The communication experience of tracheostomy patients with nurses in the intensive care unit: A phenomenological study

Communication difficulties in mechanically ventilated voiceless patients in intensive care units: A qualitative study

BACKGROUND

Mechanically ventilated patients are unable to verbally communicate due to the endotracheal tube or tracheostomy, rendering them temporarily 'voiceless'. More and more patients are conscious during mechanical ventilation because of a new paradigm based on mild/no sedation. Communicating with conscious voiceless patients can be complex and frustrating, leading to negative outcomes and experiences for patients, family members and health care professionals.

AIM

To explore the negative effects of the inability to communicate verbally among voiceless patients in intensive care units (ICUs), considering the perspectives of voiceless patients, health care professionals and family members.

STUDY DESIGN

This qualitative study uses Interpretive Description methodology. Semi-structured interviews were conducted with patients, family members and health care professionals. Data were collected at three ICUs in Italy over 3 months. Data were analysed using the Rapid and Rigorous qualitative data analysis.

RESULTS

Forty-three people were interviewed (10 patients, 13 caregivers, 13 nurses and 7 physicians). Three major themes were identified: perception of communication difficulties, negative impacts on relationships and emotions, and negative effects on care. These findings indicate that communication difficulties in ICU have negative emotional and psychological consequences for all participants and the health care provided.

CONCLUSIONS

Effective communication with voiceless patients is essential for their well-being and quality of care. Future research should focus on identifying and evaluating tailored communication methods for voiceless patients.

RELEVANCE TO CLINICAL PRACTICE

This study emphasizes the importance of interventions improving voiceless communication, including training health care professionals and critical care nurses in alternative communication strategies, providing psychological support to voiceless patients, and encouraging extended family presence.

Management of adults with a tracheostomy: An international survey of speech-language pathologists' practice

PURPOSE

Speech-language pathologists are specialists in communication, swallowing, and weaning as core members of the multidisciplinary tracheostomy team. Inconsistent tracheostomy care is known to result in staff and patient frustration, delayed intervention, and patient harm. Little is known about international speech-language pathology tracheostomy practices.

METHOD

This global survey explored training, clinical practices, perceived knowledge, skills and roles, as well as barriers to change and successes. Questions consisted of likert scale and open-ended questions. 1 458 Speech-language pathologists completed the survey representing six continents and 52 countries.

RESULT

Overall, speech-language pathologists were confident in their knowledge and skills. Tracheostomy teams were viewed as a key facilitator of best care. Access to Flexible Endoscopic Evaluation of Swallowing was variable and considered valuable by all. Four key themes emerged: Knowledge and skills, roles and multidisciplinary tracheostomy team relationships, written documentation and protocols, and access to resources. Multidisciplinary tracheostomy team relationships and being valued as a professional were the most common concerns. Speech-language pathologists had a plethora of successes to share that had changed their workplace.

CONCLUSION

This survey shows speech-language pathologists are aligned internationally with common purpose and values. Speech-language pathologists voiced challenges in multidisciplinary tracheostomy team relationships, standardising practice, and resourcing. Benchmarking is the first step to targeted change and we hope this will support and empowerclinicians to continue to innovate tracheostomy practice.

Increased Neck Visual Fixation in Children With Tracheostomies: An Eye-Tracking Study

OBJECTIVE

The aim of this study is to objectively quantify the attentional distraction effect of a tracheostomy on visual attention and gaze using eye-tracking technology.

METHODS

This was a cross-sectional observational study. An eye-tracking device was used to capture eye movements of participants over 5 years of age who were shown 20 images of children with and without tracheostomies. The primary outcome was the number and duration of fixations on different mapped regions of the head and neck, including the central triangle (CT) and peripheral triangle (PT) of the face, and the anterior neck. Facial recall recognition was also assessed and compared across groups.

RESULTS

A total of 160 participants were recruited (57% female, median age 18 years, range 6-54 years). The greatest amount of time was spent viewing the CT of both children with and without tracheostomies. Participants viewed the necks of children with tracheotomies 3.7 times more frequently, spent eight times longer viewing the neck, and were more likely to incorrectly recall children with tracheotomies compared with the control group (3.33 vs. 0.85 fixations, p < 0.001; 0.15 vs. 1.12 ms, p < 0.0001; p < 0.001).

