Elsevier

Heart & Lung

Volume 33, Issue 2, March–April 2004, Pages 92-101
Heart & Lung

Issues in pulmonary nursing
Electronic voice-output communication aids for temporarily nonspeaking patients in a medical intensive care unit: a feasibility study

https://doi.org/10.1016/j.hrtlng.2003.12.005Get rights and content

Abstract

Background

The inability to speak during mechanical ventilation is recognized as a terrifying and isolating experience that is related to feelings of panic, insecurity, anger, worry, fear, sleep disturbances, and stress among critically ill patients. Alternative methods of communicating with temporarily nonspeaking patients in the intensive care unit (ICU) have received little study. Although electronic voice output communication aids (VOCAs) are available for disabled children and adults, the effectiveness of VOCA systems with adult medical ICU patients who may have multisystem illness, prolonged intubation, and longer ICU stays has not been explored.

Objectives

The purpose of this pilot study was to describe (1) the characteristics of intubated MICU patients who use VOCAs, (2) the usage patterns (message categories, frequency, assistance required), (3) communication quality (ease, user satisfaction), and (4) barriers to communication with VOCAs.

Methods

This pilot study used participant observation, semi-structured interviews, questionnaires, and clinical record review in a complementary design to obtain data on communication events and VOCA use with 11 critically ill adults.

Results

Study participants, 45.5 ± 16.0 years of age with 13 ± 1.9 years of education and moderately severe illness (APACHE III = 27.5 ± 16.1), used the VOCA for 5.7 ± 4.6 days. Ease of Communication Scale measurements showed significantly less difficulty with communication after device use (t > 2.62; P = .047). Almost half (n = 5) of the participants demonstrated some independent use of the device. VOCAS were used in one quarter of observed communication events. Patients used VOCAs most often to communicate with family visitors and initiated communication interactions more often when VOCAs were used than when communicating by other nonvocal methods. Poor device positioning, deterioration in patient condition, staff time constraints, staff unfamiliarity with device, and complex message screens were primary barriers to VOCA use.

Conclusions

This study showed that use of VOCAs is possible with selected critically ill adults and may contribute to greater ease of communication during respiratory tract intubation particularly with family members. Further clinical research using control or comparison groups is needed.

“People don't communicate with people who don't communicate back.”—ICU nurse

Introduction

The inability to speak during mechanical ventilation is recognized as a terrifying and isolating experience for many intensive care unit (ICU) patients. Studies of the experiences and stressful events among ICU patients show significant relationships between the inability to talk and feelings of panic, insecurity, anger, worry, fear, sleep disturbances, and perceptions of stress.1, 2, 3, 4 Alternative methods of communicating with temporarily nonspeaking patients in the ICU have received little study.5, 6 This article describes the usage patterns, user perceptions, and characteristics of 11 intubated medical ICU patients who used electronic voice output communication aids (VOCAs).

Section snippets

Background

Prior studies demonstrated that most nurse-patient communication interactions in the ICU are brief, consisting of task or procedure-oriented information, commands, or reassurances.7, 8, 9, 10 Nurse-patient communication interactions are most often initiated and controlled by the nurse and are influenced by the patient's severity of illness, level of consciousness, and responsiveness.7, 8, 9, 10, 11

There are a few preliminary studies and some anecdotal reports of the effectiveness of

Methods

This study combined quantitative and qualitative approaches in a complementary design.18 Participant observation, semi-structured interviews, questionnaires, and clinical record review were used to obtain data on VOCA use with 11 critically ill adults.

