Quality of care and resource use among mechanically ventilated patients before and after an intervention to assist nurse-nonvocal patient communication

Effects of implementation strategies on nursing practice and patient outcomes: a comprehensive systematic review and meta-analysis

BACKGROUND

Implementation strategies targeting individual healthcare professionals and teams, such as audit and feedback, educational meetings, opinion leaders, and reminders, have demonstrated potential in promoting evidence-based nursing practice. This systematic review examined the effects of the 19 Cochrane Effective Practice and Organization Care (EPOC) healthcare professional-level implementation strategies on nursing practice and patient outcomes.

METHODS

A systematic review was conducted following the Cochrane Handbook, with six databases searched up to February 2023 for randomized studies and non-randomized controlled studies evaluating the effects of EPOC implementation strategies on nursing practice. Study selection and data extraction were performed in Covidence. Random-effects meta-analyses were conducted in RevMan, while studies not eligible for meta-analysis were synthesized narratively based on the direction of effects. The quality of evidence was assessed using GRADE.

RESULTS

Out of 21,571 unique records, 204 studies (152 randomized, 52 controlled, non-randomized) enrolling 36,544 nurses and 340,320 patients were included. Common strategies (> 10% of studies) were educational meetings, educational materials, guidelines, reminders, audit and feedback, tailored interventions, educational outreach, and opinion leaders. Implementation strategies as a whole improved clinical practice outcomes compared to no active intervention, despite high heterogeneity. Group and individual education, patient-mediated interventions, reminders, tailored interventions and opinion leaders had statistically significant effects on clinical practice outcomes. Individual education improved nurses' attitude, knowledge, perceived control, and skills, while group education also influenced perceived social norms. Although meta-analyses indicate a small, non-statistically significant effect of multifaceted versus single strategies on clinical practice, the narrative synthesis of non-meta-analyzed studies shows favorable outcomes in all studies comparing multifaceted versus single strategies. Group and individual education, as well as tailored interventions, had statistically significant effects on patient outcomes.

CONCLUSIONS

Multiple types of implementation strategies may enhance evidence-based nursing practice, though effects vary due to strategy complexity, contextual factors, and variability in outcome measurement. Some evidence suggests that multifaceted strategies are more effective than single component strategies. Effects on patient outcomes are modest. Healthcare organizations and implementation practitioners may consider employing multifaceted, tailored strategies to address local barriers, expand the use of underutilized strategies, and assess the long-term impact of strategies on nursing practice and patient outcomes.

TRIAL REGISTRATION

PROSPERO CRD42019130446.

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.

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.

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.

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.

Usability Testing of an iPad Communication Application for Mechanically Ventilated Patients

BACKGROUND

Patient communication challenges during mechanical ventilation can negatively impact symptom management and psychological recovery. Alternative communication (AC) aids have the potential to improve mechanically ventilated (MV) patient experiences.

OBJECTIVES

This study evaluated the feasibility and usability of a communication application on a tablet (iPad).

METHOD

A single-group pilot study was guided by the augmentative and alternative communication acceptance model. We recruited patients from 1 medical intensive care unit. Existing communication application software (Proloquo2Go) was tailored to MV patients' needs. Usability testing included patient communication of 5 messages with data collected on success, message completion time, and patient feedback.

RESULTS

Ten patients with a mean age of 50 years (SD, 16.7) were enrolled. Of the 7 patients able to complete usability testing, 85.7% found the device easy to use, and 100% wanted the iPad available for their use when on the ventilator. Three patients were extubated immediately after usability testing. Two patients preferred other modes of communication (writing). Two patients used the iPad as their primary mode of communication during the remainder of their time on the ventilator. Nurse feedback on the communication application was positive.

DISCUSSION

Tablet-based communication applications can be successfully used by MV patients and should be considered as 1 tool to support effective patient communication during mechanical ventilation. Future research is needed to identify which patients may be most likely to benefit from the availability of these devices.

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.

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.

