Annotated Bibliography on Patient-Provider Communication
By Heather Smith and Andrea Pietrzyk
Research and Resource Associates
Central Coast Children's Foundation, Inc.
Communication problems between patients and health care workers are far too often at the root cause of inadequate medical treatment, unnecessary errors, excess pain, and even death. There are lots of reasons for these communication problems. There are lots of (often inexpensive and simple) things that can be done about them. But far too little actually happens, with regard either to understanding these problems or applying the readily available solutions, in part because there is no single convenient place to go to gain access to information about either (1) the causes of the problems or (2) the tools available for dealing with them.
The following collection is intended as one small step towards alleviating this access problem. Hopefully, it will make it a little easier for people interested in bridging the communication gaps between patients and health care workers to know where to find useful information on the subject.
A. Understanding Language and Culture Issues Between Patients and Providers
Over the past four decades, the United States has attracted immigrants from all around the world, with the majority emigrating from Latin America, Asia and Europe. The resulting increase in ethnic, cultural and linguistic diversity has been accompanied by a great — and growing — need for language access services in health care settings. However, most health care organizations provide either inadequate interpreter services or no services at all, and patients who have limited English proficiency do not receive needed health care or quality health care. Often, persons enlisted to help patients communicate with health care providers are not trained interpreters; instead, they are fellow patients or are family members, friends, un-trained nonclinical employees, or non-fluent health care professionals. Reliance on such ad hoc services has been shown to have negative clinical consequences like longer hospital stays, patients becoming sicker because of failure to continue treatment, missed appointments, passing infectious diseases to others, misdiagnoses by doctors, and low patient satisfaction. Moreover, these adverse outcomes are often exacerbated by the vulnerability and fear patients experience when they do not speak the same language as their caregivers.
Indeed, interpretation mistakes underpin many preventable adverse outcomes in medical settings. RMarchione writes about a study involving thirteen medical visits between pediatricians and Spanish-speaking mothers at a Boston clinic to illustrate the gravity of medical interpretation errors in health care settings. The study reports that an average of thirty-one interpretation errors occurred during each of the thirteen doctor visits. Of these errors, sixty-three percent were considered serious enough to have adverse medical consequences due to altered descriptions of illnesses to doctors, misstated diagnoses or treatment options, misunderstandings about a child's condition, or misconceptions about the need for follow-up visits or referrals. The author comments that when professional interpreters are not available, health care staff often rely on nurses, social workers, friends, or family members of patients, increasing the risk of interpretation errors.
Although many preventable adverse events in health care settings occur as a result of language and cultural barriers, a study about parental reports of communication problems with health care providers showed that foreign-born parents were 11.8% more likely to report communication problems than American-born parents. This demonstrates that many patients and their families recognize that there are serious communication problems that inhibit them and their loved ones from getting the care they need. However, according to the same study, cultural and socio-economic influences and health literacy issues also affect communication in health care settings even more; 24.4% of low-income parents reported poor communication with health care providers.
As the population of the United States becomes ever more diverse and the languages spoken multiply, growing numbers of patients who speak no English are being isolated by language barriers. Moreover, cultural and socio-economic influences affect the continuum of patient-provider communication. The consequences of medical miscommunication can be severe. Patients become sicker because they fail to stick to treatment regimens that they do not understand. They miss appointments. They pass on infectious diseases because they do not know how often to take their medication or when to return for follow-up care. Doctors miss diagnoses, or get people to agree to procedures they do not fully understand. To compensate for their sketchy knowledge of patients' symptoms, doctors order too many tests, some very expensive, others potentially risky.
However, according to a 2002 report from the Office of Management and Budget it would cost, on average, only $4.04 (0.5 percent) more per physician visit to provide all U.S. patients who have limited English proficiency with appropriate language services for emergency-department, inpatient, outpatient, and dental visits. This seems like a small price to pay to ensure safe, high-quality health care for the 49.6 million Americans who have limited English proficiency.
The following articles provide additional help in understanding the nature of language and cultural barriers to patient: provider communication:
1. Fein, Esther B. (1997, November 23). Language Barriers Are Hindering Health Care. The New York Times.
Many years ago, Fein explores the growing likelihood that, as immigrants settle in the United States and the number of languages in the country continues to multiply, more non-English speaking patients are isolated due to communication barriers in hospitals. She discusses several of the problems that can arise due to medical miscommunication (patients becoming sicker because of failure to continue treatment, missed appointments, passing infectious diseases to others, misdiagnoses by doctors, etc). A trained medical interpreter is the best option for reducing communication barriers between caregivers and patients, but this is not always possible; sometimes children, friends, or telephone interpreting services are used instead.
2. Saha, Somnath and Fernandez, Alicia. (2007). Language Barriers in Health Care. Journal of General Internal Medicine, 22(2), 281—282.
The article begins with a scenario in which the reader is visiting a small town in China's Yunnan Province and does not speak the native language. The reader falls ill and is taken to a clinic where he is seen by a doctor who prescribes him medication. Unable to properly explain his symptoms and allergies to certain medications, the reader leaves the clinic unable to discern what is wrong with him or if the medication will heal or harm him. This story exemplifies the daily language barriers in health care occurring in the United States by providing insight into the vulnerability and fear patients experience when they do not speak the same language as their caregivers.
3. Clemens-Cope, Lisa and Kenney, Genevieve. (2007). Low Income Parents' Reports of Communication Problems with Health Care Providers: Effects of Language and Insurance. Public Health Reports, 122, 206-216.
The research article discusses a study about parental reports of communication problems with health care providers, focusing on low-income families. The researchers use literature and quantitative analysis as the primary methods in their study, and they analyze data from the 1999 and 2002 National Survey of America's Families. The results show that 24.4% of low income parents reported poor communication with health care providers, and foreign-born parents were 11.8% more likely to report communication problems than American-born parents. The authors advise using professional translating services in hospitals and clinics to reduce communication barriers and improve health care.
4. Marchione, Marilynn. (2003, January 6). Language linked to medical mistakes: Study at Boston clinic examines growing problem of errors made by interpreters. JS Online: Health & Science. Article available for purchase through the following website:
http://www.alcinc.com/PressRelease/2004/1stQt/PDF/1stQt04.pdf (see pg. 5)
To illustrate the gravity of medical interpretation errors in health care settings, Marchione writes about a study involving thirteen medical visits between pediatricians and Spanish-speaking mothers at a Boston clinic. The study shows that an average of thirty-one interpretation errors occurred during each of the thirteen doctor visits, which were tape-recorded and subsequently analyzed to detect such interpretation mistakes. Of these errors, sixty-three percent were considered serious enough to have adverse medical consequences due to altered descriptions of illnesses to doctors, misstated diagnoses or treatment options, misunderstandings about a child's condition, or misconceptions about the need for follow-up visits or referrals. The author comments that when professional interpreters are not available, health care staff often rely on nurses, social workers, friends, or family members of patients, increasing the risk of interpretation errors.
5. Flores, Glenn. Language Barriers to Health Care in the United States. The New England Journal of Medicine. Volume 355:229-231 (July 20, 2006), Number 3.
