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Improving Pa-ent-Nurse Communica-on in the ICU

Se9ng: A Best Prac-ce Recommenda-on

PICOT Ques-on

Introduc-on
Issue:
Current prac-ce for communica-on with mechanically
ven-lated, conscious pa-ents is impaired due to the lack of
educa-on and resources available to ICU nurses.

Signicance:
Lack of nurse-pa-ent communica-on can lead to lengthy
hospital stays and adverse pa-ent outcomes ul-mately
resul-ng in decreased pa-ent sa-sfac-on.

Devyn Weber Rayna McParlane

Kaitlyn Parks Pa-ence Bekoe
Marlee Feinholz Lauren Grin
Mary Sepulveda Madison Bardsley

(Otuzoglu & Karahan, 2014)

In the popula-on of non-speaking,

intubated, ICU pa-ents with a GCS score
of 13 or higher, how does the use of the
illustra-ve and
assis-ve communica-on
devices, when compared
to current prac-ce,
inuence the overall
pa-ent-nurse
communica-on aYer a
single 12-hour shiY?

(Tingsvik, Bexell, Andersson, & Henricson, 2013)

Summary of Current Prac-ce

Within various ICU se9ngs, there are
no well-established levels of
communica-on between nurses and
their pa-ents.

Examples of current methods include:
Lip reading, gestures, wri^en
messages, head nodding, subjec-ve
provider interpreta-on, and the use of
alphabet boards
(Otuzoglu & Karahan, 2014)
(Happ et al., 2014)

Nega-ve Outcomes Associated with

Current Prac-ce

Current Prac-ce Regula-ons

Na#onal Prac#ce

American Associa-on of Cri-cal Care Nursing denes access to appropriate tools

for eec-ve nurse-pa-ent communica-on to be a cri-cal element, though a
formal policy is not implemented.

1) Increased Risk for Aspira-on

Lip reading, head-nodding, and excessive upper-body
movements may increase the risk for ven-lated pa-ents to
aspirate oropharyngeal contents, enhancing their likelihood for
injury or respiratory infec-on

State of Arizona

Suggests the prac-ce of u-lizing eec-ve communica-on strategies throughout

ICU admi^ance, though no formal policy is implemented.

Banner UMC

Evalua-on of pain and physiological needs will be assessed via the Cri-cal-Care
Pa-ent Observa-on Tool (CPOT), a behavioral scale relying on providers personal
interpreta-on of pain and physiological needs.

2) Increased Oxygen Demand

Excessive movement increases a pa-ents oxygen demand
which commonly leads to nega-ve hemodynamic altera-ons

(Banner Health, 2011)

(American Assoication of Critical Care Nursing, 2005)

(Otuzoglu & Karahan, 2014)

Synopsis of Current Literature

Synopsis of Current Literature

Synopsis of Current Literature

What is the issue with current prac-ce?

Best Prac-ce: Why is it important?

Solu-ons to current prac-ce issue:

In order to evoke change, evidence based interventa-ve
strategies include:
The use of visual diagrams allowing
pa-ents and nurses to point out
specic pa-ent needs

Clinical educa-on to teach nurses about
the use of low-tech communica-on
devices including spiral notebooks,
whiteboards, and whiteboard markers.

Basic pa-ent needs including toile-ng, pain management,

reposi-oning, and emo-onal and social support are
ineec-vely being met with current prac-ce.

Improving the communica-on between nurses and pa-ents in

the ICU will increase
sa-sfac-on and create less
trauma-c experiences for the
pa-ents.

37.7% of ven-lated ICU pa-ents

report unsuccessful a^empts at
eec-vely communica-ng their
pain with their nurse.
(Happ, et al., 2011)
(Otuzoglu & Karahan, 2014)

(Karlsson, Forsberg & Bergbom, 2011)

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Synopsis of Current Literature

(Happ et al., 2014)

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Synopsis of Current Literature

Summary of Strengths and Limita-ons...

Why change is necessary:

Why change is necessary:

Pa-ents view the ICU environment as unfamiliar and feel that
they have no impact on how it is organized, which leads to
dependency, especially on the nursing sta.
ICU pa-ents commonly report feelings of frustra-on, lack
of control/self-determina-on, and physical discomfort
during their stay in the ICU.
Being voiceless creates a loss of pa-ent freedom and
personhood
(Otuzoglu & Karahan, 2014)
(Karlsson, Forsberg & Bergbom, 2011)

Pa-ents feel that they

are unable to build
trust and condence in
their nurse, resul-ng in
self-reliance for their
survival.