Speech-language pathology approaches to neurorehabilitation in acute care during COVID-19: Capitalizing on neuroplasticity

Neurologic manifestations associated with a coronavirus disease 2019 (COVID‐19) diagnosis are common and often occur in severe and critically ill patients. In these patients, the neurologic symptoms are confounded by critical care conditions, such as acute respiratory distress syndrome (ARDS). Patients with dual diagnoses of COVID‐19 and neurologic changes such as myopathy, polyneuropathy, and stroke are likely at a higher risk of experiencing deficits with swallowing, communication, and/or cognition. Speech‐language pathologists are an integral part of both the critical care and neurologic disorders multi‐disciplinary teams, offering valuable contributions in the evaluation, treatment, and management of these areas. Patients in intensive care units (ICUs) who require mechanical ventilation often experience difficulty with communication and benefit from early speech‐language pathology intervention to identify the most efficient communication methods with the medical team and caregivers. Moreover, patients with neurologic manifestations may present with cognitive‐linguistic impairments such as aphasia, thereby increasing the need for communication‐based interventions. Difficulties with voice and swallowing after extubation are common, often requiring frequent treatment sessions, possibly persisting beyond ICU discharge. After leaving the ICU, patients with COVID‐19 often experience physical, cognitive, and mental health impairments collectively called post‐intensive care syndrome. This is often a lengthy road as they progress toward full recovery, requiring continued speech‐language pathology treatment after hospital discharge, capitalizing on the principles of neuroplasticity.

VidaTalk™ patient communication application "opened up" communication between nonvocal ICU patients and their family

OBJECTIVES

To explore family members' perceptions of an electronic communication application, VidaTalk™, their communication experience, and emotional reactions to communication with mechanically ventilated patients in the intensive care units.

RESEARCH METHODOLOGY/DESIGN

Qualitative phase of a mixed-methods study nested within a randomised controlled trial. Family members in the intervention group received the VidaTalk™ app as a communication aid during their intensive care stay. Seven family members participated in 18 semi-structured email interviews after discharge between May and December 2018. Interviews were analysed using qualitative content analysis.

SETTING

Families were recruited in multiple intensive care units located in one university hospital.

MAIN OUTCOME MEASURES

Communication experience with the VidaTalk™ and emotions while communicating with the patient. Basic qualitative description and constant comparative techniques were used to code and analyse the text using ATLAS_ti (Version 7.5.18).

FINDINGS

The VidaTalk™ opened up family-patient communication by allowing clear communication and expanding communication content. Family members felt happy and thankful to communicate with the patient. They also expressed feelings of relief and less frustration and less stress while communicating with the patient.​ On the other hand, the patient's ability to express their worries or anxiety sometimes made families feel sad or distressed.

CONCLUSION

The VidaTalk™ was helpful for family-patient communication. The VidaTalk™ may help families reduce psychological distress. However, ​expanded communication with critically ill patients may cause other negative feelings.

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.

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.

Intensive Care Unit Nursing Priorities in the United States

This integrative review presents the most recent and relevant critical care nursing research publications in the United States. A comprehensive search identified publications on the topics of delirium; early mobility; communication; palliative care; tele-intensive care unit; care bundle implementation; and prevention, detection, and early management of infection. The evidence is summarized for each of these topics, as well as other research, with suggestions and guidance for end users.

Improving Nonvocal Critical Care Patients' Ease of Communication Using a Modified SPEACS-2 Program

OBJECTIVE

To evaluate the feasibility and impact of implementing the "study of patient-nurse effectiveness with assisted communication strategies-2" (SPEACS-2); a program to facilitate communication with nonvocal patients.

STUDY DESIGN

The plan-do-study-act quality improvement methodology guided the implementation of a modified SPEACS-2 program within a pre and posttest design. The Ease of Communication Scale (ECS) measured patients' communication difficulty, and care processes measured the program's success.

STUDY POPULATION

Nurses (N = 385) across 5 intensive care units were trained in SPEACS-2. We assessed 354 nonvocal patients (aged 18-95 years) requiring continued mechanical ventilation after withdrawal of heavy sedation. Patients were evaluated over one 2-week preintervention (n = 163) and two 3-week postintervention periods (n = 128; n = 63). A subsample of intervention patients (n = 204) completed the ECS.

RESULTS

Ease of Communication Scale scores improved significantly (p = .027) from baseline (mean 25.86 ± 12.2, n = 71) to postintervention period 2 (21.22 ± 12.2, n = 63). Nurses' use of communication techniques and compliance with communication plans of care incrementally increased after training.

