FEATURE ARTICLE
Use of Communication Tools for Mechanically Ventilated
Patients in the Intensive Care Unit
Anna Holm, MScN, RN, Pia Dreyer, PhD, MScN, RN
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The use of light and no sedation is gaining currency in the in-
tensive care unit, resulting in more conscious patients. Due
to mechanical ventilation, patients are unable to communi-
cate verbally, and may feel frustration. Communication tools
may help; however, they are not used systematically in clini-
cal practice. Based on “complex interventions” and a quali-
tative approach, a communication tool was modified, tested,
and evaluated in this study. The tools consisted of a tablet
with communication software and a laminated “communica-
tion book” with identical structure. Seven nonsedated, me-
chanically ventilated patients tested the tools and were
observed in field studies. Findings show that challenges
in using communication tools may be related to the patient,
nurses, and/or technology. Patients may experience diffi-
culties in using the tools, especially if they are extremely fa-
tigued or have cognitive impairments and/or reduced muscle
strength. Communication tools were not always necessary;
however, some found them very helpful and the only way of
conveying a message. Findings also show that the best way
to facilitate communication is through a systematic commu-
nication strategy initiated by the nurse.
KEY WORDS: Communication, Intensive care nursing,
Mechanical ventilation, Qualitative research
he findings presented in this article are from a pilot
T study testing communication tools to assist conscious,
voiceless, mechanically ventilated patients in the inten-
sive care unit (ICU).
BACKGROUND
Current sedation practices are moving toward light or no-
sedation protocols for patients in the ICU.1,2 Thus, more pa-
tients are awake during mechanical ventilation but are unable
to communicate verbally.3 Mechanical ventilation causes
Author Affiliations: Department of Anaesthesiology and Intensive Care, Aarhus University Hos-
pital (Ms Holm and Dr Dreyer), and Institute of Public Health, Section of Nursing, University of
Aarhus (Dr Dreyer), Denmark.
Corresponding author: Anna Holm, MScN, RN, Department of Anaesthesiology and Intensive
Care, Aarhus University Hospital, Nørrebrogade 44, Building 21, 1. Floor, 8000 Aarhus C,
Denmark (annasoe6@rm.dk).
The authors have disclosed that they have no significant relationships with, or financial interest
in, any commercial companies pertaining to this article.
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/CIN.0000000000000449
398 CIN: Computers, Informatics, Nursing
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
communication difficulties, and 16% to 24% of patients ad-
mitted to the ICU experience sudden speechlessness,4 which
may cause anxiety, frustration, fear, and loss of control.5–7
Communication is an interpersonal interaction, and nurses
are the most frequent communication partners for patients
in the ICU, but nurses can experience guilt, frustration,
and feelings of incompetence when communication fails.8
Various well-documented strategies may improve communi-
cation, and some recommend the use of augmentative and
alternative communication (AAC), which includes tools
and strategies to facilitate communication when the patient
is voiceless.3,9–15 Communication challenges can be caused
by (1) the patient’s acute condition and level of conscious-
ness, (2) inattentive nurses, (3) a noisy and stressful environ-
ment, (4) time restraints, (5) lack of nurse competencies, and
(6) unavailability or poor quality of communication aids.16
According to Happ et al,17,18 53.9% of mechanically venti-
lated patients meet the basic communication criteria and
are awake, alert, and responsive to verbal communication,
but nurses rarely initiate use of communication tools. The
introduction of communication tools has the potential to
improve nursing care quality in clinical ICU practice.
AIM
The aim of this study was to modify, test, and evaluate com-
munication tools for the conscious, mechanically ventilated
patient in the ICU. The purpose was to tailor existing com-
munication software to accommodate the needs of ICU pa-
tients and test how and whether the chosen AAC tool supported
nurse-patient communication in the ICU context.
METHODS
Design
The Medical Research Council’s widely used method for
healthcare interventions, “complex interventions,”19 was cho-
sen as the overall framework. The design within the frame-
work was qualitative with a phenomenological-hermeneutic
approach. The phenomenon “communication” is a very com-
plex and relational concept; therefore, a methodology with an
open approach was chosen to explore the phenomenon in-
depth. A phenomenological-hermeneutic methodology allows
the researcher to gain insight into the experiences of the infor-
mants, which is useful when developing and evaluating
August 2018
complex interventions from a qualitative perspective.20 One
way to capture experiences is to be open and attentive in
both interviews and observations and then, in the interpreta-
tion guided by Ricoeur’s21 philosophy, see something new in
what is taken for granted, and disclose a new sort of being-
the-world. We used this method of interpreting interviews
and observations transcribed as text to explain and under-
stand the meaning of the informants’ experiences, which
gave credibility and reliability to the results.
