READ: Physical Impairment

Background

  • The inability to speak during critical illness is a major source of distress for patients.

  • Systematic studies on nurse-patient communication in the intensive care unit (ICU) have not been thoroughly conducted.

Objectives

  • To describe communication interactions, methods, and assistive techniques between nurses and nonspeaking critically ill patients in the ICU.

Methods

Study Design

  • Descriptive observational study of the nonintervention/usual care cohort from a larger clinical trial on nurse-patient communication in medical and cardiothoracic surgical intensive care units.

  • Video recorded interactions between 10 randomly selected nurses (5 per unit) and 30 critically ill adults (15 per unit) who were awake, responsive, and unable to speak due to respiratory tract intubation.

Measures

  • Rated for frequency, success, quality, communication methods, and assistive communication techniques.

  • Patients provided self-ratings of communication ease.

Results

Communication Frequency and Initiation

  • Nurses initiated 86.2% of communication exchanges.

  • Mean rate of completed communication exchanges was 2.62 exchanges per minute.

  • Most common positive act by nurses: making eye contact with patients.

Success of Communication

  • Communications were generally successful (>70%), yet more than one-third (37.7%) concerning pain were unsuccessful.

  • 40% of patients rated communication sessions with nurses as somewhat to extremely difficult.

Use of Assistive Communication Strategies

  • Assistive communication strategies were rarely employed; little to no use of tools like writing supplies or communication boards.

Conclusion of Results

  • Key areas identified for improving communication between nurses and non-speaking patients in the ICU, with significant focus on pain communication and assistive communication strategies.

Background and Significance

  • The communication difficulties experienced by ICU patients are well-documented through various qualitative studies, indicating their correlation with greater illness severity and emotional distress such as anger, frustration, and anxiety.

Past Research

  • Ashworth’s 1980 study showed a positive correlation between nurses' communication and patients' communication capabilities.

  • Findings revealed that most interactions (71%) consisted of brief, task-related exchanges lasting less than one minute.

Study Context and Research Questions

Research Questions

  1. What are the frequency, success, and quality of communications between nurses and temporarily nonspeaking ICU patients?

  2. How do patients rate their ease of communication after interactions with nurses?

  3. What communication methods and assisted strategies are used during interactions?

Study Design

Institution and Setting

  • Conducted in a large academic medical center’s medical ICU (MICU) and cardiovascular-thoracic ICU (CTICU).

  • Limited assistive communication materials were available.

Participant Eligibility

Nurse Participants

  • 10 RNs with at least 1 year of critical care experience, working sufficient weekly shifts, and English-speaking.

  • Nurses with hearing or speech impairments were excluded due to potential previous exposure to communication services.

Patient Participants

  • 30 patients, 15 from each ICU who met specific eligibility requirements:

    • >18 years old, nonspeaking due to intubation or tracheostomy, English understanding, Glasgow Coma Scale (GCS) score of 13 or higher.

    • Excluded patients with prior communication disabilities.

Procedures and Data Collection

Communication Observation

  • Video recording of nurse-patient interactions over 4 sessions, each 3 minutes long.

  • Observational data collected twice per day over two consecutive days.

Clinical and Demographics Data

  • Severity of illness assessed via APACHE III, delirium diagnosed using CAM-ICU, and sedation assessed with the Richmond Agitation-Sedation Scale (RASS).

Data Analysis

  • Communication interactions recorded, transcribed, and coded for quantitative analysis.

  • Success measured via a 5-point ordinal rating system.

  • Quality determined by counting positive and negative communication behaviors by nurses.

Findings

Communication Frequency

  • 5140 communication acts identified from 360 minutes of interaction, with the majority between nurses and patients.

  • Mean rate of exchanges was 2.62 per minute, indicating sparse communication.

Communication Initiation

  • Most communication exchanges (86.2%) were initiated by nurses.

  • Nurse-patient communication primarily focused on care and assessments.

Success of Communication

  • Success rates high at 71.8% but highlighted a concern regarding communication about pain.

  • Complete failure occurred when patients did not receive necessary assistance.

Quality of Communication

  • Identified positive behaviors included eye contact and open-ended questions.

  • Negative behaviors included lack of attention and rapid speech tendencies.

Ease of Communication

  • Patients rated communication ease, revealing that nearly 38% experienced it as somewhat to extremely difficult.

Discussion

  • This study is the first to provide a detailed observational analysis of nurse-patient communication in the ICU.

  • It identifies areas for improvement particularly in using assistive communication and ensuring clarity in pain communication.

Limitations

  • Generalizability limited to the specific study settings; may not apply broadly.

  • Presence of observers may have influenced natural behavior during communication.

Conclusion

  • Findings highlight critical areas for effective communication strategies for nonspeaking patients and underscore the need for evidence-based practices in nurse training.