Patients hospitalized in an ICU, who are mechanically ventilated but awake, have complex communication needs which need to be addressed in a holistic and respectful way to achieve standards consistent with ethical health and nursing care (39, 40). This group of patients face temporary communication disability which, if not addressed appropriately, might leave a negative imprint in their memories (29). What is worse, basic patients’ needs might not be addressed because they cannot be communicated (41). Interestingly, hospital accreditation standards characterize the communication disability acquired as a result of endotracheal or tracheal intubation during critical illness as a condition requiring provider assessment and accommodation (42).
As the International Classification of Functioning, Disability and Health (ICF) model suggests, interventions aimed to assist people with disability should consider both intrinsic factors related to the individual with complex communication needs and extrinsic factors related to the environment(29). Furthermore, the Participation Model, a framework that guides AAC assessment, delineates access and opportunity barriers as two main barriers to successful implementation of AAC. Access barriers are based on issues related to the individual who uses AAC while opportunity barriers to participation are those imposed by people in the environment of the AAC user (26, 43). We analyzed our data based on these premises and interpreted them accordingly.
Nurses who participated in this study reported using both unaided and aided forms of communication to understand the needs of mechanically ventilated patients who are awake. The various strategies of unaided communication mentioned by participants were eye contact, head nodding, hands’ or legs’ movement, pointing, lip moving, and using gestures. Our findings confirm results from previous studies which demonstrate that nurses use several unaided forms of communication strategies. Specifically, eye contact between nurses and patients was found to be one of the most common unaided method of communication (5, 8, 10, 17, 19, 21). This is not surprising as eye-contact is a natural communication method that people use during face-to-face communication. Similarly, Karlsson et al. (2012), Tingsvik et al. (2013), Happ et al. (2011), Magnus et al. (2006) reported head nodding as a communication strategy (5, 10, 18, 20). Again, head nodding is a natural way of communication since people usually move their head to express consent or rejection of something (e.g. yes/no reply).
Close-ended questions were also reported by nurses to be of use when communicating with patients. These types of questions require a yes/no response which is easily conveyed with head nodding or the eyes. In fact, close-ended questions is a strategy reported in other studies (8–10, 18, 44). Pointing was another strategy mentioned by our participants which is also reported by Happ et al. (2011) (18). Gestures were mentioned by the nurses of this study and agrees with findings by others (5, 9, 17, 19). Finally, similar to our findings, touching has been reported previously as a communication strategy of unaided communication employed by nurses with conscious, mechanically ventilated patients (5, 8, 14, 18).
Interestingly, lip movement was used as another communication strategy by participants consistent with the existing literature (8–10, 14, 19, 21, 45). However, according to our findings the COVID-19 health protocols followed in hospitals during the pandemic prohibited the implementation of this communication strategy. Nurses were obliged to wear masks which obstructed patients from reading their lips. Using visible masks have not been reported by nurses in this study or others although they are quite popular amongst speech and language therapists. Ideally, nurses should wear visible masks, to allow patients to see their lips although masks might not always be readily available.
Nurses often attempt to improve their communication interaction with patients by seeking support by other communication partners such as relatives and/or other staff. Similarly, Bergbom et al. (1993), Karlsson et al. (2015) and Rodriquez et al. (2015) mentioned that nurses often ask help from patients’ relatives (14, 16). Specifically, Rodriguez et al. (2015) found that nurses asked family members, when available, to read patients’ handwriting (19). Alternatively, as reported by participants in our study, when one nurse managed to understand what a patient meant with a specific movement or facial expression (such as pain or thirst), they made sure to communicate it to nurses in the next shift. This is in agreement with findings by Rodriguez et al. (2015) who found that when patients could not clearly communicate their needs, nurses had to “figure out the clues” and then pass those clues on “nurse to nurse to nurse, shift to shift to shift” (19).