Review of literature iden-es the need for:
Educa-on for ICU nurses on best prac-ce
Assis-ve communica-on devices and strategies
(Karlsson, Forsberg & Bergbom, 2011)

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Training classes leY the

nurses feeling less
frustrated when
communica-ng with nonspeaking pa-ents.
14 out of 15 nurses felt that
the class was benecial.

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Assis-ve Communica-on Devices and

Strategies

Educa-ng ICU Nurses on Best Prac-ce

Strengths

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Limita#ons
Elevated cost for training
Small sample size was
tested (n=15)
Training was -me
consuming for both the
sta and hospital

(Radtke, Tate, & Happ, 2012)

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Strengths

Limita#ons

Tes-ng to narrow sample size

to exclude pa-ents with vision
loss, demen-a, orienta-on or
confusion disorders or
linguis-cs problems to prevent
skewed data
Nurses approve simplicity of
comprehension and
applica-on of devices and
strategies

Studies included narrow

pa-ent popula-ons
Change in pa-ent condi-on
altered the par-cipa-on in the
study
Pa-ents had diculty
remembering the
communica-on material due
to eects of seda-on

Evidence Based Nursing

Recommenda-ons
1. ICU nurses should complete educa-on seminar
addressing best prac-ce communica-on techniques

This seminar should include teaching the use of illustrated

communica-on materials and low-tech devices

2. Hospitals should implement the use of illustrated

pa-ent materials and low-tech devices in every pa-ent
room in various ICU se9ngs.

(Otuzoglu & Karahan, 2014)

(Happ et al., 2014)

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Overall Applica-on/Implementa-on to
Nursing Prac-ce

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Overall Applica-on/Implementa-on to
Nursing Prac-ce
Implementa-on for Recommenda-on 2:

Implementa-on for Recommenda-on 1:

Schedule a paid-for, one-hour seminar for currently employed ICU
nurses.

Newly-hired ICU nurses will be required to complete the paid-for,
one-hour seminar as part of their New Hire Orienta-on

The seminar will include demonstra-on of how to use the
illustra-ve assis-ve devices as well as teaching the pa-ents on how
to use them.

The Clinical Nurse Manager on each ICU unit will purchase supplies
with hospital funding including a diagram, white board, and
markers for each pa-ent room.

Implement a procol sugges-ng that upon admission of a nonspeaking pa-ent to the ICU, the nurse will instruct the pa-ent
about the use of the diagram and white board.

(Radtke, Tate, & Happ, 2012)

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Detailed Cost Analysis

Recommenda-on 1: Educa-on
Average hourly pay rate for ICU nurses at BUMC: $24 - $30
Number of nurses staed in ICUs at BUMC:


90
Cost to pay nurses to a^end the 1-hour seminar:
$2,160 - $2,700
Room reserva-on (College of Medicine room 5403):
$0.00
Cost of educator:



$174.55
Cost to run PowerPoint and a Projector:
$0.00
Refreshments for each nurse in a^endance:

$37.29

Total: $2,371.84 - $2,911.84

(Otuzoglu & Karahan, 2014)

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Risk vs. Benet to Hospital

Detailed Cost Analysis

Risk

Recommenda-on 2: Materials and Supplies

Whiteboard (2 cases of 48 boards, totalling 96 boards): $153.90
Markers (6 packs of 12 markers, totalling 72 markers):
$24.30
Paper for prin-ng (80 diagrams, 500 surveys):
$7.39
Color toner to print (prints up to 1,300 pages): $80.99
Lamina-on for 80 diagrams:


$160.00

Loss of money due to lack of

implementa-on of educa-on
Loss of money due to not using
supplied materials

Benet
Hospital gains be^er pa-ent
sa-sfac-on
Less cost to the hospital with
eec-ve implementa-on due to
shorter hospital stay

Total: $426.58
(Bulk Office Supply, 2015)

(Costco, 2015)

(Otuzoglu & Karahan, 2014)

(Otuzoglu & Karahan, 2014)

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Risk vs. Benet to Pa-ent

Risk

Benet

Diagram could become inaccessible

due to misplacement
Level of pa-ent educa-on may
limit understanding of material
Dependent upon nurses
willingness to teach and implement

Decrease the chance of adverse

pa-ent events including:
Risk of aspira-on, changing
oxygen levels, and an increased
risk for injury.
Increased pa-ent-nurse
communica-on and sa-sfac-on
Reduc-on of pa-ent powerlessness
Improves nurses -me
management resul-ng in
priori-za-on of pa-ent needs

(Otuzoglu & Karahan, 2014)

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Evalua-on

Summary

At the end of a single 12-hour shiY, the pa-ents will be

asked by the nurse to report their sa-sfac-on at a 5 with
the implemented communica-on techniques according to a
1-5 facial expressions scale.