Communication Tools
OnScreen Communicator (OSC), produced by Tom Weber
(Darmstadt, Germany), was chosen as the communication
software. It is a program that can be used by different groups
of people with communication difficulties and runs on Win-
dows tablets (Microsoft, Redmond, WA). The aim of the
project was not to develop communication software, but
rather to modify or tailor existing software to the needs of
ICU patients and nurses. We chose OSC because it allowed
us to select and structure its broad variety of predefined
words and pictures so that they would fit the needs of the tar-
get group. Furthermore, OSC had the technological advan-
tages of word prediction and a simple way of translating
words for patients whose native language was not Danish.
During the development phase, in which OSC was tailored
to the ICU context, a workgroup consisting of seven nurses
from the ICUs, one clinical nurse specialist, and the project
leader had several meetings with an AAC expert to discuss
the structure and content of the communication tools. There
was agreement that not all patients in the ICU would be able
to use a tablet, and therefore a laminated “communication
book” was made with structure and pictures identical to
OSC. The book could supplement the electronic version
of the tool, for example, if the patient had difficulty activating
the tablet screen due to poor motor control. During testing,
the tablet version was chosen first, but if it did not facilitate
communication, the “low-tech” communication book was
used instead. Patients thus had the opportunity to communi-
cate even if the tablet and OSC presented challenges. Both
the tablet and communication book consisted of an alphabet
board and picture boards with four overall options, each
with six subgroups. This very simple structure was chosen
to accommodate the needs of ICU patients, who are likely
to be extremely fatigued and/or have cognitive deficits.
Nurses at the participating ICUs were introduced to the
tools in 30-minute training sessions, via newsletters, and dur-
ing daily nurse conferences.
Setting
The study was done at Aarhus University Hospital, Denmark.
The two participating ICUs had a total of 18 beds and pro-
vided care to approximately 1500 patients annually. The
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departments followed the recommendations from the Danish
Society of Anaesthesiology and Intensive Medicine, and the
use of sedatives was kept to a minimum.22 Analgesics were
given to provide comfort, and mechanically ventilated pa-
tients were mostly conscious. No patients were physically re-
strained. Nurse-patient ratio was 1:1.
Inclusion and Exclusion Criteria
Inclusion criteria for the study were adult patients 17 years of
age or older who spoke Danish, were on invasive ventilation,
and had a score between −1 and (+1) on the Richmond Agita-
tion and Sedation Scores to ensure consciousness. Patients who
had a tracheostomy and an endotracheal tube were included.
Patients were excluded from the study if they were unable to
give consent for participation, or due to ethical considerations.
The project leader and the nurse in charge of the patient
assessed whether inclusion was possible. The only inclusion
criterion for the nurses was employment at one of the ICUs.
Ethical Considerations
The study was conducted in accordance with the Helsinki
Declaration. Special attention was given to the vulnerable
state of acute and critically ill patients during the inclusion
process. All patients gave their written consent to participate.
The management of the ICUs approved the study.
Data Collection
Data were collected at baseline before testing began23 and
again during the test phase. Testing was conducted from
September to December 2016. A qualitative design was
used, with observational studies and informal interviews in-
spired by Spradley.24 The researchers were able to conduct
observational studies because of their clinical experience
and employment status with the participating ICU. The de-
gree of participation varied in each field study, depending on
the patient’s condition. During observation, the researcher
focused on the communication between the nurse and the
patient, with particular focus on the use of communication
tools and whether or how the tools facilitated communica-
tion. The informal interviews were based on a semistructured
interview guide inspired by Kvale and Brinkmann.25 Partici-
pants provided overall opinions of the communication tools
and, if possible, elaborated on user-friendliness, ease of com-
munication, interface, visual aspects, and structure. Field
notes from bedside activities related to communication were
transcribed immediately after the observations, to secure as
many details as possible. Feedback from the informal inter-
views was described in detail.
