Identifying communication difficulty and context-specific communication supports for patient-provider communication in a sub-acute setting: A prospective mixed methods study

Abstract

Purpose

To identify the sub-acute rehabilitation inpatients who have communication difficulty and the range of communication supports that can facilitate communicative success.

Method

A prospective cohort mixed methods study was conducted on two inpatient sub-acute rehabilitation wards. Nurses screened all new admissions for communication difficulty using the Inpatient Functional Communication Interview, Screening Questionnaire (IFCI-SQ). Patients identified as having communication difficulty were interviewed by a speech-language pathologist (SLP) using the Inpatient Functional Communication Interview (IFCI). During the interview, the SLP trialled different communication supports. The number of patients who had communication difficulty on the IFCI-SQ was calculated. The number and type of communication supports that improved communication within the patient-SLP interview were calculated. Deductive-dominant qualitative content analysis was conducted on the communication supports used during the IFCI.

Result

Seventy patients were screened. Nurses reported communication difficulty in 45/70 (64%) of patients. A total of 15/45 patients were interviewed by an SLP using the IFCI. The provision of communication supports improved communication for all patients within the context of the patient-SLP interview.

Conclusion

Many sub-acute rehabilitation inpatients have communication difficulty in the hospital setting. A range of communication supports facilitated communication. These insights could inform future communication partner training (CPT) programs.

Keywords:

• communication difficulty
• patient-provider communication
• inpatient
• nurse

Introduction

Effective communication between patients and all healthcare providers is essential for the delivery of safe, high quality, patient-centred care (Bensing et al., 2000; Stans et al., 2016). Despite the importance of effective patient-provider communication, nurses report difficulty communicating with 40% of patients on an acute general medical ward (O'Halloran et al., 2017). When patients are unable to communicate with their healthcare providers they cannot get help when required (Hemsley et al., 2013), do not get enough to eat and drink (Iacono & Davis, 2003), do not receive effective pain management (Mencap, 2007), are unsure about when to seek help on discharge (Hvidt et al., 2014), are excluded from decisions about their own care (Penney & Wellard, 2007), and experience biographical disruption akin to the feeling of “being in a foreign country” (Clancy et al., 2018, p. 326). Ineffective communication places patients at greater risk of other consequences as well. People with communication difficulty are three times more likely to experience a preventable adverse event in hospital (Bartlett et al., 2008), have higher odds of more hospital stays and emergency department visits (Iacono et al., 2020; Stransky et al., 2018), and report lower satisfaction with healthcare services generally (Hoffman et al., 2005).

It is not only patients who are affected by ineffective patient-provider communication. Qualitative research indicates that nurses report feeling uncertain, insecure, and frustrated when communication with patients is ineffective (Hemsley et al., 2001; Sundin et al., 2002). They have described feeling exhausted by their ability to sense the patient’s vulnerability, coupled with their inability to communicate effectively about the patient’s experiences (Sundin et al., 2002). It is therefore unsurprising that nurses have reported limiting and at times avoiding communication with patients experiencing communication difficulties (Carragher et al., 2021; Kagan et al., 2018).

To improve patient-provider communication, researchers and clinicians have predominantly focused their efforts on providing communication partner training (CPT) to healthcare providers. One common example is Supported Conversation for people with Aphasia™ (SCA; Kagan, 1998). In this CPT program, healthcare providers are taught how to use a range of communication supports to facilitate more successful communication with people with aphasia. Communication supports include using gesture, written key words, drawing, asking yes/no or fixed-choice questions, additional time to respond, summarising what has been communicated, and using pictographic resources (Kagan, 1998).

Despite the availability of CPT programs, barriers to implementing CPT in hospitals exist. Both speech-language pathologists (SLPs) and healthcare providers report barriers implementing CPT, and there may be barriers with the content of CPT programs. Barriers for SLPs include a lack of access to training, limited support from other healthcare providers in the multidisciplinary team, and a lack of resources (Chang et al., 2018). Healthcare providers who have received CPT report having little time to trial different communication supports with patients who need them, given the pressure to complete care routines quickly (Horton et al., 2016). Potential barriers related to the content of CPT programs have also been identified, including (a) disorder-specific focus of existing programs, (b) limited specificity to target contexts, (c) reduced end-user engagement in program development, and (d) limited evidence regarding both broadly applicable and effective communication supports. These points are elaborated on as follows. First, all CPT programs to date have been developed to facilitate conversations with people who have a specific communication disorder, such as aphasia (e.g. SCA; Kagan, 1998) or cognitive communication disorder (e.g. TBI Express; Togher et al., 2016). Healthcare providers need to have conversations with people with different and multiple kinds of communication disorders. Therefore, disorder-specific CPT programs may be less applicable for healthcare providers who require broadly-applicable training (O'Rourke et al., 2018). Second, the outcomes of CPT programs are broad, with the aim to improve conversation in all situations and contexts. A focus on training to improve communication in specific communication situations in specific healthcare contexts may reduce barriers to implementation. Third, CPT programs have typically been developed by SLPs. Engaging end users, such as nurses and people with lived experience of communication difficulties in healthcare settings, in the development of CPT programs could result in programs that are better suited to the hospital environment (Jensen et al., 2015). Finally, there is limited empirical evidence for supports commonly employed by healthcare providers (Stans et al., 2016) and supports that are effective across a range of communication disorders (O'Rourke et al., 2018). Research evidence is needed to determine the specific communication supports that facilitate successful communication with people who have a range of different communication disorders.

In the context of ongoing implementation barriers to CPT, exploring patient-provider communication from a different perspective may prove valuable. A diagnosed communication impairment does not reliably predict whether a patient will encounter difficulty communicating with healthcare providers (O'Halloran et al., 2012a, 2012b). Identifying communication activity limitation has been proposed as an alternative method to predict ineffective patient-provider communication (O'Halloran et al., 2017). Patient-provider communication is a communication activity (O'Halloran et al., 2020) according to the World Health Organization’s International Classification of Functioning, Disability and Health (ICF; World Health Organization, 2001). In the hospital setting, communication activities include, for example, the patient following instructions, asking about medication, describing pain, or understanding information about their care. When communication is unsuccessful, it is described as a communication activity limitation. If someone has a communication activity limitation, they have either a communication difficulty or a communication disability. Disability, in the ICF, is the umbrella term that captures the impairments, activity limitations, and participation restrictions that result from a health condition—with recognition of the environmental and personal factors that interact with these components (World Health Organization, 2002). There are many factors that may contribute to a communication disability, including (a) the patient’s communication impairment, e.g. the patient has hearing loss; (b) the patient’s individual characteristics, e.g. the patient does not speak the language of the healthcare provider; (c) the hospital environment, e.g. the healthcare provider has a hearing loss, does not speak the language of the patient, and/or does not have any resources to support communication with the patient; or (d) a combination of these factors (O'Halloran et al., 2020; World Health Organization, 2001). A communication difficulty is a more general term for a communication activity limitation where there is no known communication impairment. This may be because (a) assessment of impairment has not yet occurred or (b) there is no communication impairment and the activity limitation has resulted from a miscommunication, i.e. a combination of individual characteristics and environmental factors in the absence of impairment. The ICF represented a paradigm shift, with the goal of “shifting the focus [of disability] from cause to impact” (World Health Organization, 2002, p. 3). A focus on activity limitation is a focus on impact. Exploring ineffective patient-provider communication from this perspective, as facilitated by assessments like the Inpatient Functional Communication Interview: Screening, Assessment, and Intervention (IFCI-SAI; O’Halloran et al., 2020), may complement and contribute to the existing and emerging body of evidence aimed at addressing CPT implementation barriers.

