Which alternative communication methods are effective for voiceless patients in Intensive Care Units? A systematic review

A Core Outcome Set for Research Evaluating Interventions to Enable Communication in Patients With an Artificial Airway: An International Delphi Consensus Study (Comm-COS)

OBJECTIVES

Critically ill adults requiring artificial airways experience profound communication deficits. Studies of interventions supporting communication report disparate outcomes, creating subsequent challenges in the interpretation of their effectiveness. Therefore, we aimed to develop international consensus for a communication core outcome set (Comm-COS) for future trials of communication interventions in this population.

DESIGN

1) Systematic review, 2) patient/family interviews, 3) two-round modified Delphi, and 4) virtual consensus meetings with a final voting round. A multidisciplinary expert steering committee oversaw all stages.

SETTING

Interviews and consensus meetings were conducted via videoconferencing. Digital methods were used for Delphi and final Comm-COS voting.

SUBJECTS

Three stakeholder groups: 1) patient and family members with lived experience within 3 years, 2) clinicians with experience working in critical care, and 3) researchers publishing in the field.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

We identified 59 outcomes via our systematic review, 3 unique outcomes from qualitative interviews, and 2 outcomes from our steering committee. Following item reduction, 32 outcomes were presented in Delphi round 1; 134 participants voted; 15 patient/family (11%), 91 clinicians (68%), and 28 researchers (21%). Nine additional outcomes were generated and added to round 2; 106 (81%) participants voted. Following completion of the consensus processes, the Comm-COS includes seven outcomes: 1) changes in emotions and wellbeing associated with ability to communicate, 2) physical impact of communication aid use, 3) time to functional communication, 4) ability to communicate healthcare needs (comfort/care/safety/decisions), 5) conversation agency, 6) ability to establish a communication connection to develop and maintain relationships, and 7) acceptability of the communication intervention.

CONCLUSIONS

This is the first COS to specifically focus on communication for critically ill adults. Limitations for operationalization include selection of measures to use with these outcomes. Identification of suitable measures and adoption of the Comm-COS in future trials will help establish effective interventions to ameliorate the highly prevalent and negative experience of communicative incapacity.

Augmentative and Alternative Communication Interventions in Critical and Acute Care With Mechanically Ventilated and Tracheostomy Patients: A Scoping Review

PURPOSE

Communication with nonspeaking patients is a critical challenge of person-centered care. This scoping review aimed to map the literature on augmentative and alternative communication (AAC) interventions for nonspeaking mechanically ventilated and tracheostomy patients in critical and acute care settings.

METHOD

Electronic database, ancestry, and forward citation searches were conducted using eligibility criteria established a priori. Data were extracted, synthesized, and summarized according to scoping review methodology. Studies were categorized by type of intervention and summarized in terms of purpose, participants, design, quality appraisal (including validity and reliability of selected efficacy measures), and efficacy.

RESULTS

Small-to-large treatment effect sizes indicated demonstrable impact on patient health and communication efficacy with high-tech and no-tech visual interface-based interventions and systematic nurse training interventions. Treatment effects primarily pertained to dependent variables of patient anxiety, communication satisfaction, comfort, symptom self-reporting, and nursing practice changes.

CONCLUSIONS

There is a paucity of high-quality AAC intervention research for mechanically ventilated and tracheostomy patients in critical and acute care settings. Emergent evidence suggests that select visual interface and nurse training interventions can impact efficacy of patient-provider communication and patients' overall health.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.26506102.

Facilitators, barriers and acceptability of implementing a communication board in Sri Lankan intensive care units: A qualitative descriptive study

OBJECTIVES

To explore patients' and nurses' views of potential facilitators, barriers, and prospective acceptability of implementing a communication board in Sri Lankan intensive care units.

DESIGN

A qualitative, descriptive study.

RESEARCH METHODOLOGY

Eight patients who received mechanical ventilation and nine nurses who worked in adult medical and surgical intensive care units were purposively selected. Data were collected via audio-taped, semi-structured, face-to-face interviews in January/February 2023. Interview guide questions were informed by the knowledge-to-action framework and the theoretical framework of acceptability. Data were analysed using inductive and deductive content analysis. The 32-item checklist of the consolidated criteria for reporting qualitative research (COREQ) was used to ensure the quality of reporting.

SETTING

A 3,000 bed Sri Lankan teaching hospital with 18 intensive care units.

FINDINGS

Four categories reflecting patients' and nurses' anticipated use of the board were found. The first category described patients' and nurses' 'readiness to use the communication board' and their positive attitudes towards it. The second category focused on the 'potential benefits of the communication board', while the third category emphasised the 'individual patient characteristics' that should be taken into consideration when implementing communication boards. The final category described practical aspects related to 'integrating communication boards into routine practice'.

CONCLUSION

This study demonstrates communication boards may improve communication between ventilated patients and nurses, and they are acceptable to end users. Adopting these tools may be a pivotal step to enhancing patient-centred care in demanding intensive care settings.

IMPLICATIONS FOR CLINICAL PRACTICE

An inability to communicate effectively with ventilated intensive care patients creates negative experiences for both patients and nurses. Communication boards may act as a medium to better understand patients' needs during mechanical ventilation.Understanding patients' and nurses' views is beneficial when designing patient-centred communication interventions in intensive care units.

Framework to elicit consent from lightly sedated mechanically ventilated intensive care patients in nursing practice

AIM

The study aimed to ascertain a framework of nursing practices to elicit consent from lightly sedated ventilated patients.

METHODS

Study participants were nurses working in intensive care and critical care wards, whose observations and semi-structured interviews were assessed using a modified grounded theory approach.

RESULTS

A total of 15 concepts were generated, from which three categories and three subcategories were generated. Category 1: Nurses taking the lead in providing assistance by sharing signs of change while continuing the invasive treatment, working to maintain the patient's life, alleviation of pain, promotion of awareness of the current situation, and acclimating them to the treatment environment as the basis for building a relationship between patients and nurses. Category 2: Searching for points of agreement and reaching a compromise involves the nurse drawing out the patient's thoughts, hopes, and expectations, and transforming the relationship into a patient-centered one by sharing goals with the patient in order to achieve them. Category 3: Organizing collaboration within care supported the patient's ability to move safely while maintaining the patient's pace to achieve shared goals, and guided the patient's independent actions.

CONCLUSIONS

Even when patients recover from an acute life-threatening situation, their physical sensations remain vague and their functional decline continues. Rather than simply eliciting consent from patients, the structure of nursing practice to elicit such response from patients involves drawing out the patient's thoughts, hopes, and expectations, as well as guiding the patient toward goals that they have created together with the nurse and utilizing the patient's strengths to achieve these goals.

Effectiveness, experience, and usability of low-technology augmentative and alternative communication in intensive care: A mixed-methods systematic review

BACKGROUND

Patients in the intensive care unit (ICU) are commonly on mechanical ventilation, either through endotracheal intubation or tracheostomy, which usually leaves them nonverbal. Low-technology augmentative and alternative communication (AAC) strategies are simple and effective ways to enhance communication between patients and their communication partners but are underutilised.

AIM

The aim of this study was to systematically review current evidence regarding the effectiveness, experience of use, and usability of low-technology AAC with nonverbal patients and their communication partners in the ICU.

METHODS

This review included quantitative, qualitative, and mixed-methods studies of adult ICU patients aged 18 or older who were nonverbal due to mechanical ventilation and their communication partners. Studies using low-technology AAC, such as communication boards and pen and paper, were included. Six databases were searched, and the review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A convergent segregated approach was used for data synthesis.

RESULTS

Thirty-two studies were included. Low-technology AAC improved patient satisfaction, facilitated communication, and met patients' physical and psychological needs. Communication boards with mixed content (e.g., pictures, words, and letters) were preferred but were used less frequently than unaided strategies due to patients' medical status, tool availability, and staff attitudes. Boards should be user-friendly, tailored, include pen/paper, and introduced preoperation to increase patient's comfort when using them postoperatively.

CONCLUSION

Existing evidence support low-technology AAC's efficacy in meeting patients' needs. Better usability hinges on proper implementation and addressing challenges. Further research is crucial for refining communication-board design, ensuring both user-friendliness and sophistication to cater to ICU patients' diverse needs.

REGISTRATION

The review protocol was registered in the International Prospective Register of Systematic Reviews, with registration number CRD42022331566.

Frequency and correlates of augmentative and alternative communication use in an autistic inpatient sample

Although augmentative and alternative communication (AAC) strategies are often used by autistic youth, little is known about the use of AAC in inpatient psychiatric settings. This study evaluated how demographic and clinical factors (e.g., language level, IQ) related to AAC use in a well-characterized sample of 527 autistic youth (78.7% male, mean age 12.94) who participated in the Autism Inpatient Collection. AAC use was common, with 42.5% of caregivers reporting at least one form of AAC. White children were more likely to use AAC than non-white children at the bivariate level. In regression analyses, young children were more likely to use AAC than older children. These results suggest the importance of provider training and improved equitable access to AAC.

