered in the hospital
physical and psychosocial consequences and affects on length of stay and recovery
they benefited from having the support of an unpaid caregiver (e.g., parent or
spouse) to assist them in communicating with nurses
there are specific strategies nurses used that increased communication success
nurses should:
• (a) know about AAC, (b) have access to AAC equipment, (c) have training
on caring for patients with CCN, (d) ask family members or friends to help
with communication and provide information about their interests,
preferences, skills and needs, (e) not assume that patients have an intellectual
disability and (f) take enough time to talk and inform patients when they did not
understand the patient.
Patients said it was important that nurses receive training to increase
their knowledge on how to best communicate with patients with CCN in the hospital.
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5. Table 1 (Continued)
Study n Participant population Design Summarised results
Buzio et al. (2002) 39 Patients with CP Q Patients reported that:
when they were unable to communicate verbally they experienced dissatisfaction with
the care received
they provided information about how to communicate with them in writing to hospital staff
despite this they had some difficulty in getting hospital staff to meet their basic needs
nurses did not attempt to use their AAC devices while trying to communicate with
them
Fried-Oken et al.
(1991)
5
(2W 3M)
Patients with
Guillian-Barre or
botulism
QI Patients reported:
use of a y/n system (head shake, thumbs up/down or eye movement), lip reading and
mouthing words, ABC board, Magic Slate board, switch for nurse call system,
electronic devices
preference for low tech devices
they considered electronic devices the last option
feeling frustration, fear, panic, loss of control, helplessness, impatience and apathy
every patient discussed the need for constant in-service training of nursing staff and
ICU personnel
Happ (2000) 4
9
(8W, 1M)
4
3
Patients
Nurses
Family members
Physicians
QI Patients reported that:
voicelessness influenced their critical care treatment and created feelings of regret and
anxiety
interpretation dampened the detrimental effects of voicelessness
nurses relied on family members to be the patient’s voice and to interpret their needs
and wishes
continuity and presence of nurses was necessary for credible interpretation
staffing demands frequently precluded continuity in patient-nurse assignments
the effective use of AAC is crucial in mitigating the detrimental effects of
voicelessness
Robillard (1994) 1 Patient with neuromuscular
disease
CR The patient reported that:
the lack of ‘real time’ communication appeared to be the source of discomfort in the
ICU
the sense of loss of personal control approximated in the refusal of most nurses to use
the patient’s alphabet board
not having a real time voice was the equivalent to not having any defense to what was
done to him
not being able to conversationally influence most aspects of his experience in the
hospital
not being able to communicate generated feelings of frustration and resentment
not being able to communicate with nurses impacted the nurses perceptions of his
intelligence
QI, qualitative interview; Q, questionnaire; ACE, analytical, cross-sectional experiment; NA, narrative analysis; O, observation; CR, case report; CCN, complex communication needs;
AAC, augmentative and alternative communication.
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6. Table 2 Summary of studies with nurses as participants
Study n Participant population Design Summarised results
Baker and Melby
(1999)
5 Staff nurses caring for unconscious
patients
QI Nurses reported that:
it is ‘very important’ to communicate with unconscious patients. However,
other aspects of intensive care nursing (such as monitoring equipment) take
precedence
they do not feel as if unconscious patients are fully aware of their external
environment
the level of consciousness of the patient was a major influence on the amount
of their communication with the patient; the more responsive and less
unconscious the patients is, the more communication the nurse engages in
they would communicate more with the patient during visiting times when the
patients’ family was present
Bergbom-Engberg
and Haljamäe (1993)
27 (23W, 4M) Nurses caring for patients on
ventilators
QI Nurses reported that:
after receiving a report, but before the first contact with a new critically ill
ventilator patient, they felt frustrated with the situation
after providing a few days of care, many nurses found the situation frustrating
and difficult to cope with
work overload was the most important factor limiting the time necessary for
the establishment and maintenance of effective communication with patients
with CCN
the presence of worried and anxious spouses and other relatives prohibited the
establishment and maintenance of a relationship with the patient