This article discusses the grave medical miscommunications and the increased incidence of adverse clinical consequences that occur when untrained, ad hoc interpreters are used in health care settings. Despite the growing number of people who have limited English speaking abilities in the United States, many patients who need medical interpreters have no access to them. The provision of adequate language services results in optimal communication, patient satisfaction, outcomes, resource use, and patient safety. A 2002 report from the Office of Management and Budget estimated that it would cost, on average, only $4.04 (0.5 percent) more per physician visit to provide all U.S. patients who have limited English proficiency with appropriate language services for emergency-department, inpatient, outpatient, and dental visits. This seems like a small price to pay to ensure safe, high-quality health care for 49.6 million Americans who have limited English proficiency.
6. Gregg, Jessica and Saha, Somnath. (2007). Communicative Competence: A Framework for Understanding Language Barriers in Health Care. Journal of General Internal Medicine, 22(2), 368-370.
The authors make an important distinction between translation and interpretation in health care settings, indicating that translating the words doctors and patients use to communicate does not suffice. This is because the use of certain words varies dramatically between diverse languages and cultures, which may significantly impact the success or failure of clinical encounters. When health care providers and patients do not understand the intent or context of their verbal interactions, language barriers often impede care and increase the risk of medical errors. Possible ways to reduce these kinds of language barriers include increasing the linguistic and cultural diversity of health care staff and allowing patients greater choice in selecting providers with whom they can effectively communicate.
7. No author. (2008, June 11). Children In Non-English-speaking Households Face Many Health Disparities, Researcher Concludes. ScienceDaily.
This article discusses Dr. Glenn Flores's study in which he analyzed statistics from the National Survey of Children's Health to examine disparities between health care for English-speaking and non-English primary language (NEPL) children. The survey used nationwide random sampling to interview 102,353 children (and their caregivers) in both English and Spanish between 2003 and 2004. The study found that children in households where English was not the primary language were more likely to be poor, overweight, have only fair or poor dental health, be uninsured, have made no medical visits during the previous year, and to be dissatisfied with physicians and health care providers. While this article was mainly written to address disparities in health care due to language barriers, it also discusses some strategies to eliminate barriers to care.
8. No author. (2005, 17 August). UCSF Study Finds English Proficiency A Major Hurdle In Patient Comprehension. ScienceDaily.
The article describes a University of California, San Francisco (UCSF) study in which researchers conducted telephone surveys with 1,200 Californians in eleven different languages. Researchers asked respondents forty-eight questions to find out about their experiences with health care access, satisfaction and comprehension. Limited English proficient (LEP) respondents were significantly more likely than their English-speaking counterparts to misunderstand medical situations, experience confusion in taking medication, and have trouble understanding medication labels. In addition to poorer comprehension, LEP respondents were more likely than English-speaking respondents to be female, elderly, uninsured, less educated, and have lower incomes. The results highlight the adverse outcomes resulting from communication barriers between patients and physicians, indicating a need for greater cultural and linguistic competence in the U.S. health care system.
B. Overcoming Language and Cultural Communication Barriers
Communication is a critical element of patient safety and quality care. Addressing communication barriers is also an important component of an organization's safety strategy and risk management activities, and is often a legal requirement. Language access services, including interpreters, translators, using written materials or communication boards, and using sign language in the most frequently encountered languages, are essential to meeting many of the communication needs encountered by health care organizations. The benefits of including language access services in health care settings include increased access to health care, more preventive health activities, higher quality care, increased patient satisfaction, and ensuring appropriate resource utilization.
In order to execute the most effective and wide-reaching language access services, many experts suggest that the first step in addressing communication barriers in health care facilities is to assess the language and communication needs of the population served. For example, St. Vincent's Hospital in Manhattan has made efforts to bridge language barriers, using Asian artwork, food, signs, and Chinese staff to cater to the population living in nearby Chinatown. The implementation of language access services that concentrate on the population's language and culture has been proved very successful in this instance. Indeed, picture boards and other low-tech tools help in facilitating communication in all medical settings, including but not limited to ambulances, hospitals, emergency rooms, and health clinics. Many U.S. residents do not speak proficient English, and such tools bridge the communication gap.
In addition to using alternative, low-tech tools, heath care facilities can also utilize trained interpreters and translators to mitigate language and cultural barriers. Grace Plaza of Great Neck Comprehensive Care Center's language bank program, which uses staff members and volunteer interpreters to communicate with patients and family members who do not speak English, is an interesting example of this approach. Before the program was implemented, the medical center used language boards with pictures and symbols to communicate with patients. The new language program uses a schedule showing when staff members who speak foreign languages are available to interpret, and employment applications include questions regarding prospective staff members' foreign language skills. The example of the language bank program exemplifies that using interpreting services in medical establishments enables patients to communicate their questions and needs to physicians and staff more effectively. Trained interpreters can also effectively convey messages regarding diagnosis, treatment, and payment options to patients to avoid communication errors and misunderstandings.
The following articles provide additional clues to ways to overcome language and cultural barriers to patient: provider communication:
1. Shafer, Emily. (2007). Doctor-patient communication critical to patient care, expectations often not met. HemOnc Today.
Emily Shafer advocates the importance of doctor-patient communication throughout the diagnosis, treatment, and recovery processes in order for health care professionals to provide quality care. She examines Walter Baile's (a doctor and professor of behavioral science and psychiatry) claim that it is essential for doctors to understand their patients' emotions, as well as their own, when discussing diagnoses and treatment options. The author discusses various programs that train physicians, nurses, and social workers to relay difficult messages to patients, enhancing their necessary communication skills.
2. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2008). Promoting Effective Communication-Language Access Services in Health Care. Joint Commission Perspectives, 28(2), 8-11.
The article discusses the importance of reducing language barriers for people with limited English proficiency (LEP) in health care settings, for two reasons: to promote safe, high-quality care and to comply with legal requirements. The next section addresses how to reduce language barriers by recommending that health care facilities assess the language and communication needs of the population they serve to execute the most effective and wide-reaching services. Such language services may include hiring interpreters, using written materials or communication boards, or using sign language in the most frequently encountered languages. The last section provides a list of resources to help organizations improve their language access services.
3. Pacheco, Guadalupe. (2005). A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations. Office of Minority Health (OMH), U.S. Department of Health and Human Services (DHHS) by the American Institutes for Research (AIR), 1-5.
The introduction to this guide addresses the importance of language access services (LAS) for limited English proficient (LEP) patients in health care organizations. The author illustrates several benefits of LAS, including increased access to health care, higher quality care, increased patient satisfaction, and ensuring appropriate resource utilization. The Office of Minority Health issued the National Standards for Culturally and Linguistically Appropriate Services in Health Care in 2000 to address existing inequalities in health care services. These standards are categorized into three categories: culturally competent care, language access services, and organizational supports.
4. Fischman, Josh. (2006). Bridging the Language Gap. Some hospitals make non-English-speaking patients feel right at home. U.S. News World Report, 141(2), 88, 90, 92.
