Need and barriers in Communication among ICU patients who are aphasic. Consequences of failed communication. Discussion on various methods and assistive devices to communicate. Discussion on the development & usability of a self structured communication chart as method of easy communication with ICU patients on ventilators.

1. Communication with critically ill
patients: Knowing their Needs
Mrs. Prabhjot Saini MSN PhD
Professor & Head
Medical Surgical Nursing Dept.
DMCH College of Nursing
Ludhiana

2. Objectives
 To understand the need of communication with
critically ill patients
 To describe communication interactions, methods,
and assistive techniques used commonly between
nurses and nonspeaking critically ill patients
 To validate and administer a ‘Communication Chart’
for non speaking critically ill patients
 To evaluate the effectiveness of communication
chart in knowing the needs of the patient.

3. What is communication?

4. What is Communication?
 Communication is an interactive behavior between
people and it involves the transmission of message
from one or more persons to another.
 The communication falls into one of two categories with
purposes to inform or call to action.1
 Communication is significant aspect of nursing
practice.

5. Communication and Nursing in
ICUs
 Effective communication is essential for the establishment of
the nurse-client relationship.
 Patient Outcomes are often linked with good communication
 Nurses who communicate effectively are better able to
initiate change that promotes health, establish a trusting
relationship with the client.

6. Communication and Nursing in
ICUs
 When a nurse has difficulty understanding
the message from a non-vocal individual
 Quality of care can suffer
 Communication becomes one sided.
 Feedback from patients becomes
limited.

7. If patients can express their
needs, we can ensure the best
possible care and help them get
better faster.

8. Barriers in communication by
patients in ICU
 Patients with physical and sensory disabilities, such as
deafness, blindness.
Patients with communication disabilities are already at increased risk for
depression andother co-morbidities.4
 Patient with endotracheal intubation/treacheostomy have
been shown to face considerable barriers when
communicating with health care professionals.
Patients with endotracheal intubation have been shown to face
considerable barriers when communicating with health care
professionals.
 Communication ability may be further impaired during
critical illness by sedation, fatigue, delirium, or neurological
disease.3

9. Consequences of Failed
communication
 Communication difficulty is the most commonly
reported distressing symptom for ICU patients
receiving mechanical ventilation4–7
 It is associated with anxiety, scary, panic, anger,
frustration, sleeplessness, horrible and
distress.4,5,8–11
 Nurses also report frustration when patients are
unable to verbally report their symptoms, pain
levels, and needs.12,13

10. Studies have shown that ventilated
patients in the ICU rank the
inability to speak as one of the
most stressful experiences in
the hospital.

11. Experiences of ventilated
patients
 Some patients experience an intensified need to
communicate while their ability to do so is compromised.
2
 Communication problems further distance the patients
from caregivers and loved ones

12. Many patients die without being able to express their final
messages to loved ones.

13. Communication Content
 Communication content was primarily related to pain,
symptoms, feelings, and physical needs.
 Patients also initiated communication about their
homes, families, and conditions.
Experiences of ventilated
patients

14. Experiences of ventilated
patients
Physical restraints & communication
 Most of the documented communication episodes
occurred when physical restraints were not in use.
 Physical restraints used to prevent disruption of medical
devices, further limit patients’ ability to gesture or use
alternative communication techniques.5, 14, 15

15. Regret for family members
 Patient’s inability to speak at the end of life can be a
tremendous loss for the patient’s family members.
 However, some family members find reassurance and
satisfaction in being able to “say goodbye” through non vocal
communication such as eye blinks, gestures, and touch.16, 17
“If only I could have heard his voice one last time . . .”
characterize family members’ regret about patients’ loss of
speech at the end of life.

16. Few studies reports…..

19. A study reports….
 Nurses initiated most of the communication exchanges
 Average communication of 2.62 exchanges per minute.
 The most common nurse act was making eye contact with
the patient.
 More than one-third of communications about pain were
unsuccessful.
 Patients rated 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).

21. What we can do to improve
communication among ICU patients?
Efforts to improve communication with ICU
patients should be built on a clear
understanding of existing strengths and
weaknesses in the communication process.

