Communication in the intensive care setting (ICS) is critical for both the patient and the medical staff to provide efficient care and thus alleviate possible patient adverse effects. Persons with complex communication needs are particularly vulnerable in ICSs and therefore require additional communication support.
This study focused on the perspectives of nurses about communication with patients with communication needs in ICSs using paper-based communication boards, namely the translated Vidatak EZ Board, before and after a training session.
A 1650-bed public hospital with a 26-bed ICS in a semi-urban, low socio-economic area in South Africa served as the research setting.
A quasi-experimental pre-test post-test group design with withdrawal and a control group was used. Data were gathered using a custom-designed questionnaire completed by ICS nurse participants recruited from a public hospital.
Responses of some nurses did not change in post-test 1, but their responses did change in post-test 2. Some of the nurses’ perspectives changed, as expected from the pre-test to post-test 1. Nurses recommended specific adaptations to the communication board.
Most nurses agreed that communication is crucial in ICSs and that a communication board can be implemented; however, limited success was observed implementing the board following a short training. The inter-professional collaboration between nurses and speech-language therapists to provide optimal health care to patients in ICS is emphasised.
Patients in intensive care settings (ICSs) often have an endotracheal tube or a tracheostomy tube inserted to assist with respiration which affects their spoken language (Garrett et al.
Not only is the need for effective communication between nurses and patients imperative to evade adverse medical events (Finke, Light & Kitko
One night I was being given medication and had a food tube down my nose. I started regurgitating. It had come up out of my stomach. I was trying to make the nurse understand that I was regurgitating and for her to stop pumping anything more into my stomach. And it really got so bad that I ended up with a code 99. ‘No.’ I just kept shaking my head, No, don’t do that’…. (Fried-Oken, Howard & Stewart
Furthermore, the need to communicate vital information and to express basic physical needs (i.e. pain and discomfort, difficulty breathing, use of restraints and suctioning) is recognised by nurses managing the ICSs (Ten Hoorn et al.
Augmentative and alternative communication strategies can facilitate communication for patients in the ICS who are vulnerable communicators (Beukelman & Mirenda
According to Wloszczak-Szubzda and Jarosz (
The main aim of this study was to compare the perspectives of nurses regarding communication with patients in an ICS by using an augmentative and alternative communication intervention strategy, namely the translated Setswana Vidatak EZ BoardTM. Perspectives were measured before training, after a training session and after the communication board had been implemented for a 2-week period. Furthermore, the study aimed to expand ICS nurses’ knowledge and skills regarding communicating with patients in an ICS.
A quasi-experimental pre-test post-test group design, from which participants were free to withdraw, as well as a control group, was used for a total of three measurement points.
A 1650-bed public hospital with a 26-bed ICS (six beds reserved for cardiothoracic patients in the ICS and the rest to accommodate patients with other aetiologies) in a semi-urban, low socio-economic area in South Africa served as the research setting. This training hospital serves primarily Setswana-speaking patients.
Purposive sampling was used and nurses who met the following requirements were included: being a registered or enrolled nurse; working in the ICS for at least 3 months; and competent in spoken and written English and Setswana. Forty informed consent letters were distributed to potential participants, of whom 30 consented to participate. Of these 30 participants, all but one was female and their descriptive information is shown in
Participant description (
Variable | Experimental group ( |
Control group ( |
---|---|---|
Range | 24–57 years | 25–60 years |
Mean | 36.5 | 49.9 |
s.d. | 10.5 | 11.3 |
Registered nurse who specialises in critical care | 33 | 60 |
Registered nurse with experience in critical care | 60 | 33 |
Enrolled nurse | 7 | 7 |
Post-basic diploma in critical care nursing | 33 | 47 |
Post graduate diploma in critical care nursing | 7 | 13 |
Other (e.g. diploma in general nursing) | 60 | 40 |
Range | 0.42–21 years | 1–28 years |
Mean | 6.36 | 10.6 |
s.d. | 7.66 | 9.34 |
ICS, intensive care setting; s.d., standard deviation.
Language proficiency.
Proficiency | Good (%) | Average (%) | Poor (%) | Good (%) | Average (%) | Poor (%) |
---|---|---|---|---|---|---|
Speak English | 100 | 0 | 0 | 87 | 13 | 0 |
Read English | 100 | 0 | 0 | 93 | 7 | 0 |
Write English | 100 | 0 | 0 | 100 | 0 | 0 |
Speak Setswana | 93 | 7 | 0 | 93 | 7 | 0 |
Read Setswana | 87 | 0 | 13 | 93 | 7 | 0 |
Write Setswana | 87 | 0 | 13 | 80 | 20 | 0 |
The intervention in this study entails the use of augmentative and alternative communication strategies implementing the Vidatak EZ Board™, a low-technology communication board that was specifically developed for patients in the ICS who experience communication difficulties (Patak et al.
