Impact of training nurses in illustrated communication skills on physiological indicators, pain, agitation, and communication ease in conscious patients under mechanical ventilation

doi:10.21203/rs.3.rs-4339813/v1

Background

Conscious patients under mechanical ventilation encounter significant challenges due to their inability to communicate, leading to anxiety, agitation, and uncontrolled pain. Effective communication training for nurses is crucial to manage these issues. This study aimed to determine the impact of training nurses in illustrated communication skills on physiological indicators, pain, agitation, and ease of communication with conscious mechanically ventilated patients.

Method

A quasi-experimental pre-and-post study was conducted at Besat Hospital in Hamadan, Iran, involving 37 nurses and 70 patients. Sampling was convenient and sequential. The Ease of Communication, Richmond Agitation-Sedation, Pain Numeric Rating scales, and vital signs were measured before and 48 hours after the intervention commenced. The control group did not receive training, while the experimental group was trained in the use of illustrated communication boards and interacted with patients using these boards for 48 hours. Data were analyzed using SPSS Version 16.

Result

Before the intervention, no significant differences were observed between the intervention and control groups regarding demographic variables, average pain intensity, agitation, communication difficulty, and vital signs (p > 0.05). However, after the intervention, the experimental group showed a significant reduction in all studied variables except blood pressure compared to the control group (p < 0.05).

Conclusion

Training nurses in the use of illustrated communication boards can enhance communication and reduce agitation, pain, heart rate, and respiration in patients under mechanical ventilation. Ultimately, this study highlights the importance of nurse education and the development of communication tools to improve interactions between nurses and intubated patients. Such training can improve treatment outcomes. This research could pave the way for future studies.

Communication

Communication Aids for Disabled

Intensive Care Units

Mechanical Ventilation

Nurse-Patient Relations

Psychomotor Agitation

The Intensive Care Unit (ICU) is a vital department within hospitals, providing care for patients with acute and severe medical conditions [1]. Mechanical ventilation in the ICU is utilized to support patients who are unable to breathe on their own [2]. Within these units, numerous patients on mechanical ventilation remain conscious and frequently encounter substantial communication barriers with their caregivers due to paralysis, weakness, delirium, fatigue, and diminished consciousness. These factors disrupt their ability to communicate through body language and other effective interpersonal communication methods [3–5].

Difficulties in communication between patients and healthcare staff can result in the inability of patients to self-report physiological needs such as thirst, hunger, sleep, and physical symptoms like pain, shortness of breath, and choking sensations, as well as psychological symptoms including sorrow, stress, and confusion [6]. These challenges can exacerbate stress and anxiety, despair, pain, and sleep disorders in patients, potentially influencing physiological indicators like blood pressure, heart rate, respiration, and blood oxygen levels. Moreover, the inability to articulate physiological needs, desires, and pain can lead to increased agitation, aggression, and decreased satisfaction with both communication and the care received [3, 6–11].

A primary concern for ICU patients is the experience of pain resulting from medical procedures, surgical wounds, trauma, fractures, gastrointestinal issues (such as ileus, spasm, constipation), and pressure ulcers [1]. It is estimated that between 50–71% of ICU patients suffer from undiagnosed or untreated pain, with communication barriers being a significant factor in the lack of adequate pain management [12, 13].

Effective and professional communication is a crucial component in the cohesive delivery of nursing care [4]. Communicating with patients who have endotracheal tubes is intricate and challenging, often leading nurses to experience negative emotions such as despair, pressure, incompetence, and moral distress. This is because they are unable to comprehend the patients' needs and provide suitable responses to alleviate their discomfort [4]. Despite nurses' awareness of the importance of effective communication, evidence indicates that such communication with intubated patients is often not achieved [14].

Patients have expressed a need for auxiliary tools that are straightforward and uncomplicated to use, enabling them to communicate their basic, medical, and emotional needs [3, 8]. Many patients are incapable of using technological devices like tablets, and hospital facilities frequently do not offer these tools [15]. Communication methods utilizing illustrated boards have proven to be effective in bridging this communication gap; thus, it is imperative that nurses receive proper training to employ these auxiliary tools when communicating with intubated patients [3, 16].

Illustrated communication skills include the use of images, symbols, and other visual aids for patient interaction [8, 17]. These methods can help patients more clearly express their needs, emotions, and requests, leading to improved nurse understanding of patient needs, fewer misunderstandings, better quality of patient care, and more efficient use of nurses' time and energy [8, 17, 18]. One such tool is the non-electronic illustrated communication board, which is straightforward and cost-effective [19]. These boards display symbols and images representing basic needs, and with the inclusion of the alphabet, they can assist patients in forming words [5].

