Overcoming Communication Barriers with Non-verbal Patients in the Intensive Care UnitKaren Jensen RN CNCC(C), Kathie Alary RN CNCC(C), Patricia Berger RN, Theresa Chipperfield RN,

Gurmeet Mann RN CNCC(C), Luauna McCartney RN BScN, Reena Parhar MSc RSLP CCC-SLP

ICU Point of Care Research Study

A B C DE F G HI J K L M NO P Q R S TU V W X Y Z

BARRIERS TO COMMUNICATIONPatient Perspectives • Limited ability to write due to weakness, sedation, and

physical restrictions such as intravenous lines, monitor wires, wrist restraints, or edema (1)

• Physical and emotional fatigue from mouthing words, gestures, or nodding (8)

• Patience, kindness, reassurance, and presence at the bedside are required for effective communication (7)

Environmental Perspectives• Nurses experience frustration with increased time needed

for patient communication, difficulty understanding/interpreting the patient’s message, and lack of knowledge of available communication aides (2)

• Effective communication requires a trusting nurse/patient rapport, and nurse awareness of personal non-verbal cues showing impatience, annoyance, or anger (5)

• In a technical environment, communication is often not prioritized (11)

A PLANNED APPROACH TO COMMUNICATIONSpeech Language Pathologist (SLP)• The Speech Language Pathologist (SLP) is specially

trained to assess, diagnose, and treat/manage communication and swallowing.

Referral Process• Any member of the Interdisciplinary Team may request an

SLP referral • Referral processes are typically similar across all

Rehabilitation Services departments within a site (order entry, fax).

• Once referred, the SLP will obtain a patient history and review the current medical status, select the appropriate assessment(s), make a diagnosis, and treat/manage the impairment.

• Communication and documentation of the care plan is key for all members of the Interdisciplinary Team

Augmentative and Alternative Communication (AAC)• The SLP will assess for, prescribe, and train an individual

on the use of an AAC device.• AAC devices vary from low-tech to high-tech.• The appropriateness of a device is dependent upon:

» the speech/language assessment results » the patient

� current medical status � current level of cognitive functioning � education/literacy levels

Devices may be as simple as writing materials, written and/or pictorial communication boards (i.e., yes/no boards, phrase boards, alphabet boards), or may be complex digital or electronic.

INTRODUCTIONCommunication with conscious, intubated patients is an often overlooked aspect of care, yet one that has profound effects on both the patient and the nurse. Effective communication establishes not only a relationship of trust, but also fosters a partnership in the patient’s journey to recovery. Current methods of communication which rely upon the patient’s ability to mouth words or point to letters on an alphabet board have proved tiring, ineffective, and frustrating to both. Technology has enhanced our ability to physically care for our ICU patients, but often at the cost of this basic human need. With education, commitment to care planning, and intervention with augmentative communication aids, we can shatter this silence and offer our patients a simple, yet powerful gift: their voice.

ParticipantsInclusion CriteriaDesigned to assess & include patient’s capacity to consent• Richmond Agitation Sedation Scale (RASS)

of +1/-1 • delirium score <5 • Glasgow Coma Score of >9/T• medically stable

» minimal to no inotropes » no CRRT

• adequate mobility in one limb with associated dexterity to point

• adequate vision (with or without eye glasses)

• endotracheal or tracheal tube• English as primary language• normal pre-illness speech/language

function

Exclusion Criteria:

• change in clinical, cognitive, or physical status which negates any portion of the inclusion criteria (participation postponed until baseline status at the time of inclusion regained)

• Patients who are part of a ‘double’ RN assignment

• Patients who have already participated in the study. (ie: those who have been discharged from ICU, and who are subsequently re-admitted to the unit).