The IFCI-SAI (O'Halloran et al., 2020) consists of four tools: (a) the Inpatient Functional Communication Interview, Screening Questionnaire (IFCI-SQ), (b) the Inpatient Functional Communication Interview (IFCI), (c) Impairment Rating Scales, and (d) an Environmental Audit tool. Together, the tools in the IFCI-SAI are designed to support healthcare providers to have successful healthcare conversations with inpatients who have communication disabilities. While assessing communication according to activity limitation is not a new concept, it differs from the impairment-focused biomedical model, which remains dominant in healthcare systems. Further, the IFCI-SAI is the only functional communication assessment developed for the inpatient setting (Aldridge et al, 2022). The IFCI-SQ is a validated screening tool, with excellent sensitivity and good specificity compared with an SLP assessment (O'Halloran et al., 2017). The purpose of the IFCI-SQ screening tool is to identify any patients with a communication difficulty. The IFCI is a detailed SLP assessment of the patient’s communication activity limitation in the context of their communication impairment or health condition. An SLP evaluates the patient’s communication based on their ability to engage in communication activities within a specific context, providing and documenting supports as they are required. The purpose of the IFCI is to assess, and reduce, communication disability. The changing nature of environmental and personal factors considered within the IFCI-SAI underscores that disability is not static. The dynamic nature of communication is influenced by environmental factors such as the communication partner’s level of experience or how familiar the patient is to the communication partner, and personal factors such as the patient’s level of health literacy. In other words, when the SLP assesses the patient’s communication disability on the IFCI, the clinician captures a “snapshot in time.” To account for changing environmental factors affecting patients’ communication access, it is crucial to address relevant environmental factors during this study.

A significant environmental factor that has impacted patient-provider communication in hospitals in recent years, present during the time of this study, was the COVID-19 pandemic. COVID-19-related infectious disease precautions require healthcare providers to wear personal protective equipment (PPE), including face masks, at all times. Preliminary research suggests that face masks negatively impact patient-provider communication by reducing speech loudness as well as visual and facial cues, thus impacting both patient and healthcare provider’s ability to hear, perceive, and understand what is being said (Homans & Vroegop, 2022; Saunders et al., 2021). COVID-19 also resulted in restrictions on hospital visitors. Healthcare providers and family have reported that visitor restrictions negatively impacted patient-provider healthcare communication, by reducing healthcare providers’ access to background information about the patient such as their preferences and goals of care (Krewulak et al., 2022). The COVID-19 pandemic, and subsequent requirement to provide healthcare in PPE, as well as visitor restrictions, pose further challenges to effective patient-provider communication for patients with communication activity limitation. These challenges are present regardless of whether the activity limitation is the result of communication disability or communication difficulty.

The need to manage COVID-19 has resulted in significant changes to the hospital communication environment that are beyond an individual healthcare provider’s control. However, there are other aspects of the hospital environment that may be modifiable and could be adjusted to minimise communication activity limitation for patients (O’Halloran et al., 2020). The IFCI-SAI’s dynamic assessment of communication activity limitation, rooted in the World Health Organization’s ICF biopsychosocial model, may offer a unique perspective on the range of environmental factors, including communication supports, that influence patient-provider communication. Its potential to inform CPT programs remains unexplored.

In summary, effective patient-provider communication is critical for high-quality, safe healthcare. The introduction of COVID-19 restrictions has made the hospital communication environment, and thus patient-provider communication, even more challenging. Despite this, the hospital environment may be modified in other ways to enhance patient-provider communication. CPT programs have been a proposed solution; however, design and implementation barriers have limited their broad success. Identifying communication activity limitation and potential supports may unveil supports applicable across a range of people who have communication disability. Using the IFCI-SAI to identify communication supports that increase efficacy of communication in a specific context, through an activity limitation rather than impairment lens, may support the development of CPT programs that overcome current barriers to implementation.

Therefore, the overall aims of this study were, in a sub-acute rehabilitation inpatient setting, to identify the patients with communication difficulty and to describe the types of communication supports that may facilitate communicative success. The specific research questions were as follows.

In the context of sub-acute rehabilitation inpatient wards, with COVID-19 restrictions in place, from nursing staff screening for communication difficulty:

1. How many patients were reported to have communication difficulty?

2. What healthcare communication situations did nurses report to be most difficult?

From subsequent patient-SLP semi-structured interviews:

• (3) In what specific healthcare communication situations did environmental communication supports improve communication access for patients with a range of communication disabilities?

• (4) How many communication supports were needed to facilitate effective communication within each of these specific situations?

• (5) What types of communication supports facilitated effective communication in these specific healthcare communication situations?

Method

Research paradigm

This study was embedded within a post-positivist theoretical perspective (Crotty, 1998). That is, we assumed that specific, healthcare communication situations could be recognised within nurse-patient care routines and could be measured in terms of their communicative success. We also assumed that the use of communication supports could increase the communicative success of patient-SLP interaction and that these too could be observed and measured. However, unlike a positivist approach, we also assumed that the researcher is not an independent observer and will influence what they observe and conclude (Patton, 2002), thus aligning with a post-positivist perspective. We used a prospective, cohort, mixed methods design.

Research design

This study was conducted in two phases, as depicted in Figure 1 below. In Phase 1, we sought to answer research Questions 1 and 2. In Phase 2, we investigated research Questions 3, 4, and 5.

Figure 1. The two phases of the study. ^aInpatient Functional Communication Interview, Screening Questionnaire (O’Halloran et al., 2020). ^bInpatient Functional Communication Interview (O’Halloran et al., 2020).

Participants

Phase 1: Nursing staff

Blanket ethics approval was obtained to allow registered nursing staff working on two sub-acute rehabilitation inpatient wards to screen all new admissions for communication difficulty on the IFCI-SQ over a 6-week data collection period. As the aim of this phase was to identify the patients who had communication difficulty and the communication situations that were most difficult, i.e. to capture a snapshot of nurse-patient communication from the nursing staff perspective, demographic data about the nurses and patients was not collected (consistent with the ethical approvals granted).

Phase 2: Patients

Patients who were (a) identified as having a communication difficulty from nurse screening in Phase 1, (b) not highly dependent on medical care, (c) receiving their healthcare in English, and (d) 18 years or older, were invited to participate in Phase 2 of the study. Eligible patients were approached by a third-party intermediary (an SLP who was not part of the research team) and asked whether they would like to learn more about the study. All patients who expressed interest were provided with verbal and written information about the study in a communicatively-accessible format (Rose et al., 2011, 2012) by the first author (R.S.), who is an experienced SLP. This information was then further tailored to the patient’s individual communication needs using communication supports as required (Kagan, 1998). Prospective participants were asked six yes/no questions to determine their understanding of the information provided and their capacity to consent. Where patients were interested in participating and did not demonstrate capacity to consent but provided their assent, the person responsible for the patient’s medical decisions was approached and provided with standard written information about the study and a verbal explanation (either in person or over the phone). The patient and/or person responsible were given time to consider whether they would like to participate in the study, without the primary researcher present. Where patients (a) had the capacity to provide verbal and written consent and did so, or (b) agreed to participate and the person responsible provided verbal and written consent, the patient was included in the study. Patients were excluded from Phase 2 of the study if the nurse, intermediary, third party responsible (where applicable), or first author judged them as unable to provide informed consent without the use of an interpreter. Given this was an exploratory study, recruitment of participants was limited to the 6-week period available for data collection.

