Nonvocal Ventilated Patients Perceptions of Being Understood

Brain-computer interface in critical care and rehabilitation

This comprehensive review explores the broad landscape of brain-computer interface (BCI) technology and its potential use in intensive care units (ICUs), particularly for patients with motor impairments such as quadriplegia or severe brain injury. By employing brain signals from various sensing techniques, BCIs offer enhanced communication and motor rehabilitation strategies for patients. This review underscores the concept and efficacy of noninvasive, electroencephalogram-based BCIs in facilitating both communicative interactions and motor function recovery. Additionally, it highlights the current research gap in intuitive "stop" mechanisms within motor rehabilitation protocols, emphasizing the need for advancements that prioritize patient safety and individualized responsiveness. Furthermore, it advocates for more focused research that considers the unique requirements of ICU environments to address the challenges arising from patient variability, fatigue, and limited applicability of current BCI systems outside of experimental settings.

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.

Augmentative and alternative communication (AAC) for nursing students; equipping the next generation of nursing professionals

BACKGROUND

Augmentative and alternative communication (AAC) is often used for patients who are temporarily non-speaking. However, considering AAC for these patients in intensive care units (ICUs) has only recently started to gain the attention of health care providers in the hospital setting. Currently, few nursing programs include content in their curricula as relates to this population.

OBJECTIVES

To investigate the feasibility of embedding a brief inservice into an existing undergraduate nursing course, and to determine the feasibility and relevance of AAC use during their clinical ICU rotation.

DESIGN

A longitudinal survey study using three time points: pre- and post-inservice, and post implementation following a clinical rotation.

SETTING

University nursing program classroom during an Adult Health and Illness course.

PARTICIPANTS

Twenty-seven undergraduate nursing students enrolled in the Adult Health and Illness course.

METHODS

The participants were given a brief inservice educating them on the use of AAC. The students were given AAC boards to use during their ICU clinical rotation. Survey data was collected before and after the inservice and at the end of the clinical rotation.

RESULTS

Pre-service nursing students responded favorably to a brief inservice embedded into an existing nursing course. Survey data indicated an increase in the students' knowledge of AAC (z = 4.52, p < .05) and awareness that AAC can improve communication between patients and staff (z = 2.24, p < .05).

CONCLUSION

An interdisciplinary activity between Communication Sciences and Disorders and Nursing departments about AAC could be a new and promising solution to increase communication with non-speaking patients in the ICU.

First experiences of communication with mechanically ventilated patients in the intensive care unit using eye-tracking technology

INTRODUCTION

Eye-tracking (ET) may be a novel tool for communication with intubated and mechanically ventilated critically ill patients. We hypothesized that ET could be learned fast and be used successfully by intensive care unit (ICU) and intermediate care (IMC) patients with artificial airways for communication.

METHODS

Including all patients with mechanical ventilation via oral intubation or tracheostomy, who were at least 18 years of age with a score of -1 to +1 points on the Richmond agitation-sedation scale and a history of ventilation for more than 48 h. A commercially available ET was used. The investigations were performed by a physician with the support of a psychologist following a standardized study protocol.

RESULTS

During a 4-week period a total of 11 patients completed all of the five steps of our study protocol. The time to complete our study protocol was 64 ± 23.8 min (range 43-125 min) with a mean of 1.5 ± 0.9 sessions (range 1-4 sessions). Seven patients (63.6 %) could run through all of the five steps within their first session. All patients (100%) preferred the gaze fixation technique to control the ET to the wink control.

CONCLUSION

Mechanically ventilated ICU and IMC patients are able to use ET in a very short time for communication to indicate their basic needs, answer rating scales and pain scores as well as questionnaires about quality of life and self-esteem.Implications for rehabilitationCOMFORT - The novel communication device improves the patients' ability to communicate with the attending physicians, physiotherapists and nurses in order to provide a tailored rehabilitation approach.COMPLIANCE - The use of the eye-tracking technology enables the patients to communicate special needs and fears during the course of the rehabilitation.COMPLICATIONS - The eye-tracking technology enables the attending rehabilitation team to earlier detect complications (e.g. pain, depression) during the course of the rehabilitation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Opportunities for Interactive Communication in Mechanically Ventilated Critically Ill Patients: A Video-Based Observational Study

Background

Mechanically ventilated critically ill patients need the opportunity to communicate their physical and psychosocial concerns to nurses. However, these patients face the unique problem of lacking even the opportunity to communicate.

Aims

The study aimed to describe the characteristics of communication opportunities for critically ill mechanically ventilated patients.

Methods

The study was designed as a video-based descriptive observational study. Participants included seven mechanically ventilated critically ill patients at the intensive care unit, coronary care unit, or high care unit who were conscious and seven registered nurses (seven pairs). Videos were recorded continuously from 8 am to 4 pm, and the footage was then descriptively analyzed. Data collection took place between July 2019 and June 2020.

Results

The total recording time was 668.0 minutes. Of these 668.0 minutes, nurses stayed in the Conversation Area of the Patient for 279.6 minutes, and of these 279.6 minutes, two-way face-to-face communication between nurse and patient occurred for 78.0 minutes. Of these 78.0 minutes, communications were started by nurses for 47.2 minutes (174 scenes) and by patients for 24.2 minutes (36 scenes). The patient-started two-way communication scenes included 37 instances of Patient-Intentional-Action that triggered the start of communication. Actions using the upper limbs were observed in 20 instances and represented the most frequently used body part. The head/face, lower limbs, or trunk were also used in some of the actions. Gestures were the most commonly used action type (14 instances). Other types included lip movement, grimace, leg flex/extension, and cough.