Fischman uses St. Vincent's Hospital in Manhattan to exemplify a health care facility that has made efforts to bridge language and cultural barriers, using Asian artwork, food, signs, and Chinese staff to cater to the population living in nearby Chinatown. The author cites examples of communication errors in medical centers to show how using untrained bilingual people to interpret for patients can result in major communication problems among patients, families, and medical staff. The article also discusses AnMed Health Medical Center's forty-hour course on medical interpreting, which trains interpreters to effectively convey messages regarding diagnosis, treatment, and payment options to patients to avoid communication errors and misunderstandings.
5. Reis, Helen E. (2008). Breaking language barriers: One nursing home's language bank program. Medquest Communications, LLC.
The author discusses Grace Plaza of Great Neck Comprehensive Care Center's language bank program, which uses staff members and volunteer interpreters to communicate with patients and family members who do not speak English. Before this program was implemented, the medical center used language boards with pictures and symbols to communicate with patients. The new language program uses a schedule showing when staff members who speak foreign languages are available to interpret, and employment applications include questions regarding prospective staff members' foreign language skills. The article argues that using interpreting services in medical establishments helps enable patients to communicate their questions and needs to physicians and staff more effectively.
6. Gonzales, Barbara Jean. (2004, April 21). Spanish-speaking patients get help at Health Science Center. North Texas Daily, Student Life. [Link no longer active]
The author describes the University of North Texas's master's degree program in Public Health, which has a concentration in Health Interpreting and Heath Applied Linguistics (HIHAL). Students in the program must have an interest in studying language barrier problems and must be proficient in speaking and writing English and Spanish. They are required to complete 200 hours of interpreting at health care provider sites and will be qualified to work as health interpreters or conduct research after completing the degree. The program is intended to train students to provide better health care to minorities, specifically to the growing Spanish-speaking community.
7. Johnson, Linda A. (2007, September 2). Picture boards help bridge language gap in health emergencies. USA Today, Associated Press.
This article illustrates the importance of picture boards in facilitating communication in all medical settings, including but not limited to ambulances, hospitals, emergency rooms, and health clinics. Many U.S. residents do not speak proficient English, and the author advocates using the boards to bridge the communication gap, especially since 48% of hospitals treat patients with limited English every day. The article concludes by explaining the origins of picture boards and showing how people with communication difficulties can use them to get help during emergencies and disaster drills.
8. Cowgill, Jamie and Bolek, Jim. (2003). Symbol Usage In Health Care Settings for People with Limited English Proficiency. Hablamos Juntos Report: A Program of The Robert Wood Johnson Foundation, Part One, 1-45.
This report illustrates how Limited English Proficiency (LEP) patients often become frustrated and feel isolated in hospitals when they do not understand their primary caregiver's language and cannot read signs. According to Hablamos Juntos, a national program working to eliminate language barriers and improve the quality of health care, LEP patients are often unaware of services available to them, are unable to communicate with health care staff, and suffer from more frequent medical errors. The report explores the history of symbol usage and discusses how using standardized symbols in health care settings can improve communication between caregivers and their patients. JRC Design, under the direction of Hablamos Juntos, developed recommendations for signage materials in health care settings that can be understood by patients regardless of their country of origin, primary language, or education level.
9.Wang, Frances, Chen, Lay-Lang, Rodriguez, Maytrella, & Wu, Sandy. (2007, October).Improving Doctor-patient Communication Yields Significant Health Benefits. ScienceDaily.
A University of California, San Francisco (UCSF) research team from the Center for Vulnerable Populations developed a simple tool that can be used in health care settings to improve communication between doctors and patients about taking medication. The communication tool is a computer-generated weekly calendar with color images of the medication the patient takes each day, combined with written instructions in the patient's native language for how to take it. This communication tool is called a Visual Medication Schedule (VMS), and its main purpose is to reduce misunderstandings about prescribed medications, which are most common in people with limited literacy skills, memory problems, and those who do not understand English.
10. Jacobs, Elizabeth A., Shepard, Donald S., Suaya, Jose A., & Stone, Esta-Lee. (2004, May). Overcoming Language Barriers in Health Care: Costs and Benefits of Interpreter Services. American Journal of Public Health, 94(5), 866-869.
The research team conducted a study from June 1, 1995 to May 31, 1997 in four health centers in Massachusetts to assess two groups of non-English speaking patients: one constituted the interpreter service group and the other was a comparison group whose members did not receive interpretation services. After two years of studying 4,499 patients, the authors found that emergency department costs increased among the comparison group and decreased among the interpreter service group. The cost of primary care was more expensive for the interpreter service group because interpretation services cost $279 per patient for one year. However, the researchers reasoned that improving language access for patients who have limited English proficiency may lower the cost of care in the long run because improved communication tends to reduce medical errors and increase access to preventive care.
11. Chen, Alice Hm, Ramos, Eric, Mutha, Sunita, Rodriquez, Michael E., Dressner, Mark, Jafri, Asma, & Rodrigues, Shelly B. (2007). Addressing Language and Culture: A Practice Assessment for Health Care Professionals. California Academy of Family Physicians Foundation, 1-36.
http://issuu.com/cafp/docs/addressing_language_access_toolkit Access website to view complete booklet
The California Academy of Family Physicians (CAFP) Foundation created a new toolkit in 2007 to help health care professionals incorporate language and cultural proficiency into their practices. The guide is intended to assist nurses and physicians in creating a complete and functional language access system for limited English proficient (LEP) patients. The publication starts by demonstrating why the issue is important, insisting that communication is central to medical practice. The majority of the guide gives advice about how to reach out to LEP patients and improve communication between doctors and patients in health care settings. It also illustrates ways in which doctors can assess their own language skills and those of their staff, as well as how to effectively work with professional interpreters.
12. "Overcoming Communication Barriers in Emergency Situations: Some Basic Tools." Central Coast Children's Foundation, Inc.
Available on the Patient-Provider website. Go to Useful Information. Also available at:
This compilation of resources offers advice to first responders in emergency situations about how to minimize communication breakdowns. The article demonstrates the gravity of communication barriers between caregivers and victims, which often lead to misdiagnoses, treatment errors, unnecessary pain, and even death. The author discusses the importance of communication in emergency situations since first responders reach victims first and must be able to accurately assess the type of care needed. In the next section, the author provides a list of common communication tools that first responder personnel can use to facilitate communication while in the field. Each resource is accompanied with a link where readers can retrieve more information about their use.
13. Hasselkus, A. (2009, Jan. 20). Health literacy in clinical practice. The ASHA Leader, 14(1), 28-29.
A person's health literacy is NOT dependent solely on education, socioeconomic status, native language, or disability. Even highly educated, literate people have difficulty processing, understanding, and using health-related information. The result is increased health care use, decreased adherence to medical recommendations, fewer preventative behaviors, and higher health care costs. This article discusses issues related to health literacy and is geared toward speech-language practitioners.
14. Hasselkus, A., & Moxley, A. (2009, March 24). Health literacy: Health literacy at the intersection of cultures. The ASHA Leader, 14(4), 30—31.
Speech, language, and hearing professionals must be culturally sensitive in order to provide clinically competent services. Culturally competent providers not only have clinical knowledge of disorders and recommended treatments, but also acknowledge the beliefs and values unique to their clients. This article describes issues relevant to SLPs and audiologists.
