Communication with patients in intensive care units: a scoping review

Nurses and the disabled child's perspective in the anaesthesia procedure preparation process using a picture schedule

PURPOSE

This study's purpose was to investigate how nurses, using a picture schedule, enable or hinder the realization of disabled children's agency in the preparation for an MRI procedure carried out under general anaesthesia.

METHODS

A qualitative observation study was used to explore the interaction of nurses and children. The data consisted of video recordings of 25 preparation situations of 3 (3-8 years old) children (with challenges in communication and/or cognitive skills) with 4 nurses. Verbal and nonverbal communication was analysed with interventionist applied conversation analysis.

RESULTS

What was most crucial was how the picture schedule was used during the interaction. Reciprocal information sharing, responding to the child's initiatives by negotiating and allowing the child to take physical action with the picture schedule enabled the realization of the child's agency.

CONCLUSIONS

The preparation process should aim to help the child prepare in his/her own way. The preparation tools should encourage reciprocal interaction in informing and in responding to the children's initiatives. The preparation practices should include enough time for the child's initiatives and physical participation. The results can be used in assessing preparation tools and how they are used from the perspective of the child's agency.

Communication in critical care tracheostomy patients dependent upon cuff inflation: A scoping review

OBJECTIVES

The aim of this study was to synthesise the evidence concerning communication in critically ill tracheostomy patients dependent on cuff inflation. The aim was to identify the psychological impact on patients awake and alert with tracheostomies but unable to speak; strategies utilised to enable communication and facilitators and barriers for the success of these strategies.

REVIEW METHOD USED

This scoping review was conducted using the Joanna Briggs Institute framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

DATA SOURCES

CINAHL, Embase, Medline, and Web of Science were searched from 1st January 2000 to 30th September 2023 and supplemented with hand searching of references from included studies.

REVIEW METHODS

Studies were eligible if they addressed the psychological impact of voicelessness and/or the structure, process, and outcomes of augmentative and alternative communication (AAC) systems, in addition to facilitators and barriers to effectiveness. The population of interest included critically ill tracheostomy patients dependent on cuff inflation, their families, and healthcare workers. Screening and data extraction were undertaken by two reviewers independently. Data analysis involved descriptive statistics and content analysis.

RESULTS

A total of 23 studies met the inclusion criteria: 11 were qualitative, nine were quantitative, and three were mixed-methods studies. Voicelessness elicited negative emotions, predominantly frustration. AAC systems, encompassing unaided and aided (low-tech and high-tech) methods, presented both advantages and drawbacks. High-tech strategies held promise for patients with physical limitations. Patients equally appreciated the support offered through unaided strategies, including eye contact and touch. Facilitating factors included speech therapy involvement and assessment. Patient-related challenges were the most frequent barriers.

CONCLUSION

Facilitating meaningful communication for critically ill tracheostomy patients dependent on cuff inflation is of paramount psychological significance. Whilst AAC systems are practicable, they are not without limitations, implying the absence of a universally applicable solution. This underscores the importance of continuous evaluation, reinforced by a multidisciplinary team.

REVIEW PROTOCOL REGISTERED

27 July 2022.

REVIEW REGISTRATION

Open Science Framework Registries: https://osf.io/kbrjn/.

C-L Case Conference: The Interaction Between Emotional Dysregulation and Chronic Critical Illness in a Patient With a Terminal Personality Disorder

We present a case of a patient who presented for endocarditis and subsequently had a prolonged and challenging hospital course, with much of it spent in the intensive care unit (ICU). Throughout their hospitalization, personality factors, combined with impaired communication and pain in severe medical illness, led to challenging behaviors of disengagement, impulsivity, splitting, agitation, and suicidal statements. Experts in critical care psychiatry review the case and its key elements, including principles of critical care psychiatry and pharmacologic management of ICU patients; communication problems in ICU patients and associated psychiatric distress; the benefits of proactive consultation for challenging patients; and the construct of post-intensive care syndrome. Patients with personality disorders often struggle to cope with severe medical illness, leading to challenging, self-defeating behaviors. Such acts are even more difficult to manage in intensive care, where a patient's tenuous medical status depends on smooth interactions between them and the medical team. We address how these challenges may be mitigated in collaboration with a psychiatric consult team.