Materials and data collection

Phase 1

The Inpatient Functional Communication Interview, Screening Questionnaire (IFCI-SQ)

The IFCI-SQ (O’Halloran et al., 2020) was used to screen new admissions for communication difficulty. The nurse worked an entire shift (approximately 8 hours) caring for the patient, before completing a short questionnaire. In the questionnaire the nurse is presented with 14 common healthcare communication situations and is asked whether they were able to communicate with the patient “always”, “sometimes”, “never”, or “don’t know”. Patients are classified as having a communication difficulty on the IFCI-SQ if the nurse rates being able to communicate with the patient “sometimes” or “never” in one or more of the 14 situations. Patients are classified as not having a communication difficulty if the nurse rates being able to communicate with the patient “always” in all situations rated. The IFCI-SQ is a measure of the nurses’ perspective of communicating with the patient in 14 typical healthcare situations. Nursing staff are not required to document any potential cause of communication difficulty when completing the IFCI-SQ and require no training to complete the IFCI-SQ (O'Halloran et al., 2017).

Phase 2: The Inpatient Functional Communication Interview (IFCI)

The IFCI (O'Halloran et al., 2020) was conducted by the first author. To conduct the IFCI, the SLP first documents any relevant demographic information, factors that might influence healthcare communication, and information about the patient’s medical care from the patient’s medical records. Demographic information includes the patient’s gender and age. Factors influencing healthcare communication include any cultural and linguistic factors, including if the patient’s ethnicity, language background, and/or accent is different from their healthcare providers; the presence of hearing or vision impairment and assistive aids (i.e. hearing aids, glasses); dentition and dental prosthetics; communication status (functional literacy and any pre-existing acquired or lifelong communication impairment/s); and any documented communication impairment from their current admission. Information about the patient’s medical care include the reason for the patient’s admission, current medical diagnosis if known, and current care plan.

With this background knowledge, the SLP then conducts a semi-structured interview with the patient at their bedside. During the interview, the SLP explores the patient and SLP’s ability to together communicate successfully in the same hospital communication situations listed in the IFCI-SQ. Note that a communication situation on the IFCI-SQ, “the patient understands and remembers information about what is happening, going to happen, or has happened in relation to his or her healthcare”, is broken into two communication situations on the IFCI: immediate recall of what is happening and delayed recall of what is happening. Therefore, there are 14 communication situations in the IFCI-SQ and 15 communication situations in the IFCI. During the IFCI, the clinician attempts to include all 15 communication situations in the interview; however, if a communication situation is not applicable (e.g. no pain), it is scored as not observed. In situations where the SLP and patient are unable to communicate successfully, the SLP provides one or more communication supports to see if that results in successful communication. Notably, the use of communication supports for effective patient-SLP communication is contingent on necessity. The SLP reviews the patient’s ability to communicate in each situation without any supports, prior to integrating and trialling communication supports. This is consistent with evidence that patients with communication difficulties are not typically provided with support to communicate (Hersh et al., 2016). Depending on the number of communication situations where a patient needs support, and the range of communication supports employed by the SLP, the IFCI can take up to 45 minutes to conduct. The IFCI must be administered by an SLP and is a challenging problem-solving task, which requires clinical skill and an investment of time and practice (O’Halloran et al., 2020). During the data collection period for this study, and prior to conducting the first patient-SLP semi-structured interview, the first author spent time reviewing the IFCI-SAI instruction manual in detail, reviewing the IFCI-SAI companion website’s case study videos and explanatory notes, and developing personalised quick reference notes to guide administration and scoring. Questions about administration of the IFCI were clarified with the research team (including the first author of the IFCI-SAI) as they arose during data collection.

Communication supports within the IFCI

In the IFCI, communication supports are defined as any communicative behaviour from the patient or SLP that occurs during the semi-structured interview in response to a communication breakdown, which are intended to repair that breakdown. The IFCI manual lists many different communication supports that could be employed by the SLP to facilitate communication access. However, it is not prescriptive. For example, if the clinician asked the patient “what happened to bring you into hospital?” and the patient did not answer, the clinician could rephrase the question by asking a forced alternative question such as, “were you home or were you out when you noticed something was wrong?” Or they might choose to ask a yes/no question such as, “were you home when you noticed something was wrong?” Alternatively, they could decide to repeat the question, write down key words, or try several different supports in combination.

At the end of the interview, the SLP documents the communication supports that were employed during the interview and the supports that facilitated successful communication. The SLP also scores each communication situation as “successful”, “partially successful”, “unsuccessful”, or “not observed/not interviewed” according to the IFCI scoring manual. For example, in the situation “understanding the implications of their medical condition” the patient needs to demonstrate understanding of at least one implication of their condition (e.g. since I fell, I need help to walk) and not demonstrate a lack of insight into any other implications (e.g. I don’t need to be here, I can go home on my own) to be scored as able to communicate successfully. This score is not dependent on the level of communication support provided. That is, even if multiple communication supports are needed (e.g. additional time, probing questions, yes/no questions, closed questions), if the patient meets the criteria above, they are scored as being able to successfully communicate. The SLP documents the kinds of communication supports that were required to enable successful communication in each situation. On completion of the IFCI, the SLP writes a healthcare communication plan to support healthcare providers to communicate more successfully with the patient.

Procedure

Phase 1

Nursing staff working on one of two sub-acute rehabilitation wards of a tertiary hospital in metropolitan Melbourne screened every patient consecutively admitted to the ward for communication difficulty. This was completed over 6 weeks. The IFCI-SQ was used to screen for communication difficulty. The two wards were a neurorehabilitation ward, and a combined geriatric evaluation and management (GEM) and movement disorders ward. Completed IFCI-SQ forms were stored in a box on each ward and collected by the first author throughout the week.

Phase 2

The first author conducted the IFCI with the participants identified as having a communication difficulty. As described above, the SLP trialled different and multiple communication supports to facilitate communication access in each of the healthcare communication situations interviewed. Where participants required extensive support for effective communication, the interview was conducted across two separate sessions. Following each interview, the communication situations where successful communication was achieved, and the number and type of communication supports trialled in each communication situation, were documented. To answer research Questions 3, 4, and 5, data were collected on the communication situations that could be facilitated by supports, the number of communication supports needed to facilitate effective communication, and the type of communication supports that contributed to successful communication.