In Iran, research on the clinical application of illustrated communication boards is scant, and according to the researcher's clinical experience, this beneficial method is underutilized. Moreover, communication disorders between patients and nurses can lead to complications such as inadequate pain management, increased agitation, aggression, stress, anxiety, pressure, and disturbances in physiological indicators (heart rate, respiration, and blood pressure). These issues can also result in a lack of mutual understanding and dissatisfaction with nursing care. Although some nurses may utilize alternative communication methods, the effective use of these methods requires proper training [20]. The impact of training nurses in these communication tools on various outcomes for intubated patients, especially concerning pain and agitation, remains unexplored. Therefore, this study was conducted to determine the effect of training nurses in illustrated communication skills on physiological indicators, pain intensity, agitation, and ease of communication with conscious patients undergoing mechanical ventilation.

Study design

This study employed a semi-experimental design, incorporating both pre-test and post-test assessments. It involved two distinct groups to facilitate a comparative analysis of the outcomes.

Study setting

The research was carried out at Besat Hospital in Hamadan, located in Iran's northwest. The duration of the study extended from April 2, 2023, to March 19, 2024.

Participants and recruitment

Conscious patients under mechanical ventilation in the general ICU (16 beds) and all nurses working in this department were included as the study samples. The inclusion criteria for patients were: being aged between 18–60 years, undergoing invasive mechanical ventilation, having a Glasgow Coma Scale (GCS) score greater than 13, not using sedative or sleep-inducing drugs, possessing the ability to read and write at a minimum literacy level, being able to speak and understand Persian, and having been intubated for at least 24 hours. The exclusion criteria included: unwillingness to continue participation in the study, weaning patients from the ventilator, transfer to another department, and patient death. For nurses, the inclusion criteria were their willingness to participate in the study and the responsibility for direct patient care.

To determine the appropriate sample size, we consulted a similar study [8], considering a 95% confidence level (Type I error of 5%), a test power of 90%, and allowing for a potential 10% dropout rate. This calculation resulted in a sample size of 36 patients per group. To safeguard against the dissemination of study information, control group participants were initially selected using consecutive sampling. Subsequently, patient recruitment for the experimental group followed the same approach. Furthermore, all nurses (37 individuals) directly involved in patient care within the department were included in the study through a complete enumeration.

Measures

Data collection tools comprised demographic questionnaires for both patients and nurses, the Ease of Communication Scale (ECS) [8], the Pain Numeric Rating Scale [21], the Richmond Agitation-Sedation Scale, and measurements of patients' blood pressure, heart rate, and respiration rate. With the exception of demographic variables, all instruments were administered by a bachelor's degree nurse not affiliated with the research team. This nurse, blind to the study groups, either interviewed the patient or directly assessed them.

Demographic questionnaire for patients

The patient demographic questionnaire covered variables such as age, gender, body mass index, native language, education level, reason for hospitalization, duration of hospitalization, and duration of tracheal tube use. The principal investigator completed this questionnaire before the intervention, using data from the medical records and conducting interviews with family members. Likewise, the demographic questionnaire for nurses included age, gender, education level, work experience, and ICU work experience. Nurses completed this questionnaire through self-reporting.

Ease of Communication Scale (ECS)

The Ease of Communication Scale (ECS) comprises six items designed to assess the communication challenges faced by non-verbal patients. The responses are gauged on a 5-point Likert scale, ranging from 0 (indicating 'not difficult at all') to 4 (indicating 'very difficult'). The total score can range from 0 to 24, with higher scores denoting increased communication difficulty for patients [8]. Hosseini et al. (2018) established the validity of this instrument in a study. The reliability of the ECS was previously reported with a Cronbach's alpha of 0.9 [8], and in the present study, it was calculated to be 0.92. The scale's items were orally presented to the patient, and their responses were documented through finger or eye movements.

Pain Numeric Rating Scale

The Pain Numeric Rating Scale is a commonly utilized instrument in clinical settings, favored for its straightforwardness. Nurses requested that patients rate their average pain intensity over the preceding five hours on a horizontal scale ranging from zero (representing no pain) to ten (representing the most intense pain imaginable), by making a mark with a pencil. According to prior research, this tool has been validated as a reliable and accurate measure for evaluating pain in alert patients [21].