Sample

Sixteen adult patients (primary participants) were selected from the MICU using the following criteria: (1) intubated, (2) responsive to verbal stimuli, (3) able to follow simple commands, (4) able to understand English, and (5) able to complete 6 of 8 Initial Cognitive-Linguistic Screening Tasks.13 Cognitive Linguistic Screening Tasks is a clinical tool used to assess attention (Look at me.), orientation (Is Ronald Reagan the current president?), and the ability to follow directions (Close

Patient characteristics

Eleven MICU patients, ranging in age from 24 to 72 years (45.5 ± 16.0) were recruited to participate in the study. Primary admitting respiratory diagnoses included pneumonia, acute respiratory distress syndrome, lung cancer, chronic obstructive pulmonary disorder, and subglottic stenosis. Demographic and clinical characteristics for study participants are described in Table 2.Table 2. Few (n = 3) participants could write legibly. Four patients demonstrated difficulty or were unable to complete

Limitations

A small, purposefully selected sample of patients was used in this study. Selection criteria (performance of Cognitive-Linguistic Screening Tasks) excluded the most seriously ill patients, agitated patients, and those with acute brain injury. In addition, MICU nurses were reluctant to recommend study participation for restrained patients because VOCA use would require upper extremity restraint removal, which further excluded potential study candidates.

Given the exploratory nature of the study,

Patient characteristics

Adult patients of all ages, educational levels, and with moderate-to-low illness severity were able to use the VOCAs. The patients in this study had relatively high levels of cognitive function (GCS scores = 14-15). Neuromotor disability posed the greatest challenges to VOCA use in the critical care setting, as patients who were unable to successfully complete the Motor Screening Tasks used the VOCAs minimally.

Usage patterns

The success of a VOCA-based AAC intervention within a given ICU population is

Conclusions

This pilot study showed that use of VOCAs is possible with selected critically ill adults and may contribute to greater ease of communication particularly with family members during respiratory tract intubation. Barriers to VOCA use may be addressed by design improvements, enhanced staff education, individualized assessment, and combination strategies. This study provided preliminary description of VOCA usage patterns and user satisfaction in a previously untested MICU population. A more

Acknowledgements

Thanks to Dr. Julius Kitutu for statistical consultation, Dana DiVirgilio Thomas for assistance in manuscript preparation, and to the following manufacturers that loaned equipment: AbleNet, Inc., DynaVox Systems, Inc., and Words+, Inc.

References (34)

  • L.K. Menzel

    Factors related to the emotional responses of intubated patients to being unable to speak

    Heart Lung

    (1998)
  • A.J. Leathart

    Communication and socialisation (1)an exploratory study and explanation for nurse-patient communication in an ITU

    Intensive Crit Care Nurs

    (1994)
  • A.J. Rotondi et al.

    Patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit

    Crit Care Med

    (2002)
  • I. Bergbom-Engberg et al.

    Assessment of patients' experience of discomforts during respirator therapy

    Crit Care Med

    (1989)
  • B.E. Pennock et al.

    Distressful events in the ICU as perceived by patients recovering from coronary artery bypass surgery

    Heart Lung

    (1994)
  • L.K. Menzel

    Need for communication-related research in mechanically ventilated patients

    Am J Crit Care

    (1994)
  • M.B. Happ

    Communicating with mechanically ventilated patientsstate of the science

    AACN Clin Issues

    (2001)
  • P. Ashworth

    Care to Communicate

    (1980)
  • D.S. Hall

    Interactions between nurses and patients on ventilators

    Am J Crit Care

    (1996)
  • J. Sayler et al.

    Nurse-patient interaction in the intensive care unit

    Heart Lung

    (1985)
  • C. Baker et al.

    An investigation into the attitudes and practices of intensive care nurses towards verbal communication with unconscious patients

    J Clin Nurs

    (1996)
  • G. Vanderheiden et al.

    Overviewaugmentative communication: an introduction

    (1986)
  • P. Dowden et al.

    Serving nonspeaking patients in acute care settingsan intervention approach

    Augmentative and Alternative Communication

    (1986)
  • Dowden P, Beukelman D, Lossing C. Serving nonspeaking patients in acute care settings: intervention outcomes....
  • B. Stovsky et al.

    Comparison of two types of communication methods used after cardiac surgery with patients with endotracheal tubes

    Heart Lung

    (1988)
  • M. Fried-Oken et al.

    Feedback on AAC intervention from adults who are temporarily unable to speak

    Augmentative and Alternative Communication

    (1991)
  • J.M. Costello

    AAC Intervention in the intensive care unitThe Children's Hospital Boston Model

    Augmentative and Alternative Communication

    (2000)

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