CONCLUSION

Viewers who are looking at children with tracheostomies redirect their attention from the face toward the neck and spend a longer duration of time viewing the necks of children with tracheostomies compared to those without. Viewers are also more likely to incorrectly recall the faces of children with tracheostomies. These findings highlight a possible explanation for why social interactions may be different for children with tracheostomies beyond their underlying medical and communication problems.

LEVEL OF EVIDENCE: 3

Preliminary efficacy of the vidatalkTM communication application on family psychological symptoms in the intensive care unit: A pilot study

BACKGROUND

Family caregivers of ICU patients experience difficulty communicating with patients during mechanical ventilation. Little is known about patient-family communication in the ICU and the associated emotional distress.

OBJECTIVES

To examine the preliminary effects of the VidaTalk™ communication app on anxiety, depression, and PTSD-related symptoms among family caregivers.

METHODS

We conducted a prospective study using repeated measures to compare VidaTalk™ to an attention control condition. Twenty-eight family caregivers of nonvocal adult ICU patients participated in this study. The intervention group received VidaTalk™, whereas the attention control group received a standard tablet loaded with MyChart Bedside (EPIC) and game apps during the patient's mechanical ventilation treatment. Family caregiver anxiety and depression (Hospital Anxiety and Depression Scale) were measured at baseline, at extubation/ICU discharge, and 1-, 3-, and 6-months post-ICU discharge. PTSD-related symptoms (Impact of Event Scale-revised) were measured at 1-, 3-, and 6-months. T-tests were used for group comparisons for families' perceived communication difficulty, anxiety, and depression, and Mann-Whitney U tests were used for PTSD-related symptom comparisons.

RESULTS

No statistically significant difference was found between groups in changes in family psychological outcomes, the VidaTalk™ was associated with a small to medium improvement in anxiety symptoms (d = 0.43) at one month. The VidaTalk™ group had lower PTSD-related symptoms than the AC group with a medium effect size (ɳ2=0.07) at one month and a medium-to-large effect size (ɳ2=0.09) at three months.

CONCLUSIONS

The VidaTalk™ demonstrated potential as a family caregiving intervention that may be associated with reduced family psychological symptoms.

Critically ill patients' experiences of discomfort and comfort in the intensive care unit: A qualitative descriptive study

BACKGROUND

The physiological state of critically ill patients is severely impaired by illness or trauma and is uncomfortable. Such experiences cause long-term anxiety and post-traumatic stress disorder.

OBJECTIVE

This study aimed to understand discomfort and comfort based on the experiences of critically ill adult patients in the intensive care unit and to explore ways to improve their comfort.

METHODS

This qualitative descriptive study was conducted with 15 critically ill patients (age range: 46-81 years; six females) in the intensive care unit using semistructured interviews and participant observation. The data collected were analysed using Braun and Clarke's thematic analysis. Data were collected from the intensive care unit and general ward of a university hospital in Japan.

FINDINGS

Six themes related to discomfort and comfort were identified. The three themes related to discomfort were "overlapping uncertainties", "being unable to control physical discomfort", and "having to endure psychologically and situationally". The three themes related to comfort were "feeling connected brings calm", "routine care relieves pain and thirst", and "ease when one can decide for oneself". Participants' discomfort involved physical and psychological factors and was related to treatments, procedures, care, and the environment. Moreover, more than half of the patients endured unmet needs. Comfort was brought about by providing routine care for physical discomforts that critically ill patients often experience, feeling alive and connected to others and encouraging independence.

CONCLUSION

Recognising the potential for physical and psychological discomfort, as well as communication and other difficulties, in critically ill patients is crucial. Patients may also experience discomfort when healthcare providers take the lead, which underscores the importance of involving patients in their care. By showing respect for patients' intentions and involving them in decision-making, healthcare providers can improve patient comfort and promote a more collaborative approach to care.

Being a patient in the intensive care unit: a narrative approach to understanding patients' experiences of being awake and on mechanical ventilation

PURPOSE

Intensive care patients often struggle to communicate due to the technical equipment used for mechanical ventilation and their critical illness. The aim of the study was to achieve a deeper understanding of how mechanically ventilated intensive care patients construct meaning in the unpredictable trajectory of critical illness.

METHODS

The study was a part of a larger study in which ten patients were video recorded while being in the intensive care. Five patients engaged in interviews about their experiences from the intensive care stay after being discharged and were offered the possibility to see themselves in the video recordings. A narrative, thematic analysis was applied to categorize the patients' experiences from the intensive care.