C. Understanding Communication Barriers Between Providers and Communication Vulnerable Patients Not Related to Language or Culture
Health care delivery flaws occur today regardless of language and cultural barriers and arise across the entire continuum of care. People who are unable to use their natural speech, those who have limited speech due to surgery or other circumstances, those with brain injuries, the elderly, young children, etc. are far too often victimized by inadequate patient: provider communications. Even more troubling is the known fact that the vast majority of medical professionals have not had the requisite training to communicate effectively with their patients. As a result of these compounding factors, preventable adverse events in health care settings are often a function of poor patient-provider communication and the underutilization of inexpensive, low-tech tools and strategies.
The articles below suggest a variety of interrelated factors that contribute to poor communication in health care settings. Many propose that the main factors that lead to preventable adverse events in health care settings are communication problems and poor clinical management. Others suggest that obstacles to effective communication include the vast gap between the healthcare world and that of the average patient, low health literacy, and low standard literacy rates. Another article attributes preventable adverse events in health care settings to cognitive doctor mistakes, which are classified into three categories: (1) anchoring, or making snap judgments based on initial findings; (2) "availability," or assuming that recent experiences can explain new situations; (3) "attribution," or attributing symptoms to a preconceived stereotype about the patient.
In addition to poor management and cognitive doctor mistakes, the underutilization of alternative and augmentative communication tools contributes to the incidence of preventable adverse events in health care settings. For example, one article describes a study conducted by a group of doctors and nurses to determine the level of frustration patients experience when trying to communicate during mechanical ventilation, their level of frustration with the use of a communication board, and their perceptions of the appropriate format and content of this communication tool. Sixty-nine percent of patients in the study said that they would have experienced less frustration during mechanical ventilation if they had used a communication board.
Medical miscommunications as a result of these factors increase the incidence of adverse events and serious errors in critical care settings. In a one-year observational study using direct continuous observation throughout the time period, participating doctors studied 391 patients and found 120 adverse events in 79 of them, including 45% preventable and 55% non-preventable adverse events, as well as 223 serious errors. Among the adverse events calculated, 13% were life-threatening or fatal. They found that most serious medical errors occurred during the ordering or treatment delivery processes, especially when giving patients medicine (61%). A similar study by Groopman suggests that fifteen percent of all patients are misdiagnosed.
The following articles provide additional information regarding the nature of communication barriers not related to language or culture:
1. Patak, Lance, Gawlinski, Anna, Fung, Ng Irene, Doering, Lynn, Berg, Jill, & Henneman, Elizabeth A. (2006). Communication boards in critical care: patients' views. Applied Nursing Research: 19(4) 182-190.
The article describes a study conducted by a group of doctors and nurses to determine the level of frustration patients experience when trying to communicate during mechanical ventilation, their level of frustration with the use of a communication board, and their perceptions of the appropriate format and content of this communication tool. Sixty-nine percent of patients in the study said that they would have experienced less frustration during mechanical ventilation if they had used a communication board. The same patients identified specific characteristics the communication board should exhibit to facilitate communication with health care providers.
2. Elder, Nancy C. and Dovey, Susan M. (2002). Classification of medical errors and preventable adverse events in primary care: A synthesis of the literature. The Journal of Family Practice, 51, 927—932.
This study analyzes published medical data and literature to classify and describe preventable adverse events and process errors in primary care settings. The authors categorize preventable adverse events as diagnostic, treatment, and preventive care incidents; they also classify process errors into four major categories: clinician factors, communication factors, administration factors, and blunt end factors (insurance and government regulation errors). The study illustrates the kinds of preventable errors that occur in primary medical care settings (such as misdiagnosis or administering an incorrect dose) and explains why they occur (such as failure of clinician—patient communication).
3. Rothschild, Jeffrey M., Landrigan, Christopher P., Cronin, John W., Kaushal, Rainu, Lockley, Steven W., Burdick, Elisabeth, Stone, Peter H., Lilly, Craig M., Katz, Joel T., Czeisler, Charles A., & Bates, David W. (2005). The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Critical Care Medicine, 33(8), 1694-1700.
Article available for purchase through the following website:
A group of doctors report on their study about the nature and incidence of adverse events and serious errors in critical care settings. They conducted a one-year observational study using direct continuous observation throughout the time period. The doctors studied 391 patients and found 120 adverse events in 79 of them, including 45% preventable and 55% non-preventable adverse events, as well as 223 serious errors. Among the adverse events calculated, 13% were life-threatening or fatal. They found that most serious medical errors occurred during the ordering or treatment delivery processes, especially when giving patients medicine (61%).
4. Bartlett, Gillian, Blais, Régis, Tamblyn, Robyn, & Clermont, Richard J. (2008). Impact of patient communication problems on the risk of preventable adverse events in acute care settings. Canadian Medical Association Journal, 178 (12), 1555-1562.
A team of doctors undertook a research project to determine whether communication problems are linked to an increased risk of preventable adverse events in medical settings. The authors discuss the context of the problem in the introduction, stating that language barriers and communication disorders decrease the quality of care patients receive, and 5-10% of the general population suffers from such disorders. The authors delineate their research methods, which include a random sample of 2,355 hospitalized patients' charts with which they assess the cause and preventability of adverse events. Their results show that patients involved in adverse events were significantly more likely than those not involved in such events to have a communication problem or psychiatric disorder.
5. No author. (2002, August). Poor communication is common cause of errors; communication critical, says JCAHO official- Joint Commission on Accreditation of Healthcare Organizations- Brief Article. HealthCare Benchmarks and Quality Improvement. [no longer active link]
This newsletter is based on health care recommendations from the executive director for strategic initiatives for the Joint Commission on Accreditation of Healthcare Organizations, Dr. Richard K. Croteau. Dr. Croteau believes that improving communication in health care settings would have the greatest impact on patient safety, and he encourages health care delivery organizations to work toward this end. JCAHO provides a short list of recommendations to reduce medical errors, focusing on delays in treatment. Dr. Croteau says that communication errors can occur orally, electronically, and in writing, and he suggests limiting verbal orders whenever possible.
6. Frankel, Allan. (2008). Health literacy and harm: Who is at risk? What is the fix? Canadian Medical Association Journal, 178 (12), 1573-1574.
Dr. Allan Frankel uses a study conducted by Bartlett and colleagues to highlight major health care delivery flaws that occur today, regardless of disabilities or communication limitations. The two main factors that lead to preventable adverse events in health care settings are communication problems and poor clinical managements. The author discusses a solution to reducing communication barriers involving a communication framework that ensures patients are aware of how to properly care for themselves. Dr. Frankel advises that decreasing the risk of preventable adverse events will also require effective standardization and simplification of care. The article concludes with a brief comparison of health care systems in different world regions.
7. Groopman, Jerome. (2008). Why Doctors Make Mistakes. AARP, 40-42.
The article commences with statistics demonstrating the gravity of medical misdiagnosis, stating that around fifteen percent of all patients are misdiagnosed. According to the author, most medical diagnoses are due to mistakes in the minds of doctors. There are three kinds of cognitive mistakes that lead doctors to misdiagnose their patients. The first is anchoring, or making snap judgments based on initial findings; the second is availability, or assuming that recent experiences can explain new situations; the third is attribution, or attributing symptoms to a preconceived stereotype about the patient. The author provides a list of three questions patients can ask doctors to reduce the risk of misdiagnosis.