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.

Applying the Generalizability Theory to Identify the Sources of Validity Evidence for the Quality of Communication Questionnaire

Effective doctor-patient-family communication is an integral and sensitive part of health care, assessing its quality is essential to identify aspects needing disclosure and, if necessary, improvement. Cross-sectional study aimed to analyze the sources of evidence of validity and the number of participants needed to reliably apply the Quality of Communication Questionnaire (QoC) through Generalizability Theory (GT). The mean age of the 150 patients hospitalized at the end of life was 50.5 (SD = 13.8) years, the mean hospital length of stay was 7.5 (SD = 10.2) days, 56.9% were male. Regarding the 105 patients' family members of patients whose mean length of hospital stay was 9.5 (SD = 9.1) days, their mean age was 42.2 (SD = 14.7) years, 69.5% were female. GT was used to quantify the minimum number of questionnaires needed, with the aim of reaching a reliable estimate of QoC with G-coefficients. To reach a reliability of .90, there is a need for 25 for the Eρ2 questionnaires and 35 for the Φ. The exact estimation identified the minimum number of questionnaires required for the evaluation of physicians by patients. To obtain a reliability of .90, there is a need for 30 and 40 questionnaires for the G-coefficients. A practical and fast application makes it possible to use QoC in its entirety or alone to evaluate general communication or communication about palliative care. Furthermore, based on these results, it was possible to identify which aspects were effective or ineffective in these contexts.

Critical care nurses' experiences of communication-vulnerable patients in the intensive care unit and the influence on rendering compassionate care

Background

Interventions administered to critically ill patients, including mechanical ventilation, sedation or other treatments may hinder communication between patients and nurses. These communication challenges may affect critical care nurses' ability to provide compassionate, person-centred care.

Objectives

To identify nurses' experiences with patients who are communication-vulnerable in the intensive care unit and how they affect nurses' ability to offer compassionate care.

Methods

This qualitative explorative descriptive study involved nurses who worked in intensive care units from four private hospitals in Gauteng, South Africa. Focus groups were conducted with 30 critical care nurses in groups of two to six participants each. Thematic analysis was used to identify themes.

Results

Five main themes were identified based on nurses' reports of their experiences with critically ill patients who experience communication difficulties and their impact on rendering compassionate care. Themes were deductively identified based on the social purposes of communication categories. Participants indicated that communication-vulnerable patients influence their ability to provide compassionate care. Generally, the physical, emotional, social and communication difficulties of assisting communication-vulnerable patients caused nurses to feel frustrated and negative towards their work environment, which added to their work stress and sometimes resulted in compassion fatigue.

Conclusion

The study shows that various factors could impact the nurses' ability to provide compassionate care and that they require support to provide person-centred care. These factors can include the physical environment, the patient's alertness and awareness and institutional barriers. To support nurses in providing compassionate care, communication partner training may be warranted.

Contribution of the study

This study aims to increase awareness of the aspects that may contribute to compassion fatigue for nurses. By identifying these aspects greater support can be provided by facilities where nurses work.

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.

Development, feasibility testing, and preliminary evaluation of the Communication with an Artificial airway Tool (CAT): Results of the Crit-CAT pilot study

BACKGROUND

A purpose-built outcome measure for assessing communication effectiveness in patients with an artificial airway is needed.

OBJECTIVES

The objective of this study was to develop the Communication with an Artificial airway Tool (CAT) and to test the feasibility and to preliminary evaluate the clinical metrics of the tool.

