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ntensive and Critical Care Nursing (2012) 28, 16—25

Available online at www.sciencedirect.com

j o ur nal homepage: www.elsev ier .com/ iccn

RIGINAL ARTICLE

urses’ perceptions of communication training in theCU

ill V. Radtkea,1, Judith A. Tatea,2, Mary Beth Happa,b,c,∗

Department of Acute & Tertiary Care, University of Pittsburgh School of Nursing, 336 Victoria Building, 3500 Victoria Street,ittsburgh, PA 15261, United StatesDepartment of Critical Care Medicine, University of Pittsburgh School of Medicine, 336 Victoria Building 3500 Victoria Street,ittsburgh, PA 15261, United StatesCenter for Bioethics and Health Law, University of Pittsburgh, 336 Victoria Building 3500 Victoria Street, Pittsburgh, PA 15261,nited States

Accepted 15 November 2011

KEYWORDSAugmentative andalternativecommunication;Patientcommunication;Intensive care;Critical care;Communicationtraining;Nurses healthknowledge;Attitudes

SummaryObjective: To describe the experience and perceptions of nurse study participants regardinga communication intervention (training and communication tools) for use with nonspeaking,critically ill patients.Research methodology/design: Small focus groups and an individual interview were conductedwith six critical care nurses. Transcripts were analysed using qualitative content analysis andconstant comparison.Setting: Two ICUs within a large, metropolitan medical centre in western Pennsylvania, UnitedStates of America.Main outcome measures: Critical care nurses’ evaluations of (1) a basic communication skillstraining programme (BCST) and (2) augmentative and alternative communication strategies(AAC) introduced during their study participation.Results: Six main categories were identified in the data: (1) communication value/perceivedcompetence; (2) communication intention; (3) benefits of training; (4) barriers to implementa-tion; (5) preferences/utilisation of strategies; and 6) leading-following. Perceived value of andindividual competence in communication with nonspeaking patients varied. Nurses prioritised

communication about physical needs, but recognised complexity of other intended patient mes-sages. Nurses evaluated the BCST as helpful in reinforcing basic communication strategies andfound several new strategies effective. Advanced strategies received mixed reviews. Primarybarriers to practise integration included patients’ mental status, time constraints, and the smallproportion of nurses trained or knowledgeable about best patient communication practices inthe ICU.

∗ Corresponding author. Tel.: +1 412 624 2070; fax: +1 412 383 7227.E-mail addresses: jvr5@pitt.edu (J.V. Radtke), jta100@pitt.edu (J.A. Tate), mhapp@pitt.edu (M.B. Happ).

1 Tel.: +1 724 622 6371.2 Tel.: +1 412 624 5872.

964-3397/$ — see front matter © 2011 Elsevier Ltd. All rights reserved.oi:10.1016/j.iccn.2011.11.005

Nurses’ perceptions of communication training in the ICU 17

Conclusions: The results suggest that the communication skills training programme could bevaluable in reinforcing basic/intuitive communication strategies, assisting in the acquisition ofnew skills and ensuring communication supply availability. Practice integration will most likely

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Introduction

As a direct result of critical illness and its management, ICUpatients and their caregivers are vulnerable to communi-cation breakdown and associated adverse sequelae. Nursesare the most frequent communication partners to criticallyill patients during the period in which they are unable tospeak. However, nurses do not typically receive training inspecialised communication assessment or techniques to usewith nonspeaking patients. Rather, ICU nurses report learn-ing how to communicate with intubated patients throughtrial and error and by observing others (Hemsley et al., 2001;Leathart, 1994a; Magnus and Turkington, 2006). Nursesreport feeling frustrated by communication difficulties andadmit to avoiding patients with whom communication isdifficult (Alasad and Ahmad, 2005; Bergbom-Engberg andHaljamae, 1993; Magnus and Turkington, 2006). Interpret-ing patients’ communication attempts may not be prioritisedin ICUs, where management of complex medical equipmentand delivery of life-sustaining treatment takes precedence.Communication exchanges are often limited to brief, task-or procedure-related statements initiated and controlledby the nurse or healthcare provider (Ashworth, 1980; Hall,1996; Happ et al., 2011; Salyer and Stuart, 1985). Suchone-sided communication thwarts novel patient messages,excludes the patient from treatment decision-making, andleads to patient distress, frustration, loss of sense of con-trol and withdrawal (Bergbom-Engberg and Haljamae, 1989;Happ, 2000; Patak et al., 2009; Wojnicki-Johansson, 2001).