the most important factor for facilitating communication with ventilated
patients was a caring situation with no work overload, leaving enough time
to get to know the patient better
the presence of the patients’ spouse and relatives facilitated the establishment
and maintenance of communication
a calm, lucid and alert patient capable of eye contact and lip movements was
easier to communicate with
they felt frustration and sometimes even felt incompetent and powerless when
they could not successfully communicate with their patient
Hall (1996) 30 Nurses caring for patients with
ventilators
ACE Nurses reported that:
their positive interactions with ventilated patients were related to the degree of
perceived responsiveness of those patients
they rely on Glasgow Coma Scale scores to direct their communication efforts
rather than attempting to communicate with all patients regardless of their
level of consciousness
lack of time was an important factor, given more time, nurses were more likely
to make an effort to communicate with their patients regardless of Glasgow
Coma Scale score
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7. Table 2 (Continued)
Study n Participant population Design Summarised results
Happ (2000) 4
9
(8W, 1M)
4
3
Patients
Nurses
Family members
Physicians
QI Nurses reported that:
voicelessness influenced the application of critical care treatments and created
feelings of regret and anxiety
interpretation seemed to dampen the detrimental effects of voicelessness
they relied on family members to be the patient’s voice and to interpret needs and wishes
continuity and presence were necessary for credible interpretation
staffing demands frequently precluded continuity in patient-nurse assignments
AAC is crucial in mitigating the detrimental effects of voicelessness
they primarily nurses, used physiologic cues in addition to nonvocal behavior
to interpret patients’ needs and responses
Hemsley et al. (2001) 20 (17W, 3M) Nurses caring for patients with
severe comm. impairment
QI Nurses reported that:
they received training on disability and reported working with people with
disabilities, but none received training about communication strategies
they have had both + and experiences but also expressed frustration because
of lack of success and no access to AAC
it is important to persist in trying to communicate. Also a quiet environment,
patience and availability of AAC help
it helps to look for: (a) signs of relief in face and (b) repeating message back
Limited opportunities: Nurses reported these limitations: (a) increased time,
(b) nurse or patient frustration, (c) lack of AAC and (d) patient inability to
gain attention
CCN could affect recovery and length of hospital stay
they were notified in advance of CCN. Some thought that more information in
advance and a bedside demonstration would be helpful
they need for in-service training in AAC and increased support from the SLP.
Leathart (1994) 8 Nurses caring for patients with
ventilators
O
QI
Nurse-initiated interactions ranged from 74–85%
The greatest proportion of interactions (35–77%) were conducted in
30 seconds
Patients communicated by using sign language, nurses’ lip-reading and pen
and paper
The following reasons were cited for difficulty with communication with
patients: (a) difficult to understand lip reading, (b), frustration at not being
able to understand, (c) leading to reluctance to persevere, (d) patient unable
to write, (e) nurses do not want to confuse patients with complicated
explanations, (f) no feedback from patient, (g) lack of appropriate
communication training and (h) the presence of other people
All nurses agreed that it was easier to communicate with a conscious intubated
patient because the patient was able to provide some feedback
QI, qualitative interview; ACE, analytical, cross-sectional experiment; O, observation, CCN, complex communication needs; AAC, augmentative and alternative communication.
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8. the patient would be at risk of being neglected, ignored, or
isolated and possibly injured secondary to ineffective com-
munication with nurses (Hemsley Balandin 2004).
Barriers to effective nurse-patient communication
Eleven of the 12 studies reported information related to
perceived barriers to effective communication between nurses
and patients. Perspectives from nurses, patients and unpaid
caregivers, were represented. All six studies with nurses as
participants (Bergbom-Engberg Haljamäe 1993, Leathart
1994, Hall 1996, Baker Melby 1999, Happ 2000, Hemsley
et al. 2001), five of the six studies with patients as participants
(Robillard 1994, Happ 2000, Balandin et al. 2001, 2007, Buzio
et al. 2002) and two of the two studies with caregivers as
participants (Happ 2000, Hemsley Balandin 2004) gener-
ated results relative to the perceived barriers to effective
communication between nurses and patients.