Data analysis

Phase 1

Descriptive statistics were used to identify the number of patients screened and the number identified as having communication difficulty on the IFCI-SQ. To determine the communication situations that nurses perceived as most difficult, a descriptive count of how often each communication situation was rated as “always”, “sometimes”, or “never” successful and “don’t know” was calculated. These scores were converted into a percentage of total responses. Situations were then ranked from “easiest” (highest percentage of nurses selecting “always” able to communicate with the patient in that situation) to “hardest” (highest percentage of nurses selecting “sometimes” or “never” able to communicate with the patient in that situation).

Phase 2

Each communication situation in the IFCI was scored by the SLP as successful, partially successful, or unsuccessful according to the IFCI scoring manual (O’Halloran et al., 2020). The communication supports used by the first author to facilitate patient-provider communication in each communication situation were then coded using a deductive-dominant qualitative content analysis approach (Armat et al., 2018; Elo et al., 2014). Specifically, the first author reviewed the way communication supports were described in the IFCI (pp. 39–41, O’Halloran et al., 2020) and the summary of communication supports reported in a review of communication partner programs (O'Rourke et al., 2018). Then, using a deductive analysis approach, they reviewed their detailed notes, including descriptions of communication supports used, observations of the environmental supports available, and summaries of communication interactions, to identify all the supports trialled during the interaction. The same support was described using the same code to allow for a frequency count of supports used. Where a support was identified that did not fit neatly into an existing category, an inductive analysis approach was adopted and a new category of support was created.

Information about whether the supports trialled facilitated effective communication in each situation during the patient-SLP interview was then analysed to identify the specific healthcare communication situations that could be enabled through the use of supports, the number of communication supports needed to aid effective communication in each situation, and the type of communication supports that contributed to effective communication across the range of communication disabilities represented in the patient-SLP interviews.

Researcher characteristics and reflexivity

The research team comprised an experienced SLP (first author) and three experienced research SLPs with clinical backgrounds, one of whom was an author of the IFCI-SAI. The primary researcher had worked clinically for 6 years across a range of medical contexts in acute and sub-acute rehabilitation hospital settings, in addition to facilitating a community aphasia group for 2 years prior to and during the study. She also had participated in a CPT program (Supported Conversation for Adults with Aphasia™; Kagan et al., 2018) and had completed a 2-month student placement using this method of CPT in a clinical setting with clients with aphasia. Content analysis was completed by the first author. A reflexive journal was kept throughout data collection and data analysis to ensure that the first author remained aware of the influences on her decision making, and open to trialling different communication supports across interviews. The first author regularly met with the broader research team to engage in peer checking by discussing the study throughout data collection and analysis.

This study was approved by the Monash Health (RES-19-0000-779L) and La Trobe University (RES-19-0000-779L) Human Research Ethics Committees. Ethics approval number: HREC 19-0000-779 L.

Result

Sample

Data collection occurred from 15 March 2021–25 April 2021, during the COVID-19 pandemic. Throughout this period, personal protective equipment (surgical masks) was required to be worn by all healthcare providers for all patient contact and visitor restrictions (one visitor only per day, shortened hours) were in place. Therefore, nursing staff and the SLP were wearing surgical masks during all interactions with patients and evaluating the patients’ communication in this context. Nursing staff and the SLP had reduced access to family or carers during their interactions with patients.

Phase 1

All new patients admitted to either the neurorehabilitation ward (n = 30) or the GEM and movement disorders ward (n = 40) of an inpatient sub-acute rehabilitation hospital during the data collection period were screened by nursing staff for communication difficulty using the IFCI-SQ.

Phase 2

Of the 45 patients that nurses identified with communication difficulty, 34 were identified as able to be approached for consent to an IFCI without an interpreter. Three participants were transferred to another hospital prior to consent and five declined to participate. Given the time-limited data collection period, 11 participants who were identified as having a communication difficulty on screening by nurses could not be approached for an interview. Therefore, of the 45 patients identified as having difficulty communicating about their healthcare, 15 participated in an IFCI. Further details are provided in Figure 2 below.

Figure 2. Participant flow diagram. ^aInpatient Functional Communication Interview, Screening Questionnaire (O'Halloran et al., 2020). ^bInpatient Functional Communication Interview (O'Halloran et al., 2020).

The 15 patient participants with communication disability, interviewed by the SLP, ranged in age from 51 to 92 years (mean 72 years) and seven (47%) were female (see Table I for details). Demographic information and factors influencing healthcare communication are documented in Table I. Based on the participants’ medical records, nine of 15 participants had some form of pre-existing acquired or lifelong communication disorder (dysarthria: n = 4; cognitive communication impairment: n = 6; hearing impairment: n = 2). The primary reason for admission to the neurorehabilitation or GEM/movement disorders ward was acute neurological injury stroke (n = 7), with the remainder being admitted with a primary diagnosis of falls (n = 4) or management of a neurological condition (e.g. neurodegenerative conditions, seizures, brain tumour, cognitive decline/delirium: n = 4). All 15 participants interviewed had one or more documented communication impairments (cognitive/cognitive-communication impairment: n = 10; aphasia: n = 2; motor speech impairment: n = 5).

Table I. Demographic and communication factors for participants interviewed in Phase 2.

Variables	N	%
Demographic details
Gender
Female	7	47%
Male	8	53%
Other	0	0%
Age
50–59	3	20%
60–69	4	27%
70–79	4	27%
80–89	3	20%
90–99	1	7%
Cultural and linguistic factors
Ethnicity
Shared ethnicity (participant and researcher)	8	53%
Ethnicity not shared (participant and researcher)	7	47%
Language background
Shared language background (participant and researcher)	11	73%
Language background not shared (participant and researcher)	0	0%
Not known if language background is shared (participant and researcher)	4	27%
Accent
Shared accent (participant and researcher)	6	40%
Accent not shared (participant and researcher)	8	53%
Not known if accent is shared (participant and researcher)	1	7%
Sensory impairments and assistive aids
Hearing impairment
Hearing impairment	4	27%
No hearing impairment	10	67%
Unknown hearing status	1	7%
Hearing aids prescribed
Yes	3	20%
No	12	80%
Presence of hearing aids (n = 3)
Present	1	33%
Not present	2	67%
Vision impairment
Vision impairment	13	87%
No vision impairment	2	13%
Optical lenses required
Yes	12	80%
No	3	20%
Presence of optical lenses (n = 12)
Present	10	83%
Not present	2	17%
Dentition and dental prosthetics
Dentition
Natural dentition	10	67%
Dentures	5	33%
Presence of dental prosthetics (n = 5)
Present	1	20%
Not present	4	80%
Communication status
Functional literacy
Yes	6	40%
No	0	0%
Not known	9	60%
Pre-existing acquired or lifelong communication impairment
Yes	9	60%
No	6	40%
Documented communication impairment
Cognitive/cognitive-communication impairment
Mild	4	27%
Moderate	4	27%
Severe	2	13%
Profound	0	0%
Aphasia
Mild	0	0%
Moderate	0	0%
Severe	1	7%
Profound	1	7%
Motor speech (dysarthria or apraxia)
Mild	3	20%
Moderate	1	7%
Severe	0	0%
Profound	1	7%

Phase 1

How many patients were reported to have communication difficulty?