Communication training programmes for nurses havebeen developed and tested in oncology and long-term caresettings (Buckwalter et al., 1988; Burgio et al., 2001;McCallion et al., 1999). Researchers in Mexico evaluated theeffect of a nurse training programme on perceived well-being and medical recovery of ICU patients (de los RiosCastillo and Sanchez-Sosa, 2002). The training programmefocussed on relational interactions (e.g., smiling, touching,praising, eye contact) rather than assistive communicationassessment and techniques. There are no published reportsof nurses’ experiences of training in assistive communicationassessment and techniques with nonspeaking patients in theICU. The SPEACS (Study of Patient—Nurse Effectiveness withAssisted Communication Strategies) study is the first to testthe efficacy of training and the provision of communicationmaterials on nurse—patient communication in the ICU (Happet al., 2008).

The purpose of this article is to describe nurses’experiences and perceptions regarding a communicationintervention (nurse training and communication tools) foruse with non-speaking patients in the intensive care unit,implemented as part of the SPEACS study (Happ et al.,

2008). We obtained nurses’ opinions about their experi-ences in the basic communication skills training programme(BCST), delivered in Phases 2 and 3 of the SPEACS study, and

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heir perceptions of electronic communication devices andpeech and language pathologist support, delivered in Phase

only.

ethods

tudy background

he SPEACS study was guided by a model of nurse—patientommunication, developed and refined by Dr. Happ andolleagues (Campbell and Happ, 2010; Happ, 2000), inhich the intervention is posited to impact communica-

ion performance (proximally) and nursing care quality andlinical outcomes (distally) for communication vulnerableCU patients. Intervention content was consistent with therinciples of augmentative and alternative communicationAAC) (Beukelman et al., 2007) and relationship-centredare (Koloroutis, 2004). Nurses in Phase 1 of the study wereonsidered a control group, and therefore received no com-unication training. In Phase 2, nurse participants received

he BCST. This programme, taught by a speech and languageathologist (SLP), introduced augmentative and alternativeommunication (AAC) techniques relying on familiar, intu-tive communication modalities, including writing, mouthingnd gesturing, in addition to more specialised communica-ion boards, hearing and vision aids. For example, patientsith intact cognition and mouthing abilities (i.e., those with

racheostomy) are presented with an alphabet board andsked to point to the first letter of the intended word orhrase whilst mouthing it to improve interpretability of lip-eading. This technique is referred to as ‘‘mouthing with firstetter spelling’’ (Beukelman and Yorkston, 1977; Yorkstont al., 2004). Examples of additional strategies taught asart of the BCST are listed and described in the glossaryTable 1).

Nurses participating in Phase 3 of the SPEACS studyeceived additional instruction on the use of electronic com-unication devices, including electrolarynxes, hearing-aid

mplifiers and electronic typing and menu-selection devicesith speech generating functions. Nurses in Phase 3 hadngoing, individualised consultation with a speech-languageathologist interventionist who assessed and initiated imple-entation of the communication devices/strategies with

ach study patient.

etting

CT-ICU) in a large, metropolitan medical centre in westernennsylvania, United States of America (USA). Discussionsook place in a private hospital conference room away

18 J.V. Radtke et al.

Table 1 Glossary of assistive communication strategies.

Strategy Description/purpose

Gaining attention and making eyecontact

Ensuring patient and nurse focus oneach other’s faces and messages

(Light and Binger, 1998)

Confirming all patient messages Validating that messages are understood by repeatingmessage or understanding of message(Beukelman and Mirenda, 2005;

Hemsley et al., 2001)Establishing clear YES/NO signal Ensuring that signal for YES-NO can be consistently executed

and remembered by patient, and understood by others(Beukelman and Mirenda, 2005;Hemsley et al., 2001)

Patient gesture or signal dictionaries Displayed list of frequently used patient-specificgestures or signals and their meanings(Beukelman and Mirenda, 2005;

Connolly, 1992)Pause time Allowing increased time between communication

exchanges to facilitate patient thought processing(Basil, 1992; Calculator, 1988; Lightand Binger, 1998)

Partner-assisted scanning Patient confirms correct row of, and then actual letter/word/picture ona communication board, as CP announces it aloud(Beukelman et al., 2007; Beukelman

and Mirenda, 2005)Written choice strategy CP asks questions, writes possible answers using key words in large print,

reviews the choices aloud whilst pointing to them, and instructs the patient topoint or signal YES/NO to the most accurate answer

(Garrett and Beukelman, 1992, 1995;Garrett and Huth, 2002)