RESULTS

A pattern of shared experiences among intensive care patients were identified. Three main themes capture the patient's experiences: 1) perceiving the intensive care stay as a life-changing turning point, 2) being dependent on and cared for by others, and 3) living with negative and positive ICU experiences.

CONCLUSION

The patients' narratives revealed how being critically ill affected them, and how they understood their experiences in relation to themselves and their surroundings. The results can be used to pose important questions about our current clinical practice.

Lived Experiences of Conscious Intubated Patients in the Intensive Care Units: A Qualitative Phenomenological Study in Iran

OBJECTIVE

Mechanically ventilated patients experience significant suffering in intensive care units (ICUs). Recognising and understanding these patients' distressing experiences can greatly improve the quality of care provided. This study aims to explore the lived experiences of conscious intubated patients in ICUs in Iran.

DESIGN

A qualitative study was conducted using an interpretative phenomenological approach. In-depth interviews served as the primary means of data collection. Subsequently, the collected data was analysed using the method of Diekelmann et al (1989).

SETTING

The study was conducted in the ICU.

PARTICIPANTS

A purposive method was employed to select 13 patients who underwent conscious intubation for over 24 hours.

RESULTS

Three main themes and seven subthemes emerged from the data analysis of the lived experience: (1) interpersonal discourse complexity (semantic misalignment and others' impressionability), (2) sensory disquietude (pharyngeal discomfort, thirst beyond the quench and disgust with oral hygiene) and (3) resilient adaptation (emotional responses and coping strategies).

CONCLUSIONS

The findings of the lived experiences reveal a nuanced understanding of the intricate interplay between communication barriers, sensory discomfort and the adaptive capacities of conscious intubated patients in the ICU. This comprehensive analysis contributes to a deeper appreciation of their multifaceted experiences.

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/.

Enhancing the use of Makaton in nurse education and practice

Makaton is a unique multimodal language programme that uses signs, symbols and speech. It offers a flexible communication system that can be used across settings with a wide range of people, including those with learning disabilities or communication difficulties. This article explains what Makaton entails and how it can be used to aid communication with service users. The authors suggest that Makaton should be integrated in preregistration nurse education for all fields of practice, particularly learning disability nursing. Effective communication skills are essential for all nurses and learning Makaton as part of their preregistration education programmes could improve their competence and confidence in engaging in meaningful dialogue with people who find it challenging to communicate verbally.

Longing for a Voice: A Qualitative Study

Tracheostomy involves a challenging care process in which both patients and caregivers have difficulty communicating. Loss of speaking ability negatively affects caregivers as well as patients. The objective of this study was to examine the experiences of caregivers of patients with tracheostomy during care and after the first vocal exercise. This is a qualitative interview study using in-depth interviews. We used Colaizzi's method of data analysis. The interviews were carried out with 17 caregivers from March to July 2023. Two main themes were identified: the communication process and the first time hearing the patient's voice. In addition, communication techniques, difficulty in communication, providing motivation, and emotions were considered as subthemes. A better quality of care can be provided by understanding the experiences of caregivers of patients with tracheostomy, by sharing feelings and thoughts, and by using patient-specific communication methods.

Nurses Response to the Physical and Psycho-Social Care Needs of Patients with COVID-19: A Mixed-Methods Study

The COVID-19 pandemic heavily impacted nursing care. This study aimed to understand which nursing interventions were instrumental in responding to COVID-19 patients' needs by exploring the experiences of patients and nurses. In this mixed-method study with an explanatory sequential design, we involved nurses caring for COVID-19 patients in intensive and sub-intensive care units and patients. In the first phase, we collected data through a survey that assessed patients' needs from the perspective of nurses and patients, as well as patient satisfaction. In the second phase, qualitative data were collected through interviews with patients and nurses. In the third phase, we extracted quantitative data from patients' records. Our sample included 100 nurses, 59 patients, 15 patient records, and 31 interviews (15 patients, 16 nurses). The results from the first phase showed patients and nurses agreed on the most important difficulties: "breathing", "sleep/rest", and "communication". Nursing care was rated positively by 90% of the patients. In the second phase, four themes were identified through the patients' interviews: "my problems", "my emotions", "helpful factors", and "nursing care". Five themes were identified through the nurses' interviews: "the context", "nurses' experiences and emotions", "facilitators and barriers to patient care", "nursing care", and "the professional role". From the third phase, the analysis of the clinical documentation, it was not possible to understand the nursing care model used by the nurses. In conclusion, nurses adopted a reactive-adaptive approach, based on experience/knowledge, pursuing generalized objectives, and adapting their response to the clinical evolution. In difficult contexts, nursing care requires a constant competent technical-relational presence at the patient's bedside.