Conclusions

We found that nurses tended to start communication more frequently than patients did and that patients demonstrated Patient-Intentional-Action with a variety of actions using various body parts. Communication opportunities for patients were created when nurses took the initiative to start communication or when they noticed and responded to the Patient-Intentional-Action. Our findings demonstrate that nurses need to recognize and always respond to Patient-Intentional-Action and to take the initiative in communicating rather than waiting for the patient to do so.

Eye Tracking communication with intubated critically ill patients: a proof-of-concept multicenter pilot study

BACKGROUND

Communication is essential to establish patient-caregivers relationship in the intensive care unit. Intubated patients are not able to speak because the tracheal tube prevents vocalization. Use of communication tools such as eye tracking device could improve communication with intubated patients. The objective of this feasibility pilot study was to demonstrate that an eye tracking device specifically developed for the intensive care could be used easily by awake intubated patient with a very short training time.

METHODS

This prospective multicenter study was conducted in four intensive care units. We included awake adult intubated patients. The device used included an eye-tracking infrared detection and a communication interface specifically developed.

RESULTS

A total of 151 patients were included: the median age of patients was 66 years (56-72) and 97 (64%) were male, 97 patients (64%) succeed totally (installation; calibration, succeed to select all three icons), 124 (82%) succeed to select at least one icon, and 111 (74%) succeed to point to at least two icons. The main reasons for failure to use the device were: difficulties to open or to keep the eyes open, difficulties to installing the device occurred, and patient fatigue.

CONCLUSIONS

This study shows that the use of an eye tracking technology device specifically designed for the intensive care setting, with a short training is easy to use for intubated patient. Patients, relatives and caregivers showed high satisfaction.

Evaluating the clinical benefit of brain-computer interfaces for control of a personal computer

Brain-computer interfaces (BCIs) enabling the control of a personal computer could provide myriad benefits to individuals with disabilities including paralysis. However, to realize this potential, these BCIs must gain regulatory approval and be made clinically available beyond research participation. Therefore, a transition from engineering-oriented to clinically oriented outcome measures will be required in the evaluation of BCIs. This review examined how to assess the clinical benefit of BCIs for the control of a personal computer. We report that: 1) a variety of different patient-reported outcome measures can be used to evaluate improvements in how a patient feels, and we offer some considerations that should guide instrument selection. 2) Activities of daily living can be assessed to demonstrate improvements in how a patient functions, however, new instruments that are sensitive to increases in functional independence via the ability to perform digital tasks may be needed. 3) Benefits to how a patient survives has not previously been evaluated, but establishing patient-initiated communication channels using BCIs might facilitate quantifiable improvements in health outcomes.

iPad-based Apps to Facilitate Communication in Critically Ill Patients with Impaired Ability to Communicate: A Preclinical Analysis

Background

Inability to communicate is very distressing for patients in the intensive care unit (ICU). Most communication exchanges in ICU are initiated by healthcare workers (HCWs). Touch screen apps may enable patients to initiate communication and improve their interactions.

Objectives

This study aimed to evaluate the pertinent features of iPad-based apps designed for communication in ICU.

Methods

Apple “App Store” and Google “Play Store” were searched for keywords “communication” and “intensive care.” Related app suggestions were screened. Two independent assessors evaluated iPad-based apps that were deemed useful. The assessors resolved the discrepancies by re-evaluating the apps and reaching a consensus.

Results

Nine apps met the inclusion criteria. Of these six apps were free. There were seven apps specific to intensive care. Most apps had preloaded phrases for the patient to request to see someone (e.g., family), personal hygiene (e.g., bowel care), seek help with symptoms (e.g., pain), or a comfort item (e.g., blanket). CALD Assist, Patient Communicator, VidaTalk, and YoDoc were available in more than eight languages. VidaTalk and YoDoc allowed the user to write. Four apps were deemed not suitable for routine ICU use, while the remaining five had several attractive features.

Conclusion

Several high-quality apps are available to assist with patient-initiated communication exchange in ICU. This study provides a guide for readers to choose the app most suited to their needs. In the opinion of the authors, YoDoc is the most suitable app for routine use in ICU. Among free apps, CommuniCare appears to be the most user-friendly.

How to cite this article

Dind AJ, Starr JS, Arora S. iPad-based Apps to Facilitate Communication in Critically Ill Patients with Impaired Ability to Communicate: A Preclinical Analysis. Indian J Crit Care Med 2021;25(11):1232–1240.

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.

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.

Patient's experiences of endotracheal tubes and suction following cardiac surgery

BACKGROUND

There is a growing body of evidence addressing the patient experience of intensive care, including patient reports that the presence of an endotracheal tube is bothersome and distressing, and that endotracheal suction is moderately to extremely painful. Yet there remains little information about the patient experience of the endotracheal tube and suction in those patients receiving planned short-term mechanical ventilation.

AIMS AND OBJECTIVES

This study aimed to describe the patient experience of the endotracheal tube and suction, following mechanical ventilation in post-operative cardiac surgical patients.

DESIGN

This qualitative study used inductive thematic analysis. Participants having planned cardiac surgery, anticipated to receive less than 12-hours mechanical ventilation, were approached pre-operatively and written consent provided.