Tagged YES/NO strategy CP asks a question and tags the end with ‘‘Yes. . .or No?,’’ alertingpatient to response choices(Beukelman and Mirenda, 2005;

Binger and Light, 2007)Messaging strategy Patient composes written message in advance, for CP to read upon

return to room, conserving HCP time and patient energy(Beukelman and Mirenda, 2005;Garrett et al., 2007)

Eye gaze board An eye gaze communication board is a vertically held/mountedboard, made of Plexiglas or sturdy paper with a window cut in themiddle. A person with severe speech and motor impairmentscommunicates by focussing their gaze on selected items (symbols,

) disp

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rom the clinical units. A light dinner was provided for allarticipants.

thical approval

his study received Institutional Review Board approval andaintained compliance with ethical standards set forth by

he University Institutional Review Board.

articipants

ll SPEACS nurse participants who received BCST (Phases 2nd 3) and were still practising in their study ICUs werenvited to participate in focus groups. Recruitment wasependent on nurse availability to attend a focus groupnd aimed for variability in ICU, gender and critical carexperience. Two small groups (2—3 nurses per group) andn individual interview for a nurse unable to attend a

roup were conducted after Phase 3 (2009). In total, sixritical care nurses participated. This was considered a rep-esentative proportion of the 26 ICU nurses who originallyeceived BCST training in the SPEACS study (>20% of the total

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layed in quadrants or sections of the board.

umber of nurses trained). Several SPEACS nurse partici-ants left the unit or hospital before this follow-up studyas conducted. Although the timing of the focus groups

‘limited’’ our sample to mostly Phase 3 nurses (5 out of), we consider these nurses ‘‘best’’ informants, as theyeceived all components of the communication interventionBCST and advanced training with electronic devices). Infor-al group feedback after Phase 2 was used for interventiononitoring and was not included in the results. See Table 2

or participant characteristics.

ata collection

he focus group interviews utilised a traditional research-riented format (e.g., moderator interviewing participantss a group regarding a common experience), although groupsere unconventionally small (e.g., 2—3 participants). Focusroups were considered a suitable data source for this study

ue to their utility in generating rich discussions basedn individual perceptions and reactions to others’ percep-ions of a shared experience (Patton, 2002). Because thenterviews were conducted some time after actual study

Nurses’ perceptions of communication training in the ICU 19

Table 2 Study participant characteristics.

Total participants Group #1 Group #2 Individual interview(n = 6) (n = 2) (n = 3) (n = 1)

Study phase*

2 1 0 1 03 5 2 2 1

Participant sexFemale 5 2 2 1Male 1 0 1 0

UnitCTICU 2 0 1 1MICU 4 2 2 0

Years of critical care experience<1 year 0 0 0 01—5 years 4 2 2 05—10 years 1 0 0 1≥11 years 1 0 1 0

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Phase 1 was a control group whose participants did not receivpated in Phase 1 were not interviewed.

participation, the group approach was considered advan-tageous in stimulating recall amongst participants. Theinterviews were conducted by the principal investigator(MBH), an experienced qualitative researcher, and followeda semi-structured interview guide pertaining to aspects ofthe communication skills training and communication tools(see Table 3 for script and summary of responses). The inter-view guide was influenced by informal feedback sessionsheld with nurses during data collection and at the conclusionof Phase 2. The SPEACS training manual and materials wereavailable during each interview session and reviewed withparticipants. Discussions were audio-recorded, transcribedverbatim and reviewed for accuracy. As recommended byKrueger (1994), a research assistant recorded observationalfieldnotes during the interviews to allow the facilitator tofocus on the dual task of moderating and interviewing. In thiscase, fieldnotes were used to capture non-verbal behavioursand to differentiate speaker and tone within the group(Patton, 2002).

Data analysis

Qualitative content analysis was used. Transcripts were firstanalysed using constant comparison by all authors in a joint,collaborative effort, and initial categories were developed.A more detailed analysis then commenced in the form ofline-by-line coding to identify sub-categories and to validatethe initial categories. Two authors (JVR, MBH) met regu-larly to review and discuss the analysis. The third author(JAT) provided review, critique and validation of the emerg-ing analysis. Categories were further validated by commentsgathered in earlier, informal feedback sessions with Phase

2 study nurses. Fieldnotes were reviewed to clarify non-verbal agreement/disagreement amongst participants andto ensure the mood and tone of the groups were accuratelyconveyed in the final analysis.

ning or additional communication materials. Nurses who partici-

esults

ix major content categories were identified in theranscripts: (1) communication value and perceived compe-ence; (2) communication intention; (3) benefits of training;4) barriers to implementation; (5) preferences and util-sation of strategies; and (6) leading and following. Toacilitate transparency in reporting of comments and agree-ent amongst participants, each participant is referred to

n-text with a unique, non-identity linking number (i.e.,1—06).

ommunication value and perceived competence

here was wide variation amongst participants in the valuehey placed on communication in the ICU and their per-eived competence in communicating with critically ill,on-speaking patients. The perceived value of effectiveommunication ranged from ‘‘low priority’’ or merely‘interesting,’’ to ‘‘critical’’ to recovery.

