Picture boards help those who can't speak for themselves

More hospitals are using pictures to communicate with non-English speakers, the deaf and other nonverbal patients.


Clear communication between patients and hospital staff is essential to providing high-quality care, but that can be a challenge when patients cannot convey their thoughts verbally. To overcome that barrier, a growing number of hospitals are using picture boards to make sure that such patients' needs and symptoms are not misconstrued or ignored.

At Nazareth Hospital in Philadelphia bilingual employees helped provide words in different languages to accompany the hospitals picture board
At Nazareth Hospital in Philadelphia, bilingual employees helped provide words in different languages to accompany the hospital's picture board.

“We use the picture board primarily for people with neurological problems or who are on ventilators,” said Anju Agarwal, ACP Member, a hospitalist with Central DuPage Inpatient Physicians in Winfield, Ill. For example, she may ask a patient if he or she is hungry by touching a picture of a steaming bowl of rice with the word “hungry” beside it or offer to call a friend or relative by pointing to a picture of a phone.

If a patient indicates she has pain, Dr. Agarwal uses a picture board to gain a clearer idea of the nature, intensity and location of the pain. To communicate “sharp” pain, for example, the patient points to a jagged, lightning-streak image. “New versus old pain” is represented by a picture of a new car next to an antiquated model.

Hospitals are also using picture boards to communicate with patients who speak little or no English, an effort that is being championed by the Department of Health and Human Services' Office for Civil Rights under its Effective Communication in Hospitals initiative ().

“Picture boards are a vital aspect of a good tool kit to help deal with communication challenges in hospitals,” said Tamara Miller, deputy director of the HHS Civil Rights Division. For example, she added, “visual images can be the most effective way to communicate with people who have been deaf since birth and rely on sign language as their primary way of communicating.”

Using multilingual boards

At Nazareth Hospital in Philadelphia, bilingual employees helped provide words in different languages to accompany the 32 pictures on the hospital's picture board, which also has an alphabet and numbers. The available translations include Russian, Urdu, Filipino, Spanish, Italian, French and Polish, said Evelyn Kozlowski, RN, a nurse manager in the transitional care unit at the hospital.

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“We have found that Russian and Polish have many dialects,” she said. So the care staff keeps picture boards with blank spaces in which the patients' families fill in the words in their dialects.

Barnes-Jewish Hospital in St. Louis worked collaboratively with the Missouri Hospital Association (MHA) to create a picture communication board/poster with about 74 pictures, each paired with one- or two-word descriptions. MHA is translating the words into different languages and will then post the picture board on its Web site for the public to access, said Laurie Wood, RN, patient education program coordinator in the hospital's Center for Practice Excellence.

The emergency department at University Hospital in Newark, N.J., uses picture boards with words in French Creole and Spanish to speed up triage of patients who have limited or no English proficiency. As part of the assessment, the physicians or nurses try to get the person to point to a body part, said Tom-meka Archinard, MD, associate medical director for the ED.

“Some people catch onto [the picture board] very quickly—they will point to a picture of pain or a burn,” said Dr. Archinard. “The pictures for itch, cut, burn, breathing or bites tend to be easier than general symptoms like nausea.”

Overcoming the limits of symbols

Finding and using pictures to communicate instructions or abstract ideas can be a challenge. With that in mind, a picture board should include an image that states, “What I want to say is not on this board,” according to Carrie Kane, a speech pathologist and assistive technology practitioner for Good Shepherd Rehabilitation in Allentown, Pa.

Picture boards also have to be “culturally appropriate,” stressed the HHS’ Ms. Miller. That means hospitals must be aware of pictorial symbols that have very different meanings in various cultures.

As one example, a picture of an extended hand connotes a “helping hand” for many people in the U.S., explained Nataly Kelly, a consultant on cultural and language issues in health care in Nashua, N.H. But the symbol can mean “prohibited” or can be considered obscene in other cultures, she added.

“If you're going to use a picture, another option is to also have an audio component you can play by pushing a button or playing a compact disc,” Ms. Kelly said. That way, the patient can hear the question accompanying the picture in his or her own language. But the only way to truly communicate in both directions is to use a professional interpreter, she said.

Hospitals using pictures boards do tap interpreter services as needed. Central DuPage's Dr. Agarwal notes that if a patient can't speak English, staff has immediate access to interpreter services through an 800 number available on every phone.

Special techniques can improve effectiveness

Some patients require training or time to learn to use a picture board. If a patient can't physically point to a picture, health care staff can use a concept called scanning, Ms. Kane said. That's where the physician or nurse will ask row by row, “Is what you want in this row?”

Using a yes/no response, “the user directs the listener to the row and then to the targeted letter/picture,” Ms. Kane explained.

For that approach to work with a nonverbal patient, the physician or nurse has to establish a clear “yes/no” system with the patient as soon as possible. Ms. Kane advocates having the patient use head nods and “thumbs up” for yes. “For people who are unable to move any extremity consistently, we use eyes up for ‘yes' and eyes down for ‘no,’” she added.

To help a patient get used to a picture board on the day of admission, Nazareth Hospital's transitional care unit nursing staff pulls it out each time they speak with the person, said Ms. Kozlowski. If staff has to turn the person, for example, they pick up the board and point to the picture of turning. “The board gives us a chance to show patients what we are going to do before we touch them,” she said.

A plethora of picture boards

Hospitals in the market for picture boards can design their own, partner with their state hospital association to develop one, as Barnes-Jewish Hospital has done—or buy a board from a vendor.

There are dozens of premade manual communication boards for adults in acute care settings, said Good Shepherd's Ms. Kane. Vendors also sell software packages that health care providers can use to make customized communication boards.

HHS’ Ms. Miller notes that, as part of the Effective Communication in Hospitals initiative, the agency hopes to “stimulate dialogue and information exchange so that hospitals critique the various picture board products available.”