METHODS

Ten participants were recruited using purposive sampling. Semi-structured interviews were conducted between days four and six post-operatively. One researcher interviewed all participants; two researchers independently read, coded, and agreed themes.

FINDINGS

None of the participants recalled endotracheal suction, while half had no recollection of the endotracheal tube. Three themes were identified; the experience of the endotracheal tube and extubation, the experience of emerging from sedation, and participants concerns about the future. The presence of the endotracheal tube was described as bothersome, whilst breathing through the tube and extubation were described as 'weird' and 'strange' but not painful.

CONCLUSIONS

Knowledge of the patient experience can help inform nursing practice by improving pre and post-operative care planning.

RELEVANCE TO CLINICAL PRACTICE

This study adds to the body of knowledge about the patient experience of the endotracheal tube and extubation.

TRIAL REGISTRATION

Prospective registration with the Australian New Zealand Clinical Trials Registry. www.anzctr.org.au (ACTRN12616001515482).

Development of a brain-computer interface for patients in the critical care setting

Objective

Behaviorally unresponsive patients in intensive care units (ICU) are unable to consistently and effectively communicate their most fundamental physical needs. Brain-Computer Interface (BCI) technology has been established in the clinical context, but faces challenges in the critical care environment. Contrary to cue-based BCIs, which allow activation only during pre-determined periods of time, self-paced BCI systems empower patients to interact with others at any time. The study aims to develop a self-paced BCI for patients in the intensive care unit.

Methods

BCI experiments were conducted in 18 ICU patients and 5 healthy volunteers. The proposed self-paced BCI system analyzes EEG activity from patients while these are asked to control a beeping tone by performing a motor task (i.e., opening and closing a hand). Signal decoding is performed in real time and auditory feedback given via headphones. Performance of the BCI system was judged based on correlation between the optimal and the observed performance.

Results

All 5 healthy volunteers were able to successfully perform the BCI task, compared to chance alone (p<0.001). 5 of 14 (36%) conscious ICU patients were able to perform the BCI task. One of these 5 patients was quadriplegic and controlled the BCI system without any hand movements. None of the 4 unconscious patients were able to perform the BCI task.

Conclusions

More than one third of conscious ICU patients and all healthy volunteers were able to gain control over the self-paced BCI system. The initial 4 unconscious patients were not. Future studies will focus on studying the ability of behaviorally unresponsive patients with cognitive motor dissociation to control the self-paced BCI system.

A Communicative Intervention to Improve the Psychoemotional State of Critical Care Patients Transported by Ambulance

BACKGROUND

Communication is key to understanding the emotional state of critical care patients.

OBJECTIVE

To analyze the effectiveness of the communicative intervention known as CONECTEM, which incorporates basic communication skills and augmentative alternative communication, in improving pain, anxiety, and posttraumatic stress disorder symptoms in critical care patients transported by ambulance.

METHODS

This study had a quasi-experimental design with intervention and control groups. It was carried out at 4 emergency medical centers in northern Spain. One of the centers served as the intervention unit, with the other 3 serving as control units. The nurses at the intervention center underwent training in CONECTEM. Pretest and posttest measurements were obtained using a visual analog scale to measure pain, the short-version State-Trait Anxiety Inventory to measure anxiety, and the Impact of Event Scale to measure posttraumatic stress disorder symptoms.

RESULTS

In the comparative pretest-posttest analysis of the groups, significant differences were found in favor of the intervention group (Pillai multivariate, F2,110 = 57.973, P < .001). The intervention was associated with improvements in pain (mean visual analog scale score, 3.3 pretest vs 1.1 posttest; P < .001) and posttraumatic stress disorder symptoms (mean Impact of Event Scale score, 17.8 pretest vs 11.2 posttest; P < .001). Moreover, the percentage of patients whose anxiety improved was higher in the intervention group than in the control group (62% vs 4%, P < .001).

CONCLUSION

The communicative intervention CONECTEM was effective in improving psychoemotional state among critical care patients during medical transport.

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.

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.

The Facilitated Sensemaking Model as a Framework for Family-Patient Communication During Mechanical Ventilation in the Intensive Care Unit

Family caregivers of intensive care unit (ICU) patients are at high risk for adverse psychological outcomes. Communication difficulty due to mechanical ventilation may induce or worsen adverse psychological outcomes. The Facilitated Sensemaking Model (FSM) is the first model to guide nursing interventions to help ICU family caregivers overcome and prevent adverse psychological outcomes. We address an understudied phenomenon, communication between patients and family caregivers during mechanical ventilation. The FSM guides supportive interventions for critical care nurses to improve patient-family communication in the ICU. We provide an example of communication intervention, an electronic communication app, within the preexisting FSM.

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.

Uncovering Consciousness in Unresponsive ICU Patients: Technical, Medical and Ethical Considerations

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

The work undertaken by mechanically ventilated patients in Intensive Care: A qualitative meta-ethnography of survivors' experiences

BACKGROUND

Mechanical ventilation is a routine intervention for the critically ill but patients' experiences of this intervention are largely hidden from clinicians. A comprehensive understanding of Intensive Care Units survivors' accounts is required to provide health professionals with evidence about the patients' experience to deliver patient-centred care.

OBJECTIVES

To synthesise qualitative findings from international studies to understand Intensive Care Unit survivors' experiences of mechanical ventilation, clarify the components of patient-centred care from the patient perspective and understand what can be done by health professionals to improve care processes.