Richmond Agitation-Sedation Scale

The Richmond Agitation-Sedation Scale (RASS) is a 10-item instrument that evaluates patient sedation and agitation levels, ranging from − 5 (deep sedation) to + 4 (severe agitation). The assessment process, which should not exceed 60 seconds, includes patient observation and both auditory and physical stimulation. A score of zero indicates that the patient is calm and alert. Positive scores (+ 1 to + 4) progressively reflect increasing levels of restlessness and aggression, while negative scores (-1 to -5) represent varying degrees of sedation, from mildly drowsy to completely unresponsive [22, 23]. Tadrisi et al. [23] have corroborated the reliability and validity of this scale in Iran.

Physiological indicators

The physiological indicators included blood pressure, heart rate, and respiratory rate. These indicators were measured and recorded for all patients using a portable electronic monitoring device, Vectra, by the assigned nurse.

Intervention procedure

Illustrated communication boards

The illustrated communication boards utilized in this study were partially adapted from the Vidatak EZ Board, measuring 42 × 29.7 centimeters. One side of the board depicted the patient's needs with relevant images and accompanying text. The reverse side featured a schematic illustration of the body to identify areas of pain, an alphabet grid enabling patients to spell out specific needs, and a whiteboard section where, if physically capable, patients could write down their requirements [24].

Initially, at 8 AM, all data collection tools were completed. Notably, measures were taken to ensure that patients were not subjected to psychological stimulation, invasive procedures, dressing changes, medication administration, or physiotherapy activities within 10 minutes prior to the measurement of these variables.

Control group

To prevent the dissemination of information, sampling for the control group was conducted initially. Nurses in this group did not receive any training. After completing the questionnaires at 8 AM, nurses in the control group communicated with intubated patients for 48 hours using conventional methods such as gestures, inference, and sequential questioning until the patients' needs were understood and addressed.

Intervention group

Once all patients from the control group were discharged, sampling for the experimental group commenced. Initially, the principal investigator divided the nurses into five groups of eight and conducted a 45-minute training session with each group on how to communicate with intubated ventilated patients using illustrated communication boards. To ensure proper understanding and utilization of these boards, the principal investigator, alongside nurses from each group, assessed the needs of three patients using these boards. Each nurse then replicated this process under the researcher's supervision to address any issues. Nurses were also tasked with educating their patients on how to utilize these boards at the beginning of each shift. Subsequently, nurses employed the illustrated communication boards for 48 hours to evaluate patients' needs, desires, issues, and pain intensity. Nurses were encouraged to address patients' expressed needs to the best of their abilities. At the end of 48 hours, at 8 AM, the nurse responsible for collecting the pre-intervention data administered all data collection tools, except for demographic variables, again.

Data Analysis

The collected data were analyzed using SPSS software, version 16. Statistical tests employed included the Kolmogorov-Smirnov, independent t, Mann-Whitney U, chi-square, Fisher's exact, paired t, and Wilcoxon signed-rank tests. A significance level of less than 0.05 was considered indicative of statistical significance.

Ultimately, three individuals from the intervention group and two from the control group were excluded due to ventilator weaning and tracheal tube removal. The final analysis included 33 individuals in the intervention group and 34 in the control group. The study also assessed the demographic characteristics of 37 participating nurses. Their mean age, work experience, and ICU tenure were 34.92, 12.24, and 7.22 years, respectively. Most of the nurses participating in the study had a bachelor's degree and were female. Notably, these nurses provided care for both groups (Table 1).

Table 1

Demographic variables of nurses participating in the study
Variables	Nurses(n = 37)
Age (mean ± sd )	34.92 ± 6.52
Work experience (Mean ± SD )	12.24 ± 5.10
Work experience in ICU (Mean ± SD )	7.22 ± 3.85
Gender (Frequency (%))
Female	9(24.3)
Male	28 (75.7)
Educational level (Frequency (%))
Bachelor	35(94.6)
Master of sciences	2 (5.4)

The results of the independent t-tests, chi-square, and Fisher's exact test indicated no statistically significant differences between the intervention and control groups in terms of demographic and clinical patient variables, including age, body mass index (BMI), length of hospital stay, ICU length of stay, duration of tracheal intubation, gender, cause of hospitalization, education level, and native language (p > 0.05). Consequently, the two groups were homogeneous regarding these variables. The majority of patients were male, hospitalized due to surgery, with literacy for reading and writing levels in the control group and below a diploma in the intervention group, and had Turkish as their native language (Table 2).