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adoption and Utilization of Heat and Moisture Exchangers (HMEs) in the Tracheostomy Patient

OBJECTIVE

Management of tracheostomized patients typically involves a conventional external humidification system (CEHS). CEHS are noisy, negatively impact patient mobility, and increases costs. Additionally, they prevent phonation and the ability to cough. Alternatively, heat and moisture exchange (HME) devices have been used in laryngectomized patients. We present an institutional quality improvement project exploring the use and efficacy of an HME device following tracheostomy.

METHODS

Health care professionals and stakeholders from multiple disciplines were identified: otolaryngology, nursing, administration, case management, and speech-language pathology. The focus was on an otolaryngology acute care nursing unit. Protocols for product acquisition, nursing education, care flowcharts, and discharge planning were established. Efficacy was assessed by tracking patient pulmonary status, nursing notes, and questionnaires.

RESULTS

Seventy-one tracheostomized patients were enrolled. Two patients (2.8%) were unable to tolerate the HME. There were no complications from mucous plugging or respiratory distress. Eighty-nine percent of nursing staff surveyed preferred the use of an HME device over CEHS, particularly for ease of patient mobility. Additional favorable findings were patient satisfaction, cost savings, reduced noise, communication, and ease of discharge education and planning.

DISCUSSION

Replacing CEHS with HMEs provides distinct advantages, with a positive impact on patients, family members, and health care personnel. Resistance to changing from the traditional standard of care was alleviated with education, focused training, and positive outcomes.

IMPLICATIONS FOR PRACTICE

These data indicate that an HME device is safe and offers advantages to both patients and nurses over traditional CEHS.

Determinants of Communication Failure in Intubated Critically Ill Patients: A Qualitative Phenomenological Study from the Perspective of Critical Care Nurses

AIM

To explore what factors determine communication with awake intubated critically ill patients from the point of view of critical care nursing professionals.

BACKGROUND

Impaired communication frequently affects mechanically ventilated patients with artificial airways in the intensive care unit. Consequences of communication breaches comprise emotional and ethical aspects as well as clinical safety, affecting both patients and their conversation partners. Identification of determining factors in communication with awake intubated patients is needed to design effective action strategies.

DESIGN

A qualitative phenomenological approach was used.

METHODS

Semi-structured interviews were used as the data collection method. A total of 11 participants from three intensive care units of three Majorcan public hospitals, selected by purposive sampling, were interviewed.

FINDINGS

Three major themes regarding the communication determinants of the awake intubated critically ill patients were identified from the interviewees' statements: factors related to the patient (physical and cognitive functionality to communicate, their relational and communicative style and their personal circumstances), to the context (family presence, ICU characteristics, workload, availability/adequacy of communication aids, features of the messages and communication situations) and, finally, those related to the professionals themselves (professional experience and person-centredness).

CONCLUSIONS

The present study reveals determinants that influence communication with the awake intubated patient, as there are attitudes and professional beliefs.

RELEVANCE TO CLINICAL PRACTICE

The discovery of relations between different kinds of determinants (of patient, context or professionals) provides a multi-factor perspective on the communicative problem which should be considered in the design of new approaches to improve communicative effectiveness. This study is reported according to the COREQ checklist.

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.

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.

What matters most to adults with a tracheostomy in ICU and the implications for clinical practice: a qualitative systematic review and metasynthesis

PURPOSE

Tracheostomy is a common surgical procedure in ICU. Whilst often life-saving, it can have important impacts on patients. Much of the literature on tracheostomy focuses on timing and technique of insertion, risk factors and complications. More knowledge of patient experience of tracheostomy in ICU is needed to support person-centred care.

MATERIALS AND METHODS

Qualitative systematic review and metasynthesis of the literature on adult experience of tracheostomy in ICU. Comprehensive search of four bibliographic databases and grey literature. Title and abstract screening and full text eligibility was completed independently by two reviewers. Metasynthesis was achieved using thematic synthesis, supported by a conceptual framework of humanised care.