Nurses identified 45/70 (64%) admissions as having a communication difficulty on the IFCI-SQ. That is, nurses reported 64% of new admissions were perceived to be only “sometimes” or “never” able to communicate with them in one or more of the 14 common healthcare communication situations listed in the questionnaire. Excluding the 11 patients requiring an interpreter, nurses reported difficulty communicating with 34 of the remaining 59 (58%) patients from an English-speaking background.

What healthcare communication situations do nurses report to be most difficult?

As detailed in Figure 3, nurses reported that 21/34 (62%) of patients could “never” or only “sometimes” “tell about any medical concerns they had”. Over 50% of patients with communication difficulty were identified as not consistently able to “understand their medical condition” (56%; n = 19) or “its implications” (53%; n = 18).

Figure 3. Nursing report of communicating with patients on the Inpatient Functional Communication Interview, Screening Questionnaire (O'Halloran et al., 2020).

Half of participants (n = 17/34) were assessed by nurses as “never” or only “sometimes” able to “understand and remember information about what is happening, going to happen, or has happened in relation to their health care”. For an additional five (15%) patients, nurses “didn’t know” if their patients could do this. When considered together, this means that nurses reported that 65% of these 15 patients with communication difficulty could not consistently, across the course of a shift, demonstrate an ability to understand what was happening in their healthcare during routine care interactions. In contrast, nurses reported “always” being able to get the patient’s attention with 27/34 (79%) of patients. Similarly, nurses reported 22/34 (65%) of patients were “always” able to follow instructions.

Phase 2

The following results are derived from the SLP’s semi-structured interviews with 15 patient participants with communication disability. These results focus on the supports used to aid effective communication during the interview, in the context of each healthcare communication situation represented in the IFCI.

In what specific healthcare communication situations do environmental communication supports improve communication access for patients with a range of communication disabilities?

The provision of communication supports improved communication access across all communication situations. Table II provides details of the number of participants interviewed in each situation, the number who needed communication supports, and how often this led to communication success. For example, 10/11 (91%) of participants interviewed regarding “telling about pain or discomfort” needed communication support and the provision of supports led to successful communication with 9/10 (90%).

Table II. Inpatient Functional Communication Interview^a Communication situations: Requirement for and effect of communication supports (ranked by level of support required).

Communication situations	Patients interviewed (n)^b	% patients interviewed requiring support (n)	% patients supported, requiring one support (n)	% patients supported, requiring >1 support (n)	% occasions support led to communication success (n)
Telling about pain or discomfort	11	91% (10)	30% (3)	70% (7)	90% (9)
Telling what they do/don’t like	14	29% (4)	25% (1)	75% (3)	100% (4)
Asking questions about their care	14	64% (9)	22% (2)	78% (7)	78% (7)
Following instructions	13	77% (10)	20% (2)	80% (8)	50% (5)
Gaining the patient’s attention	15	73% (11)	18% (2)	82% (9)	82% (9)
Calling for a nurse	15	40% (6)	17% (1)	83% (5)	33% (2)
Telling what happened to bring them into hospital	13	100% (13)	15% (2)	85% (11)	69% (9)
Asking for something	13	69% (9)	11% (1)	89% (8)	100% (9)
Telling about any medical concerns	12	100% (12)	8% (1)	92% (11)	75% (9)
Expressing how they are feeling	14	93% (13)	8% (1)	92% (12)	100% (13)
Understanding the medical condition or reason for admission	14	100% (14)	7% (1)	93% (13)	71% (10)
Understanding what is happening (immediate recall)	14	100% (14)	7% (1)	93% (13)	71% (10)
Telling about their pre-admission medical history	14	100% (14)	0	100% (14)	71% (10)
Remembering what is happening (delayed recall)	13	100% (13)	0	100% (13)	54% (7)
Understanding the implications of their current medical condition	14	100% (14)	0	100% (14)	36% (5)

^aInpatient Functional Communication Interview (O’Halloran et al., 2020).

^bNumber of patients who were interviewed and scored on each situation.

In seven communication situations—“telling what happened to bring them into hospital”, “telling about any medical concerns”, “understanding the medical condition or reason for admission”, “understanding what is happening (immediate recall)”, “telling about their pre-admission medical history”, “remembering what is happening (delayed recall)”, “understanding the implications of their current medical condition”,—all participants required communication supports to communicate. However, the effect of providing supports on the success of the interaction varied. The SLP was able to communicate effectively with 9/12 (75%) of participants in the situation “telling about medical concerns” when supports were provided. In comparison, the SLP was only able to communicate effectively with 5/14 (36%) of participants regarding “understanding the implications of their current medical condition” with supports.

The situation “calling for a nurse” had both a lower percentage of participants requiring communication supports and a low success rate when supports were provided. Forty percent of participants needed communication supports in this situation and, when given supports, only 33% were then able to communicate successfully. Figure 4 provides further information on how many participants needed communication supports by situation and how often those supports led to successful communication.

Figure 4. Participants requiring support and communication success when supports were provided.

How many communication supports were needed to facilitate effective communication within each of these specific situations?

As depicted in Table II, in most situations (12/15) the vast majority (≥80%) of participants required multiple supports to facilitate communication access. For example, when “telling about their pre-admission medical history”, “remembering what is happening (delayed recall)”, and “understanding the implications of their current medical condition” all participants interviewed needed multiple supports. Comparatively, the number of participants who required a single support in each situation was low. There were only three situations where more than 20% of participants required just one support. Table III provides further detail on the total number of supports used in each situation across all participants interviewed.

Table III. Total communication supports trialled in each Inpatient Functional Communication Interview^a communication situation (ranked by number of communication supports).

Communication situations	Participants interviewed (n)	Number of supports implemented across dataset (effective/ineffective)
Understanding the implications of their current medical condition	14	80 (34/46)
Understanding what is happening (immediate recall)	14	79 (23/5)
Telling what happened to bring them into hospital	13	69 (50/19)
Telling about their pre-admission medical history	14	63 (40/23)
Expressing how they are feeling	14	62 (62/0)
Understanding the medical condition or reason for admission	14	61 (37/24)
Remembering what is happening (delayed recall)	13	60 (31/29)
Telling about any medical concerns	12	50 (37/13)
Asking questions about their care	14	36 (22/14)
Gaining the patient’s attention	15	33 (25/8)
Following instructions	13	33 (12/21)
Asking for something	13	30 (30/0)
Telling about pain or discomfort	11	28 (23/5)
Calling for a nurse	15	18 (3/15)
Telling what they do/don’t like	14	12 (12/0)

^aInpatient Functional Communication Interview (O’Halloran et al., 2020).

Across the dataset (n = 15), communication supports were implemented on a total of 714 occasions. Once provided, an individual support contributed to the SLP and participant achieving communication success on 66% (n = 473) of occasions. In the remaining 34% (n = 241), the support was not effective. These details are depicted in Table III. Three situations required the highest number of unique categories of communication support to be implemented (24 different categories of support) as seen in Table IV. These were: “understanding the medical condition or reason for admission”, “understanding the implications of their current medical condition”, and “understanding what is happening (immediate recall)”.

What types of communication supports facilitated effective communication in these specific healthcare communication situations?