METHODS

Eligible patients with an artificial airway in the Intensive Care Unit were enrolled in the pilot study (Crit-CAT). The CAT was administered at least twice before and after the communication intervention. Item correlation analysis was performed. Participant and family member acceptability ratings and feedback were solicited. A qualitative thematic analysis was undertaken.

RESULTS

Fifteen patients with a mean age of 53 years (standard deviation [SD]: 19.26) were included. The clinician-reported scale was administered on 50 attempts (100%) with a mean completion time of 4.5 (SD: 0.77) minutes. The patient-reported scale was administered on 46 out of 49 attempts (94%) and took a mean of 1.5 (SD: 0.39) minutes to complete. The CAT was feasible for use in the Intensive Care Unit, with patients with either an endotracheal or tracheostomy tube, whilst receiving invasive mechanical ventilation or not, and while using either verbal or nonverbal modes of communication. Preliminary establishment of responsiveness, validity, and reliability was made. The tool was acceptable to participants and their family members.

CONCLUSION

The clinician-reported and patient-reported components of the study were feasible for use. The CAT has the potential to enable quantifiable comparison of communication interventions for patients with an artificial airway. Future research is required to determine external validity and reliability.

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.

Unidentified communication challenges in the intensive care unit: A qualitative study using multiple triangulations

BACKGROUND

Communication in the intensive care unit is challenged by patients' inability to speak owing to intubation, treatment, and illness. Research has focused on the use of communication tools or techniques, characteristics of the communication between patients and clinicians, and their experiences of communication challenges. However, few studies have combined the perspectives of patients, family members, and clinicians. We explored communication from different angles and investigated challenges that cannot be explained by ineffective use of aids and communication techniques.

OBJECTIVES

The aim of this study was to explore communication between patients, family members, and nurses and to investigate previously unidentified communication challenges.

METHODS

This study used a case-oriented design with multiple triangulations. It was conducted in two general intensive care units at a Norwegian university hospital. Participant observations were conducted on nine mechanically ventilated patients while communicating with family members and healthcare personnel. Following the observations, individual interviews were conducted with six patients, six family members, and nine healthcare personnel.

FINDINGS

Communication often seemed uncomplicated at the time of observations, but information from the interviews revealed another picture. We demonstrate what participants emphasised differently when they discussed their experiences, revealing a discrepancy in perceived importance in the situation. Family members had an important role in interpreting signs from the patient, uncovering challenges that would have been unknown to the nurses otherwise.

CONCLUSIONS

This study illustrates how communication challenges in the intensive care unit may not be perceptible to an observer or to all of the participants involved at the time of the communication. Nurses need to be aware of these communication challenges and realise that the patient might face issues that cannot be easily solved without extensive involvement of the patient, family, and nurses, and perhaps not even until a later stage in the patient's recovery process.

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.

Benefits and options for voice restoration in mechanically ventilated intensive care unit patients with a tracheostomy

Communication difficulties and their effects on patients who are mechanically ventilated are commonly reported and well described. The possibility of restoring speech for patients has obvious benefits, not only for meeting patient's immediate needs, but for helping them to re-engage in relationships and participate meaningfully in their recovery and rehabilitation. This opinion piece by a group of United Kingdom (UK) based Speech and Language Therapy experts working in critical care describes the various ways by which a patient's own voice can be restored. Common barriers to using different techniques and potential solutions are explored. We therefore hope that this will encourage intensive care unit (ICU) multi-disciplinary teams to advocate and facilitate early verbal communication in these patients.