Table 2

Comparison of demographic characteristics of patients in experimental and control groups
Variables	Experimental group (n = 33)	Control group (n = 34)	P-value
Variables	M ± sd	M ± sd	P-value
Age (year)	50.93 ± 7.59	52.35 ± 6.19	^*0.406
Body mass index	25.96 ± 2.66	26.21 ± 3.25	^*0.729
Length of stay in hospital (day)	15.54 ± 6.07	17.73 ± 9.83	^*0.279
ICU length of stay (day)	11.06 ± 5.51	12.97 ± 8.17	^*0.268
Duration of tracheal intubation (day)	9.93 ± 5.18	11.17 ± 7.10	^*0.420
Variables	Frequency (%)	Frequency (%)	P-value
Gender
Male	22 (66.7)	14 (41.2)	^**0.615
Female	11 (33.3)	20 (58.8)	^**0.615
Cause of hospitalization
Internal	6 (18.2)	8 (23.5)	^**0.765
Surgery	27 (81.8)	26 (76.5)	^**0.765
Level of education
Literacy for reading and writing	6 (18.2)	12 (35.3)	^**0.356
Under diploma	10 (30.3)	9 (26.5)
Diploma	9(27.3)	9 (26.5)
Academic	8 (24.2)	4 (11.8)
Native language
Persian	5 (15.2)	2 (5.9)	^⬥0.092
Lorry	7(21.2)	9 (26.5)
Turkish	14 (42.4)	9 (26.5)
Kurdish	6 (18.2)	6 (17.6)
Laky	0(0.0)	6 (17.6)
Other	1 (3.0)	2 (5.9)
Independent t test, * Chi square, ^⬥Fisher Exact Test

Prior to the intervention, the use of Mann-Whitney U and independent t-tests revealed no significant statistical differences between the control and intervention groups in terms of mean pain severity scores in the past 5 hours, agitation, communication difficulty, respiratory rate, heart rate, and mean arterial, systolic, and diastolic blood pressure ((p > 0.05)). However, following the intervention, these tests showed a significant reduction in pain severity, agitation, communication difficulty, respiratory rate, and heart rate in the intervention group compared to the control group ((p < 0.05)). Nonetheless, no significant statistical differences were observed in mean arterial, systolic, and diastolic blood pressure between the two groups at this time ((p > 0.05)), as presented in Table 3.

Table 3 Comparison of study outcomes within and between the two groups before and after the intervention

P-value	Statistic	Control group (n= 60)	Experimental group (n= 60)	Time of evaluation	Variables
P-value	Statistic	M±SD	M±SD	Time of evaluation	Variables
^u0.081	-1.743	7.18 ± 0.97	7.58 ± 1.15	Before	Average pain intensity in the last 5 hours
^u˂0.001	-4.416	6.15 ± 1.37	4.52 ± 1.23	After
		-3.676	-4.928	statistic
		˂0.001	˂0.001	p-value^uu
^u0.415	-0.815	0.88 ± 0.73	0.72 ± 0.84	Before	Richmond agitation-sedation score
^u0.006	-2.738	0.70 ±0.58	0.30 ± 0.53	After
		-1.144	-2.428	statistic
		0.253	0.015	p-value^uu
^*0.271	-1.110	22.62± 2.52	21.85 ± 3.12	Before	Ease of communication score
^*˂0.001	-13.730	17.38 ± 3.23	8.03 ± 2.24	After
		7.256	19.343	statistic
		˂0.001	˂0.001	p-value**
^*0.424	0.805	23.44 ± 2.96	24.00 ± 2.72	Before	Respiration rate
^*0.003	-3.069	22.21 ± 2.48	20.30 ± 2.59	After
		2.472	6.323	statistic
		˂0.019	˂0.001	p-value**
^*0.816	0.23	91.26 ± 4.81	91.57 ± 5.98	Before	Heart rate
^*0.036	-2.13	90.58 ± 5.28	87.81 ± 5.32	After
		11.824	7.543	statistic
		0.057	˂0.001	p-value**
*0.460	-.743	115.00 ± 12.31	112.58 ± 14.34	Before	Systolic blood pressure
*0.272	-1.108	112.50 ± 10.85	109.48 ± 11.42	After
		2.068	3.064	statistic
		0.047	˂0.004	p-value**
^*0.677	-0.419	75.74 ± 10.91	74.42 ± 14.50	Before	Diastolic blood pressure
^*0.681	-0.413	71.50 ± 9.55	70.58 ± 8.74	After
		1.868	1.910	statistic
		0.071	0.065	p-value**
^*0.516	-0.653	88.82 ± 8.84	87.14 ± 12.05	Before	Mean atrial pressure
^*0.358	-0.925	85.17 ± 6.45	83.55 ± 7.84	After
		2.155	2.638	statistic
		0.039	0.013	p-value**

