Improving Communication in the ICU
Many tools and strategies exist to help caregivers understand the needs
of patients unable to express themselves
By Ruth M. Kleinpell, PhD, RN, FAAN, Lance Patak, MD, MBA, Amy Wilson-Stronks, MPP, CPHQ, John Costello, MA, CCC-SLP, Colleen Person, MMA, BSN, RN, Elizabeth A. Henneman, PhD, RN, FAAN, & Mary Beth Happ, PhD, RN, FAAN
Posted on: July 13, 2009
Communication is essential to effective care in the hospital setting, especially in the ICU where patients can experience altered communication abilities due to their critical illness. Patient outcomes are influenced by patients' abilities to communicate effectively and participate in their care.
The importance of communication and its impact on patient outcomes is recognized by several entities, including the Joint Commission, the Society of Critical Care Medicine (SCCM), and the NIH.1-3
Recent recommendations from the American College of Chest Physicians and the American Association of Critical-Care Nurses focus on the importance of skilled communication as an essential element of providing care for acute and critically ill patients.4SCCM's clinical practice guidelines for patient-centered care in the ICU also advocate for effective communication to enhance care for ICU patients.5
Communication Barriers
Patients in the ICU can experience altered communication abilities due to their critical illness (e.g., extreme weakness, fatigue, immobilization, deconditioning) and various treatments (e.g. intubation, tracheostomy). Barriers to verbal communication, such as endotracheal intubation and mechanical ventilation, can prevent speech, making communication difficult.
The administration of sedative medications also may limit the ability of the patient to understand information.6In addition, patients may experience communication difficulties and disabilities, including linguistic, cultural, behavioral, and physical barriers (e.g., the patient wears glasses or uses hearing aids or the patient does not speak/understand English).
Ensuring adequate communication for ICU patients is an important priority area for care as communication difficulties and disabilities experienced by patients may increase their risk for adverse events or medical errors.7,8
Patients in the ICU who are unable to communicate verbally may use nonverbal communication techniques to relate their needs, such as mouthing words, writing, or using gestures. However, these techniques, which can be subjectively interpreted by communication partners, may lead to misinterpretation of patient intent, further contributing to patient frustration and distress.9-13Still, patients report employing communication aids such as prefabricated patient communication boards can reduce their frustration with the inability to verbally communicate.14
Tools & Strategies
Several tools and strategies can be used to enhance communication in the ICU for patients with altered communication abilities. Many patients may be candidates for augmentative communication tools like alphabet or communication boards and other readily available resources such as pen and paper, etc., which should be available at the bedside.
An augmentative communication consultation with speech-language pathology services may yield more patient-specific tools and strategies. Further, strategies such as the use of qualified healthcare interpreters, communication skills training, and family care conferences are critical toward addressing the complex needs of a patient who cannot effectively communicate in the healthcare setting.
Patients who are hearing-impaired and rely on hearing aids or are vision-impaired and need glasses should have access to these devices as soon as a procedure or test that restricted access is complete. This simple solution can often be overlooked or dismissed, secondary to the presumption that a patient is not ready or has her needs met adequately by a family member.
All devices essential for communication should be documented in the patient's plan of care. To optimize both practitioner and patient efforts in overcoming patient communication impairments, such tools should be evidence-based when available.
Readily available resources to aid in communication should not only be present in the ICU, but also a mainstay of an ICU patient's daily plan of care. In addition, healthcare practitioners should be trained to value the importance of using such devices identified in the patient's plan for care.
Adopting patient communication assessment and interventions as routine care for ICU patients can be formally incorporated using an ICU daily goal worksheet. This worksheet incorporates patient communication into the plan of care and allows for the daily assessment and evaluation of effectiveness of communication aids, resources and interventions, as well as the need to request a referral to a communication specialist when point-of-care resources fail to achieve stated goals.15-18
Professional healthcare interpreters should be used whenever a language barrier is present or when a patient who is deaf communicates via sign language. The use of ad hoc interpreters such as family members or untrained bilingual hospital staff can lead to increased miscommunication and medical errors, which can result in ineffective patient communication.19-21
To prevent communication errors, trained medical interpreters should be used to provide accurate interpretation of communications between the healthcare team and the ICU patient and/or family members. However, research has indicated that, even with the use of trained medical interpreters, inaccuracies in communication can occur.22 herefore, it becomes important to validate the ICU patient and/or family members have a correct understanding of information that is communicated.
Translation communication boards are available; however, to date they have not been tested or evaluated for effectiveness. Although a translation communication board may not be comprehensive, it may provide the prompt to obtain an interpreter when otherwise the patient's nonverbal communication cues may not be understood or may be misread.
Members of the ICU team, including physicians, respiratory therapists, nurses, therapists from various other disciplines, and other staff need to be trained on how to work effectively with an interpreter and to know when to consult speech-language pathology clinicians. In addition, training should be conducted on the organization's policy for obtaining language access services and how those services should be documented.
Targeting Communications
these multidisciplinary resources should be made when a patient's communication needs exceed the resources and training available to the patient at the point of care.24Communication skills training also can be used to improve patient/provider communication. Healthcare providers need to be aware of the resources available and trained on the importance of incorporating communication aids into routine care for ICU patients; this includes when and how to use each resource.25-26
In targeting communications with family members of the acute and critically ill ICU patient, family care conferences can be used to enable focused discussion of patient care issues and promote understanding and communication of patient preferences for treatment. As some patients in the ICU lack the ability to communicate, family care conferences play an important role in enhancing communication with family members and in medical decision-making in the ICU.27However, the family care conference should not be the only point for engaging the family, especially when working with the healthcare proxy. Healthcare proxies should have access to the entire care team, especially when the patient is unconscious.
Priority Area
The literature on health literacy pertaining to hospitalized patients acknowledges the importance of making effective communication a priority to ensure patient safety and to address patient communication needs.28As patients in the ICU are often prone to altered communication abilities, it becomes especially important that effective communication is recognized as an a priority area of focus for care. Improving patient/provider communication in the ICU is vital to improving the quality of patient care, patient safety, patient outcomes and patient satisfaction with care.
References
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