Several participants became outspoken advocates formproved communication (01, 02, 03). They describedfforts to share training information, the communica-ion strategies and the many benefits they had observedrst-hand with their colleagues. One nurse viewed poor com-unication and the resultant stress for patients as a primaryarrier to timely hospital discharge and recovery from criti-al illness (03). Several nurses also reported a change in theirttitudes about communication with ICU patients after thePEACS training:

‘‘The part that really enlightened me was watching the[communication training] videos. . .and just the whole,

seeing the miscommunication and how the patient endsup giving up, [they] become really passive, and it hap-pens all the time. . .and that’s me and my patients. . .butbefore [training], it’s not brought to your attention that

20 J.V. Radtke et al.

Table 3 Focus group scripts and summaries.

Script Summary of participant comments

Tell us what you thought about the basiccommunication skills training (BCST)?

• Enlightening; helpful; introduced or reinforced knownstrategies• Could ‘‘relate’’ to video BCST exemplar training featuringcolleagues• Some strategies novel or ‘‘interesting’’ but impractical(e.g., eye-gaze board)

What skills, knowledge, techniques do you usefrom the BCST?

• Encouraging printing; watching as patients write; makingeye contact; voice inflexion; gaining attention byaddressing patient by name• Incorporation of communication assessment into shiftreport

If you were going to improve/enhance the BSCT,what one thing would you change?

• Extend training to other HCPs; emphasise need/role ofSLP to physicians• More intuitive terminology• Enlarge print of some boards for patients withmotor/visual limitations

Can it be shorter? • Shorten to 1 hour (from 4 hours)What do you think was the most essential information? • Independent BCST strategies not requiring SLP supportWhat additional information would you have liked to receive? • No suggestions; felt information received was sufficient

What were the most important aspects of theprogramme to you?

• Learning through colleague video exemplars• Availability of communication materials on units• Consultation with the SLP

What information or strategies have you usedmost? Least?

• MOST: Making eye contact, tagged yes/no, 1st letterpointing and mouthing words, communication boards;electronic voice output devices (some nurses)• LEAST: Eye-gaze boards, written-choice, partner-assistedscanning, emotion boards

Was the training website valuable? How often did you use it? • No recall of website; unclear whether this resource wasreferenced in all training sessions

Was the communication algorithm pocket carduseful? Did you refer to it?

• Mixed reactions: helpful vs. too ‘‘busy’’• Great for new graduate nurses• Intuitive design for ICU nurses familiar with treatmentalgorithms• Misplaced pocket reference card frequently

How would this work as an on-line educationaloffering?

• As part of new nurse orientation or online nurse trainingmodules• Unit champions/leaders to supplement online information• Use real nurse exemplars/simulations• Incorporate definitions and scenarios of ‘‘when to use’’

What would you tell other ICU nurses about theprogramme?

• Surprisingly informative; worthwhile• Improved practice: more patience, increased confidence

Any success stories that you would like to share? • Multiple success stories with implementation of electronicAAC devices: permitted greater patient autonomy, gavepatient purpose/voice, allowed nurse to multi-task

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HCP = healthcare provider.

[it is] a problem, so you don’t think about it a lot untilyou go the class.’’ (02)

‘‘I do make more eye contact with my patients which Ididn’t really kind of do in the beginning. . .I guess it taughtme patience.’’ (05)

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Alternatively, some nurses noted that communicationechniques were ‘‘interesting,’’ but required ample time

nd a responsive/non-sedated patient (02, 05, 06). Par-icipants admitted that these conditions rarely occurred.or patients with compromised mental status, in particu-ar, medical tasks took priority over communication, and

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Nurses’ perceptions of communication training in the ICU

assistive communication strategies, such as the eye gazeboard, that were perceived as too time-consuming weredismissed by some as impractical (05, 06).