One of the barriers cited in eight of the twelve studies in
this review was that communicative interactions between
nurses and patients tend to be task-focused, nurse-controlled
and associated mainly with physical needs and medical/care
Table 3 Summary of studies with carers as participants
Study n Participant population Design Summarised Results
Happ (2000) 4 Patients QI Carers reported that:
9 (8W, 1M) Nurses voicelessness affected family members and they
grieved for the loss of the patient’s voice
family members were put in the role of
interpreters and had to convey the patient’s
wishes and preferences with regard to treatment
and care
4 Family members being an interpreter is difficult because of competing
explanations, contradictory signals and interpreter bias
3 Physicians
Hemsley and
Balandin (2004)
6 (3W, 3M) Unpaid carers QI
NA
Carers reported that:
nurses do not know how to communicate with
people with CCN and therefore could not
provide adequate care
they needed to protect the person with CCN from
potentially harmful situations arising from lack
of communication between the patient and
hospital staff
they were not confident about nurses’ capacity
and willingness to provide adequate care for the
person with CCN
nurses could not understand the communication
attempts of the person with CCN
they believed that some nurses had disabling
attitudes to people with CCN and that these
precluded successful communication
they feared that the person with CCN would be at
risk of being neglected, ignored, or isolated and
possibly injured because of the absence of
effective communication with the nurse
they interpreted messages, spoke for the person
with CCN
they had to give information about
communication, yet having to repeat this
information to every nurse throughout the
duration of the stay
they provided written information about
communication with the person with CCN,
realising that they could not tell every nurse
everything
QI, qualitative interview; NA, narrative analysis; CCN, complex communication needs.
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9. procedures (Bergbom-Engberg Haljamäe 1993, Leathart
1994, Hall 1996, Baker Melby 1999, Balandin et al. 2001,
2007, Hemsley Balandin 2004). Further, these task-
focused communicative interactions between nurses and
patients are minimal and are often ineffective at getting all
of the patient’s needs met, leading to considerable frustration
for both the nurse, the patient and the caregiver (Bergbom-
Engberg Haljamäe 1993, Leathart 1994, Hemsley et al.
2001, Hemsley Balandin 2004, Balandin et al. 2007).
The perception that a major source of the difficulty in
nurses’ communication with patients stems from the lack of
AAC knowledge and training was evident in seven of the 12
studies in the current review (Fried-Oken et al. 1991,
Bergbom-Engberg Haljamäe 1993, Leathart 1994, Balan-
din et al. 2001, 2007, Hemsley et al. 2001, Hemsley
Balandin 2004). Further, six of the 12 studies implicated
attitudinal barriers, specifically citing that some nurses view
patients as having no real need to communicate (Hemsley
et al. 2001, Balandin et al. 2007), or that it is not their job to
provide patients with the special tools needed for effective
communication (Leathart 1994, Hall 1996, Hemsley et al.
2001, Buzio et al. 2002, Hemsley Balandin 2004, Balandin
et al. 2007). Eight of the 12 studies also indicated that nurses
perceived the increased time required for caring for and
communicating with patients as a major barrier to effective
communication (Fried-Oken et al. 1991, Bergbom-Engberg
Haljamäe 1993, Leathart 1994, Hall 1996, Balandin et al.
2001, 2007, Hemsley et al. 2001, Hemsley Balandin
2004).
Other factors that were cited as barriers to effective
communication between nurses and patients include: (a) lack
of access to communication tools such as AAC (Robillard
1994, Happ 2000, Balandin et al. 2001, 2007, Hemsley et al.
2001, Buzio et al. 2002, Hemsley Balandin 2004); (b)
inability of the patient to gain the attention of a listener (e.g.,
the nurse; Balandin et al. 2001, Hemsley et al. 2001, Hemsley
Balandin 2004, Balandin et al. 2007); (c) level of cognitive,
psychological and/or language impairment of the patient
(Leathart 1994, Baker Melby 1999, Balandin et al. 2001,
Hemsley et al. 2001, Hemsley Balandin 2004); (d) lack of
continuity in nurses assigned to care for the patient (Happ
2000, Hemsley Balandin 2004); and (e) presence of family
members in the care environment (Bergbom-Engberg
Haljamäe 1993, Leathart 1994, Happ 2000, Hemsley
Balandin 2004).
Supports for effective nurse-patient communication
Eleven of the 12 studies reported information related to
supports perceived by the participants to increase the
effectiveness of communication between nurses and patients.
The supports reviewed herein pertain to intrinsic and
extrinsic factors that: (a) were currently in place; or (b) the
participants thought would have a positive impact on
communication between patients and their nurses had they
been in place. Perspectives from nurses, patients and unpaid
caregivers, were represented in the results generated (Fried-
Oken et al. 1991, Bergbom-Engberg Haljamäe 1993,
Leathart 1994, Hall 1996, Baker Melby 1999, Happ 2000,
Balandin et al. 2001, 2007, Hemsley et al. 2001, Buzio et al.
2002, Hemsley Balandin 2004).