All voiceless participants had received a tracheostomy,
and none were on a speech valve during the observational
studies. Four participants had a speech valve inserted during
follow-up, and answered additional questions to enrich
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FEATURE ARTICLE
descriptions. One participant was able to pronounce a few
words because the cuff was not fully inflated. Otherwise,
communication with voiceless participants was achieved
using the tablet and supplemented with simple yes/no ques-
tions to which the participant could respond. In one case, the
participant preferred writing on a piece of paper.
Data Analysis
Analysis was inspired by Ricoeur’s26 theory of interpretation.
Ricoeur27 is known for his perspectives on bridging the gap
between the phenomenological way of understanding data
and the hermeneutic way of interpreting data in a hermeneu-
tic spiral. However, Ricoeur himself did not operationalize
the analysis; instead, he provided philosophical perspectives
on it.28 Therefore, research must be inspired by those who
have transformed his ideas into a practical way of analyzing
data, and the approach by Dreyer and Petersen28 was ap-
plied. Guided by Ricoeur’s27 interpretation theory, in which
he argues that “What has to be interpreted in a text is what
it says and what it speaks about,” Dreyer and Pedersen28 ar-
gue that this involves a dialectic movement between the parts
and the whole in a hermeneutic spiral. To gain an in-depth
understanding, the analysis process involves three steps: (1) na-
ive reading where the reader acquires a general sense of the
text as a whole; (2) structural analysis, which is the movement
from what the text says to what the text speaks about, and fi-
nally development of themes; and (3) critical analysis and dis-
cussion, in which the interpretation continues with discussion
of the findings in a dialectic movement between explanation
and comprehension, achieved by relating to the quotes from
the interviews and observations and thereby interpreting a
new sort of being-in-the-world.21 This dialectic movement
continues in the discussion, where relevant literature and
existing knowledge are used to argue in favor of one or sev-
eral suitable interpretations. Ricoeur21 referred to this as the
final act of comprehension.
Inspired by Spradley’s24 participant observations with in-
formal interviews, data were viewed and therefore analyzed
as a collected body, not separated from observations and in-
terviews but rather analyzed together. Also, because com-
munication is the unique interaction that occurs when two
(or more) people interchange needs, beliefs, and opinions,
the data analysis focused on the collected experiences of the
nurse-patient communication process, which was expressed in
the data. The research software NVivo 10 (QSR International,
Melbourne, Australia) was used to structure the data in the
analysis. It provided the ability to easily move between the
parts and the whole, which complies with the hermeneutic
spiral and the Ricoeurian approach. To ensure further rigor,
researchers worked together on the analysis and discussion
to validate and check whether they agreed on the themes that
represented the meaning of the lived experiences.
400 CIN: Computers, Informatics, Nursing
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FINDINGS
Participants
Eight participants met the inclusion criteria, but one died be-
fore it was possible to test the tool. This left a sample of seven
patients. There were three men and four women between 50
and 81 years of age. They were admitted to the ICU because
of respiratory failure after surgery, gastrointestinal bleeding,
pneumonia, sepsis, respiratory insufficiency, amyotrophic
lateral sclerosis, or Guillain-Barré syndrome. At the time of
observation, patients had been admitted to the ICU for be-
tween 2 and 22 days and had been on ventilator support
between 2 and 22 days. Twenty-five nurses gave feedback
on the communication tool either by e-mail or during
observations.
Structural Analysis
During the analysis, three themes emerged that character-
ized the use of communication tools in the described setting.
Also, a comprehensive understanding characteristic in all
three themes was identified.
Theme 1: When Communication Tools Do Not
Facilitate Communication
There were three perspectives on the reason why communi-
cation tools did not facilitate communication, related to
(1) patients, (2) healthcare personnel, and (3) technical issues.
Patients in the ICU had physical, cognitive, and psycho-
logical challenges that made the use of communication tools
difficult or even impossible. Acute status meant that patients
experienced an overwhelming fatigue that caused difficulty
in concentration and reduced physical strength; the level of
energy required to interact and use tools was not always pres-
ent. This observation expresses how fatigue affected the ability
to use a communication tool: “The patient seems very tired
after morning care. After some time, she starts writing, but
when she pushes the letters on the tablet, several of the same
appear, because she rests her finger on the screen. This makes
it hard to interpret the message.” The state of fatigue could
change within days, hours, or minutes, and it was essential
that the nurses assessed when the patients had the necessary
resources to use a communication tool.