Furthermore, nurses employed aided methods of communication to facilitate their communication with patients who were mechanically ventilated, and awake. Similar to others, nurses in this study stated that they often use pen and paper, markers and frames (8, 9, 14, 17–19). These are considered low-tech products and are widely used in ICU settings because they are relatively inexpensive. In addition, communicating via pen and paper is familiar to most people. Naturally, easy ways of communication are selected first since augmentative and alternative communication strategies require training. However, some low-tech strategies themselves require training, such as the e-tran frame. This is potentially why it was not frequently reported by nurses in our study but was used by nurses in other studies (8–10, 14, 19, 44). Lack of exposure and training to alternative and augmentative communication methods can be facilitated by bringing together communication partners (i.e. nurses) with speech and language therapists/ AAC experts who can provide appropriate support to improve communication with ICU patients who are ventilated and awake.
Barriers to Communication
Nurses in our study identified several barriers in their efforts to communicate with patients who were mechanically ventilated and awake as summarized in Table 4. Access barriers (issues related to the individual who uses AAC) were mainly related to patients’ medical condition, medication regimen as well as language. Cognitive dysfunction was identified as an important barrier in this study similar to the findings of others (9, 10, 18, 28). In addition, we found that muscle weakness made it extremely difficult to even use a pen to write on a paper or hold a board to find appropriate signals. Similar findings have been reported by Holm et al. (2017) who identified that patients’ level of fatigue, muscle strength, consciousness, cognitive ability and participation in care were of great importance for communication (9). Moreover, according to nurses the patients’ psychological state acts as a barrier to communication. This is consistent with findings by others (16, 19) who reported that many patients refused to engage in any communication due to feelings of frustration of not being able to speak. Similarly, patients’ feelings of anger, anxiety and depression have been reported as a communication barriers between nurses and patients (10).
Furthermore, several opportunity barriers (those imposed by people in the environment) that deter communication with mechanically ventilated patients who are awake were acknowledged by nurses in our study. Nurses’ identified their own attitudes (such as willingness and compassion) along with their lack of knowledge and training on how to use assistive technology as important barriers to communication. Our findings are in line with those of others who found that lack of patience was a defining factor for nurses’ attitudes towards sedation which in turn affected communication with patients (20). Also, Mortensen et al. (2019) reported that nurses in their study acknowledged their lack of knowledge and expressed willingness to improve it (21). Most importantly, our findings are in agreement with the Participation Model which describes that skills, knowledge and attitudes are important features of the communication partner when facilitating AAC (46). For instance, if the person does not have a good attitude towards AAC forms of communication or the person lacks relevant experience then communication breakdowns will occur. Importantly, previous work showed significant improvements in nurse-patient communication in the ICU with training and the use of AAC (47). This lends serious support for the use of structured approaches to address issues related to AAC use for the improvement of communication with mechanically ventilated patients who are awake in an ICU.
Additionally, the ICU environment imposed serious challenges in the quality of the communication between nurses and awake, mechanically ventilated patients. Nurses in our study agree with others (48, 49) that constant noise, lack of privacy as well as lack of physical light make nurses’ and patients’ orientation towards communication extremely difficult. Furthermore, we found that assistive technology for aided forms of communication is not readily available in ICUs in Cyprus imposing further limitations to patients when trying to express their needs. To make matters worse, patients themselves often lack the required knowledge on how to use assistive technology which combined with ICU nurses’ feelings of exhaustion due to work overload leads to communication breakdowns.
COVID-19 health protocols
Undoubtedly, the COVID-19 restrictions added communication barriers between nurses and patients mainly due to the compulsory use of protective health equipment. The latter prohibited the use of unaided communication strategies. Participants mentioned that health protocols imposed limitations on the way they talk (speech output), use facial expressions and touching to communicate with patients. Nurses in our study recognize the importance of all three strategies for successful communication with patients and elaborate on the difficulties that the pandemic is imposing on their practice. This is one of the first studies to portray the challenges that the pandemic has brought in the communication between nurses and patients who are ventilated and awake. What is worse, nurses reported that without the unaided methods of communication as basic tools (speech, face, touch), not only does communication in the ICU fail, it also causes feelings of distress to both patients and nurses.