RESULTS

2971 search returns were screened on title and abstract and 127 full texts assessed for eligibility. Thirteen articles were included for analysis. Five descriptive and three analytical themes were revealed. The over-arching theme was 'To be seen and heard as a whole person'. Patients wanted to be treated as a human, and having a voice made this easier.

CONCLUSIONS

Voice restoration should be given high priority in the management of adults with a tracheostomy in ICU. Staff training should focus on both technical skills and compassionate care to improve person-centred outcomes.

Amplifying patient voices amid pandemic: Perspectives on tracheostomy care, communication, and connection

OBJECTIVE

To investigate perspectives of patients, family members, caregivers (PFC), and healthcare professionals (HCP) on tracheostomy care during the COVID-19 pandemic.

METHODS

The cross-sectional survey investigating barriers and facilitators to tracheostomy care was collaboratively developed by patients, family members, nurses, speech-language pathologists, respiratory care practitioners, physicians, and surgeons. The survey was distributed to the Global Tracheostomy Collaborative's learning community, and responses were analyzed.

RESULTS

Survey respondents (n = 191) from 17 countries included individuals with a tracheostomy (85 [45 %]), families/caregivers (43 [22 %]), and diverse HCP (63 [33.0 %]). Overall, 94 % of respondents reported concern that patients with tracheostomy were at increased risk of critical illness from SARS-CoV-2 infection and COVID-19; 93 % reported fear or anxiety. With respect to prioritization of care, 38 % of PFC versus 16 % of HCP reported concern that patients with tracheostomies might not be valued or prioritized (p = 0.002). Respondents also differed in fear of contracting COVID-19 (69 % PFC vs. 49 % HCP group, p = 0.009); concern for hospitalization (55.5 % PFC vs. 27 % HCP, p < 0.001); access to medical personnel (34 % PFC vs. 14 % HCP, p = 0.005); and concern about canceled appointments (62 % PFC vs. 41 % HCP, p = 0.01). Respondents from both groups reported severe stress and fatigue, sleep deprivation, lack of breaks, and lack of support (70 % PFC vs. 65 % HCP, p = 0.54). Virtual telecare seldom met perceived needs.

CONCLUSION

PFC with a tracheostomy perceived most risks more acutely than HCP in this global sample. Broad stakeholder engagement is necessary to achieve creative, patient-driven solutions to maintain connection, communication, and access for patients with a tracheostomy.

Tracheostomy care and communication during COVID-19: Global interprofessional perspectives

Objective

Investigate healthcare providers, caregivers, and patient perspectives on tracheostomy care barriers during COVID-19.

Study design

Cross-sectional anonymous survey

Setting

Global Tracheostomy Collaborative Learning Community

Methods

A 17-item questionnaire was electronically distributed, assessing demographic and occupational data; challenges in ten domains of tracheostomy care; and perceptions regarding knowledge and preparedness for navigating the COVID-19 pandemic.

Results

Respondents (n = 115) were from 20 countries, consisting of patients/caregivers (10.4%) and healthcare professionals (87.0%), including primarily otolaryngologists (20.9%), nurses (24.3%), speech-language pathologists (18.3%), respiratory therapists (11.3%), and other physicians (12.2%). The most common tracheostomy care problem was inability to communicate (33.9%), followed by mucus plugging and wound care. Need for information on how to manage cuffs and initiate speech trials was rated highly by most respondents, along with other technical and knowledge areas. Access to care and disposable supplies were also prominent concerns, reflecting competition between community needs for routine tracheostomy supplies and shortages in intensive care units. Integrated teamwork was reported in 40 to 67% of respondents, depending on geography. Forty percent of respondents reported concern regarding personal protective equipment (PPE), and 70% emphasized proper PPE use.

Conclusion

While safety concerns, centering on personal protective equipment and pandemic resources are prominent concerns in COVID-19 tracheostomy care, patient-centered concerns must also be prioritized. Communication and speech, adequate supplies, and care standards are critical considerations in tracheostomy. Stakeholders in tracheostomy care can partner to identify creative solutions for delays in restoring communication, supply disruptions, and reduced access to tracheostomy care in both inpatient and community settings.

Speech and language therapy service provision in spinal injury units compared to major trauma centres in England: Are services matched?