Seven of the 12 studies reported results relative to intrinsic
supports. Intrinsic factors relative to nurses that were
perceived to increase the effectiveness of communication
with patients were the nurses’ prior training and experience
working with people with disabilities (Hemsley et al. 2001),
the nurses’ willingness to take the time necessary to commu-
nicate with patients and their fortitude in persisting until the
message was understood (Bergbom-Engberg Haljamäe
1993, Leathart 1994, Balandin et al. 2001, 2007, Hemsley
et al. 2001). The nurses’ willingness to ask for help (from
family members, speech-language pathologists, or other
nurses) when communication barriers prevented effective
communication with patients (Bergbom-Engberg
Haljamäe 1993, Hemsley et al. 2001), as well as the nurses’
willingness to share the information that had been learned
about communicating with patients during shift changes were
seen as supports to effective nurse-patient communication
(Happ 2000, Hemsley et al. 2001, Hemsley Balandin
2004).
Seven of the 12 studies reported on supports that nurses
themselves could implement (but that were currently not in
place) that may increase the effectiveness of their commu-
nication with patients. These supports included: (a) fol-
lowing written directives for communication strategies
provided by the patient and/or the patient’s family mem-
bers (Hemsley et al. 2001, Buzio et al. 2002, Hemsley
Balandin 2004, Balandin et al. 2007); (b) looking for
physiologic and/or nonverbal cues from the patient to
ensure that the message was received/understood
(Fried-Oken et al. 1991, Leathart 1994, Happ 2000,
Hemsley et al. 2001); (c) being and/or becoming familiar
with and use AAC systems, tools and strategies (Fried-
Oken et al. 1991, Leathart 1994, Happ 2000, Hemsley
et al. 2001); (d) asking patients, family members and/or
other professionals (e.g., speech-language pathologist) for
suggestions for how to make communication with the
patient more effective and efficient (Happ 2000, Hemsley
et al. 2001, Hemsley Balandin 2004); and (e) sharing
any information about how to enhance the effectiveness of
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10. communication with a patient with other nurses or medical
staff (Happ 2000, Hemsley et al. 2001).
Four of the 12 studies reported intrinsic factors relative to
the patient that were perceived to increase the effectiveness of
communication with nurses. These factors included the
patient’s level of alertness (Bergbom-Engberg Haljamäe
1993, Leathart 1994, Hall 1996, Baker Melby 1999) as
well as his/her capability for making eye contact and moving
the lips (Bergbom-Engberg Haljamäe 1993).
Extrinsic factors, or factors related to the environment
thought to improve the effectiveness of communication were
reported in nine of the 12 studies reviewed and included: (a)
availability of AAC tools and strategies (Fried-Oken et al.
1991, Leathart 1994, Happ 2000, Hemsley et al. 2001,
Balandin et al. 2007); (b) presence of a quiet environment
(Hemsley et al. 2001); (c) small care loads for nurses
(Bergbom-Engberg Haljamäe 1993); (d) length of time
caring for the patient (Bergbom-Engberg Haljamäe 1993);
and (e) presence of friends or family members in the care
environment (Baker Melby 1999, Balandin et al. 2001,
2007, Hemsley Balandin 2004).
Recommendations
Four of the 12 studies reported information related to
recommendations for how to improve and increase effective
communication between nurses and patients. Perspectives
from nurses, patients and unpaid caregivers, were represented
in the recommendations generated (Fried-Oken et al. 1991,
Balandin et al. 2001, 2007, Hemsley et al. 2001, Hemsley
Balandin 2004).
The most consistent recommendation offered in the four
studies was that nurses should receive training in AAC and
the implications of severe communication impairment (Fried-
Oken et al. 1991, Balandin et al. 2001, 2007, Hemsley et al.
2001, Hemsley Balandin 2004). This recommendation was
offered by nurses, patients and their caregivers alike. In two
of the 12 studies, patients recommended that nurses receive
training on caring for patients and that nurses not assume
that patients have intellectual disabilities (Balandin et al.
2001, 2007). Further, patients recommended that nurses take
the time to talk to patients and that they inform patients
when they did not understand the patient’s message (Balandin
et al. 2001, 2007). Finally, patients recommended that nurses
realise that communication is important to recovery. Patients
and caregivers suggested nurses receive training and infor-
mation about the effects of lack of communication on
relationships and the emotional status of the patient and
his/her family and friends (Balandin et al. 2001, Hemsley
Balandin 2004).
