Patients in Critical Care
Aziza M. Salem1*, Nagwa M. A. Mohamed1,21University College of Umluj, University of Tabuk, Tabuk, Saudi Arabia. 2Department of Medical Surgical Nursing, Faculty of Nursing, Assiut University, Assiut, Egypt.
*Corresponding author:
[email protected]
AbstractBackground: Mutual communication among critical care nurses and patients is a basic part of patient care. Effective communication is as an important vehicle to convey patients‟ needs and the feedback decisions and interventions.
Objective: Our aim was to identify the invasive mechanical ventilated (IMV) patients‟
needs through using electronic augmentative and alternative communication (AAC) device ("Be My Voice") during IMV period.
Patients and Methods: A total of 74 patients participated in this study. The study was conducted in four hospitals at Amman, Jordan. During the study, IMV patients used I pad to communicate their needs to ICU nurses. All their communication trails were saved on these I pads for further analysis by researcher.
Results: Most of IMV patients experience pain, breathing difficulties and other distressing symptoms during being placed on invasive mechanical ventilation. "Be My Voice" is one nurse-patient communication applications, which was used to uncover the needs of patients on IMV. As a result, critical care nurses were able to fulfill these needs.
Conclusion: Enhancing communication with IMV patients can lead to appropriate symptom management and the fulfillment of patients‟ needs.
Key words: Critical care, Invasive mechanical ventilation, Electronic augmentative and alternative communication, Communication strategies, Intensive care, Nursing.
Citation: Salem AM, Mohamed NMA. The use of an Electronic Augmentative Communication Device to assess the needs of Mechanically Ventilated Patients in Critical Care. JUMJ, December 1, 2018; 5(4): 27 - 32.
Introduction
Inability to communicate verbally associated with many problems during invasive mechanical ventilation (IMV) period(1). Patients who require IMV suffer from discomfort due to the endotracheal tube and communication difficulties, which are significant causes of anxiety(2). More than one-third of communicative attempts between nonverbal intensive care unit (ICU) patients and their nurses (to express the pain they were experiences) were found to be unsuccessful(1). Failed communication attempts between patients and health care providers could result in experiencing pain that is not being appropriately assessed or managed(3).
The communication abilities of IMV patients could be significantly enhanced through augmentative and alternative communication (AAC) that could become the means for increased efficiency and speed of communication. Augmentative and alternative communication has been in use since 1975 to help IMV patients communicate(4). However, a few studies have addressed its effects on patient outcomes in ICU(5). There is a wide range of communication aids from basic to high technology, but the selection of the most effective, efficient, and safe method should be based on a patient‟s clinical condition. There are several studies supporting the use of AAC to enhance communication with non-speaking
Salem & Mohamed - The use of an Electronic Augmentative Communication Device to ….. 2018 2018
patients in order to alleviate their frustration and ensure their needs are met(5,6,7).
ICU nurses state that their communication with intubated patients is based on observing senior nurses or trial-and- error(8). Therefore, ICU nurses report feeling frustrated due to communication difficulties with IMV patients, and actually attempt to avoid patients with communication problems(9). Thus, it seems that ICU nurses need comprehensive training and educational support to maintain effective and efficient communication with IMV patients.
Furthermore, the Joint Commission International Accreditation (JCIA) consider the effective communication as a requirement for patient safety(10).
A number of articles address the lack of use of augmentative and alternative communication (AAC) systems in ICU(6,8,9,11). Therefore, the effects of AAC implementation are not adequately investigated. Sharing information among nurses and patients is an essential part of patient care. However, in the Arabic region there are no protocols in ICUs regarding communication with IMV patient. Thus, the main purpose of this study was to identify IMV patients‟ needs while using electronic AAC device during IMV period. The solicited data can be considered as baseline study in the field of communication with IMV patients.
Patients and Methods Design and Setting
The descriptive design was used in view of its benefit in obtaining empirical information that addresses the most common needs among IMV patients while using electronic AAC. In this study, IMV patients were defined as patients with invasive (endotracheal or Tracheostomy tube) and connected to mechanical ventilator regardless of their mode of ventilation (control, SIMV, ect.).
Before introducing AAC devices to patients, training for nurses on about the importance of communication with IMV patients and how to run electronic AAC device was conducted. Nurses' training was done by the researcher during the in- service education time, and once any IMV
patient met the selection criteria, an enforcement training session was conducted to the assigned nurse by the charge nurse at that shift. The charge nurses at the selected hospitals attended a training workshop about the application (BE MY VOICE) for 4 hours that was conducted by the researcher.
