Abstract

In recent years, with the reduction in sedation use among mechanically ventilated patients, research indicates that a considerable number of patients stay conscious yet are incapable of verbal communication. The presence of an endotracheal tube or tracheostomy cannula, necessary for mechanical ventilation, disrupts or even prevents communication in these patients. As a result, communication challenges pose a major problem for patients receiving mechanical ventilation in intensive care units (ICUs), as well as their families and healthcare providers. These patients face considerable challenges in communication, as they are unable to convey verbal messages or respond to communication attempts. Only a small percentage of the messages conveyed by mechanically ventilated patients are received and understood by healthcare providers, indicating communication difficulties compounded by comprehension challenges. Effective communication with awake and responsive patients during mechanical ventilation facilitates early extubation and reduces ICU stay durations. Nurses must be well-versed in and must apply appropriate communication methods. Additionally, the use of various communication tools, such as low-tech communication boards, high-tech tablet computers, and communication cards, with great awareness is crucial for effective communication with this patient group. The aim of this review is to examine the effects of communication tools used with patients undergoing mechanical ventilation in ICUs on the communication between patients and health workers.

INTRODUCTION

When examining sedation strategies applied to patients in intensive care during the last three decades, a transition has occurred from deep sedation practices to lighter sedation in terms of duration and intensity.^1-3 It is an established fact that a significant number of patients remain conscious and responsive during mechanical ventilation, yet are unable to speak due to the use of artificial airways.^{2, 4, 5} Approximately 40% of intensive care unit (ICU)  patients require endotracheal intubation or tracheostomy, which can impair their verbal communication.⁵ During this process, the inability to speak among a considerable number of patients is frequently coupled with physical weakness, resulting in the incapacity to use gestures.⁶ Consequently, there are challenges in receiving and understanding the messages conveyed by mechanically ventilated patients. Only about 5% of the messages patients attempt to convey are correctly perceived and understood by healthcare providers. This indicates that communication difficulties reported by 50% of mechanically ventilated patients are compounded by comprehension and perception challenges.^{5, 7}

Communication difficulties pose significant challenges for mechanically ventilated patients in ICUs, their families, and healthcare providers.⁸ Literature reviews reveal that various communication methods have been created and implemented in clinical settings to address communication issues with mechanically ventilated patients.^{1, 2, 5, 9-14} There are limited comprehensive studies in the current literature that cover all communication tools used in intubated patients. Considering the clinical impacts and benefits, along with the current gaps in the literature, this study seeks to elucidate the barriers to communication with mechanically ventilated ICU patients. Additionally, it seeks to evaluate and improve the effectiveness of communication, and develop new communication strategies by discussing the benefits of different communication tools and offering a perspective on existing deficiencies. In this context, addressing communication with conscious mechanically ventilated patients; the challenges of communication; the techniques used; and the materials employed for communication, along with their benefits, is believed to significantly enhance and facilitate nurse-patient communication.

Communication Methods and Tools Used in Patients Who Cannot Communicate Verbally

In ICUs, both verbal and non-verbal communication methods are used with mechanically ventilated patients, considering their health status and communication abilities. Different communication techniques can be employed simultaneously with the same patient.¹⁵

Common non-verbal communication methods used in ICUs include hand, eye, and head movements, gestures, eye-letter coding, writing yes-no questions, and lip reading.^{7, 9, 14, 16, 17} However, the lack of lip-reading skills among healthcare providers often leads to misunderstandings. Additionally, these time-consuming methods can drain patients’ energy, leaving them unable to communicate effectively.^{2, 7, 18}

To overcome these challenges, various communication tools have been developed for non-verbal patients.¹⁴ These tools typically include expressions related to physical needs (e.g., thirst, toilet needs), emotional states (e.g., anger, anxiety), requests (e.g., massage, turning lights on/off), hygiene needs (e.g., oral care), titles of healthcare providers (e.g., doctor, nurse), and pain assessment scales.^{7, 14}

Augmentative and alternative communication (AAC) methods, which include both aided and unaided techniques, have been developed to address communication deficits. Unaided techniques involve non-verbal communication methods (e.g., facial expressions, body posture, gestures), while aided techniques include low-tech and high-tech interfaces.^{1, 5} Low-tech AAC materials include writing tools, communication boards, and pain charts, whereas high-tech AAC materials encompass computer-based communication applications, tablet computers, eye-tracking devices, and speech-generating devices.^{2, 5, 12, 13} High-tech communication methods and communication boards are considered more user-friendly than other methods.^{5, 10, 11, 19} However, a consensus has yet to be reached regarding the most appropriate communication tool for ICUs, and more comparative research is needed.²⁰

A Look at Studies Examining the Effectiveness of Communication Tools in Mechanically Ventilated Patients

It is evident that effective communication is of paramount importance in determining the course and outcome of patient treatment. Therefore, addressing communication problems in mechanically ventilated patients is of utmost importance.²¹ In healthcare settings where services are meticulously provided, patient-centered communication enhances patient satisfaction, improves health outcomes, and increases care quality. However, patients who cannot communicate verbally due to illness or treatment processes often struggle to convey their needs to nurses or other healthcare providers.²² In this context, examining the communication tools used with mechanically ventilated patients is crucial (Table 1).

An examination of studies conducted over the last ten years (2014-2023) reveals that low-tech communication tools developed for conscious patients in ICUs in our country include “pictorial communication materials”⁷, “pictorial communication cards”⁹, and “visual communication guides”¹⁶. High-tech communication tools include “computer-based communication tools” and “AAC systems (AACS) prototypes”¹⁴. Studies indicate that communication boards, a low-tech communication tool, are highly beneficial and effective in facilitating communication among patients, their families, and nurses.^{2, 10, 11, 21, 23-26} Examples of communication boards are provided in Figures 1,2.²³

Additionally, studies have utilized tablet computers^{6, 27}, eye-tracking communication devices^{28, 29}, voice-activated systems^{30, 31}, and advanced support systems such as speech-generating devices^{32, 33} among the high-tech communication tools in the literature. Studies examining the effectiveness of communication tools used with mechanically ventilated patients are summarized in Table 2.

CONCLUSION

Communication difficulties between healthcare providers and mechanically ventilated patients in ICUs are common. The findings of the studies reviewed in this article suggest that both low-tech and high-tech communication tools used in ICUs can be effective in improving communication between ICU patients and healthcare providers. The use of low-tech and high-tech communication tools can enhance communication and improve patient-centered outcomes. A combination of methods is recommended. However, the implementation of advanced eye-tracking-based communication devices in ICU practices can significantly contribute to patient-centered care by improving communication in mechanically ventilated patients. Furthermore, integrating technological advancements into care will enhance the satisfaction of both patients and healthcare providers in this group, as well as improve nursing care outcomes.