DESIGN

A meta-ethnography of qualitative evidence following ENTREQ recommendations for reporting systematic reviews.

DATA SOURCES

Eight databases (MEDLINE, AMED, CINAHL, PsychINFO, Scopus, WileyOnline, PubMed Central, TRIP) were systematically searched using a piloted strategy described in a published protocol. Searches were completed on 31.8.16 and no date restrictions were placed. Searches were updated on 25.4.17.

REVIEW METHODS

Two researchers independently reviewed studies against pre-determined inclusion criteria to assess their eligibility. Studies were included if they reported on the adult patient experience of mechanical ventilation and used qualitative data collection and analysis methods. All included studies were quality appraised. Participant quotes and concepts, described within the categories and themes of published studies, were extracted by one reviewer and coded by two reviewers. A process of constant comparison, which is central to meta-ethnography, facilitated the re-interpretation of data by a team of researchers to generate the final qualitative synthesis. The Enhancing Transparency in Reporting the Synthesis of Qualitative (ENTREQ) statement was used to ensure that all synthesis stages were comprehensively reported.

RESULTS

Findings from 38 studies, with 608 participants, informed a patient-centred trajectory model; three overlapping stages; alienation, hidden work and recovery characterised the experiences of mechanical ventilation survivors. Health professionals could positively influence the patient experience by promoting 'trust' and being vigilant so that patients felt 'safe'. Care provision that promoted 'personalisation' helped participants to retain their identity as unique human beings.

CONCLUSIONS

For the first time the pooling of qualitative findings from international studies, using meta-ethnography, has provided a patient-centred model of mechanical ventilation survivors' experiences of their care processes. Patients may actively engage or passively endure the treatment burden associated with mechanical ventilation.

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

OBJECTIVES

To describe the experience and sources of comfort and discomfort in tracheostomy patients, when they communicate with nurses in the Intensive Care Unit.

RESEARCH METHODOLOGY/DESIGN

Benner's interpretive phenomenology. Data were collected through: a) semi-structured interviews conducted with the patients after leaving the intensive care unit; b) participant observation; c) situated interviews with intensive care nurses.

SETTING

The intensive care unit of a hospital in Northern Italy.

FINDINGS

Eight patients and seven nurses were included in this study. Two main themes were identified 1) feeling powerless and frustrated due to the impossibility to use voice to communicate; 2) facing continual misunderstanding, resignation, and anger during moments of difficulty and/or communication misunderstandings. The main communication discomfort factors were: struggling with not knowing what was happening, feeling like others had given up on me, living in isolation and feeling invisible. The main comfort factors were: being with family members, feeling reassured by having a call bell nearby and nurses' presence.

CONCLUSIONS

This study highlights the important role of communication in tracheostomy patients in intensive care and how closely it is linked to all the aspects of a person's life, which cannot be underestimated as just not being able to use one's voice.

Quality of life improves for tracheostomy patients with return of voice: A mixed methods evaluation of the patient experience across the care continuum

OBJECTIVES

A tracheostomy tube can profoundly impact ability to communicate. The impact of this on patients' self-esteem and quality of life in the care continuum from the intensive care unit to after decannulation has not been reported. Therefore, the aim was to investigate the patient-reported experience regarding change in communication function, communication-related self-esteem and quality of life.

RESEARCH DESIGN

A mixed methods approach was utilised. Quantitative data were obtained using validated measures of self-esteem related to communication-related quality of life and general health. Data were measured before return of voice, within 48 hours of voice return and six months after tracheostomy decannulation. Qualitative data were collected through structured interviews six months after tracheostomy.

RESULTS

Seventeen participants completed the study. Four themes emerged from the interviews: It's hard communicating without a voice; What is happening to me?; A storm of dark emotions and More than a response…it's participating and recovering. Significant positive change occurred in six items of self-esteem related to communication from baseline to return of voice. Overall, positive changes in quality of life scores were observed.

CONCLUSIONS

Voice loss with tracheostomy significantly affected participants' abilities to effectively communicate their care and comfort needs. Restoration of voice occurred in conjunction with patient-reported improved mood, outlook and sense of recovery.

Portable Brain-Computer Interface for the Intensive Care Unit Patient Communication Using Subject-Dependent SSVEP Identification

A major predicament for Intensive Care Unit (ICU) patients is inconsistent and ineffective communication means. Patients rated most communication sessions as difficult and unsuccessful. This, in turn, can cause distress, unrecognized pain, anxiety, and fear. As such, we designed a portable BCI system for ICU communications (BCI4ICU) optimized to operate effectively in an ICU environment. The system utilizes a wearable EEG cap coupled with an Android app designed on a mobile device that serves as visual stimuli and data processing module. Furthermore, to overcome the challenges that BCI systems face today in real-world scenarios, we propose a novel subject-specific Gaussian Mixture Model- (GMM-) based training and adaptation algorithm. First, we incorporate subject-specific information in the training phase of the SSVEP identification model using GMM-based training and adaptation. We evaluate subject-specific models against other subjects. Subsequently, from the GMM discriminative scores, we generate the transformed vectors, which are passed to our predictive model. Finally, the adapted mixture mean scores of the subject-specific GMMs are utilized to generate the high-dimensional supervectors. Our experimental results demonstrate that the proposed system achieved 98.7% average identification accuracy, which is promising in order to provide effective and consistent communication for patients in the intensive care.