The communication supports used during the IFCI interviews were coded into 33 distinct categories. These categories are listed in Appendix 1, ranked by frequency of use and effectiveness in facilitating effective communication. The three supports used most often, and with highest efficacy, were “ask follow-up/probing questions”, “closed, yes/no questions”, and “additional time”. In contrast, the three supports that were used least and had the lowest efficacy facilitating effective communication in the specific communication situations within this exploratory study were “give person pen to write”, “prompt to wear glasses/communication aid”, and “photo/pictorial support”.

The category of communication supports implemented and the number of unique supports used in each situation varied by participant and communication situation. For example, as seen in Table IV, “ask follow-up/probing questions” was the most used support to facilitate effective communication for eight of the 15 communication situations. In contrast, “reduce background noise” was the most used support for “gaining the patient’s attention”. Further details about the most effective supports by communication situation are also provided in Table IV.

Table IV. Top effective supports and total unique supports per communication situation.

Communication situation	Most effective supports (frequency used)	Total number of different supports
Gaining the patient’s attention	Reduced background noise for attention (7)	8
	Verbal prompt to maintain attention (5)
	Increased volume of communication partner voice (4)
Telling what happened to bring them into hospital	Ask follow-up/probing questions (8)	22
	Summarise person’s output (6)
	Closed questions, yes/no questions (5)
	Additional time (5)
Understanding the medical condition or reason for admission	Ask follow-up/probing questions (6)	24
	Closed questions, yes/no questions (6)
	Reworded question/input (4)
Understanding the implications of their current medical condition	Ask follow-up/probing questions (5)	24
	Additional time (4)
	Summarise person’s output (4)
Following instructions	Repetition of question (4)	9
	Break into component parts/chunk (3)
Expressing how they are feeling	Additional time (10)	17
	Reworded question/input (7)
	Break into component parts/chunk (7)
Telling about their pre-admission medical history	Closed questions, yes/no questions (10)	19
	Spoken options (8)
	Ask follow-up/probing questions (5)
Understanding what is happening (immediate recall)	Closed questions, yes/no questions (5)	24
	Reworded question/input (5)
	Summarise person’s output (5)
	Written key words (4)
Asking questions about their care	Ask follow-up/probing questions (5)	18
	Reworded question/input (2)
	Summarise person’s output (2)
	Accept vague responses (2)
	Written key words (2)
Telling about any medical concerns	Ask follow-up/probing questions (8)	18
	Reworded question/input (6)
	Break into component parts/chunk (4)
Telling about pain or discomfort	Ask follow-up/probing questions (7)	13
	Closed questions, yes/no questions (4)
Asking for something	Closed questions, yes/no questions (7)	13
	Spoken options (4)
	Ask follow-up/probing questions (3)
	Summarise person’s output (3)
Telling what they do/don’t like	Ask follow-up probing questions (2)	11
Remembering what is happening (delayed recall)	Ask follow-up/probing questions (6)	17
	Semantic/gestural/tactile cues (5)
	Handouts to refer to (3)
Calling for a nurse	Repetition of question (2)	9
	Additional time (1)

Discussion

The overall aims of this study were to identify the sub-acute rehabilitation inpatients who had a communication difficulty and to identify the types of communication situations and supports that facilitated communication within patient-SLP interviews. The goal of this research was to inform the evidence base underpinning future CPT programs; specifically, to identify supports that are effective across a range of communication disorders, customised for specific healthcare communication situations within a sub-acute rehabilitation inpatient context. Additionally, it sought to incorporate a contextual understanding of the environment, informed by nurses.

Nurses identified communication difficulty in almost two-thirds of inpatients (45/70; 64%) across two sub-acute rehabilitation wards. The assistance of an interpreter may have resolved nurse-patient communication difficulties with 11 of these patients. However, nurses still faced difficulty communicating with 34/59 (58%) of patients from an English-speaking background. Nurses identified that “telling about any medical concerns” was the most challenging situation for them to communicate with patients about. The use of communication supports during the patient-SLP interviews facilitated communication for all patients, albeit to varying degrees across different situations. In this sample of patients, the communication situations (i.e. communication activities) most receptive to positive change with the addition of environmental communication supports included “telling what they did/didn’t like”, “asking for something”, and “expressing how they were feeling”. The most challenging situations to modify with communication supports included “calling for a nurse” and “understanding the implications of their current medical condition”. Supports were implemented on a total of 714 occasions across 15 interviews and were successful in 66% (473/714) of instances. The most frequently used and effective supports included “asking follow-up/probing questions”, “closed, yes/no questions”, and “additional time”. This study provides novel insights into the communication difficulties faced by sub-acute rehabilitation nurses, offers an understanding of communication activity limitations in sub-acute rehabilitation inpatient settings, and presents evidence regarding the types and quantity of supports required for effective communication facilitation, when administered by an experienced SLP.

Previous research has found that nurses had difficulty communicating with 40% of inpatients on an acute general medical ward (O'Halloran et al., 2017) and 55% of inpatients on an acute stroke unit (O'Halloran et al., 2012a, 2012b). Whilst the prevalence of communication difficulty identified by nurses in this study is similar, it is slightly higher. As noted earlier, data collection occurred in the context of COVID-19 when all healthcare providers were required to wear PPE, including face masks, and visitors were restricted. It may be that the strategies, put in place by hospitals to minimise the spread of COVID-19, also contributed to the higher rate of communication difficulty reported in this study. Given these earlier studies were conducted in an acute setting pre-COVID-19 and this study was completed in a sub-acute rehabilitation setting during COVID-19, together these findings suggest that patient-provider communication is challenging, and many healthcare providers and patients experience difficulty communicating effectively about healthcare across neurological and general medical/rehabilitation inpatient settings.

The kinds of communication situations that nurses reported difficulty communicating with patients about also warrants further attention. In this study, nurses reported that the most difficult situation was communicating with patients about their medical concerns. As described earlier, there is extensive literature on the impact of ineffective patient-provider communication on patients’ ability to participate in and receive appropriate healthcare (Bartlett et al., 2008; Clancy et al., 2018; Hemsley et al., 2013; Hoffman et al., 2005; Hvidt et al., 2014; Iacono et al., 2020; Iacono & Davis, 2003; Mencap, 2007; Penney & Wellard, 2007; Stransky et al., 2018). If nurses are unable to communicate with patients about their medical concerns, inadequate, inappropriate, and delayed care is likely.

The personal and professional toll on healthcare providers when they are unable to communicate with patients is becoming better understood (Carragher et al., 2021; Hemsley et al., 2001; Kagan et al., 2018; Sundin et al., 2002). The findings of this study may add to this body of work. Nurses reported that a significant proportion of their patients had difficulty not only in consistently “telling about their medical concerns”, as mentioned above, but also in “asking questions about their care”. Further, up to 50% of their patients were unable to “call for help” when needed. That is, these nurses could not be sure whether the majority of patients in their care were comfortable, informed, and could get help when needed. Compounding the communication challenges faced by nurses, requirements for PPE, such as face masks, is ongoing in healthcare. Evidence suggests face masks contribute to ineffective patient-provider communication (Homans & Vroegop, 2022; Saunders et al., 2021). These factors underscore the challenging working conditions routinely dealt with by healthcare staff. In this context, the burden of ineffective communication could be a contributing factor towards workforce shortages (Cornish et al., 2021; Lopez et al., 2022) and burnout amongst healthcare professionals (Bismark et al., 2022) post-COVID-19. This highlights the critical need to address ineffective patient-provider communication, to support both patients and healthcare providers in inpatient settings.