BACKGROUND

National UK guidance makes recommendations for speech and language therapy staffing levels in critical care and rehabilitation settings. Traumatic spinal cord injury patients often require admission primarily to critical care services within a major trauma centre prior to transfer to a specialist spinal injury unit but may not receive similar levels of care. Dysphagia and communication difficulties are recognised features of cervical spinal cord injury; however, little is known about access to speech and language therapy services to provide rehabilitation and improve outcomes.

AIMS

The aim of this study was to compare the workforce and clinical practices of speech and language therapy services in eight spinal injury units and four major trauma centres in England through an online survey.

METHODS & PROCEDURES

An online survey was created with 26 multiple-choice questions across seven sub-sections, with options for free-text comments. These were sent to a named speech and language therapy contact at each of the specified units. Responses were uploaded into Excel for analyses, which included descriptive statistics and analysis of themes.

OUTCOMES & RESULTS

Responses were received from 92% (11/12) speech and language therapy services invited, which included seven out of eight spinal injury units and all four major trauma centres. No units met national staffing recommendations. Staff in spinal injury units provided an average of 27 h per week input to the unit compared to 80 h in a major trauma centre. Despite caseload variations, speech and language range of therapy involvement and prioritisation process were equivalent. Access to instrumental assessment varied, with less use of Fibreoptic Endoscopic Evaluation of Swallowing in spinal injury units despite its clinical value to the spinal cord injury caseload.

CONCLUSIONS & IMPLICATIONS

Speech and language therapy services delivering post-acute and long-term rehabilitation to spinal cord injury patients are limited by their resources and capacity, which restricts the level of therapy delivered to patients. This may have an impact on clinical outcomes for communication and swallowing impairments. Further evidence is needed of the interventions delivered by speech and language therapists and outcomes will be beneficial alongside benchmarking similar services.

WHAT THIS PAPER ADDS

What is already known on this subject In England, people who sustain a spinal cord injury are admitted to a major trauma centre prior to transfer to a specialist spinal injury unit. Dysphagia and communication impairments are recognised as a complication of cervical spinal cord injury and benefit from speech and language therapy intervention. National recommendations exist for staffing levels, expertise and competencies for speech and language therapists working in critical care and rehabilitation units. What this study adds This study identified variations in the levels of speech and language therapy staffing, seniority, service delivery and access to instrumental assessments for dysphagia between major trauma centres and spinal injury units. None of the services complied with national staffing recommendations. Clinical implications of this study Speech and language therapy services in spinal injury units are often available part-time or have limited access to diagnostic tools which limits the range and intensity of rehabilitation input available. This has clinical implications for outcomes for swallowing and communication as well as long-term consequences for integrating back into community.

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.

Strategies used by nurses and tracheostomized users in communication: systematic review

Communication is a basic human need necessary to establish a relationship of trust between patients and multidisciplinary team, especially with nursing team. With this, it is necessary to find strategies that allows not only the tracheostomized patients but also nurses to communicate in an effective way [1].

This is a systematic review that aims to give an answer to our investigation question: “Which strategies are used by nurses and tracheostomized patients in communication?” To understand which strategies are used by nurses and tracheostomized patients in communication. Our research was based on electronic data such as B-On, SciELO, RCAAP and EBSCOhost. According to our descriptors: communication, strategies, nursing and tracheostomy, we included articles published between 2011 and 2019, in Portuguese or English. Seven articles were included in this systematic review.

From the analysis of the data emerged three fundamental themes regarding the strategies used by nurses and tracheostomized patients in communication, that are: (1) Communication strategies used; (2) Communication facilitators; (3) Difficulty in communication and social interaction. Regarding the first theme, we consider that the alternative communication strategies used by tracheostomized individuals involve gestures or writing, lip reading, illustrative cards, the speech valve and tracheostomy occlusion [2]. According to the second theme, we found that the user must be encouraged to speak clearly and slowly, taking into account key words or phrases (that may give clues) and to blink differently for yes or no [3]. Regarding the last theme, the difficulties shown by the tracheostomy user go through the inability to change the volume and tone of voice, thereby affecting social interaction with others [4]. The knowledge of health professionals regarding the stress factor of these users leads to a lack of expressiveness due to the inability to communicate. The communication of these two actors is considered a key element, helping to reassure the user [5]. For all these strategies, the positioning of the user and the receptor of the message is a primary factor [2]. The need for strategies to overcome the difficulties experienced by tracheostomized users provides a consistent basis for promotion quality nursing care [1,2].