‘‘I mean, you know the one thing where you have to, like‘‘gaze eyes,’’ [sarcastic tone] that, half those people areon Fentanyl so they’re gazing and you don’t know wherethey’re gazing. . . I mean it was interesting but that wouldbe not very practical for us.’’ (05)

Two participants described abdicating to the SLPinterventionist for communication with patients beyondascertaining basic needs (05, 06). Their perspectives oncommunication and communication success were framedas ‘‘basic needs’’ and ‘‘what I need’’ from communicationwith patients rather than attempting to meet or determinepatients’ communication needs. One nurse (05) describedtaking communication materials away from patients andfamilies, citing her own rationale that some patients are‘‘not appropriate’’ for communication assistance, using anexample of a cognitively impaired older adult.

Nurse participants attributed the low priority that facili-tating patient communication receives in the ICU to a varietyof causes, including time constraints inherent in caring forcritically ill individuals, as well as lack of training and atten-tion to learning technical aspects of care. ‘‘It got overlookedin ICU orientation because you were too busy trying to learnthe skills,’’ ‘‘how to set up those [arterial] lines.’’ (02)

Most participants found themselves increasingly morecomfortable with communication and communication inter-ventions with non-speaking ICU patients after training.

‘‘I have different tools now, whether it be an actual phys-ical tool or just the skills that I have gotten where I canwork with [the patient] a little bit better. It benefitsboth of us. I don’t get so frustrated. . .it cuts down onmy time trying to figure out what they are saying. Theydon’t get as frustrated. They get their needs met, youknow, whether it be a physical need or just an emotionalneed like needing a question answered.’’ (01)

Communication intention

Communication intention encompassed the perceived topicsand complexity of patient messages to healthcare providersand family. Nurses’ opinions of communication intentionvacillated. Group discussions typically began with nurse par-ticipants agreeing that patients primarily intend to conveybasic needs, such as symptoms and requests for treatment orcomfort measures. Over the course of the discussion, partic-ipants revealed that more novel patient messages related tothoughts, feelings, and participation in treatment decisionswere likely misinterpreted, ignored, or stifled:

‘‘And the nurse is asking things like pain, family. . .water,and the patient’s asking about their dog at home.’’ (02)

‘‘And we had a patient the other day. . .it was somethinghe wanted to eat. . .he did a lot of hand gestures, so weknew it was eating or drinking, and I was sure he’d want

ice chips. . .it was cold outside and we were talking aboutsnow and cold and he wanted. . .’Swiss Miss,’ [an instanthot cocoa]. . .and that’s what he was dreaming of: his firstthing to drink, and I would not have guessed that.’’ (04)

21

However, interventions to facilitate patients’ abilitieso express novel messages were sometimes perceived asouble-edged. Nurses reported being placed ‘‘in the mid-le’’ as interpreters of patient messages, even beforearticipating in the SPEACS study (01, 02, 04).

‘‘And people do go towards the–, to the nurse to say‘what’s he trying to say?’ The doctor will turn to you,[indicating doctor’s response] ‘well you’re the nurse,what’s he trying to say?’ And I’ll say, ‘well. . .you knowas much as I do.’’’ (04)

This comment illustrates the sentiment to which otherPEACS nurse participants had eluded in informal feed-ack sessions: that improved communication may ethicallybligate the nurse to the time- and emotionally intensivendeavour of being the intermediary between the non-peaking patient and entire healthcare team. For example,uring the SPEACS study, a nurse related an instance in which

patient, who was enabled to communicate, expressed areatment preference in conflict with that of the physiciansnd family.

Our interview participants revealed other practical ethi-al dilemmas as well.

‘‘I find myself pulling the (isolation) mask down. . .Causeit’s like, you’re reading, trying to read their [empha-sis] lips, and I’m thinking, ‘oh, they’re trying to read my[emphasis] lips and they can’t hear me cause I’m yelling.’And it’s like, can they hear me? I guess, why am I yelling?’’(05)

enefits of training

urses ascribed personal, patient and family benefits tohe communication training programme. Personal benefitsncluded practical and professional gains, as well as egonhancement. For instance, nurses noted a reduction intress and change in their attitudes and practice as a resultf the training. They reported feeling ‘‘less frustrated’’ and‘more patient’’ during communication attempts, as wells more persistent in aiding patients with communicationmpairments (03, 05, 06). Nurses provided several examplesf how they used the new techniques with their nonspeakingatients.

