Patient Provider Communication: Preparation of Speech-Language Pathology Externship Students This article reviews pertinent policies, information, and materials that assist speech-language pathologists (SLPs) to support effective communication between health care providers and communication vulnerable patients across health care settings. Five types of communication vulnerable patients and the roles of communication support personnel are discussed. Several types of medical referrals to ... Article
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Article  |   April 30, 2016
Patient Provider Communication: Preparation of Speech-Language Pathology Externship Students
Author Affiliations & Notes
  • David R. Beukelman
    Institute for Rehabilitation Science and Engineering, Madonna Rehabilitation Hospital, Lincoln, NB
  • Susan Fager
    Institute for Rehabilitation Science and Engineering, Madonna Rehabilitation Hospital, Lincoln, NB
  • Suzanne Seberg
    Speech Language Pathology, Madonna Rehabilitation Hospital, Lincoln, NB
  • Disclosures
    Disclosures ×
  • Financial: The preparation of this article was supported in part by funding from the U.S. Department of Health (Grant H133E140026, NIDILRR).
    Financial: The preparation of this article was supported in part by funding from the U.S. Department of Health (Grant H133E140026, NIDILRR).×
  • Nonfinancial: The authors have no relevant nonfinancial interests to disclose
    Nonfinancial: The authors have no relevant nonfinancial interests to disclose×
Article Information
Speech, Voice & Prosodic Disorders / Professional Issues & Training / Part 1
Article   |   April 30, 2016
Patient Provider Communication: Preparation of Speech-Language Pathology Externship Students
Perspectives of the ASHA Special Interest Groups, April 2016, Vol. 1, 35-40. doi:10.1044/persp1.SIG11.35
History: Received December 1, 2015 , Revised March 25, 2016 , Accepted March 28, 2016
Perspectives of the ASHA Special Interest Groups, April 2016, Vol. 1, 35-40. doi:10.1044/persp1.SIG11.35
History: Received December 1, 2015; Revised March 25, 2016; Accepted March 28, 2016

This article reviews pertinent policies, information, and materials that assist speech-language pathologists (SLPs) to support effective communication between health care providers and communication vulnerable patients across health care settings. Five types of communication vulnerable patients and the roles of communication support personnel are discussed. Several types of medical referrals to initiate patient provider communication (PPC) support are introduced. Access to a variety of communication support materials and tools is provided. Instructional strategies to integrate PPC instruction into preprofessional programs and externship experiences are described.

Why Prepare Speech-Language Pathology Externship Students to Provide Patient Provider Communication (PPC) Support?
The failure of patients and health care providers to communicate accurately and effectively has several potential consequences on medical care. Research shows that communication breakdowns can lead to: negative health outcomes; increased costs; lack of adherence to provider recommendations; longer stays in intensive care units; longer acute hospital stays; increased hospital readmissions; an increase in sentinel events; and reduced patient satisfaction. Errors in communication result in inappropriate medical diagnoses, care decisions, and compliance. Misunderstandings also result in errors in decisions involving nutrition, physical transfers, and pain management. Communication failures have been shown to result in rehospitalization of patients, as well as the devaluation by patients and their families of the quality of care that they have received (Bartlett, Blais, & Tamblyn, 2008; Blackstone, Beukelman, & Yorkston, 2015).
As was documented in a recent book on patient provider communication (PPC; Blackstone et al., 2015), the evolving emphasis on effective PPC that is being driven in part by the Joint Hospital Commission and by the implementation of the Affordable Care Act provides an opportunity for the speech-language pathologists (SLPs) who practice in a variety of medical settings. The purposes of this article are: (a) to describe communication vulnerable patients and the personnel who are responsible to facilitate and support accurate and effective communication with health care providers; and (b) to discuss policies, information, instructional strategies, and materials related to PPC that preprofessional programs in speech-language pathology might consider integrating into their preprofessional course work and medical externship experiences.
What Is Effective PPC in Medical Settings?