The studies analysed indicate that currently, despite the existence of several communication techniques between the user and the other health professionals, (namely nurses), there is still some difficulty in teaching them. This difficulty has implications for the continuity of health care and affects not only users, but also their family and all professionals with whom they are in contact during hospitalisation. This review is important because it contributes to the improvement of nursing care and the compliance of the user.

Computer-Based Communication Tool Provides Effective Communication for Non-speaking Patients: A Quasi-experimental Study

Even though they are conscious, patients who are unable to speak while connected to a mechanical ventilator have serious difficulties in communicating with healthcare staff. This research aimed to determine the effectiveness for patients of a computer-based communication tool (CBCT) and to compare these results with patients using a routine method. This quasi-experimental study was conducted with 90 intubated patients. It was found that 20.0% of the patients using CBCT stated that they had difficulties in communicating, while this rate was 82.2% among patients not using CBCT. Compared with participants in the control group, experimental group patients reported a lower median score for the anxiety levels (23.0 [20.0-39.0], 29.0 [20.0-57.00], p < .001) and higher mean comfort levels (130.2 ± 9.0, 109.6 ± 13.3, p < .001). Positive impacts of the CBCT are its suitability for patients who are dependent upon ventilation for different reasons and their improved ability to communicate effectively.

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.

Gaining Experience Over Time: The Family Caregivers' Perception of Patients with a Tracheostomy in Home Care

Background

The transition of tracheostomy patients to the home poses many challenges for both the patient and the family. Identifying and understanding the experiences of family caregivers pave the road for discovering and meeting care needs. This study has been aimed to explain the experiences of family caregivers of patients with a tracheostomy about patient care at home.

Materials and Methods

This qualitative study was conducted using a conventional content analysis approach from September 2018 to January 2019. Participants included nine family caregivers and one professional caregiver who were selected through purposive sampling method. The in-depth interviews were conducted at home or in health centers using field notes. Data were recorded manually and analyzed using the five-step method proposed by Granehim and Lundman.

Results

The data led to the emergence of 1591 initial codes, 23 subcategories, and 6 categories. Categories include the need for training, the need for receiving care support, care challenges, care burden, gaining experience, hope, and inner satisfaction.

Conclusions

In this study, the family caregivers faced with lots of challenges in caring patients with tracheostomy so that they were in needs of training and support from professionals. Although they got skillful in care and endure burden, they were so hopeful and satisfied with their attempts. Hence, there is a need for official nongovernmental organizations with the aim of maintaining care and protecting their families.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Needs and burdens of palliative care patients with advanced and/or metastatic head and neck tumors]

Hintergrund

Neue Therapieformen ermöglichen auch bei Patienten mit fortgeschrittenen und metastasierten Kopf-Hals-Tumoren gute Behandlungsansätze. Gespräche über das Lebensende, vorausschauende Versorgungsplanung und auch palliativmedizinische Konzepte geraten dadurch oft in den Hintergrund.

Ziel der Arbeit

Analyse von Symptomen, Belastungen sowie dem Vorliegen von Vorsorgedokumenten, von stationär palliativmedizinisch mitbetreuten Patienten durch Selbsteinschätzung. Erhebung der Integration der spezialisierten Palliativversorgung in die Versorgung stationär verstorbener Patienten anhand des Qualitätsindikators nach Earle.

Material und Methoden

Retrospektive Analyse der vom Palliativdienst mitbetreuten Patienten mit Kopf-Hals-Tumoren durch Nutzung des standardisierten IPOS Fragebogens.

Ergebnisse

Die häufigsten physischen Symptome waren „Schwäche“ (77 %), „Appetitlosigkeit“ (65 %) und „eingeschränkte Mobilität“ (65 %). „Schmerzen“ wurden von 42 % der Patienten angegeben. Die häufigsten emotionalen und psychosozialen Belastungen waren „Traurigkeit“ (97 %) und „Sorgen des Patienten“ (94 %), die „fehlende Möglichkeit Gefühle“ zu teilen (77 %), „unzureichende Informiertheit“ (85 %) und „organisatorische Probleme“ (77 %). Bei 23 % der Patienten lagen Vorsorgedokumente vor. Das Qualitätsziel nach Earle wurde nicht erreicht.