Communication between healthcare providers and communicatively-vulnerable patients with associated health outcomes: A scoping review of knowledge syntheses

OBJECTIVE

Summarize literature on provider-patient communication linked to health outcomes in communicatively-vulnerable patient populations.

METHODS

Scoping review of reviews: systematically searched six databases.

INCLUSION CRITERIA

systematic searches and syntheses of literature; one or more providers and communicatively-vulnerable patients; synchronous in-person communication; intermediate or health outcome linked to communication.

RESULTS

The search yielded 14,615 citations; 47 reviews - with wide range of providers, communication vulnerabilities, communication practices, and health outcomes - met inclusion criteria. Methodology included qualitative, quantitative, and mixed approaches. Quality ranged from very low to high. Six categories of communication practices linked to health outcomes were identified: 1) motivation-based; 2) accommodation of language, culture, gender, sexual identity, and other concordance with the patient; 3) cultural adaptations of interventions; 4) use of interpreters; 5) other provider-patient communication practices; 6) patient communication practices.

CONCLUSION

Communication practices were studied in a wide range of providers, with common themes regarding best practices. A unique finding is the role of the patient's communication practices. The specificity of communication practices studied is heterogeneous, with many reviews providing insufficient details.

PRACTICE IMPLICATIONS

Motivation-based practices and culturally- and linguistically-appropriate care have impacts on patient outcomes across a range of settings with different professions and communicatively-vulnerable groups.

Comparison of communication interfaces for mechanically ventilated patients in intensive care

OBJECTIVES

This study aimed to compare the use of a conventional low-tech communication board and a high-tech eye tracking device to improve communication effectiveness of mechanically ventilated patients in intensive care.

DESIGN

A prospective randomized crossover was conducted with a mixed method approach (quantitative primary method and qualitative complementary method) to compare the two technologically opposed communication interfaces.

SETTING

The mechanically ventilated patients were recruited from the general intensive care unit of the Marie Curie Civil Hospital (Charleroi University Hospital, Belgium).

MAIN OUTCOME MEASURES

The communication exchanges were assessed through effectiveness indicators covering the quantity of messages transmitted, success rate, patient satisfaction, communication content and difficulties of use.

RESULTS

The sample consisted of 44 mechanically ventilated patients, covering 88 communication exchanges. The intervention effects on the quantity of messages transmitted (two median messages per exchange for the board versus four median messages per exchange for the eye tracking, p < 0.0001), success rate (80 % for the board versus 100 % for the eye tracking, p < 0.05) and patient satisfaction (66 % "not satisfied", 32 % "satisfied" and 2 % "dissatisfied" for the board versus 52 % "satisfied" and 48 % "very satisfied" for the eye tracking, p < 0.0001) were significant. The communication content covered eight themes for the board compared to nine themes for the eye tracking and the use difficulties included four categories for the board as well as for the eye tracking.

CONCLUSION

The eye tracking device may further improve communication effectiveness of mechanically ventilated patients compared to the conventional communication board, both quantitatively and qualitatively.

IMPLICATIONS FOR CLINICAL PRACTICE

The implementation of high-tech communication devices based on eye tracking in intensive care practice can significantly contribute to patient-centered care by improving communication of mechanically ventilated patients.

Instrument adaptation and preliminary validation study of the Laryngeal Hypersensitivity Questionnaire used for assessment of laryngeal symptoms in patients with artificial airways

BACKGROUND

The Newcastle Laryngeal Hypersensitivity Questionnaire (LHQ) was developed to measure abnormal laryngeal sensation and was originally validated in a patient sample from otolaryngologic and respiratory outpatient clinics. Modification is needed for patients who are mechanically ventilated via an endotracheal tube or a tracheostomy tube.

OBJECTIVES

We sought to adapt and preliminarily validate a modified version of the LHQ appropriate for nurses and other clinicians to administer in acute hospital settings called the LHQ-Acute (LHQ-A).

METHODS

Internal consistency and construct validity analyses using secondary data from patients at a tertiary teaching hospital who presented with symptoms of laryngeal irritability/hypersensitivity between September 2012 and October 2013 were performed.

RESULTS

A total of 131 patients, most complaining of coughing and dysphonia, with a median age of 58 (interquartile range: 48, 66) years and 29 healthy participants with a median age of 62 (interquartile range: 50, 66) years were analysed. The original LHQ was reduced from 14 questions with responses on a 7-point scale to the LHQ-A containing 13 questions with responses on a 4-point scale. Correlations between items of the LHQ and LHQ-A were similar, and internal consistency was excellent and highly comparable, with Cronbach's alpha = 0.906 and 0.902, respectively.

CONCLUSIONS

The LHQ-A, which has been adapted for nurses and other clinicians to administer to a critically ill patient population, demonstrated comparable reliability and validity to the original LHQ. Validation of the LHQ-A in independent patient populations from acute settings is necessary to better understand norms and changes during recovery from acute illness.

The EyeControl-Med device, an alternative tool for communication in ventilated critically ill patients: A pilot study examining communication capabilities and delirium

INTRODUCTION

Communication with ventilated patients in the Intensive care unit (ICU) is challenging. This may lead to anxiety and frustration, potentially contributing to the development of delirium. Various technologies, such as eye-tracking devices, have been employed to facilitate communication with varying grades of success. The EyeControl-Med device is a novel technology that delivers audio content and allows patients to interact by eye movements and could potentially allow for better communication in this setting. The aim of this exploratory concept study was to assess communication capabilities and delirium incidence using the EyeControl-Med device in critically ill patients unable to generate speech.

MATERIAL AND METHODS

A single-arm pilot study of patients in a mixed ICU. Patients were approached for consent if they were invasively ventilated and/or tracheotomized, hence unable to generate speech, but had no severe cognitive or sensory impairment that could prevent proper usage. Patients underwent at least 3 sessions with the EyeControl-Med device administered by a speech-language pathologist. Communication and consciousness were assessed using the Loewenstein Communication Scale (LCS) tool during the first and last sessions. Delirium was assessed using a computerized CAM-ICU questionnaire.

RESULTS

15 patients were included, 40% of whom were diagnosed with COVID-19. All patients completed three to seven usage sessions. The mean LCS score improved by 19.3 points (p < 0.0001), with each of its five components showing significant improvements as well. The mean number of errors on the CAM-ICU questionnaire decreased from 6.5 to 2.5 (p = 0.0006), indicating a lower incidence of delirium. No adverse effects were observed.

CONCLUSION

The EyeControl-Med device may facilitate communication and reduce the manifestations and duration of delirium in ventilated critically ill patients. Controlled studies are required to establish this effect.

Communication functions of adult patients admitted to intensive care: A multicentre, binational point prevalence study

BACKGROUND

Patient communication is profoundly impacted during the intensive care unit (ICU) stay. While the impacts of altered communication are recognised, there is a paucity of data on the prevalence of communication attempts as well as modes utilised by patients and unit practices to manage communication function.

OBJECTIVE

The objectives of this study were to describe the prevalence and characteristics of observed communication attempts (nonverbal, verbal, and use of the staff call bell) in adult ICU patients and report on unit-level practices on communication management.

METHODS

A prospective, binational, cross-sectional point-prevalence study was conducted across 44 Australia and New Zealand adult ICUs. Data on communication attempts, modes, ICU-level guidelines, training, and resources were collected in June 2019.

RESULTS

Across 44 ICUs, 470 of 623 (75%) participants, including ventilated and nonventilated patients, were attempting to communicate on the study day. Of those invasively ventilated via an endotracheal tube for the entire study day, 42 of 172 (24%) were attempting to communicate and 39 of 45 (87%) patients with a tracheostomy were attempting to communicate. Across the cohort, the primary mode of communication was verbal communication, with 395 of 470 (84%) patients using speech; of those 371 of 395 (94%) spoke English and 24 of 395 (6%) spoke a language other than English. Participants attempting to communicate on the study day had a shorter length of stay (LOS), a mean difference of 3.8 days (95% confidence interval: 0.2; 5.1) shorter LOS in the ICU than those not attempting to communicate, and a mean difference 7.9 days (95% confidence interval: 3.1; 12.6) shorter LOS in hospital overall. Unit-level practices and supports were collected. Six of 44 (14%) ICUs had a protocol for communication management, training was available in 11 of 44 (25%) ICUs, and communication resources were available in 37 of 44 (84%) ICUs.

CONCLUSION

Three-quarters of patients admitted to the ICU were attempting to communicate on the study day, with multiple methods used to support verbal and nonverbal communication regardless of ventilation status. Guidance and training were absent from the majority of ICUs, indicating a need for development and implementation of policies, training, and resources.