Discussion
Nurses receive little formal training about and have limited
experience with, AAC systems or associated supports to
prepare them for caring for patients with CCN (Hemsley
et al. 2001). Without this training and experience nurses
report that caring for and communicating with a patient with
CCN is extremely challenging (Hemsley et al. 2001). Nurses
and other stakeholders, such as patients and their caregivers,
have identified that providing nurses with training on how to
prevent communication breakdowns with patients is a
priority (Fried-Oken et al. 1991, Balandin et al. 2001,
2007, Hemsley et al. 2001, Hemsley Balandin 2004).
Nurses need to learn that patients with CCN are able to
communicate quite effectively given the right tools and
interactional circumstances (Yorkston 1992, Beukelman et al.
2007). There are two basic types of AAC tools and strategies
that could be used by patients with CCN to increase effective
communication: unaided AAC and aided AAC (Romski
Sevcik 1996, Sigafoos Drasgow 2001, Mirenda 2003).
Unaided AAC techniques involve the use of other parts of the
patients’ body (e.g., hands, face and/or feet) for communi-
cation. These strategies include communication through
modalities such as manual sign (e.g., American Sign Lan-
guage, pantomimes, gestures, eye blink systems and facial
expressions). Aided AAC strategies and techniques, on the
other hand, require materials that are external to the
individuals who use them (e.g., pictures, alphabet boards,
pencil and paper systems, communication books and/or
computers that ‘speak’; (Romski Sevcik 1996, Sigafoos
Drasgow 2001, Mirenda 2003). Unaided and low
technology aided AAC systems (e.g., pictures, alphabet
boards, pencil and paper systems, etc.) are the types of
AAC strategies most frequently used by patients with CCN in
the hospital setting (Fried-Oken et al. 1991). The reader is
referred to Beukelman et al. (2007) for more specific
information on AAC strategies used with individuals with
acute and/or chronic conditions.
The ultimate goal of any AAC strategy, is for the patient
with CCN to be able to effectively engage in interactions
with a variety of communication partners (e.g., family,
friends, nurses, other medical professionals) and communi-
cate a variety of different messages to meet several different
types of communicative functions (Beukelman et al. 2007).
To reach this ultimate goal, both the patient with CCN
and their communication partner (i.e., the nurse), need to
bring specific skills to communicative interactions. The
presence or absence of these skills by either partner in a
communicative interaction has been shown in the literature
to contribute to the success or failure of communicative
Review Nurse-patient communication with AAC
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 2111

11. interactions (Kent-Walsh McNaughton 2005). Therefore,
when communicating with patients with CCN, the success
of the communication is not only reliant on the patients’
ability to adequately use their prescribed communication
system, but is also reliant on the skills of the nurse as the
communication partner.
Using AAC strategies to establish effective
nurse–patient communication
With support and training, nurses will be able to take a more
active role in implementing AAC strategies with their patients
with CCN, which will increase their confidence when
communicating with patients and allow more effective
communication with these individuals to transpire (Hemsley
Balandin 2004). Nurses need to place more emphasis on
listening to their patients, responding to their cues and
allowing them to lead the conversation (Ashworth 1984). The
purpose of AAC in the medical setting is to provide the
patient with a means to express basic physical needs or vital
information and to increase the amount of interactions
between the patient, medical staff and family members
(Fried-Oken et al. 1991).
Required knowledge and skills for nurses
It has been documented that patients need communication
partner support to successfully participate in communication
and fulfill communicative opportunities (Light 1997, Kent-
Walsh 2003). Thus, there is an argument that natural
speaking partners, including nurses, are critical to the success
of communicative interactions with patients (Yorkston 1992,
Hemsley et al. 2001, Beukelman Mirenda 2005). It is also
documented, however, that many communicative partners do
not naturally provide the support needed by the patient
(Light et al. 1985, Light 1997).
Improving the communication between nurses and patients
can occur in various ways. There is evidence in the research
literature to support the training of communication partners
in strategies for interacting with patients (Kent-Walsh
McNaughton 2005). Nurses, as communication partners for
patients, need: (a) to determine the mode(s) of communica-
tion used by the patient; (b) to pause/wait, to allow time for
the patient to participate in the interaction; (c) to confirm the
message communicated by the patient with the patient; and
(d) to use AAC to support comprehension if required (Gries
Fernsler 1988). Please see Table 4 for research evidence to
support the need for the use of these AAC strategies by
communication partners of patients.