8. Murphy, Joan and Cameron, Lois. (2006). The Acute Hospital Experience for Adults with Complex Communication Needs. Communication Matters, 20(2), 7-10.
(starts on pg. 7)
The article summarizes a study funded by Forth Valley, Ayrshire and Arran Primary Care NHS Trusts in the U.K. that highlights the experiences of eight patients with Complex Communication Needs (CCN) in an acute hospital ward. The article discusses the aims, methodology, and results of the study, the latter of which involves feedback from patients with CCN, hospital staff members, and caregivers. The study focuses on problems that occur when people with CCN are hospitalized, such as patients' inability to describe pain and a lack of available communication resources. The article also makes recommendations for improving communication among patients, hospital staff, and caregivers in healthcare settings.
9. Tarkan, Laurie. (2008, September 15). E.R. Patients Often Left Confused After Visits. The New York Times, p. F1.
This article discusses how a majority of emergency room patients are sent home without understanding the treatment they received or how to care for themselves once they are home. When patients are not properly prepared for self-care, they are more likely to be readmitted to the hospital or become more seriously ill. Hospitals are often pressured to serve many patients a day, and care givers tend to devote little time explaining diagnoses, treatments, and self-care instructions to patients. Dr. Eric Coleman, director of the Care Transitions Program at the University of Colorado, claims that nearly half of all patients are considered to lack the ability to process and understand basic health information they need to make decisions. This, coupled with many doctors' failure to communicate effectively with patients, leads to misunderstandings and subsequent medical errors.
10. Sullivan, Roberta and Ferriter, Ann. (2008). Prevent life-threatening communication breakdowns. FDA: U.S. Food and Drug Administration's Center for Devices and Radiological Health.
This article describes a serious medical error in which a middle-aged man died after surgery because no one turned his implantable cardioverter defibrillator (ICD) back on after the procedure. After several unsuccessful attempts to resuscitate him, doctors deemed the cause of death to be ventricular fibrillation. No one was unable to immediately detect and treat the man's condition because of a previous failure to reactivate his ICD after surgery. The authors list and describe several circumstances under which implanted electronic devices need to be turned off, followed by suggestions about how to promote public health and safety when this is the case. One suggestion involves maintaining clear communication with all professional staff members who treat the patient about the type of device being deactivated, as well as its status.
11. Pear, Robert. (2008, March 29). Study Finds Many Patients Dissatisfied With Hospitals. The New York Times, U.S.
The United States government conducted a national survey in which a random sample of patients treated at more than 2,500 hospitals from October 2006 to June 2007 completed questionnaires about hospitals and their staff and cleanliness. Nationwide, 67 percent of patients said they would recommend the hospital at which they were treated to friends and relatives. However, many patients complained that they were not treated with respect by caregivers, did not receive adequate pain medication after surgery, and did not understand the instructions they received for home care once they left the hospital. Dr. Carolyn M. Clancy, director of the Agency for Healthcare Research and Quality, claimed that poor communication was a major source of medical errors, encouraging doctors and nurses to listen more carefully to their patients.
12. Hemsley, Bronwyn, Sigafoos, Jeff, Balandin, Susan, Forbes, Ralph, Taylor, Christine, Green, Vanessa A., & Parmenter, Trevor. (2001). Nursing the patient with severe communication impairment. Journal of Advanced Nursing, 35(6), 827-835.
http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2648.2001.01920.x/full (by subscription only)
The authors of this study interviewed twenty nurses from four hospitals in Sydney, Australia who had experience communicating with patients with severe communication impairment. The aim of the study was to find out about the successes and obstacles nurses encountered during patient-nurse communication to better understand how to train nurses to effectively interact with non-verbal patients. In half of the interview responses, nurses identified a lack of access to appropriate augmentative and alternative communication (AAC) strategies as a major problem in interacting with patients. The lack of communication systems in hospital settings increased the amount of time and effort spent on communication, leading to considerable frustration for both nurses and patients.
13. Happ, Mary Beth. (2001, May). Communicating With Mechanically Ventilated Patients: State of the Science. AACN Clinical Issues: Advanced Practice in Acute and Critical Care, 12(2), 247-258.
Article available for purchase through the following website:
The author discusses the difficulties and stresses mechanically ventilated patients experience in the intensive care unit (ICU) when trying to communicate with doctors and nurses. Critical care nurses rarely receive training in effective communication with non-verbal patients, and most are unfamiliar with augmentative communication methods. Dr. Happ's article explores the existing research
D. Overcoming Communication Barriers Between Providers and Communication Vulnerable Patients Not Related to Language or Culture
Many assistive technologies and low tech tools can help to overcome communication barriers and allow patients to more effectively participate in their own treatment and rehabilitation in health care settings. Such tools are available to help people communicate more effectively in their current communication settings, as they make the transition through care in a hospital, in rehabilitation centers, and at home. These tools and strategies go well beyond "talking boxes" and picture boards—they include a comprehensive collection of communication strategies that provide external support for many different types of people in health care settings. The use of such strategies in health care settings can significantly reduce medical miscommunications and allow for more successful patient-provider communication.
People sometimes associate some of these tools and strategies only with people who enter the medical setting already burdened by complex communication needs. However, these tools and strategies can be used in a much wider range of health care settings and situations to improve communication. For example, intensive care units (ICUs) may provide an appropriate location for using both low-tech and high tech speech generating devices, as so many ICU patients temporarily cannot rely on their usual powers of speech and require aid in communicating their questions and needs to caregivers. Several articles are now available to provide concrete examples of how augmentative communication devices can prove useful in the ICU.
One article in particular exemplifies New Jersey University Hospital's use of communication picture boards to bridge communication barriers between health care professionals and patients. The New Jersey Department of Health and Senior Services (NJDHSS) has distributed more than 2,200 boards to facilities across the state in its efforts to ensure that every patient receives effective medical care. The article strongly advocates the use of communication boards, stating that they should become an integral part of the U.S. Department of Health and Human Services' "Effective Communication in Hospitals" program. Although communication boards may not be an appropriate tool for diagnosing diseases or requesting consent, they are useful for everyday communication purposes.
Other articles suggest that training in effective communicating is imperative to improving patient-provider interactions. Realizing the link between how well a provider understands the communication process and patient satisfaction and outcomes, a growing number of health care systems are beginning to train employees in this critical skill.
The articles below suggest a wide variety of ways to overcome communication barriers and mitigate the incidence of preventable adverse events in health care settings:
1. Lasker, J.P, & Garrett, K.L. (2008, June 17). Aphasia and AAC: Enhancing communication across health care settings. The ASHA Leader, 13(8), 10-13.
The authors advise health care professionals about how to effectively assess and treat clients suffering from aphasia by enhancing natural communication strategies and using appropriate AAC technologies. The article delineates two partner-dependent strategies, three transitional strategies, and two independent strategies patients can use depending on their needs and cognitive and speech abilities. The authors encourage the use of AAC technologies in health care settings to accomplish communication goals and allow patients to effectively participate in their own rehabilitation.