Mixed-method acceptability evaluation of a co-designed bundled intervention to support communication for patients with an advanced airway in the intensive care unit during a pandemic

BACKGROUND

Although bundled communication interventions are recommended to address communication barriers for patients with an advanced airway in the intensive care unit (ICU) such interventions have not been evaluated in pandemic conditions.

AIM

To evaluate the acceptability, appropriateness, and feasibility of a co-designed bundled intervention to support communication with adult patients with an advanced airway in ICU in pandemic conditions.

STUDY DESIGN

Prospective, convergent mixed method design in a single centre medical-surgical ICU in Toronto, Canada between September 2021-March 2022. After the use of the co-designed bundled communication intervention quantitative data were collected from health care providers using validated acceptability, appropriateness, and feasibility measures and analysed using descriptive statistics. Qualitative data were collected from providers, patients and families using semi-structured interviews and analysed using content analysis applying the theoretical framework of acceptability. Joint table analysis enabled the integration of the two data sets.

RESULTS

A total of 64 (41.3%) HCPs responded to the survey: 54 (84.4%) rated the intervention acceptable; 55 (85.9%) appropriate; and 49 (76.6%) feasible for use in this context. Qualitative data (23 interviews: 13 healthcare providers, 6 families and 4 patients) and the joint table analysis extended the understanding that intervention acceptability was related to positive affective attitudes and reduced communication frustration. Appropriateness and feasibility were promoted through intervention alignment with values, ability to personalize tools, and ease of access. Recommendations to improve the acceptability included adaptation for immobilized and/or restrained patients, additional education, and integration into existing workflows.

CONCLUSIONS

This mixed method evaluation of a co-designed bundled intervention to support patient communication in the ICU during pandemic conditions demonstrated high rated and described acceptability, appropriateness, and feasibility by participants.

RELEVANCE TO CLINICAL PRACTICE

A co-designed communication intervention demonstrating stakeholder acceptability, appropriateness, and feasibility can be implemented into clinical practice in pandemic and other infection prevention and control contexts.

Augmentative and alternative communication tools for mechanically ventilated patients in intensive care units: A scoping review

OBJECTIVES

The aim of this scoping review was to understand the extent and type of evidence on augmentative and alternative communication tools used with mechanically ventilated patients in the intensive care unit.

REVIEW METHOD USED

This scoping review was conducted using Arksey and O'Malley's methodological framework, followed by PAGER (Patterns, Advances, Gaps, Evidence for practice and Research recommendations) framework to provide a structured approach to analysis of reviews.

DATA SOURCES

In December 2021, six electronic databases-CENTRAL, CINAHL, Embase, Medline (Ebscohost), PyscINFO, and Web of Science-were searched. Searches were supplemented with hand searching of reference lists of included studies.

REVIEW METHODS

Studies were selected according to inclusion and exclusion criteria. Full-text review was completed by two independent authors, with any disagreement resolved by consensus or with consultation with a third reviewer. A table was developed to extract key information from the eligible studies. The Mixed Methods Appraisal Tool and Supporting the Use of Research Evidence checklist were used to quality appraise the selected primary research and reviews, respectively.

RESULTS

Twenty-three studies (19 primary studies and four reviews) were included in the review. Findings highlighted five main patterns: (i) Co-designing of the augmentative and alternative communication tools; (ii) Patients' and healthcare professionals' training needs on augmentative and alternative communication tools; (iii) Implementation of validated communication assessment algorithms; (iv) Amalgamate several communication methods/approaches; (v) Technical competency required for high-technology augmentative and alternative communication tools.

CONCLUSION

Both low- and high-technology augmentative and alternative communication tools are widely used for mechanically ventilated patients in intensive care units, but there is a need for systematically assessing the communication needs and implementing communication interventions to promote meaningful patient-centred clinical outcomes.

Intensive care professionals' perceptions of the quality of counselling provided in the ICU: A cross-sectional study

BACKGROUND

Intensive care professionals (ICPs) have a key role in counselling adult intensive care unit (ICU) patients and their family members. The counselling provided to ICU patients and their family members can be described based on the content, implementation, benefits, and resources.

AIMS

The study had two specific aims: first, to assess ICPs' perceptions of the quality of counselling provided to ICU patients and their family members; and second, to explore which factors ICPs feel is associated with the quality of counselling.

STUDY DESIGN

A cross-sectional survey of ICPs working in adult ICUs in Finnish university hospitals. Data were collected using the Counselling Quality Instrument. The data were analysed by descriptive statistics and chi-square and t-test statistical methods.

RESULTS

A total of 182 ICPs returned the questionnaire, reflecting a response rate of 18.6%. Most of the respondents were nurses (97%) and the mean age was 42 years. The ICPs reported having adequate time for patient- (77%) and family-centered (73%) counselling, but only 47% felt that their units had the appropriate facilities. There were statistically significant differences between patient- and family-centered counselling and the ICP's self-assessed competence (p < .001), goal-oriented counselling (p < .001), and atmosphere during counselling (p < .001). ICPs' attitudes towards counselling impacted how these professionals assessed patients' and family members' confidence, along with patient recovery (p < .001).

CONCLUSIONS

This study confirms that the provision of high-quality counselling has beneficial effects; however, it also indicates that there is a need for training that considers each ICP's professional experience and patient- and family-centered factors, which may differ from one another.

RELEVANCE TO CLINICAL PRACTICE

According to ICPs, the quality of counselling can be enhanced by empowering ICPs to improve counselling and providing appropriate ICU facilities for counselling, such as a private room for family members.

Tracheostomy clinical practices and patient outcomes in three tertiary metropolitan hospitals in Australia

BACKGROUND

There is a paucity of literature in Australia on patient-focused tracheostomy outcomes and process outcomes. Exploration of processes of care enables teams to identify and address existing barriers that may prevent earlier therapeutic interventions that could improve patient outcomes following critical care survival.

OBJECTIVES

The objectives of this study were to examine and provide baseline data and associations between tracheostomy clinical practices and patient outcomes across three large metropolitan hospitals.

METHODS

We performed a retrospective multisite observational study in three tertiary metropolitan Australian health services who are members of the Global Tracheostomy Collaborative. Deidentified data were entered into the Global Tracheostomy Collaborative database from Jan 2016 to Dec 2019. Descriptive statistics were used for the reported outcomes of length of stay, mortality, tracheostomy-related adverse events and complications, tracheostomy insertion, airway, mechanical ventilation, communication, swallowing, nutrition, length of cannulation, and decannulation. Pearson's correlation coefficient and one-way analyses of variance were performed to examine associations between variables.

RESULTS

The total cohort was 380 patients. The in-hospital mortality of the study cohort was 13%. Overall median hospital length of stay was 46 days (interquartile range: 31-74). Length of cannulation was shorter in patients who did not experience any tracheostomy-related adverse events (p= 0.036) and who utilised nonverbal communication methods (p = 0.041). Few patients (8%) utilised verbal communication methods while mechanically ventilated, compared with 80% who utilised a one-way speaking valve while off the ventilator. Oral intake was commenced in 20% of patients prior to decannulation. Patient nutritional intake varied prior to and at the time of decannulation. Decannulation occurred in 83% of patients.

CONCLUSIONS

This study provides baseline data for tracheostomy outcomes across three large metropolitan Australian hospitals. Most outcomes were comparable with previous international and local studies. Future research is warranted to explore the impact of earlier nonverbal communication and interventions targeting the reduction in tracheostomy-related adverse events.

Simulation-based training program on patient safety management: A quasi-experimental study among new intensive care unit nurses

BACKGROUND

Patient safety is an essential responsibility of nurses. However, newly graduated nurses experience patient safety incidents due to a lack of patient safety competency. In particular, intensive care unit nurses provide care to critical patients, making it difficult for new nurses to maintain patient safety. Therefore, it is necessary to improve the patient safety competency of newly graduated nurses working in the intensive care unit.

OBJECTIVES

To analyze the effects of a simulation-based training program on patient safety management on the patient safety competency, patient safety management activity, communication self-efficacy, and teamwork of newly graduated nurses working in an intensive care unit.

DESIGN

A quasi-experimental study.

SETTINGS

The study was conducted at a university in Korea.

PARTICIPANTS

A total of 44 newly graduated nurses working in the intensive care unit of a university hospital.

METHODS

A simulation-based training program on patient safety management was applied to the experimental group (n = 22), while only the usual hospital training program was used for the control group (n = 22). A structured questionnaire survey comprising Patient Safety Competency Self-Evaluation, Patient Safety Management Activities, the Korean version of the self-efficacy questionnaire, and K-self assessment of teamwork was conducted at baseline test (T1), post test (T2), and follow-up test (T3). Data were analyzed using a repeated measures ANOVA.