Challenges and Learning Needs of Nurse-Patients' Family Communication: Focus Group Interviews With Intensive Care Unit Nurses in South Korea

Intensive care unit (ICU) nurses are expected to facilitate effective day-to-day communication with patients and family members at the bedside. To date, communication training for ICU health care professionals has targeted mainly intensivists-in-training, but there is limited data on communication experience and needs to be evaluated among ICU nurses. This qualitative study used focus group interviews to explore daily communication experiences with patients' families and communication training needs and preferences among ICU nurses in South Korea. Five focus group interviews were conducted with 27 ICU nurses (4-6 nurses per group). The results of inductive qualitative content analysis highlighted four main categories: "Perceived difficulties during communication," "burden from working conditions," "endeavors to promote communication skills," and "strategies for cultivating effective communication." Regarding suggestions for future communication training, nurses preferred interactive learning with peer-support over traditional methods (e.g., lectures). Nurses also suggested that communication training for ICU nurses should include learning skills appropriate for difficult situations (e.g., angry family members). Findings from this study can serve as a framework for stakeholders in ICU care and healthcare education (e.g., hospital and nursing administrators, nurse educators) when designing communication training to support ICU nurses with their practical knowledge and communication skills.

ASAD: A Novel Audification Console for Assessment and Communication of Pain and Discomfort

Pain and discomfort are subjective perceptions that are difficult to quantify. Various methods and scales have been developed to find an optimal manner to describe them; however, these are difficult to use with some categories of patients. Audification of pain has been utilized as feedback in rehabilitation settings to enhance motor perception and motor control, but not in assessment and communication settings. We present a novel tool, the Audification-console for Self-Assessment of Discomfort (ASAD), for assessing and communicating pain and discomfort through sound. The console is a sequence of increasing pitch and frequencies triggered at the press of buttons and displayed as a matrix that can be associated with the subjective perception of pain and discomfort. The ASAD has been evaluated in its ability to capture and communicate discomfort, following a fatigue test in the lower limbs with thirty healthy volunteers, and compared to the most common self-reported methods used in the NHS. (The National Health Service (NHS) is the publicly funded healthcare system in England and one of the four National Health Service systems in the United Kingdom.) This was a qualitative, within subjects and across groups experiment study. The console provides a more accurate assessment than other scales and clearly recognizable patterns of sounds, indicating increased discomfort, significantly localized in specific frequency ranges, thus easily recognizable across subjects and in different instances of the same subject. The results suggest a possible use of the ASAD for a more precise and automatic assessment of pain and discomfort in health settings. Future studies might assess if this is easier to use for patients with communication or interpretation difficulties with the traditional tools.

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.

A comparative study of patient safety in the intensive care units

Aim

This study aimed to assess patient‐safety principles in ICUs.

Design

This is a descriptive‐comparative study.

Methods

The research environment includes ICUs of hospitals affiliated to the two universities of medical sciences in Tehran. Sampling was done by census using Time and Event Sampling methods. Research instrument was “Patient Safety Principles Checklist”. Data analysis was performed using SPSS‐20 and descriptive‐inferential statistics with a significance level of 0.05.

Results

There is no significant difference (p‐value = .15) in the level of observance of patient‐safety principles in two university‐affiliated hospitals A (133.26 ± 9.14) and B (128.16 ± 18.01). Evaluation of the mean scores obtained in each dimension and in each of the ICUs was showed that only in dimension No.3 the difference was significant (F[68,2] = 5.20, p‐value = .008) and in the AICUs (16.13 ± 1.8) (p‐value = .04), it was significantly lower than other ICUs. Identifying risk factors for the patient’s immunity reduces the side effects of patient care.

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.

Communication experiences of tracheostomy patients with nurses in the ICU: A scoping review

INTRODUCTION

The quality of care for tracheostomy and mechanically ventilated patients in intensive care units (ICUs) has improved considerably. However, the communication barrier attributable to these procedures generates many problems for patients, as they are unable to communicate effectively with family members and ICU healthcare professionals, especially nurses.

AIMS

To describe (1) tracheostomy patients' needs, emotions and difficulties when communicating with ICU nurses and (2) which strategies nurses and patients have adopted to improve their communication.

METHODS

A scoping review was completed using the Joanna Briggs Institute method and following the PRISMA-ScR Checklist. The research question was developed using the Population, Concept and Context framework. Five databases were searched. After screening, two researchers independently analysed the 75 papers, and finally, 19 studies were included in this review.