2. Communication Matters (ISAAC, UK). (2008). Communicating with Patients who have Speech/Language Difficulties: Guidance for Medical & Nursing Staff. Communication Matters.
Article may be purchased through the following website:
This free, downloadable leaflet provides guidelines for medical and nursing staff to communicate effectively with patients who have speech, language, or communication difficulties due to injury, illness, or learning disabilities. It discusses both general and specific tips for facilitating communication with patients, including asking questions one at a time and writing words on paper while speaking. The leaflet also defines communication aids and describes how patients can use them to communicate their needs, questions, and desires.
3. U.S. Department of Justice, Civil Rights Division. (2003). ADA Business Brief: Communicating with People who are Deaf or Hard of Hearing in Hospital Settings. Americans with Disabilities Act.
The Americans with Disabilities Act mandates that all hospital programs and services provide effective communication for patients, family members, and visitors who are deaf or hard of hearing. The document briefly describes four communication methods used by such people, including sign language interpretation, oral interpretation, cued speech interpretation, and Computer Assisted Real-time Transcription (CART), explaining the conditions under which each is used. The remaining portion of the brief delineates what services hospitals are required to provide people who are deaf or hard of hearing, as well as what is not required of them.
4a. Blackstone, Sarah W. (2007). Upfront. Augmentative Communication News (ACN): 19(1) 1-2.
This article introduces a new book, Augmentative Communication Strategies for Adults with Acute or Chronic Medical Conditions, which offers practical tools and strategies for providing AAC services to adults with medical conditions which hinder effective communication. Blackstone advocates for the use of augmentative and alternative communication (AAC) and assistive technologies (AT) for people who suffer from severe communication impairments either because of disease or injury and gives examples of people with different conditions who could benefit from AAC or AT. This issue of Augmentative Communication News then summarizes several chapters from the book, in the following articles.
4b. Garrett, Kathryn, Happ, Mary Beth, Costello, John, & Fried-Oken, Melanie. (2007). AAC in the ICU. ACN: 19 (1) 1-3. (From chapter 2 of Augmentative Communication Strategies for Adults with Acute or Chronic Medical Conditions).
Chapter 2 of the Beukelman book demonstrates why intensive care units (ICUs) are ideal locations for AAC technology use, as many admitted patients cannot speak and require aid in communicating their questions and needs to caregivers. Aware that the efficacy of AAC in such emergency settings is not well documented, the authors attempt to fill this gap by providing concrete examples of how AAC is useful in the ICU. They then recommend four major areas in which AAC treatment should be considered: (1) Natural communication signals and gestures, (2) use of pre-existing sensory aids, (3) strategies to support attention and comprehension, and (4) strategies to support expression.
4c. Culp, Delva, Beukelman, David, & Fager, Susan. (2007). Brainstem Impairment. ACN: 19(1) 4-6. (From chapter 3 of Augmentative Communication Strategies for Adults with Acute or Chronic Medical Conditions).
This chapter discusses the daily communication needs of people with brainstem impairments and delineates key assessment and treatment strategies to effectively address them. The authors begin by describing four phases of treatment that medical providers can use in multiple service delivery settings: Initial assessment, early intervention, formal assessment, and ongoing assessment. They then discuss four clinical profiles of patients with various degrees of brainstem impairment recovery, ranging from complete locked-in syndrome to functional speech. In each case, they describe what kinds of communication tools and technologies each patient uses, based on his or her condition and needs.
4d. Fager, Susan, Doyle, Molly, & Karantounis, Renee. (2007). Traumatic Brain Injury. ACN: 19(1) 6-8. (From chapter 5 of Augmentative Communication Strategies for Adults with Acute or Chronic Medical Conditions).
The authors propose five treatment guidelines for people suffering from TBI: An ongoing and dynamic assessment process, use of natural motor responses, accounting for the patient's residual strengths, periodic reassessment of the patient's capabilities, and inclusion of family members and caregivers in AAC assessments and interventions. The article then discusses three levels of recovery (Stimulation, Structured, and Compensation) and recommends AAC treatments corresponding to each level. The authors use a case study about a man who sustained a severe TBI after a motor vehicle accident to exemplify how such patients use AAC technologies during and after recovery.
4e. Britton, Deanna and Baarslag-Benson, Ross. (2007). Spinal Cord Injury. ACNs: 19(1) 8-9. (From chapter 4 of Augmentative Communication Strategies for Adults with Acute or Chronic Medical Conditions).
The article argues that communication is an essential component of the recovery and rehabilitation process after a patient suffers a spinal cord injury (SCI). The authors discuss seven "principles of AAC treatment" for SCIs, such as inclusion of the patient in treatment decisions and the benefit of an interdisciplinary rehabilitation team in carrying out AAC interventions. Lastly, the article discusses three phases of AAC treatment for SCI patients, including the early, formal, and AAC solutions phases.
5. Boodman, Sandra G. (2008, November 27). Second opinion helps diagnose woman's tumor. The Monterey County Herald, p. C10.
Article is available for purchase through the following website:
This article discusses Carol Welsh's illness, which began in early November, 1999, characterized by morning attacks of nausea and vomiting. Her doctor at the College of William and Mary student health center believed her symptoms were due to a gastrointestinal problem and/or stress from her studies, and she was treated for those, with minimal effect. On April 19, 2000, Carol's condition turned into a crisis and she returned to her school's health clinic, where she was seen by a new doctor. After listening to her symptoms and examining her, the new doctor realized that she suffered from a rare brain tumor that needed to be operated on immediately. He observed that actively listening to patients is the best way to avoid misdiagnoses and provide quality care.
6. Thompson, Laura Eckert. (2007). Picture Boards Help Patients Communicate Ailments To Nurses. Nurse.com, Gannett Healthcare Group.
The author exemplifies New Jersey University Hospital's use of communication picture boards to bridge communication barriers between health care professionals and patients. The New Jersey Department of Health and Senior Services (NJDHSS) has distributed more than 2,200 boards to facilities across the state in its efforts to ensure that every patient receives effective medical care. The article strongly advocates the use of communication boards, stating that they should become an integral part of the U.S. Department of Health and Human Services' "Effective Communication in Hospitals" program. Although communication boards may not be an appropriate tool for diagnosing diseases or requesting consent, they are useful for everyday communication purposes.
7. Miyasaka, Katsuyuki, Suzuki, Yasuyuki, Sakai, Hirokazu, & Kondo, Yoichi. (1997). Interactive Communication in High-technology Home Care: Videophones for Pediatric Ventilatory Care. Pediatrics: Official Journal of the American Academy of Pediatrics, 99(1), 1-6.
This article discusses a study in which Japanese doctors assess the clinical impact of a home videophone system for patients receiving home respiratory care. The doctors compare two groups of patients to whom the videophone system was introduced, evaluating its impacts on the type and quality of care. The authors conclude that using this technology significantly reduces the number of house calls by physicians, unscheduled hospital visits by patients, and hospital admission days. Furthermore, both patients and health care professionals considered the videophone system to be acceptable and beneficial. The authors strongly advocate the use of this communication tool to improve the quality of pediatric home ventilatory care.
8. Makoul, G. (2001). Essential elements of communication in medical encounters: The Kalamazoo consensus statement. Academic Medicine: Journal of the Association of American Medical Colleges, 76(4) 390-393.