CONCLUSIONS

Implementing SPEACS-2 demonstrated positive changes in patients' ease of communication and feasibility of incorporating evidence-based communication strategies into practice.

Competence in caring for patients with respiratory insufficiency: A cross-sectional study

OBJECTIVES

To compare nurses' self-assessed competence and perceived need for more training in intensive care units treating patients with respiratory insufficiency before and after completion of a seven-hour educational programme, and to assess whether factors such as age, educational level, years of experience and percentage of employment are associated with these outcomes.

RESEARCH METHODOLOGY

The study had a quantitative, cross-sectional, descriptive design, with two measurement times. The ProffNurse SAS questionnaire was used to assess nurses' self-assessed competence and perceived need for more training.

SETTING

Nurses in one medical/surgical intensive care unit and one medical intensive care unit in a hospital in Norway.

MAIN OUTCOME MEASURES

Nurses' self-assessed competence and perceived need for more training.

RESULTS

The pre- and post-education studies comprised responses from 85 (52%) and 52 (32%) nurses, respectively. The educational programme contributed to increased self-assessed competence in seven items. Self-assessed competence was significantly associated with nurses' educational level, and critical care nurses reported higher self-assessed competence than registered nurses on 50% of the items.

CONCLUSION

The findings fill a gap in knowledge about nurses' competence in treating patients with respiratory insufficiency in intensive care units. Both education days and further education have beneficial effects on self-assessed competence.

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.

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.

Nursing perspectives and strategies in patients with respiratory insufficiency

BACKGROUND

Approximately 30% of patients admitted to an intensive care unit experience respiratory distress. The COVID-19 pandemic has led to an enormous increase in patients with respiratory symptoms. Nurse competence is essential for ensuring quality treatment and care for these patients; however, research on nursing strategies for patients with respiratory insufficiency is limited.

AIM

This study explored nurses' perspectives on and nursing strategies in patients with respiratory insufficiency when admitted to three different intensive care units.

DESIGN

The study had an exploratory, descriptive, qualitative design.

METHODS

Four focus group interviews with a total of 20 nurses, critical care nurses, and critical care nursing students were conducted. Data were analysed using content analysis.

RESULTS

Participants' perspectives fell into two main themes: "nurse competence" and "the art of balancing." "Nurse competence" incorporated the sub-themes "observations and assessments," "to make decisions," and "collaboration." The theme 'the art of balancing' incorporated the sub-themes "nursing interventions," "patients feeling safe," and "patient participation."

CONCLUSION

This study contributes new knowledge about nurses' perspectives on patients with respiratory insufficiency. Nurse competence was assumed essential to observe, assess, and treat patients with respiratory insufficiency. Nursing strategies included balancing nursing interventions, conducting medical treatment, and taking a whole-person approach to patients' needs.

RELEVANCE TO CLINICAL PRACTICE

The COVID-19 pandemic has shown the need for nurse competence in caring for patients with respiratory insufficiency. This study adds to existing literature emphasizing the need for competence in health care services. Caring for patients with respiratory insufficiency requires nurses with experience; competence in observation, assessment, and medical treatment; and a whole-person approach to patients' needs.

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.

Nursing Research Priorities in Critical Care, Pulmonary, and Sleep: International Delphi Survey of Nurses, Patients, and Caregivers

The objective of this workshop was to determine current nursing research priorities in critical care, adult pulmonary, and sleep conditions through input from consumer (patient, family, and formal and informal caregivers) and nursing experts around the world. Working groups composed of nurses and patients selected potential research priorities based on patient insight and a literature review of patient-reported outcomes, patient-reported experiences, and processes and clinical outcomes in the focal areas. A Delphi consensus approach, using a qualitative survey method to elicit expert opinion from nurses and consumers was conducted. Two rounds of online surveys available in English, Spanish, and Chinese were completed. A 75% or greater threshold for endorsement (combined responses from nursing and consumer participants) was determined a priori to retain survey items. A total of 837 participants (649 nurses and 188 patients, family, and/or caregivers) from 45 countries responded. Survey data were analyzed and nursing research priorities that comprise 23 critical care, 45 adult pulmonary, and 16 sleep items were identified. This project was successful in engaging a wide variety of nursing and consumer experts, applying a patient-reported outcome/patient-reported experience framework for organizing and understanding research priorities. The project outcome was a research agenda to inform, guide, and aid nurse scientists, educators, and providers, and to advise agencies that provide research and program funding in these fields.