Furthermore, the findings show that the COVID-19 pandemic has exacerbated the problem of limited time devoted to communication with mechanically ventilated patients who are awake. Acute patients’ needs force nurses to prioritize their activities even if they are willing to try to communicate. Reduced staffing is a well-known problem in ICUs as it associates with reduced patient outcomes (50) but during the pandemic this problem reached unprecedented levels (51). This combined with safety considerations further exacerbated communication deficits with patients. What the consequences of these impairments in communication might be for patients is still too early to observe. Patients might take some time to be able to talk about their experience in the ICU during the pandemic which, in turn, makes it hard to understand how this experience affected their quality of life during and after ICU stay. Additionally, the impact of communication breakdowns with patients on nurses’ feelings will be worth exploring in the future.
Categories and Sub-categories of communication barriers
COVID 19 communication barriers
-Lack of knowledge and training on AAC
-Lack of ICU experience
-Noise and lights
-Lack of privacy
-Lack of equipment
-Lack of patients’ knowledge to use assistive technology
-Protective dressing equipment
-Problems with unaided communication
-Limited time in patients’ room due to safety protocols
Strengths and limitations
Research on the experiences of nurses communicating with awake ventilated patients is limited. For this reason, we employed a qualitative research approach to investigate experiences of nurses working in ICUs in Cyprus. The in-depth data collection led to interesting findings regarding the experiences of nurses when trying to communicate with ventilated, awake patients during a pandemic. In terms of trustworthiness, the research team followed the guidelines proposed by Shenton et al. (2004) (52). Additionally, during the data analysis all transcripts were analysed in their original language. Following Marshall and Rossman’s (2011) guidelines, transcripts were translated in English by one of the authors. The other two authors read both the original extracts and those translated from Greek to English to confirm that the translation supported the trustworthiness of the data (53). Furthermore, the composition of our research team includes academic, clinical nurses as well as speech and language therapists which helps approach patients’ complex communication needs from different perspectives.
The sample was relatively homogeneous, with Cypriot-speaking nurses from three urban areas. Participants worked in various types of ICUs in Cyprus (i.e. public versus private, open versus closed) which adds to the variety of experiences that nurses might have had and covered a wide range with both short and long professional experience. Strangely, the gender distribution strangely favoured male nurses’ selection which might relate to the fact that female nurses were more reluctant to participate during a pandemic due to burn-out or safety considerations. The interviewer’s experience of working in intensive care facilitated a trustful relationship with the participants but could also be seen as a limitation if the participants’ pre-understanding of the context was taken for granted. The interviewer was aware of this risk and strived to be open minded during the interviews, pose clarifying questions, and avoid drawing conclusions without reiterating participants’ answers. Finally, an important strength of this study and its primary contribution is the fact that data was collected during the period of the COVID-19 pandemic. This is one of the first studies, if not the first, that explores communication barriers caused by the COVID-19 pandemic. As such, its findings can create new research areas worth of further exploration in terms of the consequences of COVID-19 to both nurses and patients.
Recommendations for clinical practice
The present study has provided an in-depth view of how nurses working in critical care communicate with patients who are mechanically ventilated but awake. The results point to the active role that nurses take in assisting patients to communicate their needs using various aided and unaided methods. Nurses need advanced communication skills given that patients who become suddenly voiceless due to intubation regard high-tech AAC devices as a useful, reliable, and acceptable alternative communication choice in the ICU (54). Correspondingly, this research needs to inform undergraduate nursing programmes in order to equip future professionals with the skills required to efficiently communicate with mechanically ventilated patients who are awake.
Alternatively, close collaboration with speech and language therapists can be achieved if they are invited in the ICU for the assessment and management of a patient with complex communication needs. This would set the stage for interdisciplinary collaboration during which speech and language therapists can share with nurses (and caregivers) their expertise on unaided methods of communication (such as visible masks) and aided tools and help them familiarize with their use to achieve efficient communication without barriers. Currently, similar interventions are being developed that employ a multi-component bundle (55). It remains to be seen how they will be received by nurses and patients. With this study, we aspire to contribute to this effort and improve the communication between nurses and mechanically ventilated, conscious patients.