There are several options for determining a patient’s mode
of communication. These options included speaking with
family members, talking with the speech-language patholo-
gist, asking other nurses or medical professionals who have
cared for the patient, as well as looking in the patient’s
medical chart.
Once the patient’s mode of communication is known, it is
critical for the nurse to acknowledge and remember that
communication with a patient with CCN is generally slow
and that communication using AAC may be even slower for a
patient who is medically fragile. Pausing to give the patient
the extra time to communicate is a strategy that nurses can
employ to facilitate effective communication. Further, it has
been established that providing a delay after asking a
question or making a comment is an especially appropriate
strategy for use with patients who may not have frequent
opportunities to communicate (Basil 1992, Calculator 1988,
Light Binger 1998). Waiting clearly marks the communi-
cation opportunity for the patient and indicates that the
communication partner wants their input and interaction
(Light Binger 1998). There are two elements that should be
incorporated into the waiting strategy so that the desire for
the patient with CCN to communicate and interact with them
is clearly established (Light Binger 1998). These elements
include: (a) maintaining eye contact with the patient while
Table 4 Evidence for AAC strategies for nurses
AAC strategy for communication
partner
Evidence for use of
the AAC strategy
1 Determine the mode(s)
of communication
used by the patient
(yes/no as well as other messages)
Costello (2000)
Fried-Oken et al. (1991)
Gries and Fernsler (1988)
Happ (2000)
Hemsley and Balandin (2004)
Hemsley et al. (2001)
Russell (1999)
2 Pause/wait, to allow
time for the patient to
participate in the
interaction and communicate
Basil (1992)
Binger and Light (2007)
Calculator (1988)
Costello (2000)
Goossens (1989)
Hemsley and Balandin (2004)
Hemsley et al. (2001)
Russell (1999)
3 Confirm the message
communicated
by the patient with the patient
Costello (2000)
Happ (2000)
Hemsley and Balandin (2004)
Hemsley et al. (2001)
4 Use AAC to support
comprehension if required
Goossens (1989)
Gries and Fernsler (1988)
Hemsley et al. (2001)
Kent-Walsh (2003)
Romski and Sevcik (1996)
AAC, augmentative and alternative communication.
EH Finke et al.
2112 2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd

12. using an expectant facial expression and (b) actually waiting.
The amount of time that the nurse will need to wait for a
response will vary from patient to patient (Light Binger
1998). This may seem like a very simple strategy to employ,
but nurses are inherently busy professionals with many
responsibilities to manage throughout their work day. Wait-
ing for a patient to communicate using an AAC tool or
strategy may take more time than communicating with a
patient who is able to speak. It is ultimately more efficient,
however, for a nurse to know what a patient needs and what
they are experiencing, than for the nurse to have to guess the
patient’s needs without any communicative support (Alasad
Ahmad 2005).
In addition to providing enough time for a patient to
communicate and respond, nurses need to confirm the
message with the patient to ensure that they have under-
stood the message that is being communicated before
acting on it, asking further questions, or moving on to
other care or medical issues (Light Binger 1998). This is
essential because it not only demonstrates the nurse’s
willingness to communicate and interact with the patient,
but shows that the nurse cares about the message and
wants to ensure that it has been understood as was
intended by the patient.
Finally, some patients with CCN will require other types
of support as a result of having difficulty with comprehen-
sion. Comprehension may be a factor with patients who
have traumatic brain injury, stroke, intellectual disabilities,
cerebral palsy, autism spectrum disorder, Down syndrome
and dementia. To communicate with patients with CCN, a
nurse may need to provide information to support these
patients’ understanding. This support is often referred to as
augmented input. Augmented input has been defined as
‘incoming communication/language from the learner’s part-
ner that included speech which is augmented by other AAC
components’ (Romski Sevcik 1993). According to this
definition, augmented input is considered an AAC inter-
vention strategy which may include a communication
partner supplementing his/her speech input using either
aided AAC techniques (e.g., graphic symbols) or unaided
AAC techniques (e.g., sign language; Romski Sevcik
2003, Binger Light 2007). Three main functions of
augmented input have been identified: (a) providing a
model of how an AAC system can be used; (b) providing
illustrations the meaning of AAC symbols and or spoken
words; and (c) providing an implicit statement that the
AAC system is an accepted and encouraged form of
communication (Romski Sevcik 1993).