* Independent t test, **paired t test, ^uuWilcoxon, ^uMann-Whitney U

Furthermore, the use of Wilcoxon signed-rank and paired t-tests showed that in the intervention group, the mean scores for pain severity, agitation, communication difficulty, respiratory rate, heart rate, mean arterial pressure, and systolic blood pressure significantly decreased after the intervention compared to before ((p < 0.05)). However, no difference was observed in diastolic blood pressure within this group ((p > 0.05)). In the control group, these tests indicated a significant reduction in pain severity over the past 5 hours, and communication difficulty, as well as in mean arterial and systolic blood pressure after the intervention compared to before ((p < 0.05)), but no differences were noted in terms of agitation, heart rate and diastolic blood pressure ((p > 0.05)). Further details are provided in Table 3.

Communication is a crucial factor that influences treatment outcomes. Patients in intensive care units (ICUs) who are intubated cannot communicate with nurses, leading to distress for both parties [25]. Thus, nurses' utilization of alternative communication methods can facilitate understanding patient needs, providing appropriate support, and alleviating unpleasant experiences [26]. The findings of this study indicate that training nurses to use visual communication boards has reduced pain severity in conscious patients undergoing mechanical ventilation in ICUs. This reduction may result from patients' enhanced ability to convey the intensity and location of their pain, request pain management assistance, and nurses' improved comprehension of patients' pain. Nurses were instructed to promptly address patients' pain after its report, employing various methods such as medications or nursing interventions for pain relief. When patients perceive that nurses are responsive to their individual needs and understand their concerns, and when suitable treatments are offered, they experience increased security, which can reduce stress, anxiety, and consequently, pain. Since anxiety and stress can exacerbate pain, their reduction can further alleviate it. Moreover, patient communication provides crucial emotional support, contributing to pain relief. Despite this study's reliance on low-technology communication, the outcomes align with the findings of Ju X et al., who demonstrated that high-technology communication reduces patients' pain severity [27]. Conversely, Carruthers et al.'s results showed no impact of low-level alternative communications on pain reduction, which contrasts with this study [16]. The discrepancies in outcomes might be attributed to methodological variances in the source articles. Additionally, nurses in this study were prompted to act immediately upon pain reports from patients.

Training nurses in the use of visual communication boards has reduced signs of restlessness in mechanically ventilated patients. These improvement likely results from effective communication, clear delivery of information, mutual understanding between nurses and patients, increased patient trust, reduced stress and anxiety levels, addressing both physical and psychological needs, and optimal pain management. Such communication can enhance patients' feelings of comfort, security, and tranquility, thereby reducing restlessness, resistance to ventilation, and stress. While studies have not directly assessed the effect of nurse training on calming patient restlessness, these findings are consistent with Kolcak et al.'s research, which indicated that visual communication boards decrease anxiety and improve comfort in intubated patients [20]. Additionally, Hosseini et al. reported that communication cards more effectively met patients' needs and reduced their anxiety [8].

The current study's results showed that the use of communication boards in conscious intubated patients led to reduced communication difficulty, such that using images and symbols, nurses were able to communicate more effectively with intubated patients who cannot speak. This could be due to increased accuracy in understanding patients' needs, reducing misunderstandings, increasing mutual understanding, expressing concerns, simplifying complex concepts, and facilitating care so that instead of spending a lot of time explaining concepts, needs, and desires of patients using words, nurses were able to quickly convey information using images. Radtke et al., who found that low-technology alternative communication methods improve communication effectiveness in intubated patients, support these findings [28]. Similarly, the results of this study are consistent with those of Hosseini et al., who endorse pictorial cards as an effective means of facilitating communication with intubated patients [8].