Exploring the scope of communication content of mechanically ventilated patients

PURPOSE

Ineffective communication during mechanical ventilation (MV) and critical illness is distressing to many patients. This study aimed to describe the scope of communication content of ventilated critically ill patients.

MATERIALS AND METHODS

We performed a prospective qualitative interview study in a multidisciplinary intensive care unit. Ten alert, orientated adult patients who previously underwent MV for at least 24h and were able to speak at the time of interview were recruited. Semi-structured interviews with stimulated recall technique were conducted. A descriptive thematic analysis was performed of the patient-generated content using a free coding technique, where recurrent themes and subthemes were noted, coded and analyzed.

RESULTS

Patients' communication content included medical discussions with clinicians; communication with family to provide advice or comfort, make requests and plans, express feelings and convey personal perspectives on medical care; and expression of their own psychoemotional needs.

CONCLUSIONS

The scope of communication content of ventilated ICU patients was broad, extending far beyond task-focused subject matter. Content ranged from conveying symptom-related messages to active participation in medical discussions, to conversing with family about a range of complex multi-dimensional issues, to sharing their own psychoemotional experiences. These patient-centered needs should be recognized and addressed in communication strategies.

Communication aid requirements of intensive care unit patients with transient speech loss

Alert and transiently nonvocal intensive care unit (ICU) patients are dependent on augmentative and alternative communication (AAC). Unfortunately, the literature demonstrates that existent AAC devices have not been widely adopted, and unaided methods are often the primary modalities used despite being insufficient, and frustrating. We present the results of a qualitative semi-structured interview study with 8 ex-ICU patients, 4 ICU patient relatives, and 6 ICU staff, exploring their AAC needs and requirements. Participants identified important AAC hardware, software, and content requirements. Salient factors impacting on AAC adoption in the ICU setting were also highlighted and included the need for staff training and bedside patient assessment. Based on the study results, we propose a series of recommendations regarding the design and implementation of future AAC tools specifically targeted at this group.

A pilot study of eye-tracking devices in intensive care

BACKGROUND

Eye-tracking devices have been suggested as a means of improving communication and psychosocial status among patients in the intensive care unit (ICU). This study was undertaken to explore the psychosocial impact and communication effects of eye-tracking devices in the ICU.

METHODS

A convenience sample of patients in the medical ICU, surgical ICU, and neurosciences critical care unit were enrolled prospectively. Patients participated in 5 guided sessions of 45 minutes each with the eye-tracking computer. After completion of the sessions, the Psychosocial Impact of Assistive Devices Scale (PIADS) was used to evaluate the device from the patient's perspective.

RESULTS

All patients who participated in the study were able to communicate basic needs to nursing staff and family. Delirium as assessed by the Confusion Assessment Method for the Intensive Care Unit was present in 4 patients at recruitment and none after training. The device's overall psychosocial impact ranged from neutral (-0.29) to strongly positive (2.76). Compared with the absence of intervention (0 = no change), patients exposed to eye-tracking computers demonstrated a positive mean overall impact score (PIADS = 1.30; P = .004). This finding was present in mean scores for each PIADS domain: competence = 1.26, adaptability = 1.60, and self-esteem = 1.02 (all P < .01).

CONCLUSION

There is a population of patients in the ICU whose psychosocial status, delirium, and communication ability may be enhanced by eye-tracking devices. These 3 outcomes are intertwined with ICU patient outcomes and indirectly suggest that eye-tracking devices might improve outcomes. A more in-depth exploration of the population to be targeted, the device's limitations, and the benefits of eye-tracking devices in the ICU is warranted.

Nurses' experiences of communicating with hospitalized, suddenly speechless patients

We used a qualitative focus group design to explore the experiences and challenges of nurses who work with hospitalized patients experiencing the sudden inability to verbalize their needs, also known as sudden speechlessness. In response to open-ended questions in facilitated focus groups, 18 nurses discussed issues around the care and communication needs of suddenly speechless (SS) patients. Nurses identified multiple, commonly occurring communication challenges when caring for SS patients. They believed these challenges led to poorer recognition of patient needs, with the potential for compromised patient care. Nurses described how the lack of reliable strategies to facilitate communication sometimes resulted in negative patient outcomes, including unmet psychosocial needs and the potential that informed consent and educational issues were being inadequately addressed for the SS patients. Even experienced nurses indicated ongoing problems in communicating with SS patients, despite using a multitude of strategies, leaving many to deal with issues of frustration and role conflict.

The number of mechanically ventilated ICU patients meeting communication criteria

OBJECTIVES

(1) Estimate the proportion of mechanically ventilated (MV) intensive care unit (ICU) patients meeting basic communication criteria who could potentially be served by assistive communication tools and speech-language consultation. (2) Compare characteristics of patients who met communication criteria with those who did not.

DESIGN

Observational cohort study in which computerized billing and medical records were screened over a 2-year period.

SETTING

Six specialty ICUs across two hospitals in an academic health system.

PARTICIPANTS

Eligible patients were awake, alert, and responsive to verbal communication from clinicians for at least one 12-h nursing shift while receiving MV ≥ 2 consecutive days.

MAIN RESULTS

Of the 2671 MV patients screened, 1440 (53.9%) met basic communication criteria. The Neurological ICU had the lowest proportion of MV patients meeting communication criteria (40.82%); Trauma ICU had the highest proportion (69.97%). MV patients who did not meet basic communication criteria (n = 1231) were younger, had shorter lengths of stay and lower costs, and were more likely to die during the hospitalization.