‘‘You know, letter boards are really good when you getfrustrated and the patient gets frustrated, and . . . justas long as they’re able to point, or able to nod theirhead, and are, you know, alert and oriented, you canget them. . .[to] just, follow the letter board and go onthis column, ‘Is it in this column? Is it in this one, thisone, this one. . .?’ That’s time consuming, but at the sametime, you can get to, you know, where you want to be,so. . .I always go to that, when all else fails.’’ (01)

In terms of patient benefits, several nurses linkedmproved communication to relief of patient anxiety andnhanced patient well-being (01, 02, 03, 04), and a quickerecovery from critical illness:

‘‘. . .I so. . .believe that information and communica-tion relieve anxiety. And when people are less anxiousthey heal better. . . I think that these people that are

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depressed and anxious and frustrated are the ones thatare still in the ICU six months after the operation.’’ (03)

A connection between improved communication andnhanced patient affect was also observed:

‘‘[Communication] brings their spirits up.’’ (01)

‘‘[Patients] just love it when they cancommunicate. . .finally, they’ve been trying—–[now theycan] get through. . .you have a patient that’s involved intheir healthcare, progressing, even if they say strangethings. They feel good, they’re communicating.’’ (04)

One participant (03) reported that families werentrigued by and grateful to her for introducing new commu-ication strategies. She commented that families had moreime to invest and a greater stake in utilising the commu-ication strategies to decipher more complex thoughts andmotions. This was consistent with comments from nursesho participated in the informal feedback sessions.

arriers to implementation

urses encountered multiple barriers that impeded fullmplementation or utilisation of their new communicationnowledge and skills. Most notably, they evaluated cer-ain communication aids and strategies, such as eye gazeoards and partner-assisted scanning, as unfeasible, tooime-consuming, or inappropriate for use in critical care,here cognitive debilitation and sedation frequently accom-anied motor limitations. Alternatively, patient conditionnd unit time constraints sometimes served as a motivator tomplement communication devices and AAC techniques. Forxample, several nurses reported that the electronic speechenerating devices allowed the nurse to multi-task duringommunication interactions with nonspeaking patients, thusaving time (01, 02, 03). Nurses also found certain AACtrategies, including partner assisted scanning, communi-ation boards and patient signal dictionaries (see Table 1),elpful when simpler techniques were hampered by patientnxiety or physical limitations (e.g., writing affected byand oedema, mouthing ineffective when patient was anx-ous or having difficulty weaning) (02, 03, 05).

Participants acknowledged that it was difficult to fullymplement the AAC strategies and electronic devices whenther nurses on the units did not share their communica-ion expertise, training and/or enthusiasm. This sentimentas echoed in the informal feedback session, as well; theseurses acknowledged the difficulty in changing practiceithin an established culture, such as the ICU.

‘‘You would find that machine [electronic communicationdevice] laying over on the windowsill, battery’s dead. I’mlike, ‘Why aren’t you using this?!’ And the [nurses un-trained in the communication program] are like, ‘I don’tknow, no one does it’. . .so that’s frustrating.’’ (01)

In particular, it was difficult for participants to directther nurses to use certain assistive communication strate-

ies when the terms or descriptions of techniques wereot intuitive or familiar. For example, although partici-ants described utilisation of ‘‘partner-assisted scanning,’’

technique involving pointing to letters or words on a

J.V. Radtke et al.

ommunication board until the patient signals the correctelection (Beukelman et al., 2007; Beukelman and Mirenda,005), none were familiar with the term when it was intro-uced in the focus groups.

‘‘I think the most difficult thing that I found was try-ing to explain to other nurses, because you went throughthe classes, ‘use this!’ and always forgetting the nameof it. So, here you are representing something youwent through and you’re supposed to remember and youcouldn’t remember.’’ (01)

Nurses suggested implementing communication traininguring new nurse critical care orientation, forming com-unication committees, offering the training as an onlineodule, increasing the availability of SLPs, and having

mple communication supplies on hand in the ICU. Theydvocated retaining the real nurse—patient video exemplarsn future training programmes (01, 02, 04, 05, 06).

trategy utilisation and preferences

ll nurses reported informal incorporation of the SPEACSommunication assessment algorithm into their daily assess-ents after training, and one described passing this

nformation on in shift reports (03). However, some par-icipants still described using a trial and error approachhen incorporating communication enhancement strate-ies, which tended to be time-consuming (01, 05). As aorkaround, Phase 3 nurses described successfully consult-

ng with the SLP for assistance at the assessment stage.The nurses found training to be very helpful in rein-

orcing natural communication strategies, such as gaininghe patient’s attention prior to a communication exchange,aintaining eye contact, using voice inflexion and confirm-

ng all patient responses. They described these techniquess often the most effective and frequently utilised. Par-icipants also described continued use of patient writing,outhing, gestures and communication topic boards. Someescribed incorporating minor variations on these strategieso improve communication success as a result of the train-ng, such as encouraging printing rather than writing (01),atching the patient as they write (04) and establishinglear, patient-specific gestures and signals (03).