Recruitment & Data Collection • Goal - minimum 36 patients (6 per group)• Patient census assessed daily by ICU Team member or PCC• Invitation to Participate package offered to eligible patients: Brochure & Consent

Form• Follow up within 24 hours by Team member for consent & enrolment• Once enrolled, Research Package with block randomization assignment placed

on patients’ chart for use the following day; 0700 – 1900• Data collection through short patient and nurse Likert-scale surveys

SYNOPSIS OF OUR PILOT STUDY Methods• Experimental 6 month Pilot Trial: June 1 – November 30, 2013.•Block randomization assignment into groups:

Objectives: feasibility trial of study methods, and evaluation of patient and nurse response to communication methods

Group 1: Control Group (mouthing words/alphabet boards)

Group 2: Vidatak EZ Board (12)

LESSONS LEARNED TO DATE

LITERATURE REVIEW (42 articles were reviewed for our research proposal)• Critical illness is often-unexpected, and temporarily renders

patients unable to communicate their basic physical and emotional needs due to intubation, and mechanical ventilation (1)

• Most interactions are nurse-initiated, short in duration, and limited to explanations of care or procedures (9)

• Nurses receive limited training in communication assessment, care planning, or use of alternative communication aides (6;11)

• Few actual studies have been done using communication boards or electronic aids within the ICU environment (7;8)

• Gaps identified include » Need for further study of the effectiveness of communication aides to improve patient outcomes (8);

» Further study into methods of training communication assessment techniques and interventions to health care providers (11).

INABILITY TO COMMUNICATE — THE IMPACT ON PATIENTS• Patients identify inability to communication as the most

significant problem for them while ventilated (3;7), leading to feelings of frustration, anxiety, panic, sleeplessness, depersonalization, loss of control, and unrecognized pain.

• Patient’s efforts to communicate are often misunderstood; creating patient/nurse frustration, increased sedation use, avoidance from staff, and communication failure (5; 11;13).

• Messages regarding symptoms, treatment preferences, needs & concerns are easily misinterpreted & responded to incorrectly (10;8).

Successes• Strong collaboration within the ICU

Interdisciplinary Team • Greater awareness of care planning and

available communication strategies for staff• Raised public awareness of available

communication tools for families

Challenges• ‘Wean, wake, extubate’ creates narrow

window for recruitment• Significant language barriers in our patient

population• Overwhelming amount of information for

patients to process• iPad technology intimidating to some

candidates

REFERENCES1. Broyles, L., Tate, J., & Happ, M. (2012).

2. Etchels, M., Ashraf, S., MacAuly, A., Judson, A., Ricketts, I.W., Waller, A., …Gordon, B. (2002).

3. Happ, M., Garrett, K., DiVirgilio-Thomas, D., Tate, J., George, E., Houze, M., ...Sereika, S. (2011).

4. iTunes Preview. SmallTalk Intensive Care.

5. Laakso, K., Hartelius, L., & Idvall, M. (2009).

6. Lindgren, V., & Ames, N. (2005).

7. Patak, L., Gawlinski, A., Fung, I., Doering, L., & Berg, J. (2004).

8. Patak, L., Gawlinski, A., Fung, I., Doering, L., Berg, J., & Hennerman, E. (2006).

9. Price, A. (2004).

10. Radtke, J., Baumann, B., Garrett, K., & Happ, M. (2011).

11. Radtke, J., Tate, J., & Happ, MB. (2012).

12. Vidatek EZ Board: ICU Board.

13. Wojnicki-Johannsson, G. (2001).

Group 3: iPad SmallTalk ICU (4)

ACKNOWLEDGEMENTSDynamics of Critical Care Conference 2012. Elaine Doucette, Sarina Fazio, Shane Anzovino, Ahsan Bandeali, Virginie Constantin, Laureanne Khouri, Carol Kwon and Fannie Painchaud. Technology at the Bedside: The Evolution of Patient Communication in Critical Care.

Our thanks to:• Fraser Health Authority: Professional Practice and

Integration, Department of Evaluation and Research Services, Nursing Research Facilitators

• Michael Smith Foundation for funding this project• Bernie Garrett PhD RN, Associate Professor,

University of British Columbia.

CONTACT INFORMATIONFor additional information and the complete list of references, please contact: Karen Jensen at karen.jensen@fraserhealth.ca