Communication interaction with intubated patients: what are the values and practices of intensive care nurses?

Abstract

Aim: The aim of this study was to explore and describe the values and practices of intensive care nurses towards communication interactions with critically ill patients in the adult intensive care units at a public hospital in Johannesburg. Setting: The setting for the study was two adult intensive care units at a university-affiliated, public sector and tertiary level healthcare institution in Gauteng province, South Africa. Research Methods: An explanatory sequential mixed methods design that comprised both quantitative and qualitative methods was used. The study was conducted in phases, phase one (objective 1 & 2) focused the qualitative component of the study while phase two (objective 3) focused on the qualitative component. The first objective (step 1) of this study was to observe and describe the frequency and content of nurses’ communication interaction with intubated patients. An observational tool developed by Sayler and Stuart (1985) was used to observe patient and nurse interactions in order to achieve this study objective. The second objective (step 2) was to describe the value nurses place on communication with patients by soliciting their thoughts and feelings about communication with critically ill patients. A survey questionnaire developed by Binn (1998) was used to achieve the study objective. The third objective was to explore the nurses experience of tools and strategies used during communication with intubated patients. This was achieved by using individual semi structured interviews. Data analysis: The quantitative data analysis was analysed using descriptive summary statistics such as frequencies, percentages, means, medians, IQR, and standard deviations. Statistical tests included Chi-square tests, Fisher’s exact test, .Mann Whitney test and linear regression. Statistical testing was done on the 0.5 (p<0.05) level of significance. All data was analysed using the statistical software package STATISTICA version 13.2. Also, the qualitative data were analysed using the Clarke and Braun (2013) method. Themes and sub-themes were identified and reported in the narrative. Results- Phase One – Objective 1 A total of 60 (n=60) participants were involved in this component of the study. The study comprised two steps. Step 1 involved 36 (n=36) nurses and 24 (n =24) patients who were observed to describe the frequency and content of nurses’ communication interaction with intubated patients. The results demonstrated silence as the most frequently occurring action-reaction interaction. Findings also indicated that positive nurse action yields a positive patient reaction and that a negative nurse action yields a negative patient reaction, this is true for actions initiated by the patient as well. Results- Phase One – Objective 2 involved 110 nurses who participated in a survey; findings demonstrated by a low median score was that nurse participants considered themselves to have good communication skills. Nurses agreed that they are motivated to communicate with patients who can tell them how they feel and what they need. Sedation was also believed to be a necessary component to reduce anxiety in patients who are intubated and mechanically ventilated. Nurses refuted statements relating to justifications for the reduced need to communicate with patients who are intubated. The survey revealed that nurses do not prioritise physical treatment implications. A deterrent for communication could be linked to emotional implications associated with the communication.

Results- Phase Two – Objective 3 A total of twenty (n=20) nurse participants were interviewed to explore nurses’ experiences of tools and strategies used during communication with intubated patients. The findings demonstrated that communication breakdown frequently occurs due to challenges associated with alternative communication strategies, this leads to frustration for the patient and the nurses as well. A variety of alternative communication strategies were used as well as strategies to enhance comprehension of the content being communicated. The most commonly used alternative communication strategy was writing with pen and paper (65%) furthermore innovative alternatives such as the use of mobile phones were also identified. Factors affecting communication were identified to stem from nurse related factors as well as patient-related factors. Nurse related factors included being gentle, confident, repeating and keeping the patients informed. Patient-related factors included limb weakness and paralysis, cognitive deficiency and delirium, fluctuating medical condition and variations in spoken languages. Conclusion: This study has demonstrated a disparity between nurses values and nurses practice regarding communication interactions with intubated patients. During surveys and interviews nurses have demonstrated that they are aware role of communication in patient care. However, during the observation component, it was found that nurses were silent during majority of the interactions. Recommendations: The findings of this study provide evidence that supports the theory – practice gap in the ICUs that call for training and educational interventions. This will enhance the focus of nurses within the clinical area, and it is imperative that professional development, in terms of alternative communication strategies is carried out.