In 2010 The Joint Commission, a health care accrediting agency in the United States, adopted the following definition of PPC. “Effective communication is the successful joint establishment of meaning wherein patients and providers exchange information, enabling patients to participate actively in their care from admission through discharge, and ensuring the responsibilities of both patients and providers are understood. To be truly effective, communication requires a two-way process (expressive and receptive) in which messages are negotiated until the information is correctly understood by both parties. Successful communication takes place only when providers understand and integrate the information gleaned from patients, and when patients comprehend accurate, timely, complete, and unambiguous messages from providers in a way that enables them to participate responsibly in their care” (The Joint Commission, 2010, p. 1).
Who Are the Communication Vulnerable Patients Who Require Patient Provider Communication Support?
There are five groups of people who are considered communication vulnerable when involved in medical situations. At times some of these individuals may experience multiple communication vulnerabilities simultaneously (Beukelman & Nordness, 2015).
People with pre-existing disabilities, such as cerebral palsy, autism, amyotrophic lateral sclerosis, aphasia, etc., that affect communication effectiveness are particularly vulnerable in medical situations and settings. During times of medical emergency resulting from vehicle accidents, falls, infections, natural disasters, etc., these individuals may be asked to communicate about medical information that is not included in their AAC system. Of course, the communication disorders professionals face an important question regarding whose responsibility it is to prepare people with severe communication limitations to communicate about medical content. Patient provider communication (PPC) needs will not be well met if no one takes responsibility until a medical emergency or experience occurs.
A second group of communication vulnerable people are those with recent onset (first time) communication disorders, such as aphasia, apraxia of speech, dysarthria, or anarthria resulting from medical conditions such as cortical strokes, brainstem strokes, or traumatic brain injury (TBI). During the hours, days, and weeks following the onset of their communication condition, these patients typically face a series of medical communication challenges in intensive care, acute medical, and rehabilitation settings.
A third group of communication vulnerable people experience communication limitations due to medical interventions (tracheostomy, ventilator, laryngectomee, or surgery to oral structures). At times, these interventions can be anticipated and there is time to prepare appropriate PPC supports. Unfortunately, the policies and practices in many emergency and acute care settings do not include the initiation of communication interventions in advance of such procedures even though such referrals for other forms of medical services are often routine.
A fourth group of communication vulnerable people are those whose native language or culture challenges effective communication in medical situations. When available, interpreters are typically recruited to translate for patients and their family members as they interact with medical providers. However, during extended hospitalizations, these interpreters are usually not present during care and therapeutic interactions; therefore, PPC supports are frequently used with messages represented with photographs or icons along with printed messages in the language of the patient and the provider (Blackstone et al., 2015).
A fifth group of people become involved in medical situations for which they have little health literacy and background. For example, patients with brainstem strokes typically face a very abrupt, unexpected loss of spoken expression followed by a period of time when they are asked to make critical medical conditions with minimal information and very limited, if any, ability to communicate using natural speech. Therefore, a health interpreter may be asked to serve as a communication intermediary to insure that the patient (and family if they are available) and the health care providers are communicating such that they accurately understand each other.
What Communication Support Roles Are Commonly Required to Support PPC?
Beukelman and Nordness (2015)  have described the roles of personnel who support effective PPC. The communication coordinator for a medical facility or unit takes overall responsibility for the communication support program for communication vulnerable people. In this role, the coordinator oversees the communication support program, makes communication materials and tools available, and provides training and instruction for therapists and staff in their communication roles. In many acute and rehabilitation units, an SLP fills the coordinator role. However, in some long-term care residential facilities and hospice facilities, a nurse or social worker will fill the role if an SLP is only available to treat specific patients within the facility as a result of a specific referral from a physician. Unfortunately, in many long-term residential care and hospice settings, there is no designated communication coordinator.
The communication facilitator supports and monitors the daily PPC effectiveness of specific patients or residents. They make sure the PPC materials or technologies are available for the patient and are charged electronically, updated, and cleaned. The facilitators are prepared to step in to facilitate effective communication when important decisions need to be made, assessments completed, or conflicts resolved. In acute and rehabilitation settings, SLPs often fill this role. Often, they instruct other staff regarding effective communication strategies with the specific patient or resident. In long-term care, hospice, or home care situations, someone else has to fill this role. If no one assumes this role, PPC effectiveness is severely limited as each staff member attempts to develop their own strategies to communicate with the patient or resident.