RESULTS

The experimental group showed significantly higher patient safety competency, patient safety knowledge, and patient safety skills, along with higher communication self-efficacy scores than the control group (p < .05) after the intervention and at four weeks after the intervention.

CONCLUSIONS

The simulation-based training program on patient safety management effectively improved the patient safety competency, patient safety knowledge, and patient safety skills as well as communication self-efficacy of newly graduated nurses working in an intensive care unit.

Symptom Assessment for Mechanically Ventilated Patients: Principles and Priorities: An Official American Thoracic Society Workshop Report

Mechanically ventilated patients experience many adverse symptoms, such as anxiety, thirst, and dyspnea. However, these common symptoms are not included in practice guideline recommendations for routine assessment of mechanically ventilated patients. An American Thoracic Society-sponsored workshop with researchers and clinicians with expertise in critical care and symptom management was convened for a discussion of symptom assessment in mechanically ventilated patients. Members included nurses, physicians, a respiratory therapist, a speech-language pathologist, a critical care pharmacist, and a former intensive care unit patient. This report summarizes existing evidence and consensus among workshop participants regarding 1) symptoms that should be considered for routine assessment of adult patients receiving mechanical ventilation; 2) key symptom assessment principles; 3) strategies that support symptom assessment in nonvocal patients; and 4) areas for future clinical practice development and research. Systematic patient-centered assessment of multiple symptoms has great potential to minimize patient distress and improve the patient experience. A culture shift is necessary to promote ongoing holistic symptom assessment with valid and reliable instruments. This report represents our workgroup consensus on symptom assessment for mechanically ventilated patients. Future work should address how holistic, patient-centered symptom assessment can be embedded into clinical practice.

Counselling offered to and needed by Finnish adult intensive care unit patients based on patients' records and memories

OBJECTIVES

Objectives of this study were to characterize the counselling (broadly defined) that Finnish adult intensive care unit patients received and needed during intensive care according to patients' records and memories.

DESIGN SETTING

The study was based on retrospective analysis of patient records and documented follow-up clinics, using a descriptive, qualitative approach and deductive-inductive content analysis.

FINDINGS

According to both the records and documented memories of 162 patients (56 women and 106 men aged 18-75 years; mean 50.8, median 53.5 years) patients' confidence in their own recovery, including feelings of safety and ability to participate, is enhanced by counselling during intensive care. They had strong memories of counselling that gave them knowledge about their medical conditions and procedures, symptoms, care, and psychological support. At follow-up, patients did not have such strong memories of lifestyle counselling that they received during intensive care.

CONCLUSION

Patients need counselling during an intensive care unit stay to improve their confidence in their recovery. The counselling strategy for intensive care should be documented, and patient memories collected during follow-up clinics, to help assessment of the quality of counselling provided in intensive care.

IMPLICATIONS FOR CLINICAL PRACTICE

Counselling during intensive care enhances patients' confidence in their own recovery. To assess the quality of counselling it is essential to recognize the types provided and needed. Appropriate documentation is crucial for evaluating intensive care unit patient counselling, and planning its continuity.

Theoretical definition of nurse-conscious mechanically ventilated patient communication: a scoping review with qualitative content analysis

Providing critical nursing care for conscious mechanically ventilated patients is mediated via effective communication. This study aimed to identify and map the antecedents, attributes, consequences, and definition of nurse-conscious mechanically ventilated patient communication (N-CMVPC). This scoping review was conducted by searching the Cochrane Library and the CINAHL, EMBASE, PubMed, Web of Science, and Scopus databases, between 2001 and 2021. The keywords queried included "nurses," "mechanically ventilated patients," "mechanical ventilation," "intubated patients," "communication," "interaction," "relationships," "nurse-patient communication," "nurse-patient relations," "intensive care units," and "critical care." Studies related to communication with healthcare personnel or family members were excluded. The results indicated that N-CMVPC manifests as a set of attributes in communication experiences, emotions, methods, and behaviors of the nurse and the patient and is classified into three main themes, nurse communication, patient communication, and quantitative-qualitative aspects. N-CMVPC is a complex, multidimensional, and multi-factor concept. It is often nurse-controlled and can express itself as questions, sentences, or commands in the context of experiences, feelings, and positive or negative behaviors involving the nurse and the patient.

Communication with mechanically ventilated patients in intensive care units: A concept analysis

AIMS

The aim of this study was to perform a concept analysis of communication with mechanically ventilated patients in intensive care units and present a preliminary model for communication practice with these patients.

DESIGN

The Im & Meleis approach for concept analysis guided the study.

SEARCH METHODS

A literature search was performed in January 2022 in MEDLINE, Embase, CINAHL, psycINFO and Scopus, limited to 1998-2022. The main medical subject headings search terms used were artificial respiration, communication and critical care. The search resulted in 10,698 unique references.

REVIEW METHODS

After a blinded review by two authors, 108 references were included. Core concepts and terminology related to communication with mechanically ventilated patients were defined by content analytic methods. The concepts were then grouped into main categories after proposing relationships between them. As a final step, a preliminary model for communication with mechanically ventilated patients was developed.

RESULTS

We identified 39 different phrases to describe the mechanically ventilated patient. A total of 60 relevant concepts describing the communication with mechanically ventilated patients in intensive care were identified. The concepts were categorized into five main categories in a conceptual map. The preliminary model encompasses the unique communication practice when interacting with mechanically ventilated patients in intensive care units.

CONCLUSION

Highlighting different perspectives of the communication between mechanically ventilated patients and providers through concept analysis has contributed to a deeper understanding of the phenomena and the complexity of communication when the patients have limited possibilities to express themselves.

IMPACT

A clear definition of concepts is needed in the further development of guidelines and recommendations for patient care in intensive care, as well as in future research. The preliminary model will be tested further.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution, as this is a concept analysis of previous research.

Defining effective communication for critically ill patients with an artificial airway: An international multi-professional consensus

OBJECTIVES

To define effective communication and identify its key elements specific to critically ill patients with an artificial airway.

DESIGN

A modified Consensus Development Panel methodology.

SETTING

International video-conferences.

MAIN OUTCOME MEASURES

Definition of effective communication and it's key elements.

RESULTS

Eight experts across four international regions and three professions agreed to form the Consensus Development Panel together with a Chair and one person with lived experience who reviewed the outputs prior to finalisation. "Communication for critically ill adult patients with an artificial airway (endotracheal or tracheostomy tube) is defined as the degree in which a patient can initiate, impart, receive, and understand information, and can range from an ineffective to effective exchange of basic to complex information between the patient and the communication partner(s). Effective communication encompasses seven key elements including: comprehension, quantity, rate, effort, duration, independence, and satisfaction. In critically ill adults, communication is impacted by factors including medical, physical and cognitive status, delirium, fatigue, emotional status, the communication partner and the nature of the ICU environment (e.g., staff wearing personal protective equipment, noisy equipment, bright lights)." The panel agreed that communication occurs on a continuum from ineffective to effective for basic and complex communication.

CONCLUSION

We developed a definition and list of key elements which constitute effective communication for critically ill patients with an artificial airway. These can be used as the basis of standard terminology to support future research on the development of communication-related outcome measurement tools in this population.

IMPLICATIONS FOR CLINICAL PRACTICE

This study provides international multi-professional consensus terminology and a definition of effective communication which can be used in clinical practice. This standard definition and key elements of effective communication can be included in our clinical impressions of patient communication, and be used in discussion with the patient themselves, their families and the multi-professional team, to guide care, goal development and intervention.

Long-term quality of life after obstetric intensive care unit admission: A cross-sectional cohort study

OBJECTIVE

To assess the long-term quality of life (QoL) after obstetric Intensive Care Unit (ICU) admission.

DESIGN

Cross-sectional survey study.

SETTING

Tertiary care centre.

POPULATION

Women admitted to the level 3 ICU during pregnancy or ≤6 weeks postpartum, between 2000 and 2015.

METHODS

Quality of life measures were compared with the population reference values. Associations with baseline ICU parameters were assessed with multivariable linear regression. Patient-reported outcome and experience measures (PROMs/PREMs) were described.

MAIN OUTCOME MEASURES

Quality of life according to the Linear Analogous Scale (LAS), the Satisfaction with Life Scale (SWLS) and the SF-36 questionnaire; PROMs/PREMs using the Pregnancy and Childbirth outcome set of the International Consortium for Health Outcomes Measurement.