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.

Communication with patients in intensive care units: a scoping review

BACKGROUND

Patients in intensive care units are generally more conscious and alert when they are on mechanical ventilation than in previous years because of the many potential benefits of being under less sedation. The endotracheal tube blocks the vocal cords when patients are on ventilation, thus making it impossible to speak. Many patients report that they struggle to make themselves understood.

AIM

The aim of this study was to assess previous knowledge about interaction and communication between health care personnel and conscious and alert patients under mechanical ventilation in intensive care units.

DESIGN AND METHODS

A literature review was performed following the steps of a scoping review. Studies published between 1998 and 2017 were identified in several databases: Cinahl, Embase, Medline, PsycINFO and Scopus. The first search returned 7386 unique references. The inclusion criteria consisted of empirical studies or studies related to interactions between health care personnel and patients over 18 years of age on mechanical ventilation. The relevant studies were summarized in a standardized data-charting sheet.

RESULTS

The inclusion criteria were met by 46 articles; 16 were qualitative studies, 17 were quantitative, 6 were mixed-methods studies, and 7 were pilot or feasibility studies. Of the studies, 37 were from nurses, 4 from physicians, 4 from speech language pathologists and 1 from psychologists. The most common topics investigated in the studies were 'experiences with communication on mechanical ventilation' and 'communication exchanges'.

CONCLUSIONS

A variety of communication aids that appear to have some effect on patients should be made available in intensive care units. More multidisciplinary approaches in future studies could enhance the knowledge in the field.

RELEVANCE TO CLINICAL PRACTICE

The education of intensive care unit personnel in the use of such aids should be a prioritized field, as should be the implementation of a variety of communication aids.

Advancing the Delivery of Communication Sciences and Disorders Services Through Research: The Promise of Health Services Research

Purpose

Traditional efficacy research, or research that studies interventions in controlled settings, can be difficult to translate to real-world clinical settings. In this article, we introduce the field of health services research (HSR) as 1 possible tool to aid this translation. HSR is a field of research that examines and intervenes in the use, cost, quality, delivery, organization, and outcomes of clinical interventions and services in the real-world setting. The complexity of the world outside the clinic walls is accounted for in HSR methods and data sources. As such, HSR often requires collaboration of stakeholders, including patients, caregivers, clinicians, and policy makers. These stakeholders are often engaged throughout the research process, from selecting research questions to disseminating results. HSR brings together researchers from multiple disciplines, including sociology, health economics, epidemiology, and implementation science, among others. The outcomes of HSR can inform policy changes both locally and nationally. To clarify the scope and impact of HSR, we present examples of HSR-based research on communication between patients with communication disorders and health care providers.

Conclusions

HSR is a critical tool for clinicians and researchers in the discipline of communication sciences and disorders who are committed to improving the lives and health of persons with communication disorders.

Systematic review showed that stepped-wedge cluster randomized trials often did not reach their planned sample size

OBJECTIVE

To determine how often stepped-wedge cluster randomized controlled trials reach their planned sample size, and what reasons are reported for choosing a stepped-wedge trial design.

STUDY DESIGN AND SETTING

We conducted a PubMed literature search (period 2012 to 2017) and included articles describing the results of a stepped-wedge cluster randomized trial. We calculated the percentage of studies reaching their prespecified number of participants and clusters, and we summarized the reasons for choosing the stepped-wedge trial design as well as difficulties during enrollment.

RESULTS

Forty-six individual stepped-wedge studies from a total of 53 articles were included in our review. Of the 35 studies, for which recruitment rate could be calculated, 69% recruited their planned number of participants, with 80% having recruited the planned number of clusters. Ethical reasons were the most common motivation for choosing the stepped-wedge trial design. Most important difficulties during study conduct were dropout of clusters and delayed implementation of the intervention.

CONCLUSION

About half of recently published stepped-wedge trials reached their planned sample size indicating that recruitment is also a major problem in these trials. Still, the stepped-wedge trial design can yield practical, ethical, and methodological advantages.