Following permission from the developer, the board was translated into Setswana because it is the official South African language spoken by the community in the region where the board was used (South Africa information
An example of the Setswana Vidatak EZ Board™ is shown in Online Appendix 1.
As this study employed a quasi-experimental pre-test post-test group design, the experimental group had to receive training to improve their knowledge on the implementation of the augmentative and alternative communication intervention strategies using the translated Vidatak EZ Board™. A detailed discussion on this training programme is as follows.
The first author, a speech-language therapist, conducted the training using a PowerPoint presentation displayed on a laptop. A training programme was developed based on that of Radtke and colleagues (
Apart from the Vidatak EZ Board™ and the training programme that were used during the intervention and training as discussed earlier, a customised three-section questionnaire (Online Appendix 2) was developed based on surveys by Costello, Patak and Pritchard (
Data collection commenced after ethics approval and permission from the relevant authorities. Participants were purposively assigned to either the experimental or control groups. The first 15 nurses who worked the day shift and consented to participate formed the experimental group and the first 15 nurses who worked the night shift and consented to participate constituted the control group.
The following procedures were followed for the experimental group: After a meeting with the unit manager, a time was scheduled to visit the ICS nurses during their tea break to explain the aim, duration and procedures of the study. This process was repeated on several days to recruit nurses from different day shift groups. Once ICS nurses confirmed their intent to participate, informed consent letters were distributed with the pre-test questionnaires. The first author negotiated a time and date for training with each participant individually. On the day of the scheduled training, signed consent forms and pre-test questionnaires were collected, followed by an hour-long training session on how to communicate with a patient using a translated communication board. Each nurse received a Setswana Vidatak EZ Board™ during training and had 2 weeks to implement the augmentative and alternative communication strategies with patients in the ICS. During this time, the researchers had no contact with the participants. Post-test 1 was distributed 2 weeks after training at the start of their shift, and the completed test was collected at the end of their shift on the same day. Following the same procedure, post-test 2 was completed 2 weeks after post-test 1.
For the control group, the procedures for recruitment and testing were identical to those for the experimental group, except that they did not receive training or the Vidatak EZ Board™ and only completed the pre-test and post-test 1 after 2 weeks.
A rigorous blind-back translation procedure ensured the construct validity and cultural equivalence of the translated measure. Soliciting expert input confirmed face validity while test-retest reliability and stability was addressed through the use of the same questionnaire for the pre- and post-tests. The potential carry-over effect was acknowledged by allowing a time lapse of two weeks between the pre- and post-test measurements.
This study used non-parametric statistics to analyse the ordinal data (Field
This research was approved by the Research Ethics Committee of the University of Pretoria and has been conducted according to the Declaration of Helsinki Code of Ethics of the World Medical Association (2013).
Data were compared for pre-test and post-test 1 measures between experimental and control groups.
Between-group comparisons on the items that were significantly different on the Mann–Whitney U test for the experimental group and the control group.
Items and categories | Test | Differences in mean ranks between experimental (E) and control (C) groups | ||
---|---|---|---|---|
Patient’s speech is not understandable (dysarthria) | Pre-test | E < C | 51.5 | 0.0431 |
Patient has a history of a stroke | Pre-test | E < C | 56.5 | 0.0073 |
I use a communication board | Post-test | E > C | 157.0 | 0.0176 |
I use sign language | Post-test | E < C | 63.0 | 0.0170 |
I use a communication device | Post-test | E > C | 132.0 | 0.0310 |
I provide patient with hearing aids | Post-test | E < C | 58.0 | 0.0318 |
ICS has limited privacy | Post-test | E < C | 49.5 | 0.0365 |
ICS, intensive care setting.
Regarding the question as to how nurses currently communicate with their patients in an ICS, results suggest that the participants in the experimental group used communication boards more frequently than those in the control group (
Individual participant responses in the pre-test and post-test for the experimental group and the control group. ICS, intensive care setting.
Regarding the frequency of using a particular method to communicate with patients: after training, the experimental group used both a communication board (
The item
To determine the effect of training, a Friedman two-way analysis of variance (ANOVA) was conducted for three measures (pre-test, post-test 1 and post-test 2). Significant results (
Within-group comparison on the items that were significantly different on the Friedman test for the experimental group.