The most positive responses were about the communi-ation supplies made available to the ICUs throughout thetudy. In particular, participants noted the convenience andtility of communication supply carts on the study units,elcro-mountable storage pouches for hearing aids or spec-acles, notebooks and simple alphabet, picture and wordoards. Consistent with nurses in the informal feedback ses-ion, a focus group participant (05) reported high-interest innd utilisation of these materials amongst other staff mem-ers:

‘‘I actually showed someone else [the communica-tion training binder]. . .cause they’re like ‘what are you

doing?’. . .You know they were nebby [curious], and Ishowed them, and they liked it. . .there’s the SPEACS[communication] cart, like most or almost everyone onour unit knows about the cart, you know. . .’’

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Nurses’ perceptions of communication training in the ICU

Nurses found the patient signal dictionary, message strat-egy, and orthotic writing devices useful, but reported usingfirst-letter pointing with mouthing words and the taggedyes/no strategy more extensively. The partner-assistedscanning and written choice strategies, as well as electronicspeech generating devices and eye gaze boards receivedmixed or unfavourable reviews. Nurses who disliked orreported non-use of these strategies tended to find them‘‘interesting,’’ but too time-consuming (01, 02, 05). SeeTable 1 for a description of strategies.

Leading and following

Advocacy for and dissemination of knowledge and skillsacquired through the communication training programmeexisted along a continuum. At one end, nurses’ commentsimplied pessimism regarding unit and system-based changeand deference to (‘‘following’’) the SLP (05, 06). Otherswere supportive of the programme, and reported passingon information about patient communication abilities andtechniques during shift reports (01, 03). Several study par-ticipants became champions on their respective units forthe techniques and strategies. These nurses demonstratedperseverance and leadership in teaching patients, familiesand colleagues learned skills (01, 02, 03). Generally, partic-ipants who saw more benefits than risks in the programmedisplayed greater commitment to educating colleagues andgenerating unit buy-in.

‘‘. . . I tell everybody. ‘Here’s this, use this!’ Not only juston my patients, but I am passing out copies [of the com-munication boards]. . .I taught many a family member touse [first letter spelling and mouthing] and they use it.’’(03)

Because most of the nurses who participated in theseinterviews had the benefit of interaction with the SLP, theywere advocates of an increased role for the SLP in the ICU.

‘‘I think almost all the patients, it seems like, deserveto have speech pathologists work with them. It wasalmost. . .unfair for patients who decided that they didn’twant to do the study. I think they really missed out.’’ (02)

Limitations

This study was limited by a number of factors, includingsmall groups and sample size and issues inherent in focusgroup data collection (e.g., self selection). Although diver-gent responses by sex, study phase, study unit and yearsof critical care experience were not observed in this study,judicious comparisons are constrained by the small sample.Sample size also limits extrapolation of study findings to ICUnurses in other settings. Likewise, the voluntary nature offocus group and SPEACS study participation increases thelikelihood that participants differed in important ways fromthose who chose not to take part in the groups or study. Forexample, those that participated in the focus groups may

have had more extreme views of the intervention, and thosewho chose to take part in the study at all may have beenmore amenable to practise changes than the general ICUnursing population. Finally, though focus groups are reputed

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o stimulate flow of ideas amongst participants and enhanceata quality (Krueger and Casey, 2000), our groups were con-ucted by the study’s principal investigator (PI), who had annterest in the success of the intervention. Although unlikely,t remains a possibility that some participants screened theirrue feelings or responded in ways during the groups thathey thought the PI desired or the group would deem sociallyesirable.

iscussion

urse participants in our study reported changed andmproved attitudes and practices regarding communicatingith nonspeaking ICU patients after basic communication

kills training. Their descriptions of feeling ‘‘less frus-rated’’ and ‘‘more patient’’ after training are consistentith findings of previous nonintervention studies in whichurses admitted to feeling frustrated and avoiding patientshose nonvocal messages are difficult to understand (Alasadnd Ahmad, 2005; Bergbom-Engberg and Haljamae, 1993;eathart, 1994a; Magnus and Turkington, 2006). Our find-ngs clearly support that lack of appropriate training,navailability of communication materials, and lack ofccess to speech language pathologists are barriers to ade-uately addressing patients’ communication needs in theCU (Hemsley et al., 2001; Leathart, 1994b). Training didot change the value that these nurse participants placed onatient communication in relation to more pressing physicalnd biotechnical duties in the care of critically ill patients.his prioritisation reflects the life and death context of criti-al care nurses’ work and training. Time constraints surfacedepeatedly as the threshold or determining factor in criticalare nurses’ preferences and decisions to use or reject AACechniques, as well as in their perceptions of barriers tomplementation of the assistive communication techniques.