22. Methods used by clients to communicate
Non -verbal forms of communication such as
 Mouthing
 Gesticulating
 Nodding
 Writing
 Lip reading
 Hand gestures
 Facial expressions
 Writing on notepads

23. Non-verbal
communication: Can we
get the message ???

24. Non-verbal communication: Can
we get the message ???
 Not all communications were interpretable or
understood by communication partners
 The patient was “attempting” or “trying” to
communicate but care providers were “unable to
understand” the communication,
 The patient’s handwritten notes were illegible
 Communication was also not understood by patients’
families
Mary Beth Happ et

25. What is the solution?

26. Use of Various assistive
devices for communication

27. Various Assistive devices for
communication by non speaking patients
Communication board/chart
Specialized talking tracheostomy tubes
Electrolarynx in tracheostomaized
patients
“High Tech” Augmentative and alternative
Communication (AAC) devices

28. Which one
would be
best to use?

29. A systematic review
 Out of 31 articles, all showed an improvement in the communication
with mechanically ventilated patients.
 A combination of various methods may create the most effective
communication option.
 Lack of evidence on which communication method is better.
 An algorithm was developed to guide for the use of assistive
communication with intubated patients in the ICU.
S. ten Hoorn, P. W. Elbers, A. R. Girbes,and P. R. Tuinman. Communicating with
conscious and mechanically ventilated critically ill patients: a systematic review.

30. Assess the patient status/ ability
Before choosing type of communication tool
assess:
 Type of intubation (endotracheal/tracheostomy)
 Level of sedation
 Cognitive function (LOC)
 Auditory/vision/ language
 Muscle power (functional ability)
 Fine motor skills
 Gross motor skills

31. Assess Functional
skills
Fine motor abilities
intact
Can patient
write?
Oral motor abilities intact
Gross motor
ability intact?
Does patient
have a
tracheostom
y?
Does patient
have an oral
tube?
If No
If No
If
Yes
If No
Provid
e pen
&
Paper
Communication
chart
/Computerized
AAC
If Yes If No
Computerized AAC
with switch/eye
blink control
Computerized
AAC with gaze/
eye blink control
•One-way speaking
valve
•Speaking tracheostomy
tube
•Electrolarynx Electrolary
nx

32. Communication chart
 It consists of icons and pictures representing. basic
needs
 Patients can easily point to letters, words, or pictures.
 It is beneficial for communication between the
medical staff and the intubated patients.
 Increased efficiency and speed of communicating,
decreased frustration, and quicker expression of
patients their needs .

34. Specialized talking tracheostomy
tubes (TT)
 Patients on long term TT need to practice
speaking with deflated cuff or speaking valve
TT
 If the cuff is deflated, the air is able to move
around the trachea and through your vocal cords.
 Speaking valves (attached to TT) can help make
noise. Speech therapist required.

35. Types of specialized talking tracheostomy
tubes
 Portex Trach-Talk
 Communi-Trach I
(It takes an average of 2.1 days (Portex “Talk”) and 5.6 days (Communi
Trach I) for intelligible speech
 Blom Tracheostomy Tube
(Two separate valve mechanisms, all of the ventilator-delivered
inspiratory air is directed to the lungs and the expiratory air can escape
via fenestrations to the upper airway to allow phonation)

38. Electrolarynx
 EL is a battery-powered
handheld device
 It is pressed onto the skin of the
neck to transmit the vibrated
electronic sound into the
oropharyngeal cavity
 The user modulates it to create
speech via articulation.

40. Types of AAC devices
 Unaided communication
 No-tech: Communication does not involve any additional equipment –
referred as 'unaided communication'. Examples are: body language,
gestures, pointing, eye pointing, facial expressions, vocalizations,
 Aided Communication
 Low-tech communication systems: do not need a battery to function.
It includes Pen and Paper, Alphabet and word boards,
Communication charts or books with pictures, photos and symbols
 High-tech communication systems need power from a battery or
mains. They are simple buttons or pages that speak when touched
(VOCA). They are based on familiar equipment such as mobile
devices, tablets and laptops.

41. AAC devices

42. Current scenario in India
 Communication with critically ill patients in Indian Hospitals
has been undervalued and not much emphasis has been
given to it.
 Not enough evidences are available regarding the use and
effectiveness of either AAC or communication charts.
 Few Indian Hospitals have developed their own
communication charts and using it in ICU’s.
 The developed communication charts/boards for Indian
population have not been published or available for
patient use.

43. Development of a “Communication Chart”
A Methodological study to develop a
‘Communication Chart’ for conscious
patients on Mechanical
Ventilator/Tracheostomy in Intensive Care
Units of a tertiary care hospital, Ludhiana,
Punjab.

44. Objectives
 To develop & validate a ‘Communication Chart’ for
conscious patients on Mechanical
Ventilator/Tracheostomy in ICUs using Delphi technique.
.
 To test the reliability of ‘Communication Chart’ for
conscious patients on Mechanical
Ventilator/Tracheostomy in ICUs.
 To administer and evaluate the developed
‘Communication Chart’ for conscious patients on
Mechanical Ventilator/Tracheostomy in ICUs.

45. Inclusion criteria
Inclusion criteria
 Conscious patients on endotracheal
intubation/Tracheostomy
 Conscious patients with GCS rating - E4 VT M6
 Adult patients above 18.