RESULTS

All studies used a qualitative design. Seven adopted a phenomenological and two a hermeneutic approach, involving a total of 265 patients. Two main themes and four subthemes were identified: (1) the tracheostomy patients' needs, emotions and difficulties communicating with ICU nurses (patients' emotions, communication needs, and their content and difficulties) and (2) strategies that nurses and patients adopted to improve communication (communication strategies).

CONCLUSIONS

It is essential to develop effective communication with tracheostomy patients to ensure they feel relieved, safe and considered. Communication content should focus on information relating to the person's personal condition and active involvement in care.

RELEVANCE TO CLINICAL PRACTICE

It is important to prioritise the communication process in tracheostomised patients and create the organisational conditions that foster effective communication processes. Developing training programmes for new or practising nurses is essential to instil greater awareness about this crucial fundamental need.

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.

Approach to the basic needs in patients on invasive ventilation using eye-tracking devices for non-verbal communication

PURPOSE

To analyze the feasibility of eye-tracking (ET) devices as a communicative approach to the basic needs (BN) of intensive care unit (ICU) and invasively ventilated nonverbal patients.

METHODS

Prospective, monocentric, and observational study including all patients without delirium, with an endotracheal tube or tracheostomy tube, with a history of invasive ventilation for more than 48 h, and inadequate nonverbal communication skills. The investigation was performed with commercially available ET devices (Tobii Dynavox I-15+) to express BN of ICU patients following a standardized 30-item yes-or-no questionnaire.

RESULTS

A total of 64 patients with a mean age of 58.6 years were included. The main diagnoses for ICU admission were major trauma (43.6%), sepsis (21.8%), and acute abdomen (15.6%). Pain during repositioning (69%), thirst (69%), sleep disorders (66%), fatigue (64%), and anxiety regarding the lifelong need for assistance (64%) were the main problems reported by the patients. However, most of the patients described expectations of health improvement (78%), good family support (66%), and an improvement in quality of life due to the use of ET devices (67%).

CONCLUSION

The use of ET in selected ICU patients with impaired communication is feasible, allowing them to express their BN. Apart from knowing the patients' individual BN, the results of our BN questionnaire may provide guidance for improvement measures in the care of patients in the ICU who are unable to speak. We believe that ET is useful for inquiring about and expressing BN and, therefore, may be capable of improving patient-medical team interactions and patient satisfaction.

Quality of Communication Questionnaire for Patients Hospitalized in Intensive and Palliative Care: Validity Evidence for Use in Brazil

The Quality of Communication Questionnaire (QoC) was culturally adapted for Brazil due to its importance and use in several studies and different scenarios. The objective of this study was to evaluate the validity evidence of the Brazilian version of the QoC. A validation study was carried out involving 253 patients admitted to five public hospitals in Southern Brazil. Data were analyzed using descriptive analysis, Cronbach's alpha (α) to assess internal consistency, exploratory factor analysis, and goodness-of-fit index. One hundred and three patients were in intensive care (IC), and 150 were in palliative care (PC). The participants' mean age was 51 years (SD = 14.2). QoC,and its general communication subscale, and end-of-life communication subscale means were 5.5 (SD = 1.6), 8.8 (SD = 1.5), and 5.5 (SD = 1.6) respectively. Among patients in IC, QoC Cronbach's alpha was .75, and .84 in the general communication subscale and .51 in the end-of-life communication subscale. Among patients in PC, QoC Cronbach's alpha was .83, and .88 in the general communication subscale, and .71 in the end-of-life communication subscale. The root mean square error of approximation was .07 (90% CI: .04 - .08); Tucker-Lewis index was .97 (95% CI: .95 - .98); comparative fit index was .98 (95% CI: .97 - .99), and χ²/df ratio was 1.33 (χ²[53] = 70.858, p = .05). The authors conclude that the general communication subscale of QoC Brazilian version has good validity evidence for patients in IC and PC, whereas the end-of-life communication subscale is only valid for patient in PC.