RESULTS

Of all 265 obstetric ICU admissions, 230 were eligible and 94 (41%) were included (median follow-up time 14 years). The LAS (75.7 versus 78.7, p = 0.077) and SWLS (25.2 versus 26, p = 0.176) sum scores were not different from the population reference values. The SF-36 subdomains bodily pain (55.3 versus 73.9), general health (58.2 versus 73.9) and vitality (56.9 versus 69.1) were lower than the reference values (all p < 0.001). PROMs/PREMs were low in 46.2% for pain, 15.1% for depression, 11.8% for satisfaction with care and 52.7% for healthcare responsiveness. An indirect obstetric ICU admission diagnosis was independently associated with a reduced physical health score (B -1.7, 95% confidence interval [CI] -3.4 to -0.1) and severe neonatal morbidity with a reduced mental health score (B -6.6, 95% CI -11.3 to -1.8).

CONCLUSION

Obstetric ICU admission is associated with reductions in long-term physical health QoL and in some patients with mental health QoL. We suggest multidisciplinary rehabilitation and long-term psychosocial support.

Evaluation of the effectiveness of a training programme for nurses regarding augmentative and alternative communication with intubated patients using Kirkpatrick's model: A pilot study

AIM

Communicating with conscious intubated patients who are unable to communicate verbally is one of the challenges faced by intensive care unit (ICU) nurses. The present study was conducted to evaluate the effectiveness of a training programme for nurses regarding augmentative and alternative communication (AAC) with intubated patients using Kirkpatrick's model.

DESIGN

This study had a one-group, before-after, quasi-experimental design.

METHODS

Totally, 45 nurses working in ICUs participated in a blended training programme using AAC strategies to communicate with intubated patients. Their contribution was evaluated based on Kirkpatrick's model at four levels. The study data were collected using the "satisfaction and ease questionnaire," "observation checklist" and "communication knowledge test." Then, the data were analysed using the SPSS 22 software and p < 0.05 was considered statistically significant.

RESULTS

Most participants were satisfied with the implementation of the programme. The nurses' mean score of communication knowledge increased after the intervention (p < 0.05). The results of evaluation of the third and fourth levels of Kirkpatrick's model also showed an increase in the success of communication, use of AAC, and satisfaction with and ease of communication (p < 0.001).

IMPLICATION

Short-term and long-term effects of the blended training programme about AAC were investigated using Kirkpatrick's model. The results indicated the positive effect of the programme on the quality of the nurses' communication with intubated patients, their understanding of the patients' messages and meeting the patients' needs at a more desirable level. Thus, nurses and other staff are recommended to use this simple method of communication with patients to provide better services. In addition, further quantitative and qualitative studies are suggested to assess these communication strategies in other patients with impaired consciousness.

Esophageal Speech for a Patient with Amyotrophic Lateral Sclerosis Who Underwent a Central-part Laryngectomy to Prevent Aspiration: A Case Report

Background

To prevent aspiration, patients with irreversible dysphagia may undergo surgeries that separate the esophagus and trachea. Such interventions result in loss of vocal function and require alternative communication methods. We report a patient with amyotrophic lateral sclerosis (ALS) who used esophageal speech after receiving a central-part laryngectomy (CPL) to prevent aspiration.

Case

A 64-year-old woman with ALS was admitted to our hospital. The patient maintained good cognitive and oral function and presented with mild dysarthria and dysphagia. Faced with rapidly worsening respiratory distress, saliva aspiration, and excessive sputum, she underwent a tracheostomy on the premise of invasive ventilation. Subsequently, the patient began using a voice-generating application for communication. Given the patient's sincere hope to prevent aspiration and aspiration pneumonia, achieve safe oral intake, and decrease caregiver burden for frequent suctioning, the patient underwent a CPL. Following surgery, belching was observed during meals, and the patient could phonate when she belched. This finding led to four speech therapy sessions to practice esophageal speech, allowing the patient to use the pseudo-speech technique for short conversations. Removal of the entire cricoid cartilage in the CPL decreases the upper esophageal sphincter (UES) pressure, thereby allowing air to easily pass through the UES. Therefore, the patient could use the air as a sound source for esophageal speech without extensive training.

Discussion

Esophageal speech may be an alternative to oral communication in patients undergoing CPL. Further research is warranted to generalize these findings to patients undergoing CPL.

Sedation, sleep-promotion, and non-verbal and verbal communication techniques in critically ill intubated or tracheostomized patients: results of a survey

BACKGROUND

The aim of this survey was to describe, on a patient basis, the current practice of sedation, pharmacologic and non-pharmacologic measures to promote sleep and facilitation of communication in critically ill patients oro-tracheally intubated or tracheostomized.

METHODS

Cross-sectional online-survey evaluating sedation, sleep management and communication in oro-tracheally intubated (IP) or tracheostomized (TP) patients in intensive care units on a single point.

RESULTS

Eighty-one intensive care units including 447 patients (IP: n = 320, TP: n = 127) participated. A score of ≤ -2 on the Richmond Agitation Sedation Scale (RASS) was prevalent in 58.2% (IP 70.7% vs. TP 26.8%). RASS -1/0 was present in 32.2% (IP 25.9% vs. TP 55.1%) of subjects. Propofol and alpha-2-agonist were the predominant sedatives used while benzodiazepines were applied in only 12.1% of patients. For sleep management, ear plugs and sleeping masks were rarely used (< 7%). In half of the participating intensive care units a technique for phonation was used in the tracheostomized patients.

CONCLUSIONS

The overall rate of moderate and deep sedation appears high, particularly in oro-tracheally intubated patients. There is no uniform sleep management and ear plugs and sleeping masks are only rarely applied. The application of phonation techniques in tracheostomized patients during assisted breathing is low. More efforts should be directed towards improved guideline implementation. The enhancement of sleep promotion and communication techniques in non-verbal critically ill patients may be a focus of future guideline development.

Outcome measurement tools for communication, voice and speech intelligibility in the ICU and their clinimetric properties: A systematic review

Purpose

To identify outcome measurement tools used to evaluate communication, voice and speech intelligibility in the mechanically ventilated ICU population. Secondly, to evaluate, synthesise and compare the clinimetric properties of the tools identified.

Materials and methods

A systematic review of articles was undertaken via electronic databases in two parts. Eligibility criteria for selection: part one - quantitative or mixed methods studies which assessed communication, voice or speech intelligibility; part two - studies which evaluated a clinimetric property for one of the tools identified in part one. Two independent reviewers assessed articles for inclusion and used the consensus-based standards for health status measurement instruments (COSMIN) risk of bias checklist.

Results

The part one search yielded five included studies comprised of eight outcome measurement tools. The part two search yielded 22 included studies comprised of nine tools. Few studies had adequate reliability and measurement error properties. No studies established responsiveness. A notable proportion of studies utilised tools that have no clinimetric properties.

Conclusions

There is a relatively small number of studies which have established clinimetric properties for outcome measurement tools that evaluate communication, voice and/or speech intelligibility, and a fewer number which have done so in the mechanically ventilated ICU population.

Attitudes toward the use of low-tech AAC in acute settings: a systematized review

The purpose of this systematized review was to investigate how attitudes toward low-tech AAC might be impacting its use in acute care settings. A comprehensive and systematic search of databases identified 23 articles for inclusion. Thematic analysis using the World Health Organization International Classification of Functioning, Disability and Health (ICF) framework facilitated a narrative synthesis of findings. Results suggest that in acute care settings (a) adult patients, families, nursing staff, medical team, and allied health professionals all have opportunities to use but do not regularly engage with AAC; (b) individuals reject low-tech AAC devices for a variety of reasons, including that they are not useful, necessary, suitable, or appropriate in settings such as intensive care units; (c) negative attitudes toward AAC are linked to a lack of initial training and ongoing support, perceived impersonal content, limited functionality, and a lack of consistent availability; and (d) positive attitudes toward low-tech AAC are more prevalent when training and support are offered, low-tech AAC effectiveness is demonstrated, and organizational, financial, and procedural commitments are provided. Limitations of the research are highlighted and future research opportunities are identified.

Non-Pharmacological Interventions for Minimizing Physical Restraints Use in Intensive Care Units: An Umbrella Review

Background

There is a relationship between the application of physical restraints and negative physiological and psychological effects on critically ill patients. Many organizations have supported and advocated minimizing the use of physical restraints. However, it is still common practice in many countries to apply physical restraints to patients in intensive care.

Objective

This study aimed to assess the effectiveness of various non-pharmacological interventions used to minimize physical restraints in intensive care units and provide a supplement to the evidence summary for physical restraints guideline adaptation.

Methods

Based on the methodology of umbrella review, electronic databases, including Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, MEDLINE, EMBASE, CINAHL, Web of Science, PsycInfo/Psyc Articles/Psychology and Behavioral Science Collection, China National Knowledge Infrastructure, SinoMed, and Wanfang Data, were searched to identify systematic reviews published from January 2016 to December 2020. Two independent reviewers undertook screening, data extraction, and quality appraisal. The methodological quality of systematic reviews was evaluated by AMSTAR 2. Evidence quality of each intervention was assessed according to GRADE. The corrected covered area was calculated as a measure of overlap.