The unique communication partner is that family member, friend, or care provider who takes the role to support effective communication interactions between the vulnerable patient or person and those who wish to interact with her or him. For example, the aphasia field has made extensive use of trained communication partners for people with severe aphasia (Simmons-Mackie, King, & Beukelman, 2013). This partner often requires training and practice from the communication coordinator or facilitator. Of course, there is always a concern when the trained partner is not available at times of medical crisis or due to death, illness, or the breakdown of close relationships, which leaves the vulnerable person without communication support. Unfortunately, this often occurs late in life, generally when the patient is in a long-term residential care facility.
A legal communication intermediary is the individual who supports effective, accurate communication during interactions that have legal consequences such as changing wills, signing contracts, preparing end-of-life documents, or testifying in legal proceedings during interactions with the police, legal hearings, or court proceedings. Given the relatively frequent occurrence of physical or financial abuse of communication vulnerable people, their need to participate in legal procedures is not uncommon (Bryen, Carey, & Frantz, 2003). The role of the legal intermediary is to confirm that communication vulnerable people accurately understand information presented to them and that they accurately and authentically express information to legal and medical personnel. In legal procedures, family members are often not allowed to serve as communication intermediaries. Legal intermediaries are those people who can effectively interact with a communication vulnerable patient, but who do not have a vested interest in the legal proceedings. For example, some medical facilities have an Ethics Committee with specific members who serve as legal intermediaries for communication vulnerable patients. However, if the legal procedures involve issues with concerns about medical care or abuse in a medical or care facility, an employee of the facility should not serve as the legal intermediary. Finally, medical or health interpreters support effective PPC information for patients with foreign primary language or minimal medical awareness or background. The role of these interpreters are to insure that health care providers accurately understand the patient and that patients accurately understand the provider. Together the provider, the patient and the interpreter can co-construct meaning in such a way that PPC is accurate and efficient.
How Are Communication Supports Ordered in Medical Situations?
Several different procedures are used in medical situations to order communication support for communication vulnerable patients. These orders are briefly reviewed below.
Specific Order (Referral)
A specific order or referral specifies the transfer of care for a patient from one clinician to another or a request made for assistance, a second opinion, an action to evaluate or manage a particular problem, or to authorize care from a specialist or agency. These specific referrals are usually ordered by a physician to address the need of specific patients.
General Referral
A general referral is filed for a specific patient prior to admission to a specific medical setting and is activated upon admission to that medical facility. For an individual with pre-existing communication conditions, a general referral authorized by their physician could identify the PPC support in terms of an AAC device and hearing amplification device, or material set that is to be incorporated when the individual becomes a patient in the local hospital or long-term care facility.
Standing Order
A standing order usually names the medical condition and prescribes the action(s) to be taken for patients who have experienced, or are scheduled to experience, procedures and strategies documented in an order set that specifies the procedures that are included in a standing order. Appropriate communication support strategies can be specified for people who require respiratory support, surgical interventions, or other procedures that will interfere with effective communication.
Care Maps
A care map, also referred to as a clinical pathway, describes the steps and decision points in the providers' management of a medical condition. It is based on medical guidelines, recent evidence, and expert consensus. A care map is made up of a series of orders that designate the complete patient journey for a specific medical condition such as cortical stroke with aphasia in a specific medical setting. For example, rehabilitation units/hospitals often make use of care maps to implement the interventions and supports needed for patients with spinal cord injuries, stroke, or TBI.
How Can an SLP Extern Access Materials, Tools, Technologies, and Strategies Used for PPC Support?
A wide range of materials and technologies are available to support effective PPC. Of course, the specific strategies are dependent upon the communication needs and capabilities of the individual patient. The augmentative and alternative communication (AAC) field has developed a range of materials and strategies that can be useful in PPC. However, these strategies usually support a wide range of social, educational, personal care communication, and some health care needs related to pain levels, food preferences, physical position, nutrition, and so on, rather than PPC with a health care providers dealing with the diagnosis of medical conditions, review of medical conditions, decision-making about health care, residential choices, or end-of-life guidance.