Patient-provider communication in some situations was more challenging than others during administration of the IFCI by the SLP. There were seven healthcare situations where the SLP needed to modify the environment with communication supports with every patient interviewed, in order to achieve effective communication. These included “telling what happened to bring them into hospital”, “telling about any medical concerns”, “understanding the medical condition or reason for admission”, “understanding what was happening (immediate recall)”, “remembering what was happening (delayed recall)”, “telling about their pre-admission medical history”, and “understanding the implications of their current medical condition”. In addition, in two situations—“calling for a nurse” and “understanding the implications of their medical condition”—providing communication supports did not typically result in more successful communication. This finding aligns with Carragher et al. (2021), where healthcare professionals reported that communication supports were not always effective. Some healthcare communication situations appear to be consistently more challenging for patients with communication disability to effectively communicate in than others, whether communication supports are available or not.

In contrast, some healthcare communication situations were easier to facilitate than others during the SLP-patient interviews. That is, providing communication supports frequently led to effective communication in these situations. For example, during the IFCI the SLP documented that most patients (93%) were initially unable to “express how they were feeling”. When the SLP used communication supports, they were able to successfully communicate with every patient in this situation. Indeed, the provision of communication supports enabled more successful communication most of the time in 12/15 situations. This suggests that despite some situations being more challenging than others, overall the majority of healthcare communication situations reviewed in the SLP-patient interviews were accessible to patients, regardless of communication disorder type, when communication supports were used by an experienced SLP. This supports the exploration of context-specific approaches within CPT programs.

A critical finding of this study was that multiple supports were typically needed to facilitate communication. Approximately one-third (34%) of the time, the supports initially trialled by the SLP were ineffective, indicating how often communication breakdown might need to be navigated during patient-provider interactions. In addition, some situations required a larger number of unique supports to be trialled, specifically the situations “understanding the medical condition or reason for admission”, “understanding the implications of their current medical condition”, and “understanding what is happening (immediate recall)”, which may speak to the inherent complexity of these healthcare communication situations. Instances where patients only needed one support to facilitate effective communication in a situation were rare and included patients “telling about pain or discomfort” and “telling what they did/didn’t like”, indicating these situations were comparatively easier to support. A novel finding of this research is that most often, multiple supports in combination are required to achieve effective communication.

Of note, the supports that resulted in successful communication most of the time in this study were relatively simple, such as “asking follow-up/probing questions”, “asking closed or yes/no questions”, and giving “additional time”. The supports with the lowest success rate were “giving a pen to write”, “prompting to wear glasses/communication aid”, and providing “photo/pictorial support”. However, given the small sample size of this study, the efficacy of these latter supports should not be dismissed. Rather, future research should further explore their efficacy across a range of communication disabilities, healthcare communication situations, and broader healthcare contexts. Another interesting finding is that, although the SLP had knowledge of the patient’s documented communication disorder/s, the selection of communication supports to be trialled was primarily based on the activity limitation in the patients’ responses and the supports that could be drawn upon most efficiently. It should be noted that similar communication supports resulted in successful communication across different patients most of the time. This contrasts with existing CPT programs that prescribe different types of supports for patients with different communication disorders with few overlapping supports (O'Rourke et al., 2018).

These research findings have several implications for CPT programs. Whilst further research is needed to understand the factors that make a healthcare communication situation easier or harder, it may be important to include this information about the impact of specific communication contexts in CPT programs. If healthcare providers knew that some healthcare situations were easier to communicate in than others, then they may be more likely to attribute communication breakdown to the situation rather than to a personal failure in themselves or the patient. This may go some way to reducing healthcare provider negative perceptions about communicating with patients with communication activity limitation, identified by Carragher et al. (2018). It may be useful to incorporate harder communication situations into CPT programs so that healthcare providers get the opportunity to practice trialling different communication supports in these particularly difficult situations. Particularly challenging healthcare communication situations may benefit from broader systemic interventions, for example, efforts to improve health literacy regarding the functional implications of common health conditions. CPT programs may target multiple levels of the health system in their approach.

Furthermore, it could be valuable for healthcare providers to know that whilst trialling communication supports in isolation is relatively simple, recognising and navigating communication breakdown during a healthcare conversation, and trialling multiple communication supports in combination to achieve more successful communication, is not. The time required to implement multiple communication supports to achieve effective communication in the face of busyness experienced by nurses (Govasli & Solvoll, 2020) must inform the design of future CPT programs, so as not to contribute to a sense of overwhelm. It may also be important to reassure healthcare providers that bedside communication supports may not always be effective for all patients in all situations, and that other alternatives may need to be found. SLPs can play a more active role supporting activity limitation in specific contexts. For example, in addition to providing contextually-specific CPT programs to healthcare providers, SLPs may use assessments like the IFCI-SAI to identify supports that are uniquely effective for individual patients and give this information to the patient’s care team.

Limitations and future directions

Whilst the findings of this research may inform the development of future CPT programs with healthcare providers, it does have some limitations. Patients who were not able to provide consent without an interpreter could not be included in Phase 2 of the study. Having greater access to interpreters to consent people with limited or no English into this study would have provided valuable insights into the number of patients from linguistically and culturally different backgrounds who are able to communicate about their healthcare with or without the assistance of an interpreter, and those who require additional communication supports.

Another limitation of this study is that any correlation between documented communication impairment, communication activity limitation, and the communication situations that were difficult or the communication supports that were effective was not investigated. This was not the aim of this work; rather, this study focused on identifying the situations that could be facilitated by supports and the supports themselves. Future research from the perspective of communication activity limitation that explores whether patients with specific and/or multiple types of communication disorders respond differently to different communication supports or communication situations may be valuable.

Given the exploratory nature of this study, further information about the context behind supports was not recorded. For example, “reduced background noise for attention” may be needed for a variety of reasons, including if the patient was easily distracted by noises outside their room, or if the patient had reduced trust in the healthcare system and privacy was important for engagement. There may be barriers to providing supports in some situations, such as shared rooms or other assessments occurring simultaneously, meaning background noise cannot be reduced. Future research looking at the context behind supports, and the relationship between effective supports and environmental factors would broaden understanding of this area.

The engagement of end users, in this case nurses, was limited. The IFCI-SQ data regarding prevalence of communication difficulty and situations rated as challenging by nursing staff aimed to provide a contextual snapshot of the communication environment on the wards. Future research could identify whether all participants identified as having communication difficulty also had a documented communication impairment. It would also be beneficial to further explore nursing perspectives of the findings of this study. Furthermore, engaging patients and their close others will also be vital to inform CPT programs that seek to improve patient-provider communication in healthcare settings.

Finally, given the exploratory nature of this project, this study is limited by the small number of patients who participated in an IFCI with the SLP and a single SLP identifying the supports that facilitated successful communication within each interview. Further investigation of the supports that facilitate effective communication in healthcare communication situations with a larger number of patients, and with the identification of supports by multiple SLPs and/or other healthcare providers, would be valuable to understanding the breadth of communication supports that could be trialled.