Results

A total of 47 systematic reviews were included in the umbrella review, of which six were evaluated as high quality, five were of moderate quality, and the rest were of low or critically low quality. The corrected covered area range was from 0.0 to 0.269, which indicated that there was mild overlap between systematic reviews. The included systematic reviews evaluated various types of non-pharmacological interventions for minimizing physical restraints in intensive care units, which included multicomponent interventions involving healthcare professionals' education, family engagement/support, specific consultations and communication, rehabilitation and mobilization (rehabilitation techniques, early mobilization, inspiratory muscle training), interventions related to reducing the duration of mechanical ventilation (weaning modes or protocols, ventilator bundle or cough augmentation techniques, early tracheostomy, high-flow nasal cannula), and management of specific symptoms (delirium, agitation, pain, and sleep disturbances).

Conclusion

The number of systematic reviews related to physical restraints was limited. Multicomponent interventions involving healthcare professionals' education may be the most direct non-pharmacological intervention for minimizing physical restraints use in intensive care units. However, the quality of evidence was very low, and conclusions should be taken with caution. Policymakers should consider incorporating non-pharmacological interventions related to family engagement/support, specific consultations and communication, rehabilitation and mobilization, interventions related to reducing the duration of mechanical ventilation, and management of specific symptoms as part of the physical restraints minimization bundle. All the evidence contained in the umbrella review provides a supplement to the evidence summary for physical restraints guideline adaptation.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=242586, identifier: CRD42021242586.

The use of predefined scales and scores with eye-tracking devices for symptom identification in critically ill nonverbal patients

BACKGROUND

Eye tracking (ET) may be a novel tool to enable nonverbal communication. We hypothesized that ET could be used successfully by intensive care unit (ICU) patients with artificial airways to express their levels of pain and mood, quality of life, and self-esteem with predefined scales and scores.

METHODS

Prospective, monocentric, observational study, including patients with an endotracheal tube or tracheostomy tube and a history of mechanical ventilation for more than 48 hours without delirium, and inadequate nonverbal communication skills. The ICU patients' pain was assessed with a numeric rating scale, their mood was tested with a smiley analog scale. Quality of life and self-esteem were measured with the European quality of life-5 dimensions-5 levels-score and the visual analog self-esteem scale.

RESULTS

A total of 75 patients with a mean age of 58.3 years were included. Main diagnoses for ICU admission were major trauma (45.3%), nonabdominal sepsis (22.6%), and acute abdomen (13.3%). Patients showed moderate levels of pain and sadness with a median of 4 (interquartile range, 3-5.5) on the numeric rating scale and a median of 4 (interquartile range, 3-4) on the smiley analog scale. The general health status on the European quality of life-5 dimensions-5 levels-score was rated as poor. Reporting on the visual analog self-esteem scale, most of the included patients felt trapped (90.7%) and not confident (72%), were frustrated (64%) or did not feel understood (56%). However, despite their severe illness, many patients classified themselves as intelligent (30.6%), not mixed up (38.6%), outgoing (38.6%), and optimistic (44%).

CONCLUSION

Eye tracking enables symptom identification in critically ill voiceless patients with impaired communication options. The results of our study may provide guidance for improvement measures in the care of voiceless ICU patients. We believe that ET is useful for symptom identification and therefore may be capable of improving patient-medical team interaction and patient satisfaction.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria, Level III.

Development of a Manually Operated Communication System (MOCS) for patients in intensive care units

Nonvocal alert patients in the intensive care unit (ICU) setting often struggle to communicate due to inaccessible or unavailable tools for augmentative and alternative communication. Innovation of a hand-operated non-touchscreen communication system for nonvocal ICU patients was guided by design concepts including speech output, simplicity, and flexibility. A novel communication tool, the Manually Operated Communication System (MOCS), was developed for use in intensive care settings with patients unable to speak. MOCS is a speech-output technology designed for patients with manual dexterity impairments preventing legible writing. MOCS may have the potential to improve communication for nonvocal patients with limited manual dexterity.

Nurses' experiences of serving as a communication guide and supporting the implementation of a communication intervention in the intensive care unit

PURPOSE

: To explore the experience of serving as a nurse communication guide, supporting the bottom-up implementation of a multi-component communication intervention prototype in the intensive care unit.

METHODS

: The overall frame was Complex Interventions, and the study was conducted within the phenomenological-hermeneutic tradition. Semi-structured telephone interviews were conducted with eight nurse communication guides. Data were analysed using a Ricoeur-inspired interpretation method.

RESULTS

: Two main themes emerged: 1) "The communication intervention components provided overview, a conceptual framework, awareness and room for reflection" and 2) "Being a communication guide illuminated the barriers and challenges of implementation". Furthermore, a comprehensive understanding was established that illuminated experiences throughout the analysis: "An ICU communication intervention has to be adaptable to the specific situation and the double need for individualization but also provide overall guidance".

CONCLUSION

: Findings showed that as communication is inherent to all human beings, it can be difficult to change the communication behaviour of nurses. Therefore, a communication intervention in the intensive care unit must be sensitive to the nurse communication guides' individual communication style. Furthermore, a communication intervention should provide nurse communication guides with overall guidance while at the same time remaining adaptable to the needs of each specific situation.

A multicomponent intervention to optimise nurse-patient communication in the intensive care unit: A mixed-methods acceptability and feasibility study

BACKGROUND

Mechanically ventilated patients in intensive care units may experience communication challenges owing to intubation, which affects nurse-patient communication. Several strategies may optimise communication, but only one previous study has tested a multicomponent intervention. Implementing such an intervention can be challenging because communication strategies may be set aside by lifesaving care tasks and procedures. In a previous study, we designed a communication intervention based on pre-existing clinical methods and evidence-based approaches. The present study evaluated the intervention to determine if it was necessary to adjust its components and the implementation strategy.

OBJECTIVES

The objective of this study was to evaluate the feasibility and assess nurses' acceptability of a patient-centred, multicomponent communication intervention prototype in an intensive care unit.

METHODS

The overall frame was the Medical Research Council's framework for developing complex interventions. Indicators of feasibility and acceptability were used for the evaluation. A mixed-methods design was applied including a survey with open-ended text boxes and qualitative observations as data sources. Quantitative data were analysed descriptively, and qualitative data were explored using content analysis. Data were compiled and displayed in a side-by-side comparison. The data were collected between September 2020 and March 2021. Nurses from four intensive care units at a university hospital in Denmark participated in the study. All nurses who were on active duty during the implementation of the intervention were enrolled for the survey and participant observations.

RESULTS

Overall, the results provided insight into the feasibility based on fidelity and context as well as nurses' acceptability based on adherence, appropriateness, convenience, and effectiveness. Qualitative and quantitative results yielded partially contrasting findings but highlighted how the intervention may be optimised to enhance fit with clinical practice and overcome implementation challenges.

CONCLUSION

The intervention was feasible and acceptable. However, implementation needs to be repeated to allow nurses to fully understand and use the intervention.

Evidence-Based Communication with Critically Ill Older Adults

Communication is a critical component of patient-centered care. Critically ill, mechanically ventilated patients are unable to speak and this condition is frightening, frustrating, and stressful. Impaired communication in the intensive care unit (ICU) contributes to poor symptom identification and restricts effective patient engagement. Older adults are at higher risk for communication impairments in the ICU because of pre-illness communication disorders and cognitive dysfunction that often accompanies or precedes critical illness. Assessing communication disorders and developing patient-centered strategies to enhance communication can lessen communication difficulty and increase patient satisfaction.

Interventions to enable communication for adult patients requiring an artificial airway with or without mechanical ventilator support

BACKGROUND

Inability to communicate in a manner that can be understood causes extreme distress for people requiring an artificial airway and has implications for care quality and patient safety. Options for aided communication include non-vocal, speech-generating, and voice-enabling aids.

OBJECTIVES

To assess effectiveness of communication aids for people requiring an artificial airway (endotracheal or tracheostomy tube), defined as the proportion of people able to: use a non-vocal communication aid to communicate at least one symptom, need, or preference; or use a voice-enabling communication aid to phonate to produce at least one intelligible word. To assess time to communication/phonation; perceptions of communication; communication quality/success; quality of life; psychological distress; length of stay and costs; and adverse events.

SEARCH METHODS

We searched the Cochrane Library (Wiley version), MEDLINE (OvidSP), Embase (OvidSP), three other databases, and grey literature from inception to 30 July 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs, controlled non-randomised parallel group, and before-after studies evaluating communication aids used in adults with an artificial airway.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Two review authors independently performed data extraction and assessment of risk of bias.