Diskussion

Die Patienten berichten in der Auswertung in hohem Maß Symptome und Belastungen, am häufigsten im emotionalen Bereich und bezüglich kommunikativer und praktischer Bedürfnisse. Hier zeigt sich möglicherweise auch ein Gesprächsbedarf über Wünsche und Vorstellungen im Hinblick auf das Lebensende. Palliativdienste sollten deshalb besonders auf die psychosozialen Bedürfnisse einzugehen.

Management of tracheostomies in the intensive care unit: a scoping review

OBJECTIVES

While there is an extensive body of literature surrounding the decision to insert, and methods for inserting, a tracheostomy, the optimal management of tracheostomies within the intensive care unit (ICU) from after insertion until ICU discharge is not well understood. The objective was to identify and map the key concepts relating to, and identify research priorities for, postinsertion management of adult patients with tracheostomies in the ICU.

DESIGN

Scoping review of the literature.

DATA SOURCES

PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature were searched from inception to 3 October 2019. Additional sources were searched for published and unpublished literature.

ELIGIBILITY CRITERIA

We included studies of any methodology that addressed the a priori key questions relating to tracheostomy management in the ICU. No restrictions were placed on language or year of publication.

DATA EXTRACTION AND SYNTHESIS

Titles and abstracts were screened by two reviewers. Studies that met inclusion criteria were reviewed in full by two reviewers, with discrepancies resolved by a third. Data were extracted for included studies, and results mapped along the prespecified research questions.

RESULTS

6132 articles were screened, and 102 articles were included for detailed analysis. Protocolised weaning was found to be successful in liberating patients from the ventilator in several cohort studies. Observational studies showed that strategies that use T-pieces and high-flow oxygen delivery improve weaning success. Several lines of evidence, including one clinical trial, support early cuff deflation as a safe and effective strategy as it results in a reduced time to wean, shorter ICU stays and fewer complications. Early tracheostomy downsizing and/or switching to cuffless tubes was found to be of benefit in one study. A substantial body of evidence supports the use of speaking valves to facilitate communication. While this does not influence time to wean or incidence of complications, it is associated with a major benefit in patient satisfaction and experience. Use of care bundles and multidisciplinary team approaches have been associated with reduced complications and improved outcomes in several observational studies.

CONCLUSIONS

The limited body of evidence supports use of weaning protocols, early cuff deflation, use of speaking valves and multidisciplinary approaches. Clinical trials examining post-tracheostomy management strategies in ICUs are a priority.

Greek nurses' perceptions on empathy and empathic care in the Intensive Care Unit

BACKGROUND

Empathy is a fundamental component of nursing practice impacting positively on the therapeutic process. Understanding the concepts of empathy and empathic care in the context of Intensive Care Units is essential for providing better care in high challenging environments. However, research on empathy in the ICU is scarce and mostly quantitative.

OBJECTIVES

To explore how ICU nurses perceive the concepts of empathy and empathic care.

DESIGN AND SETTING

A descriptive qualitative research design was applied using an inductive content analysis approach. Semi-structured interviews were conducted with nineteen ICU nurses in two hospitals in Greece.

FINDINGS

Data analysis revealed three main themes namely: "To become one of them", "Empathic Care" and "Integration of empathic care in practice". Findings corroborated the affective, cognitive and behavioral components of empathy. Nurses underlined that understaffing, increased workload and professional burnout impeded empathic care.

CONCLUSION

Empathy and empathic care in the ICU were perceived as closely related to patients' outcomes and quality care. Empathic care was arduous due to organisational issues. Despite that, ICU nurses appeared to promote empathic care in practice and sought ways to enhance it.

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.

Difficulty envisioning a positive future: Secondary analyses in patients in intensive care who are communication vulnerable

The purpose of this study was to report a secondary analysis of data collected through a primary study. The primary study was a, randomized, control trial that used a team-designed (nursing, speech language hearing, engineering, communication sciences, and biostatistics), nurse-led, electronic communication intervention (Speak for Myself Voice) and measured patient outcomes of symptoms of anxiety and depression in five intensive care units at a regional, magnet-status, academic medical center. A secondary analysis of data using the Hospital Anxiety and Depression scale is reported here. The extant literature supports patient expressions of frustration, anger, anxiety, and depression when unable to communicate. This secondary analysis study report adds information about Hospital Anxiety and Depression subscales in the communication-vulnerable population. Implications include emerging awareness of potential feelings of depression and anxiety in patients who are receiving mechanical ventilation or who are unable to verbally communicate for any reason (e.g. obstruction, trauma, head and neck cancer) in the intensive care unit.