CONCLUSIONS

We estimate that half of MV patients in the ICU could potentially be served by assistive communication tools and speech-language consultation.

Effect of a multi-level intervention on nurse-patient communication in the intensive care unit: results of the SPEACS trial

OBJECTIVE

To test the impact of two levels of intervention on communication frequency, quality, success, and ease between nurses and intubated intensive care unit (ICU) patients.

DESIGN

Quasi-experimental, 3-phase sequential cohort study: (1) usual care, (2) basic communication skills training (BCST) for nurses, (3) additional training in augmentative and alternative communication devices and speech language pathologist consultation (AAC + SLP). Trained observers rated four 3-min video-recordings for each nurse-patient dyad for communication frequency, quality and success. Patients self-rated communication ease.

SETTING

Two ICUs in a university-affiliated medical center.

PARTICIPANTS

89 intubated patients awake, responsive and unable to speak and 30 ICU nurses.

MAIN RESULTS

Communication frequency (mean number of communication acts within a communication exchange) and positive nurse communication behaviors increased significantly in one ICU only. Percentage of successful communication exchanges about pain were greater for the two intervention groups than the usual care/control group across both ICUs (p = .03) with more successful sessions about pain and other symptoms in the AAC + SLP group (p = .07). Patients in the AAC + SLP intervention group used significantly more AAC methods (p = .002) and rated communication at high difficulty less often (p < .01).

CONCLUSIONS

This study provides support for the feasibility, utility and efficacy of a multi-level communication skills training, materials and SLP consultation intervention in the ICU.

The experiences of adult ventilator-dependent patients: a meta-synthesis review

Studies exploring the perceptions of patients whose lives are maintained by mechanical ventilation highlight the stressful nature of this type of experience. The objective of this meta-synthesis study was to describe the nature of the experience of adult ventilator-dependent patients. A systematic literature search of English and Chinese databases was undertaken, covering the period between 1970 and 2012. Qualitative research findings were extracted and pooled using the Joanna Briggs Institute Qualitative Assessment and Review Instrument. A total of 1004 papers were identified from various database and hand searches. Nineteen papers were critically appraised and 16 met inclusion criteria. Five meta-synthesis themes emerged from the analysis: (1) the feelings of fear due to being dependent on a ventilator and the loss of control of life; (2) disconnection with reality; (3) impaired embodiment; (4) construction of coping patterns; (5) trust and caring relationship. Suggested implications for practice include enhancing the trust relationship with health professionals, as well as nursing actions throughout the suction procedure relating to release of patient's psychological distress and empowering their resilience factors.

Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation

BACKGROUND

Difficulties in communication in intensive care patients receiving mechanical ventilation are a source of stressful experiences and psychoemotional distress.

OBJECTIVES

To examine the association between communication characteristics and psychoemotional distress among patients treated with mechanical ventilation in a medical intensive care unit and to identify factors that may be predictive of psychological outcomes.

METHODS

A total of 65 critically ill patients, extubated within the preceding 72 hours, were included in this cross-sectional study. Data were collected by using a structured interview. Separate regression analysis of data on 3 psychoemotional outcomes (psychological distress, fear, and anger) were used for baseline variables, communication characteristics, and stressful experiences.

RESULTS

Difficulty in communication was a positive predictor of patients' psychological distress, and length of anesthesia was a negative predictor. Fear and anger were also positively related to difficulty in communication. In addition, the number of communication methods was negatively associated with feelings of fear and anger. Finally, the stressful experiences associated with the endotracheal tube were positively related to feelings of anger.

CONCLUSIONS

Patients treated with mechanical ventilation experience a moderate to extreme level of psychoemotional distress because they cannot speak and communicate their needs. Nurses should be aware of the patients' need to communicate. Decreasing stressful experiences associated with the endotracheal tube and implementing more appropriate communication methods may reduce patients' distress.

Nurse-patient communication interactions in the intensive care unit

BACKGROUND

The inability to speak during critical illness is a source of distress for patients, yet nurse-patient communication in the intensive care unit has not been systematically studied or measured.

OBJECTIVES

To describe communication interactions, methods, and assistive techniques between nurses and nonspeaking critically ill patients in the intensive care unit.

METHODS

Descriptive observational study of the nonintervention/usual care cohort from a larger clinical trial of nurse-patient communication in a medical and a cardiothoracic surgical intensive care unit. Videorecorded interactions between 10 randomly selected nurses (5 per unit) and a convenience sample of 30 critically ill adults (15 per unit) who were awake, responsive, and unable to speak because of respiratory tract intubation were rated for frequency, success, quality, communication methods, and assistive communication techniques. Patients self-rated ease of communication.

RESULTS

Nurses initiated most (86.2%) of the communication exchanges. Mean rate of completed communication exchange was 2.62 exchanges per minute. The most common positive nurse act was making eye contact with the patient. Although communication exchanges were generally (>70%) successful, more than one-third (37.7%) of communications about pain were unsuccessful. Patients rated 40% of the communication sessions with nurses as somewhat difficult to extremely difficult. Assistive communication strategies were uncommon, with little to no use of assistive communication materials (eg, writing supplies, alphabet or word boards).

CONCLUSIONS

Study results highlight specific areas for improvement in communication between nurses and nonspeaking patients in the intensive care unit, particularly in communication about pain and in the use of assistive communication strategies and communication materials.