Communicating to Non-Speaking Critically Ill Patients: Augmentative and Alternative Communication Technique as an Essential Strategy

Introduction

Communication with hospitalized patients is crucial to improve the quality and safety of health care.

Methods

The study assessed the communication methods used by nurses while communicating to non-speaking critically ill patients. The participants included staff nurses working in ICU, CICU, HD units of neuro- surgical, orthopedic, medical and oncology wards. Purposive sampling technique was used to recruit a total number of 194 nurses. The communication methods used were assessed by a questionnaire comprised of a list of 21 strategies used to communicate with non-speaking patients.

Results

The most commonly used strategies were reading the patient’s mouthing words, encouraging the patient by telling them that they are doing well and nurses helping them to get better, assessing the patients for their communication ability, “thumps up” to indicate “yes”, “shake head” indicating “no”, use OK, or point to body parts, speaking slowly and waiting for the patient’s response, spending time to listen patiently to what the patient say and touching the non-speaking critically ill patient when the nurse speaks with the patient.

Conclusion

The study reported that the nurses used variety of communication strategies while communicating to non- speaking critically ill patients. However very few nurses used Augmentative and alternative communication strategies to communicate to non-speaking critically ill patients. The study recommends the importance of establishing Augmentative and Alternative Communication strategies in the hospitals.

Health Promotion Among Long-Term ICU Patients and Their Families

Few patients are as helpless and totally dependent on nursing as long-term intensive care (ICU) patients. How the ICU nurse relates to the patient is crucial, both concerning the patients’ mental and physical health and well-being. Even if nurses provide evidence-based care in the form of minimum sedation, early mobilization, and attempts at spontaneous breathing during weaning, the patient may not have the strength, courage, and willpower to comply. Interestingly, several elements of human connectedness have shown a positive influence on patient outcomes. Thus, a shift from technical nursing toward an increased focus on patient understanding and greater patient and family involvement in ICU treatment and care is suggested. Accordingly, a holistic view including the lived experiences of ICU care from the perspectives of patients, family members, and ICU nurses is required in ICU care as well as research.

Considerable research has been devoted to long-term ICU patients’ experiences from their ICU stays. However, less attention has been paid to salutogenic resources which are essential in supporting long-term ICU patients’ inner strength and existential will to keep on living. A theory of salutogenic ICU nursing is highly welcome. Therefore, this chapter draws on empirical data from three large qualitative studies in the development of a tentative theory of salutogenic ICU nursing care. From the perspective of former long-term ICU patients, their family members, and ICU nurses, this chapter provides insights into how salutogenic ICU nursing care can support and facilitate ICU patients’ existential will to keep on living, and thus promoting their health, survival, and well-being. In a salutogenic perspective on health, the ICU patient pathway along the ease/dis-ease continuum reveals three stages; (1) The breaking point, (2) In between, and (3) Never in my mind to give up. The tentative theory of salutogenic long-term ICU nursing care includes five main concepts: (1) the long-term ICU patient pathway (along the salutogenic health continuum), (2) the patient’s inner strength and willpower, (3) salutogenic ICU nursing care (4), family care, and (5) pull and push. The salutogenic concepts of inner strength, meaning, connectedness, hope, willpower, and coping are of vital importance and form the essence of salutogenic long-term ICU nursing care.

Above cuff vocalisation (ACV): A scoping review

Introduction

Patients in intensive care frequently suffer from not being able to communicate verbally. The aim of this scoping review was to study the safety and effectiveness of the above cuff vocalisation (ACV) on speech and quality of life (QOL) in patients dependent on a cuffed tracheostomy.

Methods

A scoping review was conducted. The databases Ovid Medline, Cochrane Library, and Embase were systematically searched in May 2020. We included clinical studies with patients exposed to ACV where speech, QOL or safety issues were assessed.