46. Material & Methods
 Research design : Methodological (delphi technique)
 Target Population:. Doctors, staff nurses, patients on
ventilator/tracheostomy and
attendants in ICU
 Sampling Technique: Non-ProbabilitySampling (Purposive)
 Sample Size: n=10 Health care professional (Panelist)
n=10 Patients on ventilator/tracheostomy.
n=10 Staff Nurses working in ICU

48. Phase 1
 In depth literature review done on communication problems
faced by conscious patients on mechanical ventilator or
tracheostomy in Indian setting.
 Communication chart index was developed.
 An item pool generated to develop a ‘Preliminary
Communication Chart’.

49. Phase 1
‘Preliminary Communication Chart’ (31 items)
Orientatio
n needs
Emergency
needs
Basic needs Emotional
needs
Day/date Feeling dizziness Brush my
teeth
Need blanket Want to go
home
Time Feeling itching Need to take
bath
Need pillow Want to meet
family members
Feel like vomiting Moisten my
lips
Want to turn a side I am feeling sad
Feeling numbness Combing Want to sleep
Pain Need toilet Want to lie down
Wanted pain
medication
Feeling thirsty. Want to sit up
Feeling Choked Hungry Want to do exercise
Need my airway to
be cleaned
When the tube is
coming out
Want to meet
nurse
Want pen and paper

50. Preliminary communication chart

51. Table 3: Measures of content validity index
(CVI) of Delphi round 1 and 2.
Measures of CVI Delphi round 1 Delphi round 2
Mean I-CVI 0.93 0.96
S-CVI/Avg 0.94 0.99
S-CVI/UA 0.67 0.99

52. Delphi round - 3
70%
10%
20%
Fig 3 Percentage distribution of experts opinion
on size of chart
A-3 sheet front and
back
A-3 sheet
Chart 50X70cm

53. Figure 2: Final draft of communication chart
front side

54. Fig 3: Communication chart back side

55. Reliability & Usability of communication
chart
The inter-rater Reliability Cohen’s kappa (r
=1)
98
94
92
84
98 98 98
75
80
85
90
95
100
Meanpercentagescore

56. Views of patients regarding Communication chart
Patient
Importance of communication chart
“Chart vadiya cheej hai. Eh hona chahida” (Punjabi language)
(Chart is a very good instrument)
Usability of communication chart
“Meri jarrurat es naal puri ho gai c. Main chart de rahi ghar jan bare
pucheya atte pariwar bare pucheya c” (Punjabi language)
(With the chart I could ask to send me home and could ask about my
family)
Understanding of communication chart
“menu chart wich sab kujh samahj aa reha c.”
( I could understand every thing from chart.)

58. Views of Caregivers regarding Communication chart
Care giver Importance of communication chart
“I feel this communication chart is very effective and
should be provided to patients who are mechanically
ventilated.”
Usability of communication chart
“Communication chart is really beneficial and also help
in improving communication.”
“It’s really effective method of communication.”

60. Conclusion
 Communication board/chart should be implemented in
all ICU’s
 It improves the efficiency and speed of communication
 It facilitates meeting of basic needs of patients
 It sensitizes the health care practitioners on the
importance of communicating with intubated patients

61. Recommendations
India being a diverse country
with more than 22 languages
spoken in various parts of
India.
Communication board needs
to be developed in all the
languages to serve local
population when critically ill.

62. REFERENCES
1. Happ M B, Tuite P, Dobbin K, DiVirgilio-T D, and Kitutu J. Communication
Ability, Method, And Content Among Nonspeaking Non surviving Patients
Treated with Mechanical Ventilation In The Intensive Care Unit American
Journal of Critical Care. May 2004;13(3): 210-17
2. Eteban A, Anzueto A et al. How mechanical ventilation employed in ICU.
International utilization review. American journal of respiratory critical care
medicine.2000; 161:1450-51.
3. Carlos J, Soriano J V. Development of a wound healing index for chronic
wounds. EWMA Journal, 2012;12:2
4. Kumari S, Kaur S, Singh A, Kanchan K M. Reliability of a ‘Communication
Chart’ for Conscious Patients on Mechanical Ventilator or Tracheostomy
Admitted in Intensive Care Unit of a Tertiary Care Referral Center, India
Journal of Nursing Science & Practice, Dec 2011;1(3): 28-35.
5. Campbell GB, Happ MB. Symptom identification in the chronically critically ill. AACN
Adv Crit Care. 2010;21:64–79.
6. Baumgarten M, Poulsen I. Patients' experiences of being mechanically ventilated in
an ICU: a qualitative metasynthesis. Scand J Caring Sci. 2015;29:205–14. doi:
10.1111/scs.12177.
7. Carroll SM. Silent, slow lifeworld: the communication experience of nonvocal
ventilated patients. Qual Health Res. 2007;17:1165–77. doi:
10.1177/1049732307307334.

63. Thank u