The patient’s cognitive state had an immense impact on
communication. In particular, a state of delirium meant that
patients had difficulty using tools. Other psychological fac-
tors, such as anxiety, agitation, or depression, meant that
tools could not facilitate communication. These conditions
and feelings may have been triggered by admission to the
ICU, or present before admission. Overall, cognitive deficits
and psychological conditions significantly complicated com-
munication, regardless of the use of communication tools.
Some patients were not able to structure their thoughts into
a relevant reply or understand how to use a communication
August 2018
tool. “He wanted to use it. He looked at it for a long time and
seemed interested. However, he couldn’t transform his
thoughts into a message. The only thing he wrote was inco-
herent words.” Some patients declined into a state of apathy,
withdrawing from the outside world. Whether caused by a
psychological crisis reaction, defense mechanisms, depres-
sion, or hypoactive delirium, apathy resulted in patients
not interacting with nurses. This meant that the use of com-
munication tools was not possible until patients initiated
contact again.
Physical weakness or paralysis in the upper extremities
also caused difficulties using communication tools. Fatigue
or ICU-acquired weakness, or paralysis due to critical illness
polyneuropathy or Guillain-Barré syndrome, affected whether
the tools could facilitate communication. Reduced fine
motor-control skills meant that it was a challenge to touch
the relatively small characters on the screen, and sometimes
the patients unintentionally activated something, which dis-
turbed communication. “The nurse explains that she will
try to help the patient to communicate with the tablet. The
first couple of letters go as planned, but the patient’s hands
accidentally glide on the screen and activate a Windows
box. The nurse clicks in the corner, and it disappears. The
scenario repeats itself two times, and the patient becomes ir-
ritated. After having tried for some time, the patient finally
writes ‘wait for my…’ and the nurse guesses that he wants
to wait for his wife before he continues.”
Some patients found it difficult to see the characters or
pictures on the communication tool screen. Providing pa-
tients with their glasses sometimes resolved it. Despite using
glasses, one still expressed that “it seems blurry to look at,”
which could have been due to dry mucous membranes in
the eye or medications.
Difficulties in persuading nurses to facilitate communica-
tion using the tools were typically related to the challenges of
implementation. Many nurses found the tools interesting
and welcomed the possibilities they presented. Some, how-
ever, expressed resistance toward new interventions in which
old habits had to be unlearned and new routines embedded
in nursing care.
From a technical point of view, some improvements were
needed so the tools could facilitate communication, on which
both nurses and patients agreed. OnScreen Communicator
did not always run smoothly but exhibited some latency, or
delays in executing operations, which was the main reason
for complaints related to the technology. This could some-
times be corrected by updating the software or restarting
the tablet, but it was only a matter of time before the appli-
cation slowed and fell out of step with user input again.
When nurses repeatedly experienced latency, they became
unwilling to use the technology. A nurse expressed her expe-
riences: “I find the tablet sluggish. When I tried to use it, the
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patients simply couldn’t keep concentrated because of
the latency.”
Theme 2: When Communication Tools Are Supportive
Communication tools were supportive when the patient had
the cognitive and physical abilities to use them, as well as the
energy to engage in an interaction with the nurse. The tools
were not a substitute for the nurse-patient interaction, but
worked as a supplement in communication that could be a
great help and the only way for the patient to convey a mes-
sage. “It’s terrific! It helps when they cannot make sense of
what I’m saying.” The nurse had to initiate use of the tools
and guide the patients. Sometimes the initial approach was
unsuccessful, and the nurse had to adapt to accommodate
the patient’s state. If the nurse presented the alphabet board
but the patient did not have the cognitive ability to use it at
that time, the nurse could switch to the picture board and
go through the icons systematically. On several occasions,
this allowed the patients to express emotions like “afraid”
or “lonely,” feelings that could otherwise not have been con-
veyed. “It took some time before the patient pointed at the
pictures, but I wasn’t sure whether it was because there were
too many options or it was because she needed some time for
reflection. In the end, however, she pointed at the pictures
‘afraid,’ ‘sad,’ and ‘confused.’ The last one, she pointed at
several times.” The picture board could also facilitate the ex-
pression of basic needs like “thirst” or “pain,” but often the
nurses interpreted these needs without using communication
tools. However, following the structure of the picture board
provided a systematic questioning technique that typically
ensured that most of the patients’ needs or wishes were
addressed.
Nurses reported that the tablet had some electronic ad-
vantages that the laminated communication book did not.