This essay highlights a conference sponsored by the Bayer Institute for Health Care Communication and the Fetzer Institute. Twenty-one representatives and leaders from major medical education and professional organizations congregated to discuss the essential elements in physician—patient communication. The group collectively identified seven essential sets of communication goals for doctors and patients. These include (1) build a doctor—patient relationship; (2) facilitate open discussions; (3) gather information; (4) understand the patient's perspective; (5) share information; (6) reach an agreement on problems and plans; and (7) provide closure. These communication goals were designed to provide a coherent framework for teaching and assessing communication skills, determining relevant knowledge and attitudes, and evaluating educational programs.
9. Ricketts, I.W., MacAulay, F., Etchels, M., Judson, A., Ashraf, S., Waller, A., Brodie, J., Warden, A., Alm, N., Gordon, B., & Shearer, A. Helping patients in intensive care to communicate (accessed January 18, 2009).
This article discusses the development of a prototype software called ICU-Talk, a device used for intubated patients in intensive care units (ICUs). The authors comment that current low-tech communication tools, such as alphabet charts and picture boards, are unsatisfactory, slow, and frustrating for both patients and nursing staff. They claim that ICU-Talk is a superior communication tool that is tailored to meet the specific needs of ICU patients and the ICU environment. ICU-Talk is a computer-based communication aid that allows patients to select a phrase or question from a pre-stored database. A computer interview function was developed to allow relatives to enter information about patients' friends, family and personal interests into the database.
10. Etchels, Maria C., MacAulay, Fiona, Judson, Andrew, Ashraf, Saqib, Ricketts, Ian W., Waller, Annalu, Alm, Norman, Warden, Audrey, Gordon, Brian, Brodie, Jan, & Shearer, Alfred J. ICU-Talk: The development of a computerized communication aid for patients in ICU (accessed January 18, 2009).
This paper describes the collaborative development of a computerized communication aid designed specifically for intubated patients in the intensive care unit (ICU). This augmentative and alternative communication (AAC) device, called ICU Talk, uses a speech synthesizer to voice phrases, sentences, or questions from a pre-stored database. It is most appropriate for ICU patients who are alert but physically limited and unable to speak. The core database has two different interfaces from which patients can choose, both consisting of eight color-coded topics and related phrases and questions. Each style supports the use of touch screens, mouse emulation, and single switch scanning. These access methods permit patients at different stages of recovery to use ICU Talk, including those with severe physical impairment.
11. Glennen, Sharon L. and DeCoste, Denise C. (1997). The Handbook of Augmentative and Alternative Communication. San Diego & London: Singular Publishing Group, Inc.
Access website to view booklet
This handbook provides a comprehensive and practical guide for people working with individuals who are incapable of vocal communication. Chapter sixteen of the handbook, entitled "AAC in the Hospital Setting," discusses the acute care setting in relation to augmentative and alternative communication (AAC) practices. Many hospital professionals are unaware of AAC intervention techniques, and therefore, non-verbal patients are often excluded from AAC services from which they could benefit. The handbook provides a brief review of care givers who should be part of the AAC communication process, including physicians; nurses; respiratory, occupational, recreation and physical therapists; child life specialists; social workers; speech-language pathologists; and family members.
12. Groopman, Jerome. (2007). How Doctors Think. U.S.A.: Houghton Mifflin.
Groopman's book discusses what goes on in a doctor's mind when he or she treats a patient, illustrating the potential life and death significance of doctor-patient communication. The author describes the algorithms and evidence-based therapies doctors are trained to use for typical diagnoses and treatments. He indicates that while these methods can be useful for treating easily identifiable illnesses, they are less effective when doctors are unsure of the illness from which a patient suffers. Groopman believes that openly pondering and discussing how doctors think can reduce both the frequency and severity of medical mistakes by revealing to patients how their doctors think when they examine, question, diagnose and treat them. This in turn will bridge communication barriers between patients and their caregivers.
13. Mehallow, Cindy. (2006, July). Tips for Effective Patient-Provider Communication. Monster Health Care.
This article focuses on the importance of effective patient-provider communication to improve health outcomes. Obstacles to effective communication like the vast gap between the healthcare world and that of the average patient, low health literacy, and low standard literacy rates are discussed. Tips for effective communication for health care providers like: building relationships, treating the patient as a person, and educating the patient after discovering what he already knows are also exemplified.
14. Costello, John M. (2000). AAC intervention in the intensive care unit: The children's hospital Boston model. Augmentative and Alternative Communication, 16(3), 137-153.
Article is available for purchase through the following website:
This paper describes augmentative and alternative communication (AAC) interventions for patients admitted to the intensive care unit (ICU). Costello focuses on patients who undergo surgeries that render them temporarily incapable of vocal communication. He describes both preoperative and postoperative interventions, providing viable strategies patients can use to communicate. Some of these AAC interventions include technologies such as patient-directed vocabulary selection and digital voice message banking. Costello interviews patients, family members, and medical staff, using their responses to illustrate the benefits of AAC interventions for ICU patients who are temporarily unable to speak.
15. State Government, Department of Human Services, Victoria. (2003). Improving the admission and discharge practices of acute and sub-acute care facilities in relation to people with dementia, 52-58. (no longer an active link)
This research project demonstrates that successful communication with patients suffering from dementia is an essential component of hospital and nursing home care. The researchers interview several nurses to find out which techniques work best for them when communicating with patients. Nurses identified a variety of useful strategies, including verbal communication, body language and written messages. When there is open communication between hospital staff and family members, hospitals can obtain a detailed history about the patient that aids in providing quality care. An understanding of the patient's degree of cognitive deficit is vital in creating a comprehensive care plan, which takes into account such issues as sleeping patterns, activities the patient enjoys, and support that helps him/her cope with dementia.
16. Happ, Mary Beth, Roesch, Tricia Kenney, & Garrett, Kathryn. (2004) Electronic voice-output communication aids for temporarily nonspeaking patients in a medical intensive care unit: A feasibility study. Heart & Lung, 33(2), 92-101.
Abstract of article IS available on this site. This pilot study uses participant observation, interviews, questionnaires and clinical record review to obtain information about the use of electronic voice output communication aids (VOCAs) for patients admitted to the intensive care unit (ICU). The authors study eleven critically-ill patients who are temporarily unable to speak due to mechanical ventilation, and they find that patients attempt to communicate more frequently when VOCAs are available then when communicating with non-vocal methods. The researchers also study barriers to VOCA use, and their results show that deterioration in the patient's condition, staff unfamiliarity with the device, time constraints, poor device positioning and complex message screens are the most significant barriers. Despite these difficulties, ICU patients who use a VOCA may be able to communicate more easily during respiratory tract intubation.
- Descriptive: This annotation describes the source without summarizing the actual argument, hypothesis, or message in the content. Like an abstract, it describes what the source addresses, what issues are being investigated, and any special features, such as appendices or bibliographies, that are used to supplement the main text. What it does not include is any evaluation or criticism of the content. This type of annotation seeks to answer the question: Does this source cover or address the topic I am researching?