Items and categories | Statistic | |
---|---|---|
I use a communication board | 8.7200 | 0.0128 |
I use my mouth or lips | 7.7857 | 0.0204 |
I use a communication device | 11.4375 | 0.0033 |
I am not easily available in the ICS | 6.5000 | 0.0388 |
I have to focus on the health issues | 7.1818 | 0.0276 |
ICS, intensive care setting.
Regarding the category on how nurses currently communicate with their patients in an ICS, results suggest that there was a significant difference in responses across three measures for two items, namely for the use of a communication board and for the use of mouth or lips. In
Individual participant responses for pre-test, post-test, and post-test 1 for experimental group.
Unlike the between-group comparison, which did not show a statistically significant difference between any of the items for the category related to the frequency with which participants thought specific nurse-related characteristics resulted in communication barriers, two items yielded significant results within the experimental group, namely ‘I am not easily available in ICS’ (
Apart from the quantitative results, some qualitative comments were made related to suggestion for specific adaptations to the communication board, for example to enlarge the font on the boards (‘make the written words bigger’) and decrease the number of written word options on the board (‘there are too many words on the board’; ‘let the patient only choose between a few words because they are very ill and will struggle to read through all the words’). Examples for one word options that were provided were ‘pain’, ‘uncomfortable’, ‘thirsty’ and ‘help’.
This study investigated nurses’ perspectives regarding the use of a communication board, specifically a translated Vidatak EZ BoardTM, as an augmentative and alternative communication intervention strategy in the ICS following a brief training session. Although there is general consensus that communication is a vital component in the provision of appropriate patient care (Hemsley et al.
Despite a relatively small number of participants (
Another possible reason could be related to the training content. The training content focused on knowledge (e.g. increasing nurses’ understanding of the value of communication using communication boards) without focusing on the skills component (e.g. more hands-on practice opportunities) or the attitude component (Wloszczak-Szubzda & Jarosz
The short training that was conducted in this study certainly changed the initial behaviour of participants; however, the results were not sustained. Because communication skills are acquired through practice, follow-up training by means of additional practical exercises is suggested to reinforce the initial training on the use of the communication board (Wloszczak-Szubzda & Jarosz
For the patient-related category, there were differences (prior to the training) between the control group and the experimental group for two items: ‘Patient’s speech is not understandable’ (
The primary strength of this study is that most participants agreed that communication is critical to providing optimal health care in ICS settings. Specifically, preliminary data indicate potential for success in using a communication board in ICU settings. To limit knowledge transfer between the two groups and enhance internal validity, the participants who worked day shift were enrolled in the experimental group and those working night shift were allocated to the control group. The primary limitations were small sample size and lack of random assignments to experimental and control groups. Non-parametric statistics (typically used with small groups) were used to analyse the data, thus limiting the generalisability of the results.
It is suggested that future researchers consider investigating ICS patients’ and nurses’ perceptions on the contents of a communication board for use in ICSs in the South African context – this could be done either through focus groups or semi-structured or cognitive interviews with ICS nurses or critically ill participants who were admitted to ICSs and experience communication difficulties. Additionally, different types of training (e.g. case-based training spread over consecutive days using a problem-based learning focus) should be explored in an attempt to regulate the maintenance and generalisation of the communication board use after training. Further research on evaluating the perspective of nurses regarding the use of an English communication board with their patients will have clinical significance.
This study is an attempt to provide preliminary empirical data on a communication tool in ICS. Despite a strong agreement on the issue of communication enhancement by critical care nurses, the lack of empirically based communication intervention strategies can lead to serious health repercussions. Participants agreed that communication is crucial in the ICS and that a communication board can be used successfully. However, only limited success was observed with the implementation of the board over time, possibly because of the brief training that was provided. This indicates that sustainable change is difficult to achieve with a short knowledge-based training session. It is therefore critical that the nurses and speech-language therapists work together to provide optimal health care to patients in ICS through the implementation of augmentative and alternative communication strategies.
The authors wish to thank the hospital manager for permitting the nurses from his hospital to participate. They also wish to thank the participants for their valuable contributions. This study was conducted as part of a Master’s dissertation by the first author (M. G.). The authors alone are responsible for the content and writing of this article.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
M.G. was the Master’s student who performed the experiments. J.B. and E.J. were the supervisors responsible for the experimental and project design. M.G., J.B., E.J. and R.K. made conceptual contributions. R.K. prepared the samples and performed the calculations. M.G., J.B., E.J. and R.K. co-wrote the manuscript.
This study was supported by a Research Development Programme grant of the University of Pretoria and a Fulbright Specialist Program.
Data sharing is not applicable to this article as no new data were created or analysed in this study.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.