This research examined the impact of nurse training in illustrated communication skills on the physiological indicators of conscious patients undergoing mechanical ventilation. Pre-intervention data showed no significant statistical differences between the control and experimental groups regarding these variables, suggesting homogeneity in initial physiological conditions and thus reinforcing the study's validity. Post-intervention, a significant decline in respiration and heart rate was observed in the experimental group compared to the control group, suggesting a positive impact of training in pictorial communication skills on nurses in terms of patient stress and anxiety, potentially improving patient physiological conditions. Nurses, by attending to patients' needs and emotions, established a closer rapport with them. This active engagement fostered patient tranquility, leading to a reduction in heart rate and respiration. However, the lack of a significant training effect on blood pressure highlights the complexities of influencing this measure, with other factors such as the patient's health status and ICU medications likely having a greater impact. The reduction in heart rate is consistent with this study's findings, while the unchanged blood pressure contrasts with Divani et al.'s findings [29]. Differences might arise from variations in the duration of the intervention and the timing of blood pressure assessments—morning versus afternoon—while this study measured vital signs pre- and post-intervention at 8 a.m. Horn et al.'s systematic review demonstrated that communication boards reduce patient anxiety and stress [30], and considering that these reductions are associated with decreased heart rate and respiration, the conclusions of this study are validated.

Furthermore, post-intervention observations in the control group revealed a reduction in the mean severity of pain over the past five hours, respiratory rate, systolic blood pressure, mean arterial pressure, and communication difficulty compared to pre-study levels. These improvements are attributable to the patients' health progression over time and the effectiveness of routine communication methods used by the healthcare staff. Collectively, the study's findings confirm that traditional communication methods, such as eye contact, body language, sequential questioning, and inference, are crucial in establishing effective communication with intubated patients. This effectiveness is enhanced as patients gain experience in expressing and understanding concepts through body language.

Limitations

The limitations of this study include its semi-experimental design and the non-significant impact of training on blood pressure, which suggests a need for further investigation. It is recommended that future studies be conducted in various hospital settings to enhance the generalizability of the findings. Future research should also compare different educational strategies and communication tools to determine their effects on a range of patient health indicators. Additionally, examining the influence of training on nurses' performance and the quality of care provided could be beneficial.

Training nurses in the use of illustrated communication boards can positively influence the ease of communication; reduce pain, agitation, heart rate, and respiration in conscious patients undergoing mechanical ventilation, although it may not affect blood pressure. Training based on illustrated communication can act as a bridge between the silent world of mechanically ventilated patients and the nurses responsible for their care. Ultimately, this study highlights the importance of nurse education and the development of communication tools to improve interactions between nurses and intubated patients. Such training can improve treatment outcomes. This research could pave the way for future studies.

Acknowledgements

We express our sincere appreciation to the dedicated nurses and the patients who participated in our study. Their invaluable contributions have been instrumental to the success of our research.

Author contributions

S.K., H.A., L.T., F.R.B., and A.A wrote the main manuscript text. All authors reviewed the manuscript.

Funding

Financial support for this work was provided by the Office of the Vice-Chancellor for Research and Technology at Hamadan University of Medical Sciences, Hamadan, Iran (Grant Number 140202191107)

Data availability statement

The datasets analyzed during the current study are available from the corresponding author upon request.

Competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Ethics approval and consent to participate

This study complied with all ethical principles set forth in the Declaration of Helsinki. Ethical approval, with the code IR.UMSHA.REC.1402.062, was obtained from the Ethics Committee of Hamadan University of Medical Sciences. Given that all patient participants were fully conscious, the principal researcher elucidated the study's objectives, methodology, voluntary participation, and the potential benefits and risks involved. Upon confirming their complete understanding, those who were physically capable provided their written informed consent by signing. For those patients who were physically unable to sign, written informed consent was additionally secured from their legal guardians, following the patients' implicit agreement. Similarly, written informed consent was obtained from the participating nurses after they received all necessary information. All participants were guaranteed the right to withdraw from the study at any time without facing any negative repercussions. The protection of participants' personal data privacy and security was a critical priority throughout the research.

Consent for publication

Not applicable.

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No competing interests reported.

Impact of training nurses in illustrated communication skills on physiological indicators, pain, agitation, and communication ease in conscious patients under mechanical ventilation

Status:

Version 1

Abstract

Background

Method

Result

Conclusion

Background

Methods

Study design

Study setting

Participants and recruitment

Measures

Demographic questionnaire for patients

Ease of Communication Scale (ECS)

Pain Numeric Rating Scale

Richmond Agitation-Sedation Scale

Physiological indicators

Intervention procedure

Illustrated communication boards

Control group

Intervention group

Data Analysis

Results

Discussion

Limitations

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1