The researcher asked all ICU nurses to stop using an electronic AAC device when IMV patient has a need that must be fulfilled immediately, and, at any time IMV patient showed no interest in communication using an electronic AAC.
The study was conveniently conducted in four hospitals in Amman, Jordan. from March until July 2017. The selected hospitals were chosen because they had the largest ICUs with high occupancy rate. There were no available communication assistive devices in these hospitals during the pre-intervention phase. Institutional review board at the University of Jordan approved the study that was also approved by Bioethical Committees at each of the four hospitals where the study was conducted.
Files of patients admitted to ICU were retrieved with the help of the medical records officials through referencing them using their medical numbers. The target population of this study was all IMV patients. We reviewed the records of patients fulfilling the inclusion criteria among those placed on IMV for at least 24 hours. Patients aged ≥18 years, and patients who were able to move the upper arm and had intact visual ability (i.e., they are able to touch the electronic AAC screen) were voluntarily enrolled.
Exclusion criteria included unconscious patients, those under deep sedation (with a score of -3 or -4 on the Richmond Agitation and Sedation Score), and those or their custodians were unwilling for participation.
The Intervention and Procedure
An electronic AAC, named „Be My Voice‟ was the study intervention, which was fully described in previous paper(12). IMV patients‟ needs that are integrated in that application included basic physiological needs such as, eating, drinking and toiletings. In addition, they
Salem & Mohamed - The use of an Electronic Augmentative Communication Device to ….. 2018 2018
include the need for nursing care as (suctioning, positioning and bathing), and, the patients social needs. Other functions can be used to report IMV patients subjective symptoms such as, dyspnea, feeling cold or hot and fatigue. A professional computer programmer was hired to place "Be My Voice" application on Android tablet. All functions accessible for use were included in touch selection of graphic buttons with pre- made spoken messages representing patients‟ symptoms or needs, in addition to a typewriting on-screen keyboard. It was instructed in Arabic phrases along with an integrated picture format to enhance the patients‟ communication abilities. The pateints' legal guardian were interviewed to ensure informed consent collection before enrolment.
The mean number of communication acts within communication exchanges per 24 hrs using the electronic AAC device was 12, where the total fequencies of using an electronic AAC ranged from 8 to 240 times.
Statistical Analysis Methods
Descriptive statistics were used for patient‟s demographics using mean ± SD, and frequency; n (%). And for the patients‟ needs, data were shown as frequency; n (%).
Results & Discussion
A total of 74 IMV patients participated in this study as described in Figure 1. Table 1 provides the demographic information about the study sample.
Most common needs when using the AAC device
Study findings demonstrate the first most reported IMV patient need which was feeling pain (99%). This was consistent with the Rodriguez et al (2016)(13) stating that patients want to communicate their feeling of pain to ICU nurses. In another study by Alasad et al (2015)(9) conducted on 98 ICU patients in three hospitals in Jordan, reported that 58% of patients have pain during their ICU stay. One explanation for unsuccessful pain expression may be related to the fact that ICU nurses‟ interpreted patient‟s facial expression as a measure of pain rather than using self-expression of pain among
IMV patients. This indicates the insufficiency of pain assessment among IMV patients. For that, Azzam and Alma‟s (2013)(14) recommended using several standardized visual pain intensity assessment tools for IMV patients, such as the Numeric Rating Scale and the Faces Pain Scale, to assess pain in acutely/critically ill adults who are responsive and unable to speak.
Figure 1: Consort flow diagram of the study (n
= 74).
Table 1: Patients' characteristics (n = 74). Data shown are mean ± SD, and frequency; n (%).
Variables Mean ± SD or
n (%)
Age, Years 56.28 ± 17.76
Gender Male 50 (67.6)
Female 24 (32.4)
Diagnosis
Medical 28 (37.8) Surgical 14 (18.9) Oncology 32 (43.2) Communication acts per 24
hrs using an electronic AAC
12 ± 11.16 Our study revealed that feeling thirsty is the second highest ranked sensation (61%) among IMV patients which is consistent with Arai et al (2013)(15) addressing thirst as a common phenomenon in ICU. Furthermore, another study reported patients experiences of being conscious with IMV using a qualitative approach; within one patient described his thirst by saying, „I
Salem & Mohamed - The use of an Electronic Augmentative Communication Device to ….. 2018 2018
dreamt of getting a mouthful of water‟(16). Among IMV patient, thirst is a need that could not be fulfilled because of the presence of endotracheal tube(17).