MAIN RESULTS

We included 11 studies (1931 participants) conducted in intensive care units (ICUs). Eight evaluated non-vocal communication aids and three voice-enabling aids. Usual care was the comparator for all. For six studies, this comprised no aid; usual care in the remaining five studies comprised use of various communication aids. Overall, our confidence in results regarding effectiveness of communication interventions was very low due to imprecision, measurement heterogeneity, inconsistency in results, and most studies at high or unclear risk of bias across multiple domains. No non-vocal aid studies reported our primary outcome. We are uncertain of the effects of early use of a voice-enabling aid compared to routine use on ability to phonate at least one intelligible word (risk ratio (RR) 3.03, 95% confidence interval (CI) 0.18 to 50.08; 2 studies; very low-certainty evidence). Compared to usual care without aids, we are uncertain about effects of a non-vocal aid (communication board) on patient satisfaction (standardised mean difference (SMD) 2.92, 95% CI 1.52 to 4.33; 4 studies; very low-certainty evidence). No studies of non-vocal aids reported quality of life. Low-certainty evidence from two studies suggests early use of a voice-enabling aid may have no effect on quality of life (MD 2.27, 95% CI -7.21 to 11.75). Conceptual differences in measures of psychological distress precluded data pooling; however, intervention arm participants reported less distress suggesting there might be benefit, but our certainty in the evidence is very low. Low-certainty evidence suggest voice-enabling aids have little or no effect on ICU length of stay; we were unable to determine effects of non-vocal aids. Three studies reported different adverse events (physical restraint use, bleeding following tracheostomy, and respiratory parameters indicating respiratory decompensation). Adverse event rates were similar between arms in all three studies. However, uncertainty remains as to any harm associated with communication aids.

AUTHORS' CONCLUSIONS

Due to a lack of high-quality studies, imprecision, inconsistency of results, and measurement heterogeneity,  the evidence provides insufficient information to guide practice as to which communication aid is more appropriate and when to use them. Understanding effectiveness of communication aids would benefit from development of a core outcome measurement set.

Protocol for a mixed method acceptability evaluation of a codesigned bundled COmmunication intervention for use in the adult ICU during the COVID-19 PandEmic: the COPE study

INTRODUCTION

Patients requiring invasive mechanical ventilation via an artificial airway experience sudden voicelessness placing them at risk for adverse outcomes and increasing provider workload. Infection control precautions during the COVID-19 pandemic, including the use of personal protective equipment (eg, gloves, masks, etc), patient isolation, and visitor restrictions may exacerbate communication difficulty. The objective of this study is to evaluate the acceptability of a codesigned communication intervention for use in the adult intensive care unit when infection control precautions such as those used during COVID-19 are required.

METHODS AND ANALYSIS

This three-phased, prospective study will take place in a medical surgical ICU in a community teaching hospital in Toronto. Participants will include ICU healthcare providers, adult patients and their family members. Qualitative interviews (target n: 20-25) will explore participant perceptions of the barriers to and facilitators for supporting patient communication in the adult ICU in the context of COVID-19 and infection control precautions (phase 1). Using principles of codesign, a stakeholder advisory council of 8-10 participants will iteratively produce an intervention (phase 2). The codesigned intervention will then be implemented and undergo a mixed method acceptability evaluation in the study setting (phase 3). Acceptability, feasibility and appropriateness will be evaluated using validated measures (target n: 60-65). Follow-up semistructured interviews will be analysed using the theoretical framework of acceptability (TFA). The primary outcomes of this study will be acceptability ratings and descriptions of a codesigned COmmunication intervention for use during and beyond the COVID-19 PandEmic.

ETHICS AND DISSEMINATION

The study protocol has been reviewed, and ethics approval was obtained from the Michael Garron Hospital. Results will be made available to healthcare providers in the study setting throughout the study and through publications and conference presentations.

Ensuring communication access for all during the COVID-19 pandemic and beyond: supporting patients, providers, and caregivers in hospitals

The COVID-19 pandemic has revealed substantial gaps in communication access for patients across hospital settings. With the rise in positive cases globally, the need for communication enhancement strategies, including augmentative and alternative communication (AAC), has emerged as a critical need. Many resources exist that describe AAC assessment and intervention processes in the acute care setting; however, AAC service provision in the COVID-19 pandemic is fraught with many unanticipated challenges. Patients, providers, and caregivers have encountered significant communication strain both at the bedside and beyond hospital walls, resulting in a communication crisis induced by many COVID-19 related variables. This article describes the sequelae of symptoms a person with COVID-19 may experience, progression of communication needs, and evidence-based solutions to supporting communication access. Barriers related to the COVID-19 pandemic are outlined (e.g., evolving infection control practices, personal protective equipment requirements, visitor policies, and more) along with response recommendations to support communication enhancement efforts for people with and without COVID-19 benefiting from access to AAC.

Giving Voice: Nurse-Patient Communication in the Intensive Care Unit

Communication is the essence of the nurse-patient relationship. The critical care nurse's role in facilitating patient communication and enabling communication between patients and their families has never been more important or poignant than during the COVID-19 pandemic. We have witnessed tremendous examples of resourceful, caring nurses serving as the primary communication partner and support for isolated seriously ill patients during this pandemic. However, evidence-based tools and techniques for assisting awake, communication-impaired, seriously ill patients to communicate are not yet systematically applied across all settings. Missed communication or misinterpretation of patients' messages induces panic and fear in patients receiving mechanical ventilation and can have serious deleterious consequences. This lecture presents a 23-year program of research in developing and testing combination interventions (eg, training, tailored assessment, and tools) for best practice in facilitating patient communication during critical illness. Evidence from related nursing and inter pro fessional research is also included. Guidance for unit-based assessment, tailoring, and implementation of evidence-based patient communication protocols also is provided.

Nurses' perspectives on alternative communication strategies use in critical care units

BACKGROUND

Critically ill patients have the right to communicate and participate in their treatment to avoid adverse medical outcomes due to the severity of their illness, their responsiveness, and level of consciousness. This human right has often been neglected by health care professionals, as a result of limited alternative communication support provided to patients who are unable to speak due to, for example, endotracheal intubation. Despite the successful use of alternative communication strategies in critical care units (CCUs) in other countries, limited implementation in South African hospitals has been reported.

AIMS AND OBJECTIVES

This study aimed to determine the perspectives of South African nurses working in CCUs on the frequency of use of alternative communication strategies to support patient-centred communication with critically ill adult patients.

DESIGN

The study followed a quantitative non-experimental survey research design.

METHODS

A total of 210 nurses working in both private and public hospitals completed a survey on their perspectives on the use of alternative communication strategies in CCUs.

RESULTS

Nurse participants reported experience working with critically ill and communication-vulnerable patients. Nurse-patient communication mainly involved the use of pen and paper, facial expressions and gestures to obtain information relating to patients' needs and their health history. Limited use of speech-generating communication devices was reported.

CONCLUSION

Nurse training on the use and implementation of alternative communication strategies, such as communication boards or electronic speech-generating devices, should be investigated to improve nurses' communication with communication-vulnerable patients in South Africa.

RELEVANCE TO CLINICAL PRACTICE

The results are applicable in clinical practice due to patients' need for alternative communication. The nurses mainly used low-tech solutions, which are cheap and easy to access. However, there exists an opportunity to increase the use of available digital solutions.

Patient and nurse content preferences for a communication board to facilitate dialogue in the intensive care unit

OBJECTIVES

The main aim of this study was to identify patient and nurse content preferences for a communication board to facilitate effective communication (dialogue) in the critical care unit.

RESEARCH DESIGN

A qualitative research design focusing on explorative and descriptive components was used to address the aim of the research study. The study employed two participant groups. Semi-structured interviews and focus group discussions were conducted with critically ill patients (N = 10) and critical care nurses (N = 30).

SETTING

The study was conducted in four different private hospitals of the same hospital group in Gauteng, South Africa.

FINDINGS

Four distinct themes were identified in the research regarding the vocabulary items that participants would like to have included.

CONCLUSION

The findings suggest that patients perceive a communication board to be valuable in enhancing communication in the critical care unit; that cultural and linguistic diversity should be considered; and that patients and nurses have varying opinions on topics of priority during communication.

A systematic review on voiceless patients' willingness to adopt high-technology augmentative and alternative communication in intensive care units

OBJECTIVE

To systematically evaluate the acceptability of high-technology augmentative and alternative communication (high-tech AAC) among ICU patients who are voiceless guided by the technology acceptance model (TAM).

METHODS

We searched the Cochrane Library, EMBASE, PubMed, CINAHL, PsycINFO, Web of Science, SinoMed, China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database and Wanfang Database from database inception to September 2019. Studies that examined conscious nonverbal ICU patients with high-tech AAC intervention were included. Two reviewers independently collected and evaluated all the studies. The methodological quality was assessed by using the Joanna Briggs Institute critical appraisal tool.