A systematic review of the experiences of adult ventilator-dependent patients

OBJECTIVES

The objective of this meta-synthesis study was to describe the nature of the experience of adult ventilator-dependent patients.

INCLUSION CRITERIA

This review considered studies utilized qualitative methods to examine the experience of adult with ventilator. The phenomena of interest were experiences of patients who were treated with ventilator for both short term and long term in ICU settings or home settings. The research was limited to studies published in Chinese or in English language.

SEARCH STRATEGY

The searching strategy sought to find both published and unpublished studies. The CINAHL, PubMed, MEDLINE, Cochrane Library, Chinese Periodicals Index and JIB website were used to search the articles. The preliminary keywords were drawn from the natural language terms of the topic, in the title, abstract and subject descriptors.

METHODOLOGICAL QUALITY

Each paper was assessed independently by two reviewers for methodological quality. The Joanna Briggs Institute's Qualitative Assessment and Review Instrument were used to appraisal the methodological quality of the articles. Any disagreements that arose between the reviewers were resolved through discussion with a third reviewer.

DATA SYNTHESIS

Qualitative research findings were pooled and the data analysis process involved synthesizing findings to generate a set of statements that represent the nature of the experiences of ventilator-dependent adult patients. The categories and themes/meta-syntheses were emerged from the analysis process.

RESULTS

A total of 997 papers were identified from various database and hand searches. Nineteen papers were critically appraised and 15 met inclusion criteria. Four papers were excluded because they did not meet the inclusion criteria. Five themes/meta-syntheses emerged from the analysis: 1). The feelings of fear due to being dependent on ventilator and the loss of control of life, 2). Disconnection with reality, 3). Impaired embodiment (body image and body boundary), 4). Construction of coping patterns, 5). Trust and caring relationship.

CONCLUSION

The five themes/meta-syntheses derived from the review represent the patients' experiences in regarding the threatening of the integrity of self, self-other and self-environment relationships, the coping patterns and resilient resources to maintain their self-identify and the meaning of life. These findings also illustrate the resiliency factors for those patients to cope with this stressful situation.The implications to practice include enhancing the trust relationship with health professionals, as well as the nursing actions prior to suction, during the suction procedure and post suction in related to release their psychological distress and empower their resilience factors was suggested.Furthermore, the further research could focus on the development and implementation of support programs for the patients, families, and health professionals, as well as the research regarding the reduction of psychological distress and empower the coping patterns.

A qualitative study into the lived experience of post-CABG patients during mechanical ventilator weaning

AIM

Research into mechanical ventilator weaning has predominantly been devoted to analysis and evaluation of predictors of weaning success. Few studies have examined the patient experience of weaning. The aim of this study was to provide a contemporary description of the patient experience of weaning, in order to up-date this aspect of knowledge in the context of newer modalities of mechanical ventilation and sedation.

METHODOLOGY

The study had a descriptive qualitative design focusing on the lived experience of post-CABG (coronary artery bypass graft) patients ventilated > or = 24h (n=10). Data were generated using semi-structured depth interviews conducted 2-5 months after hospital discharge. A hermeneutic phenomenological approach was used to analyze the data.

RESULTS

The article presents selected themes that emerged during the process of analysis. The main findings relate to general phenomena such as discomfort and impaired communication, psychological phenomena such as loss of control and loneliness, and existential phenomena such as temporality and human interaction.

CONCLUSION

Newer modalities of sedation and mechanical ventilation have not entirely eliminated the discomforts of critical illness; the human aspects of suffering remain. In order to address some of the general, psychological, and existential patient experiences, care should be taken to acknowledge the patient and to respect the patient domain and individual time frames. In nurse-patient communication, it is recommended that caregivers give accurate and unambiguous information.

Silent, slow lifeworld: the communication experience of nonvocal ventilated patients

The author explored communication experience of nonvocal ventilated individuals in rehabilitation settings with an aim to understand the reality of being voiceless using interpersonal relations theory as the theoretical study framework. Nineteen participants of varied ages and with varied ventilator courses shared their experiences while they were still nonvocal. The author used an interpretive phenomenological approach and analyzed the data using thematic analysis. Participants described the meaning of their nonvocal experience as "Being trapped in a silent world makes me feel frustrated and incomplete," "Days pass in slow motion while the rest of the world speeds by," "Making and preserving connections is of paramount importance," and "The powerlessness of being nonvocal was ameliorated by developing coping strategies and by consistent and reliable nursing care." In the discussion, the author provides an expanded understanding of the complexities of living in a silent, slow world.

ICU patients' recall of emotional reactions in the trajectory from falling critically ill to hospital discharge: follow-ups after 3 and 12 months

Patients' memories of frightening ICU experiences may be a threat to later psychological recovery. The purpose of the study is to describe ICU patients' recall of their emotional reactions, from falling critically ill to hospital discharge; this at 3 and 12 months following discharge from the ICU. The study is qualitative and concerns eight ICU patients ventilated for more than 72h. The participants were interviewed twice and the data were subjected to qualitative content analysis. It emerged that the memories of emotions during the trajectory of critical illness were extensive, detailed and strong, and that unpleasant emotions were clearly stable over time. At 12 months as compared with 3 months, the unpleasant emotions were less intense and had less prominent; furthermore the ICU care was more greatly associated with a sense of security, and there was greater recall of caring doctors and nurses (though not of their names) as well as next of kin.