In Jordanian culture, there are strong social bonds between families where everyone supports the other in times of need. Moreover, visiting hospitalized patients is considered as social duty by their relatives and friends. In the current study, about 38% of IMV patients asked to see their families. It was obvious that IMV patients may perceive their comfort and support from their family members by their company in ICU setting. Arabs value preserving family unity(18). However, most of the selected hospitals had restricted family visiting hours especially for critical care units.
The current study findings highlighted that the 3rd most reported needs by IMV patients were asking for a change of position (37%), changing the level of the bed head (31%), and suction (35%). It is well-documented in the literature that IMV patients feel suffocated, and most IMV patients reported discomfort due to secretions from their mouth(16,17,19). IMV patients reporting dyspnea in the present study matches the findings of Karlsson et al (2012)(20) in that IMV patients constantly reported difficulties in breathing. However, the previous literature did not rank IMV patients‟
needs or wants, as most of the literature only described patients recalled memories
of being connected to IMV in ICUs using qualitative approach retrospectively(19-21). As a majority in Jordan, Muslims believe that illness and cure is God's willing, and reciting the Holy Quran can be used as mediation to cure illness. For this reason, in the current study, 31% of IMV patients asked to listen to Quran. Religious beliefs are superior during illness, especially among the critical illness(21). Meeting the religious demands of IMV patients are of great importance. In view of this, precise assessment of IMV patients‟ spiritual needs could enhance effective spiritual care(22). The low ranked needs were bed bath (8%), to see a religious figure (10%) and to listen to music (12%). The low rank of a need may give an impression that some physical, social, emotional and spiritual needs in the selected hospitals have been matched to a high degree which could reflect a good quality of patient‟s care. Furthermore, the practice to see a religious figure is not common among Muslims and can be replaced by listening to Quran.
The lowest ranked feeling among IMV patients in the current study was feeling anxiety (7%). This result was contradictory to literature about anxiety experience among ICU patients(23,24). The rationale for low anxiety reporting in the current study may be due to the timing of data collection, which was only 24 hours after using electronic AAC. All IMV patients' needs are shown in Figure 2.
Figure 2: Invasive mechanical ventilation patients‟ needs during 1st 24 hours of using electronic augmentative and alternative communication. Data shown are frequency; n.
Salem & Mohamed - The use of an Electronic Augmentative Communication Device to ….. 2018 2018
Time management in a patient with complex needs and life-threatening situations is a paramount aspect of critical care nursing. One ICU nurse mentioned,
“What the patient need is just to touch the icon, then easily we can know what he wants.” For this reason, many ICU nurses mentioned that the electronic AAC improved the quality of nursing care in ICU. ICU nurses used the time saved by not having to guess patient needs, which are easily identified using electronic AAC, to actually fulfill them. Another ICU nurse mentioned that, “using „Be My Voice‟ helped me to assess the patient pain by giving a full description of pain which helped to manage his pain appropriately, & in short period of time”.
The findings of this study demonstrated the effectiveness of using the "Be My Voice" application installed on an AAC device to ease the communication between ICU nurses and IMV patients.
This method helped unveil the patients‟
needs and nurses‟ reactions to patients using the application, and found more satisfaction and cooperation with nursing care. However, these results should be considered within limitations of the study.
Conclusion
Effective communication is recognized as a priority across the healthcare continuum, especially when the patient becomes speechless. The key finding of this study is the demonstrated effectiveness of using an electronic AAC device to facilitate IMV patient-nurse communication. The current study provides satisfactory evidence to show that most IMV patients experience pain, breathing difficulties and other distressing complaints. These problems were not properly dealt with previously because of being non-verbal during IMV use. Enhancing communication with IMV patients can lead to appropriate problems management and the fulfillment of patients‟ needs. However, the results showed that there were still some challenges in communicating with IMV patients, especially when these patients are unable to use electronic AAC devices. The future of AAC devices looks bright by virtue of continuing research into its effect on patient outcomes.
Limitations of the Study
The study is considered as baseline investigation for IMV patients‟ needs.
Thus, a convenience sample was recruited with no randomization for the study intervention. In addition, low response rate as some IMV patients were unable to utilize the electronic AAC devices due to computer illiteracy which can be considered as another limitation for this study.
Funding
The study was funded by the authors' institutions as a part of their employment duties.
Conflict of Interests
The authors declared no conflict of interests.
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