Results

Overall, 17 studies were included, of which 15 were observational and 2 were randomised controlled trials. Totally, 231 patients were included. ACV enabled most of the included patients (115/131; 88%) to speak with an audible voice or whisper (moderate quality of evidence). Voice related QOL (V‐RQOL) and QOL in mechanically ventilated patients (QOL‐MV) improved from pre‐ to post‐ ACV compared to a control group not tolerating a one‐way speaking valve (P = .01 and P = .04, respectively) (very low quality of evidence). Several minor complications or problems were reported in 20/75 (27%) cases in addition to two serious adverse events: subcutaneous emphysema in one patient where the tracheostomy was dislodged and a distended trachea in another due to the misconnection of continuous gas to the cuff (low/ very low quality of evidence).

Conclusion

ACV facilitated communication in patients dependent on a cuffed tracheostomy and attempting to communicate. Quality of evidence in improved V‐RQOL and QOL‐MV was very low. Several minor complications and two serious adverse events were reported.

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.

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.

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.

Understanding patients' experiences of being mechanically ventilated in the Intensive Care Unit: Findings from a meta-synthesis and meta-summary

AIMS AND OBJECTIVES

To synthesise the evidence reported in qualitative studies concerning the lived experiences of adult patients receiving mechanical ventilation in Intensive Care Unit (ICU).

BACKGROUND

Critically ill patients receiving mechanical ventilation in the ICU have been reported to suffer from severe physical and emotional responses such as hopelessness, anxiety, high levels of frustration and stress. Recent improvements in the field of mechanical ventilation and sedative medications as experienced by patients that can inform nursing care have not been summarised to date.

DESIGN

A systematic review of qualitative studies followed by a meta-synthesis and a meta-summary was performed.

METHODS

Four electronic databases were searched by two authors in June 2019. A total of nine studies were included and evaluated based on their methodological quality using the Critical Appraisal Skills Programme checklist.

RESULTS

A total of 24 codes emerged from the abstraction process, which were categorised into 11 categories and four themes: (a) "The effect of the intense stress on the body's systems," (b) "The induced negative emotional situations," (c) "The feeling of being cared for in a hospital setting" and (d) "The perceived support from the family and loved ones." Furthermore, the most frequent codes across studies were "Being afraid," "Feeling supervised," "Feeling comforted," "Failing to communicate," and "Experiencing difficulties in breathing," with an intensity of 66.6%.

CONCLUSION

Patients receiving mechanical ventilation have expressed a general sense of vulnerability, of which critical care nurses need to be aware.

RELEVANCE TO CLINICAL PRACTICE

Findings suggest the need for improvements at the nursing, unit, educational and policy levels; furthermore, more research is also required at the international levels given the current trends towards no sedation protocols for the management of ICU patients: listening to their experiences becomes imperative, in order to ensure an awake, comfortable and ventilator-tolerant patient.

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.

Advancing Patient-Centered Communication Content for Prelicensure Nursing Students Using StudentSPEACS: A Mixed-Methods Study

BACKGROUND

Many patients live with communication disorders that present significant challenges during interactions with health care providers across settings. Yet, nurses receive little to no training in how to communicate with communication impaired patients.

PURPOSE

The purpose of this study was to determine the feasibility and acceptability of delivering the Study of Patient-Nurse Effectiveness With Assistive Communication Strategies (StudentSPEACS) program to prelicensure nursing students and to describe student clinical applications of this content in the year following the communication training.

METHODS

We used mixed methods to describe student perceptions of StudentSPEACS content and application of content in clinical encounters.

RESULTS

Junior nursing students (n = 86, 53.75%) responded to the survey. Students rated content as very valuable and rated their overall ability to communicate with patients after the training program as average. Students provided 48 clinical case application exemplars.

CONCLUSIONS

The StudentSPEACS program can help prelicensure nursing students acquire and practice communication skills with patients who have communication impairments.