- Informative/Summative: This type of annotation summarizes what the content, message, or argument of the source is. It generally contains the hypothesis, methodology, and conclusion or findings, but like the descriptive type, you are not offering your own evaluative comments about such content. This type of annotation seeks to answer these types of questions: What are the author's main arguments? What conclusions did the author draw?
- Evaluative/Critical/Analytical: This annotation includes your evaluative statements about the content of a source. It is the most common type of annotation your professor will ask you to write. Your critique may focus on describing a study's strengths and weaknesses or it may describe the applicability of the conclusions to the research problem you are studying. This type of annotation seeks to answer these types of questions: Is the reasoning sound? Is the methodology sound? Does this source address all the relevant issues? How does this source compare to other sources on this topic?
NOTE: Strategies about how to critically evaluate a source can be found here.
II. Choosing Sources for Your Bibliography
There are two good strategies you should use to begin identifying possible sources for your bibliography--one that looks back into the literature and one that looks forward.
- The first strategy is to identify several recent scholarly books or journal articles on the topic of your annotated bibliography and review the sources cited by the author(s). Often, the items cited by an author will effectively lead you to related sources about the topic.
- The second strategy is to identify one or more important books, book chapters, journal articles, or other documents on your topic and paste the title of the item in Google Scholar [e.g., from Negotiation Journal, entering the article, "Civic Fusion: Moving from Certainty through Not Knowing to Curiosity"], placing quotation marks around the title so Google Scholar searches as a phrase rather than a combination of individual words. Below the citation may be a "Cited by" reference followed by a linked number. This link will direct you to a list of other study's that have cited that particular item after it was published.
Your method for selecting which sources to annotate depends on the purpose of the assignment and the research problem you are investigating. For example, if the research problem is to compare the social factors that led to protests in Egypt with the social factors that led to protests against the government of the Phillippines in the 1980's, you will have to consider including non-U.S., historical, and, if possible, foreign language sources in your bibliography.
NOTE: Appropriate sources to include can be anything that has value in understanding the research problem. Be creative in thinking about possible sources, including non-textual items, such as, films, maps, photographs, and audio recordings, or archival documents and primary source materials, such as, diaries, government documents, collections of personal correspondence, meeting minutes, and official memorandums. Consult with a librarian if you're not sure how to locate these types of materials for your bibliography.
III. Strategies to Define the Scope of your Bibliography
It is important that the sources cited and described in your bibliography are well-defined and sufficiently narrow in coverage to ensure that you're not overwhelmed by the number of potential items to consider including. Many of the general strategies used to narrow a topic for a research paper are the same that you can use to define the scope of your bibliography. These are:
- Aspect -- choose one lens through which to view the research problem, or look at just one facet of your topic [e.g., rather than a bibliography of sources about the role of food in religious rituals, create a bibliography on the role of food in Hindu ceremonies].
- Time -- the shorter the time period to be covered, the more narrow the focus [e.g., rather than political scandals of the 20th century, cite literature on political scandals during the 1930s and the 1990s].
- Geography -- the smaller the region of analysis, the fewer items there are to consider including in your bibliography [e.g., rather than cite sources about trade relations in West Africa, include only sources that examine trade relations between Niger and Cameroon].
- Type -- focus your bibliography on a specific type or class of people, places, or things [e.g., rather than health care provision in Japan, cite research on health care provided to elderly men in Japan].
- Source -- your bibliography includes specific types of materials [e.g., only books, only scholarly journal articles, only films, etc.]. However, be sure to describe why only one type of source is appropriate.
- Combination -- use two or more of the above strategies to focus your bibliography very narrowly or to broaden coverage of a very specific research problem [e.g., cite literature only about political scandals during the 1930s and the 1990s and that have only taken place in Great Britain].
IV. Assessing the Relevance and Value of Sources
All the items you include in your bibliography should reflect the source's contribution to understanding the research problem or the overall issue being addressed. In order to determine how you will use the source or define its contribution, you will need to assess the quality of the central argument within the source. Specific elements to assess include an item’s overall value in relation to other sources on the topic, its limitations, its effectiveness in defining the research problem, the methodology used, the quality of the evidence, and the author’s conclusions and/or recommendations.
With this in mind, determining whether a source should be included in your bibliography depends on how you think about and answer the following questions related to its content:
- Are you interested in the way the author frames the research questions or in the way the author goes about answering it [the method]?
- Does the research findings make new connections or promote new ways of understanding a problem?
- Are you interested in the way the author uses a theoretical framework or a key concept?
- Does the source refer to and analyze a particular body of evidence that you want to cite?
- How are the author's conclusions relevant to your overall investigation of the topic?
V. Format and Content
The format of an annotated bibliography can differ depending on its purpose and the nature of the assignment. Contents may be listed alphabetically by author or arranged chronologically by publication date. If the bibliography includes a lot of sources, items may also be subdivided thematically or by type. If you are unsure, ask your professor for specific guidelines in terms of length, focus, and the type of annotation you are to write.
Your bibliography should include a brief introductory paragraph that explains the method used to identify possible sources [including what sources, such as databases, you searched], the rationale for selecting the sources, and a statement, if appropriate, regarding what sources were deliberately excluded and the reasons why.
This first part of your entry contains the bibliographic information written in a standard documentation style, such as, MLA, Chicago, or APA. Ask your professor what style is most appropriate and be consistent!
The second part should summarize, in paragraph form, the content of the source. What you say about the source is dictated by the type of annotation you are asked to write. In most cases, however, your annotation should provide critical commentary that examines the source and its relationship to the topic. Things to think critically about when writing the annotation include: Does the source offer a good introduction on the issue? Does the source effectively address the issue? Would novices find the work accessible or is it intended for an audience already familiar with the topic? What limitations does the source have [reading level, timeliness, reliability, etc.]? Are any special features, such as, appendices or non-textual elements effectively presented? What is your overall reaction to the source? If it's a website or online resource, is it up-to-date, well-organized, and easy to read, use, and navigate?
Annotations can vary significantly in length, from a couple of sentences to a couple of pages. However, they are normally about 300 words. The length will depend on the purpose. If you're just writing summaries of your sources, the annotations may not be very long. However, if you are writing an extensive analysis of each source, you'll need to devote more space.
Annotated Bibliographies. The Writing Center. University of North Carolina; Annotated Bibliographies. The Writing Lab and The OWL. Purdue University; Annotated Bibliography. The Writer’s Handbook. Writing Center. University of Wisconsin, Madison; Annotated Bibliography. Writing Center. Walden University; Engle, Michael et al. How to Prepare an Annotated Bibliography. Olin Reference, Research and Learning Services. Cornell University Library; Guidelines for Preparing an Annotated Bibliography. Writing Center at Campus Library. University of Washington, Bothell; Harner, James L. On Compiling an Annotated Bibliography. 2nd edition. New York: Modern Language Association, 2000; How to Write an Annotated Bibliography. Information and Library Services. University of Maryland; Knott, Deborah. Writing an Annotated Bibliography. The Lab Report. University College Writing Centre. University of Toronto; Norton, Donna. Top 32 Effective Tips for Writing an Annotated Bibliography Top-notch study tips for A+ students blog; Writing from Sources: Writing an Annotated Bibliography. The Reading/Writing Center. Hunter College.