Conclusion

Effective patient-provider communication is key to the provision of quality care (Australian Commission on Safety and Quality in Health Care, 2022). Ineffective patient-provider communication significantly impacts patient healthcare and staff wellbeing. CPT programs for healthcare providers have been recommended to facilitate more effective patient-provider communication. However, research indicates that implementing CPT programs in practice is difficult. The findings of this research indicate that CPT programs may need to explicitly state that some communication situations are harder than others, and that successful communication is often, but not always, achieved by navigating multiple communication breakdowns and trialling multiple communication supports. This can be challenging, particularly in the context of competing demands and the busyness of hospital healthcare providers. However, the provision of communication supports that enable effective patient-provider communication may not only enhance the patient’s healthcare and healthcare providers’ own wellbeing, it will also protect the dignity, autonomy, and human rights of people with communication activity limitation in the hospital setting (McLeod, 2018).

Acknowledgements

Thank you to the Monash Health Emerging Researcher Fellowship program and the Monash Health Speech Pathology Department for funding this research project. Thank you also to the nursing staff and patients at Monash Health for participating in and supporting this research.

Disclosure statement

The first three authors report no conflicts of interest. The final author is the first author of the Inpatient Functional Communication Interview: Screening, Assessment, and Intervention (IFCI-SAI) for which she receives royalties. The authors alone are responsible for the content and writing of the paper.

Additional information

Funding

This work was supported by a Monash Health Emerging Researcher Fellowship, by the Monash Health Speech Pathology Department, and by the nursing staff and patients who kindly participated.

Appendix 1.

Supports used across all situations from Phase 2 interview

Table

Supports	Communication situations and supports used—total number of trials of each support (% effective)
	Gaining the patient’s attention	Telling what happened to bring them into hospital	Understanding the medical condition or reason for admission	Understanding the implications of their current medical condition	Following instructions	Expressing how they are feeling	Telling about their pre-admission medical history	Understanding what is happening (immediate recall)	Asking questions about their care	Telling about any medical concerns	Telling about pain or discomfort	Asking for something	Telling what they do/ don’t like	Remembering what is happening (delayed recall)	Calling for a nurse
Ask follow-up/probing questions	0	11	7	12	0	6	7	4	5	9	7	3	2	9	1
		73%	86%	71%		100%	71%	75%	100%	89%	100%	100%	100%	67%	0%
Closed, yes/no questions	0	5	7	8	0	2	13	7	1	1	4	7	0	3	1
		100%	86%	38%		100%	77%	71%	100%	100%	100%	100%		67%	0%
Additional time	0	6	2	6	2	10	3	3	1	2	2	2	0	3	1
		83%	100%	67%	0%	100%	100%	100%	100%	100%	100%	100%		67%	100%
Reworded question/input	0	5	7	9	2	7	5	8	3	8	2	0	0	4	4
		40%	57%	33%	0%	100%	40%	63%	67%	75%	50%			50%	0%
Summarise person’s output	0	7	1	6	0	5	1	5	2	2	0	3	1	0	0
		86%	100%	67%		100%	0%	100%	100%	100%		100%	100%
Increased volume of communication partner voice	5	2	1	1	3	1	1	2	3	3	2	0	1	2	0
	80%	100%	100%	100%	67%	100%	100%	100%	33%	100%	50%		100%	100%
Accept vague responses	0	1	2	3	0	5	2	2	2	3	0	2	1	1	0
		100%	50%	67%		100%	100%	100%	100%	67%		100%	100%	100%
Wait until finished talking	2	3	1	3	0	6	5	3	1	2	0	0	1	2	0
	100%	67%	100%	67%		100%	0%	33%	100%	100%			100%	50%
Written key words	0	4	5	4	2	3	2	8	4	3	1	1	1	6	1
		25%	40%	25%	0%	100%	50%	50%	50%	33%	100%	100%	100%	17%	0%
Dynamic questions	0	4	4	5	1	1	4	1	1	2	2	0	1	0	0
		75%	75%	20%	100%	100%	50%	100%	100%	100%	100%		100%
Semantic/ gestural/tactile cues	1	0	2	2	6	0	0	4	2	4	3	2	1	8	3
	0%		0%	50%	33%			75%	0%	25%	67%	100%	100%	63%	0%
Break into component parts/chunk	0	0	0	0	7	7	0	1	0	5	0	0	0	0	0
					43%	100%		100%		80%
Spoken options	0	0	1	1	0	0	9	2	2	1	0	4	1	0	0
			0%	0%			89%	100%	0%	0%		100%	100%
Repetition of question	0	2	2	2	9	1	2	3	3	0	1	0	0	5	5
		100%	50%	0%	44%	100%	0%	33%	33%		0%			40%	40%
Specific AAC device	0	1	1	1	0	0	1	1	1	1	0	1	1	1	0
		100%	100%	100%			100%	100%	100%	100%		100%	100%	100%
Relaxed, calm manner	3	2	2	2	0	0	1	1	0	0	0	1	0	1	0
	100%	50%	50%	50%			100%	100%				100%		100%
Provided answer	0	2	7	2	0	0	1	7	0	0	0	1	0	0	1
		100%	43%	0%			100%	43%				100%			0%
Topic signposting	0	4	1	2	0	0	1	4	0	1	1	0	0	1	0
		75%	100%	50%			0%	50%		100%	100%			0%
Acknowledge feelings/ output	0	2	1	3	0	2	1	4	0	0	0	0	0	0	0
		50%	100%	33%		100%	0%	75%
Expand on the person’s message	0	3	1	3	0	2	0	2	0	0	0	0	0	0	0
		100%	0%	67%		100%		50%
Assist in word finding	0	1	0	1	0	2	1	0	1	0	0	0	0	2	0
		100%		100%		100%	100%		100%					100%
Reduced background noise for attention	9	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	78%
Across two sessions	5	1	0	1	1	1	3	2	0	1	0	0	0	0	0
	60%	0%		0%	0%	100%	67%	50%		0%
Asked person to repeat response	0	1	1	1	0	0	0	0	2	0	1	1	1	0	0
		100%	100%	0%					50%		100%	100%	100%
Handouts to refer to (previously given)	0	0	2	0	0	0	0	0	0	1	1	0	0	9	0
			50%							100%	100%			33%
Verbal prompt to maintain attention	7	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	71%
“wh-” questions	0	0	0	0	0	0	0	3	0	0	0	0	0	0	0
								100%
More than one communicat-ion partner	0	1	1	0	0	0	0	0	0	0	1	2	0	1	1
		0%	0%								0%	100%		0%	0%
Communication partner in person’s field of vision	1	0	0	0	0	0	0	0	0	0	0	0	0	0	0
	100%
Prompt to read key words aloud	0	1	1	0	0	0	0	1	1	0	0	0	0	2	0
		0%	0%					100%	0%					0%
Give person pen to write	0	0	0	0	0	1	0	0	1	0	0	0	0	0	0
						100%			0%
Prompt to wear glasses/ communication aid	0	0	0	1	0	0	0	1	0	0	0	0	0	0	0
				0%				100%
Photo/ pictorial support	0	0	1	1	0	0	0	0	0	1	0	0	0	0	0
			0%	0%						0%