Kathryn L. Garrett

Nurse-Patient Communication Interactions in the Intensive Care Unit

BACKGROUND The inability to speak during critical illness is a source of distress for patients, yet nurse-patient communication in the intensive care unit has not been systematically studied or measured. OBJECTIVES To describe communication interactions, methods, and assistive techniques between nurses and nonspeaking critically ill patients in the intensive care unit. METHODS Descriptive observational study of the nonintervention/usual care cohort from a larger clinical trial of nurse-patient communication in a medical and a cardiothoracic surgical intensive care unit. Videorecorded interactions between 10 randomly selected nurses (5 per unit) and a convenience sample of 30 critically ill adults (15 per unit) who were awake, responsive, and unable to speak because of respiratory tract intubation were rated for frequency, success, quality, communication methods, and assistive communication techniques. Patients self-rated ease of communication. RESULTS Nurses initiated most (86.2%) of the communication exchanges. Mean rate of completed communication exchange was 2.62 exchanges per minute. The most common positive nurse act was making eye contact with the patient. Although communication exchanges were generally (>70%) successful, more than one-third (37.7%) of communications about pain were unsuccessful. Patients rated 40% of the 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). CONCLUSIONS Study results highlight specific areas for improvement in communication between nurses and nonspeaking patients in the intensive care unit, particularly in communication about pain and in the use of assistive communication strategies and communication materials.

A comprehensive augmentative communication system for an adult with Broca's aphasia

A multimodality augmentative communication system was developed for a 74-year-old man with Brocas aphasia. System development began with an assessment of the subjects communication competencies and needs. Decisions were made regarding which modes of communication could be capitalized on without additional instruction, and which modes could be enhanced via augmentation in order to successfully transmit messages. A multimodal communication system consisting of natural speech, gestures, writing, drawing a first letter spelling alphabet card, a thematic word dictionary, breakdown “clues,” and control phrases was eventually developed. The tangible components of the system were consolidated into a small portable notebook. Issues regarding instruction in system use, interaction, and vocabulary selection were addressed. Data collected by videotaping interaction with unfamiliar speakers revealed that fewer communication breakdowns were present in the augmented condition than in the unaugmented condition, indicat...

Augmentative and alternative communication for adults with acquired severe communication disorders

A severe communication disorder that limits the extent to which natural speech meets the communication needs of daily living can result from a variety of diseases, syndromes, and traumas across the age range. For individuals with acquired disability, a severe communication disorder may occur due to physical impairment, language impairment, cognitive impairment, or combinations of impairments. In this article the demographic patterns of acquired severe communication disorders, intervention models, intervention strategies, and intervention effectiveness results that have been reported in the literature are reviewed. In addition, future research and clinical directions are highlighted.

The impact of graphic contextual information and instruction on the conversational behaviours of a person with severe aphasia

Backgrounds: Individuals with severe expressive aphasia often have difficulty sharing adequate amounts of specific information to sustain topical conversations. Aims: This single subject experiment investigated whether graphic representations of topics increased conversational duration, number of information exchanges, proportion of participant initiations, and percentage of successful communication exchanges during dyadic conversations involving a communicator with severe, nonfluent aphasia (SD). Methods & Procedures: SD conversed with two partners about personal and current events in “no treatment” and “graphic topic-setter” conditions. He also participated in an additional “instruction” condition with Partner 2. Conversations were videotaped, transcribed, and coded for the dependent variables. Results were averaged by condition, graphed, and analysed for statistical significance using randomisation testing. Outcomes & Results: Despite variability in conversational parameters across sessions, mean data from each condition revealed that graphic topic setters increased the average duration of interactions and mean number of communication exchanges per topic across both partners. Proportion of initiations increased significantly with graphic context for Partner 1 but not Partner 2; this effect was more pronounced for current event topics than personal events. Information transmission was significantly more successful when graphic context was present with both partners, but differences were more noticeable with Partner 1. Conclusions: Participants appeared better able to co-construct conversations when graphic topic setters were available to supplement the natural communication signals of a communicator with severe aphasia. Clinical implementation issues are discussed.

Listening to the Voiceless Patient: Case Reports in Assisted Communication in the Intensive Care Unit

Communication problems experienced by nonspeaking, critically ill patients in the Intensive Care Unit (ICU) have serious implications for the physical and psychological well-being of patients and the quality of their care. These problems are most profound for those with prolonged critical illnesses who are at the highest risk of dying. Recently, speech language pathologist (SLP) services have been used to provide augmentative and alternative communication (AAC) assistance to this vulnerable group of patients, their caregivers, and medical staff. Here we present three clinical cases that illustrate the application of AAC strategies across different levels of illness severity and communication impairment for nonspeaking patients in the ICU. Both high-tech communication devices with voice output and low-tech options were used for each patient according to their motor and cognitive abilities. To accommodate fluctuations in patient status and communication needs, multiple AAC strategies were integrated into the communication repertoire and tailored for each case. Medical personnel involved in these cases attributed enhanced communication efficiency, improved ventilator weaning trials, and increased patient engagement to the AAC techniques. This approach has the potential to improve symptom communication and to ease suffering for seriously ill ICU patients with speech limitations.

Use of the quasi-experimental sequential cohort design in the Study of Patient-Nurse Effectiveness with Assisted Communication Strategies (SPEACS).

This paper describes a quasi-experimental three-phase sequential cohort design used in the Study of Patient-Nurse Effectiveness with Assisted Communication Strategies (SPEACS) to test two interventions to improve nurse-patient communication in the intensive care unit (ICU). The sample consists of 10 nurses and 30 nonspeaking ICU patients in each phase (total n=90 nurse-patient dyads). Observational techniques (video recording, transcription, and rating) measure nurse-patient communication performance. Descriptive and covariate data are collected through clinical assessment tools, questionnaires, and field notes. We discuss the practical and scientific considerations in constructing and implementing this type of clinical trial. Specifically, primary threats to validity, history and the Hawthorne effect, are considered and efforts to minimize and track these potential threats are described.