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References
American Associa-on of Cri-cal Care Nursing [AACN]. (2005). AACN standards for establishing and sustaining healthy
work environments. Retrieved from h^p://www.aacn.org/wd/hwe/docs/hwestandards.pdf
Banner Health. (2011). Policy and procedure. Retrieved from h^p://www.bannerhealth.com/NR/rdonlyres/
559C0B25-C5E1-4875-9372-77BFFF85F140/62013/MedicalRecordAbbrevia-onsandSymbols37885.pdf
Bulk Oce Supply. (2015). Wholesale pricing made easy. Retrieved from h^p://www.bulkocesupply.com/
guidedsearch.aspx?keyword=whiteboard+markers&mxp=50
Costco. (2015). Beverages: SoA drinks. Retrieved from http://www2.costco.com/Browse/Product.aspx?
prodid=11223431&whse=BD_827&topnav=b
Happ, M.B., Garre^, K.L., Tate, J.A., DiVirgilio, D., Houze, M.P., Demirci, J.R., & Sereika, S.M. (2014). Eect of a
mul--level interven-on on nurse-pa-ent communica-on in the intensive care unit: Results of the SPEACS trial.
Heart & Lung: The Journal of Acute and CriGcal Care, 43(2), 89-98. doi: 10.1016/j.hrtlng.2013.11.010
Happ, M.B., Garre^, K., Thomas, D.D., Tate, J., George, E., Houze, M., Radtke, J., & Sereika, S. (2011). Nurse-pa-ent
communica-on interac-ons in the intensive care unit. American Journal of CriGcal Care: An Ocial PublicaGon,
American AssociaGon of CriGcal-Care Nurses, 20(2) e28-e40. doi: 10.4037/ajcc2011433
Karlsson, V., Forsberg, A., & Bergbom, I. (2012). Communica-on when pa-ents are conscious during respirator
treatment A hermeneu-c observa-on study. Intensive and CriGcal Care Nursing, 28(4), 197-207. doi: 10.1016/
j.iccn.2011.12.007
Otuzoglu, M. & Karahan, A. (2014). Determining the eec-veness of illustrated communica-on material for
communica-on with intubated pa-ents at an intensive care unit. InternaGonal Journal of Nursing PracGce, 20(5),
490-498. doi: 10.1111/ijn.12190
Radtke, J.V., Tate, J.A., & Happ, M.B. (2011). Nurses percep-ons of communica-on training in the ICU. Intensive and
CriGcal Care Nursing, 28, 16-25. doi: 10.1016/j.iccn.2011.11.005
Tingsvik, C., Bexell, E., Andersson, A., & Henricson, M. (2012). Mee-ng the challenge: ICU nurses' experience of
lightly sedated pa-ents. Australian CriGcal Care, 26, 124-129. doi: 10.1016/j.aucc.2012.12.005

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Problem:
Current prac-ce allows for inadequate nurse-pa-ent
communica-on among ven-lated ICU pa-ents
Poor communica-on increases pa-ents risk for adverse
events and increased dura-on of ICU admission

What can we do?
Improving the communica-on between nurses and pa-ents
in the ICU will increase sa-sfac-on and create less trauma-c
experiences for the pa-ents.
Assis-ve and illustra-ve communica-on techniques are
evidence based solu-ons to improving ven-lated pa-ent
communica-on

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Why is it necessary?
Pa-ents view the ICU environment as unfamiliar and feel
that they have no impact on how it is organized, which leads
to dependency, especially on the nursing sta.


Lets get implemen-ng!
Oering educa-onal classes

and implemen-ng bedside

assis-ve communica-on
diagrams are feasible
interven-ons to improve
nurse-pa-ent
communica-on in the
ICU.