CONCLUSIONS

The study generated knowledge not previously described about how ICU patients' recollection of their emotions during the trajectory of critical illness changes over time. This has implications regarding future study of patients' ICU memories and regarding patients' need for support in coping with such memories.

Receiving power through confirmation: the meaning of close relatives for people who have been critically ill

AIM

This paper is a report of a study to elucidate the meaning of close relatives for people who have been critically ill and received care in an intensive care unit.

BACKGROUND

Falling critically ill can bring about a difficult change in life. In previous reports such events are described as frightening experiences, and close relatives are described as an important source of support in this difficult situation.

METHOD

A purposive sample of 10 adults, eight men and two women, narrated how they experienced their close relatives during and after the time they were critically ill. The data were collected in 2004. The interview texts were transcribed and interpreted using a phenomenological hermeneutic approach influenced by the philosophy of Ricoeur.

FINDINGS

One major theme was identified, experiencing confirmation, with six sub-themes: receiving explanations; a feeling of being understood; a feeling of safety; gaining strength and will-power; having possibilities and realizing their value. Close relatives served as tools for the person who was ill, facilitating better communication and an increased ability to do various things. Simultaneously, feelings of dependence on the close relatives were expressed. There were descriptions of loneliness and fear in the absence of close relatives and, in order to feel safe, the participants wanted their close relatives to stay near them.

CONCLUSION

Close relatives are vital, as they are the ill person's motivation to stay alive and to continue the struggle. Their presence is of great importance for the ill person and must be facilitated by staff.

Communication boards in critical care: patients' views

BACKGROUND

Some patients receiving mechanical ventilation experience an intensified need to communicate while their ability to do so is compromised as the endotracheal tube prevents speech. Although the use of a communication board to enhance communication with such patients has been suggested, few descriptive or empirical studies have addressed the content and format of these devices or of patients' perspectives on decreasing frustration with communication.

OBJECTIVES

The objectives of this study were: (1) to identify the perceived level of frustration of patients receiving mechanical ventilation while they attempt to communicate; (2) to determine patients' perceived level of frustration if a communication board had been used; and (3) to describe patients' perceptions of the appropriate content and format of a communication board.

METHODS

Twenty-nine critically ill patients who were extubated within the past 72 hours were included in this descriptive study. Subjects participated in a 20- to 60-minute audiotaped interview consisting of questions about their perceived level of frustration when communicating with and without a communication board and their thoughts about the appropriate content and format of a board. Transcripts were analyzed by questions for meaning and overall themes.

RESULTS

Sixty-two percent (n = 18) of patients reported a high level of frustration in communicating their needs while receiving mechanical ventilation. Patients judged that their perceived level of frustration in communicating their needs would have been significantly lower (P < .001) if a communication board had been offered (29.8%) than if not (75.8%). Most patients (69%; n = 20) perceived that a communication board would have been helpful, and they also identified specific characteristics and content for a communication board. A communication board may be an effective intervention for decreasing patients' frustration and facilitating communication.

CONCLUSIONS

Most patients receiving mechanical ventilation experienced a moderate to a high level of frustration when communicating their needs. In this study, a communication board, if used patiently during mechanical ventilation, has been shown to alleviate frustration with communication. Patients have specific ideas about what terms and ideograms are useful for a communication board. Further research is needed to test the effects of a communication board and other methods of facilitating communication on outcomes such as satisfaction and anxiety of patients, adequate and appropriate management of pain, and length of mechanical ventilation time and hospital stay.

Patient communication following head and neck cancer surgery: a pilot study using electronic speech-generating devices

PURPOSE/OBJECTIVES

To describe the communication of patients who received electronic speech-generating devices (SGDs) following surgical procedures for head or neck cancer.

DESIGN

Exploratory, complementary mixed methods.

SETTING

Otolaryngology surgical inpatient unit of an urban teaching hospital.

SAMPLE

10 purposively selected patients with a mean age of 57.1 years (SD = 12.8 years) and moderately severe illness (Acute Physiology and Chronic Health Evaluation III score mean = 27.1 + 13.2) who had SGDs in their hospital rooms for 9.1 + 6.2 days.

METHODS

Observation, interviews, questionnaires, and clinical record review.

MAIN RESEARCH VARIABLES

Communication methods, communication content, SGD use, communication quality (i.e., ease and user satisfaction), barriers to SGD use, and patient clinical characteristics.

FINDINGS

SGDs were used in message construction in 8 (17%) out of 48 total observed communication events. Writing (31%) and nonverbal communication (46%) were the most frequently observed primary methods of communication used by patients with head and neck cancer postoperatively. Five patients demonstrated occasional SGD use with or without cuing, and one used the SGD as the dominant communication method. Ease of Communication Scale scores showed only slightly less difficulty with communication when compared to a historic control group. Patients initiated communications more often when SGDs were used in message construction. Poor device positioning, staff unfamiliarity with SGDs, and patient preference and ability for writing were barriers to SGD use.

CONCLUSIONS

Although writing and making gestures were the most common communication methods, SGDs were used successfully by selected patients and may be particularly beneficial for constructing complex messages during conversation.

IMPLICATIONS FOR NURSING

SGDs may be an appropriate assistive communication strategy for postoperative patients with head and neck cancer. Nurses can facilitate effective patient communication with SGDs by cuing patients on device options and positioning SGDs within easy reach.