Augmented input interventions for patients contain two
key features. The first is that the communication partner (i.e.,
the nurse), points to, or selects, the graphic symbol (i.e.,
picture), or word, on the patient’s AAC device (Romski
Sevcik 2003, Binger Light 2007). The second is the
simultaneous provision of a spoken label for the chosen
graphic symbol, or word (Romski Sevcik 2003). The
effectiveness of these strategies for a patient with CCN has
been documented through investigations published in the
research literature (Romski Sevcik 2003, Binger Light
2007).
Nurses can augment the spoken message that is pre-
sented to patients, through several methods. One method
for augmenting a message includes writing words and
drawing pictures that correspond with the message that is
being spoken. Another method for augmenting a message
includes providing choices, if a choice exists (in some cases,
for example, taking a medication, a choice may not exist,
however a choice may exist regarding how the medications
are taken and in what order); providing written choices of
answers to questions that are asked; visually representing,
or illustrating, a sequence of events; pointing to pictures of
key words within a message; and writing key words of a
spoken message (Beukelman Mirenda 2005).
At the present, nurses have reported successful employment
of several strategies to improve communication with patients.
These include: (a) waiting; (b) establishing a quiet and
conducive communication environment, (c) using available
AAC devices and (d) partnering with the speech-language
pathologist and the patient to devise a common communi-
cation system (Fried-Oken et al. 1991, Happ 1991, Hemsley
et al. 2001). Nurses have reported that looking at and
attending to the patient during communicative attempts is
useful in capitalising on the patient’s nonverbal cues (facial
expressions, eye gaze and body language; Hemsley et al.
2001). Establishing a system for the patient to indicate ‘yes’
and ‘no’ (such as head nods and eye blinks) has also been
reported as helpful to nurses in facilitating successful com-
munication (Hemsley et al. 2001). These strategies, in
addition to the AAC tools and strategies mentioned above,
could greatly increase the effectiveness of nurse communica-
tion with patients with CCN when used consistently. Because
of the impact that these strategies have been shown to have
on effective communication, AAC should be considered for
all patients who do not have the ability to communicate using
the speech modality.
Nurses have also indicated that they have used several
strategies to determine if they have accurately received a
message from a patient. These strategies include: (a) watching
for relief and recognition in the patient’s facial expression
and (b) repeating back the message to ensure that it was
interpreted correctly (Hemsley et al. 2001).
Review Nurse-patient communication with AAC
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd 2113

13. AAC assessment and intervention process
Nurses can play an active role in encouraging physicians to
request AAC services for patients (Yorkston 1992, Beukel-
man et al. 2007). Nurses are generally responsible for
carrying out most care activities for patients in medical
settings and, therefore, have extensive contact with patients
and their families (Beukelman et al. 2007). Because of this
access and personal experience with the patient, nurses can
contribute significantly to the AAC assessment team by
providing information relative to the patients medical status,
coordinating AAC interventions within medical care plans,
providing information relative to the patients communication
needs, as well as keeping family members informed of any
changes in the patients communication plan (Yorkston 1992,
Beukelman et al. 2007). Nurses should be encouraged to
share their knowledge and observations of their patients with
the speech-language pathologist, as well as to notify the
speech-language pathologist when there are communication
concerns or changes in a patient’s medical status. Patients
who are alert and stable and unable to communicate using
speech are appropriate candidates for AAC tools and
strategies (Costello 2000).
Patients who are seriously ill are often too weak or
poorly positioned to write or point to pictures or words
and may lack the concentration necessary to spell and/or
read (Happ 1991). Introduction of AAC and other com-
munication supports should occur only after the patient is
stable (Costello 2000) and even when the patient is stable,
low tech AAC devices have been reported to be preferred
while the patient is still within the hospital setting (Happ
1991). A variety of these types of letter and picture-based
interventions have been employed successfully to improve
communication between nurses and patients (Fried-Oken
et al. 1991, Happ 1991). Nurses should feel free to talk to
their patients and explain all medical interventions and
care procedures to them even before this point in their
medical recovery and the introduction of AAC.
Summary
The fundamental importance of communication between
nurses and patients suggests the need for effective training
to equip nurses with the skills to communicate effectively
with the range of patients with CCN that they will
encounter. Training in ‘how to communicate’ with patients
would prepare nurses to take greater responsibility for
promoting successful communicative interactions regardless
of the patient’s level of communication impairment
(Hemsley et al. 2001).
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