Not all study participants accepted or adopted the train-ng programme principles as evidenced by their self-reportsf removing communication materials from the patients’edside and belief that patients with complex commu-ication disabilities (i.e., those who were delirious) areot ‘‘ready’’ to communicate. Techniques that requiredreater assistance from the nurse (e.g., written choices,ye-gaze boards) were not popular or were rejected out-ight. Informal feedback from nurses throughout the SPEACSroject further confirmed that critical care nurses some-imes preferred patients, particularly those with complexhysiological needs, to be silent. One ICU nurse who sharedhis perspective labelled it a ‘‘deep dark secret,’’ suggestinghame or guilt about communication avoidance as a meanso facilitate work or to avoid emotional engagement.

The nurses’ descriptions of communication intention, theerceived complexity and topics of patient messages toealthcare providers and family, are some of the most inter-sting and novel findings in this study. These nurses raisedmportant ethical, social and practical concerns about facil-tating communication with seriously ill patients who have

high likelihood of cognitive impairment and high risk of

ying (Nelson et al., 2010; Tonelli, 2005). Participants’ com-ents illustrated some everyday, ethical dilemmas involved

n facilitating patient communication in the ICU. Moreover,ur data show that nurses occupy a relational space in

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hich the critical care nurse may be caught ‘‘in-between’’atients, families and physicians as interpreter of a patient’sreatment preference or request (Happ, 2002; Varcoe et al.,004).

Our data describing perceived barriers, strategy utili-ation and leadership have several important implications.AC strategies that nurses perceive to involve greater nurs-

ng time and attention may require SLP support, modellingnd reinforcement. In addition, to achieve a more pro-ounced and sustainable change in communication practicen ICUs, development of nursing leaders, support for grad-ate nurses, wider dissemination of training amongst unitsnd healthcare providers, and practical and fiscal supportrom healthcare systems is warranted. Major changes inommunication training within healthcare organisations willikely be slow, however, as most ICUs lack any commu-ication training programme, and as this study indicates,ntrenched attitudes and practice patterns may be difficulto transform. Reasonable starting points, as suggested byur study participants, may involve formation of a commu-ication committee, development and implementation of aursing training programme or continuing education mod-le and provision of communication supplies that can beheaply procured or easily constructed by staff. In time,ith more evidence-based justification linking communica-

ion programmes to improved patient outcomes, healthcareystems may be willing to finance more intensive training,reater SLP presence, and provision of advanced electronicAC devices. In the USA, new hospital accreditation stan-ards may spur faster change. These standards becameffective January 2011 and require assessment of patientommunication needs, including the communication impair-ents that are a consequence of treatment. Hospitals wille required to provide augmentative and alternative com-unication support (The Joint Commission, 2010). Our study

llustrates that change can begin with several nursing cham-ions, simple communication supplies and a curious staff.

onclusions

he BCST programme and AAC materials used in the SPEACSntervention were generally well-received by nurses andncreased their skill and confidence in communicating withonspeaking ICU patients. Nurses also perceived patientenefits to strategy utilisation. Communication techniquesnd materials perceived as time-saving, natural and effec-ive for patients who were without major motor andognitive limitations were favoured and utilised.

onflict of interest statement

ll authors certify that no competing financial interests orources of bias exist.

cknowledgements

unding by the National Institute of Child Health anduman Development (R01-HD043988, Improving Communi-ation with Nonspeaking ICU Patients) and National Institutef Nursing Research (K24-NR010244), Mary Beth Happ,

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J.V. Radtke et al.

rincipal Investigator; Judith Tate, project director; and Jilladtke, graduate student researcher and PhD candidate.

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urther reading

he Joint Commission. Advancing effective communication, cul-tural competence and patient- and family-centred care:

Commission; 2010. p. 18 http://www.jointcommission.org/assets/1/6/ARoadmapforHospitalsfinalversion727.pdf, accessedMarch 15, 2011.