Patterns of palliative care service consultation in a sample of critically ill ICU patients at high risk of dying

OBJECTIVE

Describe patterns of palliative care service consultation among a sample of ICU patients at high risk of dying.

BACKGROUND

Patients receiving mechanical ventilation (MV) face threats to comfort, social connectedness and dignity due to pain, heavy sedation and physical restraint. Palliative care consultation services may mitigate poor outcomes.

METHODS

From a dataset of 1440 ICU patients with ≥2 days of MV and ≥12 h of sustained wakefulness, we identified those at high risk of dying and/or who died and assessed patterns of sub-specialty palliative care consultation.

RESULTS

About half (773/1440 [54%]) were at high risk of dying or died, 73 (9.4%) of whom received palliative care consultation. On average, referral occurred after 62% of the ICU stay had elapsed. Primary reason for consult was clarification of goals of care (52/73 [72.2%]).

CONCLUSIONS

Among MV ICU patients at high risk of dying, palliative care service consultation occurs late and infrequently, suggesting a role for earlier palliative care.

Abstracting ICU Nursing Care Quality Data From the Electronic Health Record

The electronic health record is a potentially rich source of data for clinical research in the intensive care unit setting. We describe the iterative, multi-step process used to develop and test a data abstraction tool, used for collection of nursing care quality indicators from the electronic health record, for a pragmatic trial. We computed Cohen's kappa coefficient (κ) to assess interrater agreement or reliability of data abstracted using preliminary and finalized tools. In assessing the reliability of study data ( n = 1,440 cases) using the finalized tool, 108 randomly selected cases (10% of first half sample; 5% of last half sample) were independently abstracted by a second rater. We demonstrated mean κ values ranging from 0.61 to 0.99 for all indicators. Nursing care quality data can be accurately and reliably abstracted from the electronic health records of intensive care unit patients using a well-developed data collection tool and detailed training.

Comparison of the Effect of Open and Closed Endotracheal Suctioning Methods on Pain and Agitation in Medical ICU Patients: A Clinical Trial

Background

Endotracheal suctioning is a necessary procedure practiced by nurses in intensive care units to remove lung secretions. This procedure leads to higher oxygenation levels and reduced breathing difficulties. It also prevents atelectasis, pulmonary infections, and the accumulation of secretions.

Objectives

The present study aims to compare the effectiveness of open and closed endotracheal suction tube systems on pain and agitation in patients under mechanical ventilation.

Methods

A randomized controlled clinical trial was conducted in the general intensive care units of Khatam-ol-Anbia hospital and Sina hospital, Tehran, Iran, in 2015. In total, 60 patients who were qualified to be included in the study were randomly assigned to either the intervention group or the control group. When necessary, suction was carried out for each patient using the standard technique. The patients’ level of pain and agitation was measured in both groups at five stages (before, during, immediately after, 5 minutes after, and 15 minutes after the intervention) using the behavioral pain scale and the Richmond agitation sedation scale.

Results

Significant statistical differences in the pain and agitation at different times within each of the two groups were observed for both open and closed suction (P > 0.001). However, these changes at different times between the two groups was not significant (P < 0.05).

Conclusions

Although statistical differences were observed in the levels of pain and agitation in the two groups, the type of suction system did not have any effect on the level of pain and agitation of patients under mechanical ventilation. The researchers recommend that other studies with larger sample sizes should be carried out.

Prevalence of Advance Directives Among Older Adults Admitted to Intensive Care Units and Requiring Mechanical Ventilation

Because older adults are at high risk for hospitalization and potential decisional incapacity, advance directives are important components of pre-hospital advanced care planning, as they document individual preferences for future medical care. The prevalence of pre-hospital advance directive completion in 450 critically ill older adults requiring mechanical ventilation from two Mid-Atlantic hospitals is described, and demographic and clinical predictors of pre-hospital advance directive completion are explored. The overall advance directive completion rate was 42.4%, with those in older age groups (75 to 84 years and 85 and older) having approximately two times the odds of completion. No significant differences in the likelihood of advance directive completion were noted by sex, race, or admitting diagnosis. The relatively low prevalence of advance directive completion among older adults with critical illness and high mortality rate (24%) suggest a need for greater awareness and education.