Recently, several resources have been developed that discuss PPC and contain materials useful to support communication in medical settings. Bourgeois (2014)  has authored a book that describes memory and communication aids for people with dementia. Hurtig and Downey (2009)  have written a book that describes PPC in acute and critical care settings. Blackstone et al. (2015)  recently recruited a number of SLPs and other health professionals who are experts in PPC to describe the services they provide in specific medical settings including emergency care, acute care, inpatient and outpatient rehabilitation, long-term residential care, and hospice (end-of-life) care. These authors have posted their PPC materials and resources on a website that is accessible without cost (Patient Provider Communication, 2016). Also, the American Speech-language and Hearing Association supports a website that focuses on PPC (Patient Provider Communication, 2016).
How Can PPC Instruction Be Addressed for SLP Students?
Several approaches to PPC instruction can be integrated with the medical externship experiences of SLP students. One strategy is to provide students with a base of information regarding policies, strategies, and materials that will potentially be used in their externship site, so that the externship supervisor does not have to be responsible for this introductory instruction and can focus on implementing this information during the externship experience.
A second strategy is to prepare students to meet PPC needs of patients during their externship experience, especially if the supervising clinicians are well versed in PPC strategies. Depending on their externship placement, students may work only in a single medical setting, such as rehabilitation, long-term residential care facilities (e.g., nursing homes and assisted living), or memory care units. However, other students may be exposed to a range of medical settings.
A third strategy is to provide student externs with PPC information and materials that can be transferred to the externship site if personnel on the site have little preparation, interest, or commitment to PPC support. While externs learn from their supervisors, the supervisors also learn from the student externs who have access to up-to-date PPC information and materials.
A fourth strategy involves collaborations with professional preparation programs in health and allied health disciplines to implement interdisciplinary coursework in PPC. At the 2015 ASHA Convention, Nancy Alarcon described such a course that has been initiated at the University of Washington that includes students from speech-language pathology, physical therapy, and occupational therapy, as well as prosthetics and orthotics. Also at the ASHA 2015 Convention, Michael Burns discussed a collaboration between the speech-language pathology program and medical school that incorporated the use of patient videos and standardized patients with neurogenic communication disorders in the training of speech-language pathology as well as second-year medical students (Beukelman, Burns, & Alarcon, 2015; Yorkston, Baylor, Burns, Morris, & McNalley, 2015).
A fifth strategy is to engage clinical externship supervisors in seminars with university faculty from the student's academic program to share information about PPC. In an effort to show appreciation for externship supervisors as well as to update their professional information base, some preprofessional SLP programs offer continuing education opportunities for the clinical supervisors who mentor their student externs. At times, this information is provided to externship supervisors and program faculty by an invited presenter. At other times a faculty member or an externship supervisor with unique expertise presents and leads discussions. Presentations focusing on PPC provide an important opportunity to prepare externship supervisors with information that they can integrate into their clinical practice, thereby providing clinical externs with the opportunity to observe PPC strategies and materials integrated into daily clinical practice.
Whose Responsibility Is the PPC Preparation of SLP Students?
While discussing PPC preparation of SLP preprofessional students with faculty from a variety of academic programs, the authors have learned that some SLP faculty integrate PPC related information in their AAC, aphasia, dementia, or motor speech disorders coursework for SLP students, while others do not. Others preprofessional programs provide intensive coursework for several days in preparation for upcoming externship experiences, while other programs provide an hour or two of class each week while students are participating in their medical externships. Of course, externship experiences in medical settings provide SLP students with a range of opportunities to receive information and engage in clinical experience related to PPC.
There are ongoing discussions about whether preprofessional training programs should be primarily responsible for PPC preparation of students or whether that information should be provided to students by externship supervisors who are providing PPC support to patients as part of their daily clinical responsibilities. Obviously, the instructional strategy is dependent upon each preprofessional training program and its collaborative externship sites now that PPC related policies, information, and materials are readily available.
Acknowledgements
The authors wish to thank the patients, medical providers, and clinical colleagues who have shared their communication experiences and insights with us through the years.
References
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