RESULTS

Eighteen studies with a total of 914 patients met the inclusion criteria, and the quality of the studies varied from low to moderate. Based on the TAM, ICU voiceless patients perceived that high-tech AAC was useful, was easy to use, decreased communication difficulties, reduced negative emotions, and improved symptom identification and management. Patients maintained a positive attitude and were willing to continue to use high-tech AAC.

CONCLUSIONS

Although the existing evidence is limited, voiceless patients regard high-tech AAC devices as a useful, reliable, and acceptable alternative communication choice in the ICU. Multicenter, large-sample, and high-quality studies are highly recommended in the future.

Patient involvement in micro-decisions in intensive care

OBJECTIVE

The objective of this study was to explore how bedside micro-decisions were made between conscious patients on mechanical ventilation in intensive care and their healthcare providers.

METHODS

Using video recordings to collect data, we explored micro-decisions between 10 mechanically ventilated patients and 60 providers in interactions at the bedside. We first identified the types of micro-decisions before using an interpretative approach to analyze the decision-making processes and create prominent themes.

RESULTS

We identified six types of bedside micro-decisions; non-invited, substituted, guided, invited, shared and self-determined decisions. Three themes were identified in the decision-making processes: 1) being an observer versus a participant in treatment and care, 2) negotiating decisions about individualized care (such as tracheal suctioning or medication),and 3) balancing empowering activities with the need for energy restoration.

CONCLUSION

This study revealed that bedside decision-making processes in intensive care were characterized by a high degree of variability between and within patients. Communication barriers influenced patients' ability to express their preferences. An increased understanding of how micro-decisions occur with non-vocal patients is needed to strengthen patient participation.

PRACTICE IMPLICATIONS

We advise providers to make an effort to solicit patients' preferences when caring for critically ill patients.

Evidence-Based Communication with Critically Ill Older Adults

Communication is a critical component of patient-centered care. Critically ill, mechanically ventilated patients are unable to speak and this condition is frightening, frustrating, and stressful. Impaired communication in the intensive care unit (ICU) contributes to poor symptom identification and restricts effective patient engagement. Older adults are at higher risk for communication impairments in the ICU because of pre-illness communication disorders and cognitive dysfunction that often accompanies or precedes critical illness. Assessing communication disorders and developing patient-centered strategies to enhance communication can lessen communication difficulty and increase patient satisfaction.

Nurses' communication with mechanically ventilated patients in the intensive care unit: Umbrella review

AIM

To conduct a review summarizing evidence concerning communication with mechanically ventilated patients in the intensive care unit (ICU).

BACKGROUND

ICU patients undergoing mechanical ventilation are unable to communicate verbally, causing many negative emotions. Due to changes in sedation practice, a growing number of patients are conscious and experience communication difficulties.

DESIGN

The umbrella review method guided by the Joanna Briggs Institute was applied.

DATA SOURCES

A systematic search was done in the Cochrane Library, the Joanna Briggs Institute database, Cinahl, Pubmed, PsycINFO and Scopus between January -April 2019. Search terms were 'nurse-patient communication', 'mechanical ventilation', 'intensive care', and 'reviews as publication type'. Literature from 2009-2019 was included.

REVIEW METHODS

Following recommendations by the Joanna Briggs Institute, a quality appraisal, data extraction, and synthesis were done.

RESULTS

Seven research syntheses were included. There were two main themes and six subthemes: (1) Characterization of the nurse-patient communication: (a) Patients' communication; (b) Nurses' communication; (2) Nursing interventions that facilitate communication: (a) Communication assessment and documentation; (b) Communication methods and approaches; (c) Education and training of nurses; and (d) Augmentative and alternative communication.

CONCLUSION

Nurse-patient communication was characterized by an unequal power relationship with a common experience - frustration. Four key interventions were identified and an integration of these may be key to designing and implementing future ICU communication packages.

IMPACT

Nurse-patient communication is characterized by an unequal power relationship with one joint experience - frustration. Four key interventions should be integrated when designing and implementing communication packages in the ICU. Findings are transferable to ICU practices where patients are conscious and experience communication difficulties.

Augmentative and Alternative Communication in Ventilated Patients: A Scoping Review

OBJECTIVES

to map the benefits of Augmentative and Alternative Communication in ventilated adults in Intensive Care Unit and identify strategies used.

METHODS

a Scoping Review was carried out according to the Joanna Brigs Institute Protocol. The research question was: "In adult patients ventilated in Intensive Care Units, what are the benefits of Augmentative and Alternative Communication?". An article research was carried out at PubMed, EBSCOhost and B-On databases. It was held between October and November 2018, from 2013 to 2018, in Portuguese and in English.

RESULTS

61 references were obtained. After selection according to the inclusion criteria, 7 articles were analyzed.

CONCLUSIONS

studies enunciate Augmentative and Alternative Communication as a strategy to enhance communication, describing methods and tools. There is no agreement on the most effective tool.

Barriers to and facilitators for the use of augmentative and alternative communication and voice restorative strategies for adults with an advanced airway in the intensive care unit: A scoping review

PURPOSE

To identify barriers and facilitators for the use of augmentative and alternative communication (AAC) and voice restorative strategies for adult patients with an advanced airway in the intensive care unit (ICU).

MATERIALS AND METHODS

Scoping review searching five databases between 1990 and 2019. We screened 13, 167 citations and included all study types reporting barriers and/or facilitators to using communication strategies in an ICU setting. Two authors independently extracted and coded reported barriers and facilitators to the Theoretical Domains Framework (TDF) domains.

RESULTS

Of the 44 studies meeting inclusion criteria 18 (44%) used qualitative, 18 (44%) used quantitative, and 8 (18%) used mixed methods. In total, 39 unique barriers and 46 unique facilitators were identified and coded to the domains of the TDF. Barriers were most frequently coded to the Skills, Environmental Context and Resources, and Emotion domains. Facilitators were most frequently coded to Reinforcement, Environmental Context and Resources, and Social and Professional Roles/Identity domains. Thematic synthesis produced four potentially modifiable factors: context, emotional support, training, and decisional algorithms.

CONCLUSIONS

Identified barriers (skills, environment, resources, emotions) and facilitators (reinforcement, resources, roles) to ICU communication strategy use in the literature may be modified through formal training and role support.

Barriers to and facilitators for use of augmentative and alternative communication and voice restorative devices in the adult intensive care unit: a scoping review protocol

BACKGROUND

Mechanically ventilated patients in the intensive care unit (ICU) experience profound communication impairment, placing them at risk for poor physical and psychological outcomes. Patient communication strategies such as augmentative and alternative communication (AAC) and voice restorative devices are recommended to facilitate communication. These strategies, however, are inconsistently adopted in ICU practice signaling utilization barriers. Our objective is to map and synthesize the current evidence-base for stakeholder-reported barriers and facilitators to patient communication strategy utilization for adults with an advanced airway in the ICU.

METHODS AND ANALYSIS

We will use Arskey and O'Malley's recommended methods to conduct a scoping review using a rapid review framework to streamline the process. A single reviewer will conduct a search and an initial screen of titles and abstracts from five electronic databases (MEDLINE, EMBASE, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature [CINAHL], and PsychInfo) from 1990 to present to identify English language peer-reviewed studies. Subsequently, two reviewers will independently screen a shorter list of studies for inclusion. We will also search the reference lists of eligible studies. Two reviewers will independently extract study characteristics, communication strategy, and stakeholder reported barriers and facilitators. We will code and categorize the extracted barriers and facilitators according to the Theoretical Domains Framework (TDF), an integrative framework of behavior change.

DISCUSSION

To our knowledge, this will be the first scoping review to map and synthesize reported barriers and facilitators to communication strategy utilization in the adult ICU using a theoretical framework. The results of this scoping review will help to identify trends and gaps in the current evidence-base and support recommendations for improving patient-centered practice, policy, and research related to successfully establishing ICU patient communication.

Strategies for communicating with conscious mechanically ventilated critically ill patients

Critically ill patients admitted to the intensive care unit (ICU) frequently require ventilatory support. To provide this life-saving therapy, oral intubation or tracheostomy placements are needed. Consequently, verbal ability to communicate is lost. Furthermore, depending on the severity of the clinical condition and other comorbidities, patients commonly develop ICU-acquired weakness, which may preclude gestural communication and motor abilities. Under this circumstance, the patient's inability to interact with health care providers and/or family members results in psychological alterations, as well as isolation and reduction of self-esteem. A variety of tools have been developed to improve patient-clinician communication. This article reviews patient complications due to lack of communication, available tools to enhance interactions, and current published evidence to support communication tools.