The speech synthesis function gave the patient a voice, the
alphabet board generally sped up the pace of writing, and
the tablet’s screen size was preferred. “It is good with the
big screen and keyboard size, which is easier for the patients
to use compared to their own smartphones. However, the
program runs too slow, and there is too much latency.”
Overall, nurses and patients welcomed the electronic possi-
bilities to facilitate communication provided by the tablet,
but nurses stated that low-tech solutions like the communica-
tion book and pen and paper should also be available.
Theme 3: When Communication Tools Are Unnecessary
Communication tools were not always necessary for me-
chanically ventilated patients. In the most acute phase of crit-
ical illness, the focus was on the fight for survival and basic
needs like pain relief and recovery. The need for more com-
prehensive communication did not emerge until later, as this
patient said: “In the beginning, you just need to rest.” At the
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FEATURE ARTICLE

other end of the illness continuum, patients who were under-
going weaning procedures and had a speech valve inserted
for a period of time could often wait to have more elaborate
communication, when the valve allowed the possibility of
speech. Patients who were able to write sometimes preferred
a piece of paper instead of the communication tools. This
was a more natural and familiar way of communicating,
and some found it to be faster than using a tablet. This very
low-tech solution made more high-tech tools unnecessary in
some cases. Furthermore, in some cases, communication was
facilitated by applying the correct strategy rather than a cer-
tain tool. For example, a nurse managed to identify a need
for ice cubes by systematically asking short and precise ques-
tions, to which the patient responded by nodding or shaking
the head. This was observed on several occasions when com-
munication was related to the nurses’ in-depth knowledge
about ICU patients’ basic physical needs, which made tool
use unnecessary.
Comprehensive Understanding of the Need for a
Communication Strategy
Consistent in all three themes was that a systematic strategy
was the best way to facilitate communication, with or with-
out a communication tool. Communication tools were not
always a guarantee of successful communication and were
supportive only if accompanied by a systematic strategy ini-
tiated by the nurse. The analysis suggests that a patient-
centered strategy should be part of the process when com-
municating with the mechanically ventilated patient. This
strategy should consist of various elements, including com-
munication tools, as illustrated in Table 1. The overall points
and supportive questions provided in Table 1 are based on
the data collection and analysis conducted in this study and
may support the nurse-patient communication process. The
strategy should be adjusted continuously, in accordance with
the patient’s condition, and both high- and low-tech solutions
should be available in a “communication toolbox” in the
ICU. The analysis also shows that nurses must be more com-
petent at communication and have knowledge of various
strategies to improve communication. Training nurses in
communication with the voiceless patient entails knowledge
about both technological and nontechnological strategies
and approaches; a systematic questioning technique with
unequivocal questions seems to be of vital importance.
DISCUSSION
The analysis shows that the communication tools, including
a tablet-based application (OSC) and laminated physical
equivalents, could be very helpful for the nurse-patient com-
munication process in the ICU. In some cases, the tools did
not facilitate communication. Overall, patient-related physi-
cal and cognitive challenges were difficult to overcome be-
cause they resulted from core characteristics of critically ill
patients and could not be eliminated, causing difficulties that

Table 1. Systematic Communication Strategy—Containing Four Overall Points to Consider When Communicating
With the Mechanically Ventilated Patient in the ICU and Supportive Questions to Get a More In-depth
Understanding of the Patient’s Way of Communicating as Well as Communication Abilities and Needs
Strategy Supportive Questions
Assessment of patient communication Is the patient conscious and participating (including score to assess level of consciousness)?
In which phase of the ICU stay is the patient—during the most acute phase or in a more stable
condition (eg, during ventilator weaning)?
How is the patient’s cognitive, mental, and physical condition (including a score to assess delirium)?
How is the patient intubated (endotracheal tube or tracheostomy)?
Does the patient use glasses and/or hearing aids?
Do the nurse and patient speak the same language?
Guiding the patient in communication Is it possible to interpret the patient’s unassisted, nonverbal communication (eg, gestures or
mouthing words)? Or should the patient have guidance in a more suitable and easily interpretable
way of communicating?
Is it relevant to present a communication tool and provide guidance on how to use it?
Are there relatives who need guidance in communicating with the patient?
Using the correct questioning technique Should the patient be presented with simple yes/no questions where reply is easy, eg, by
nodding/shaking the head?
Are the nurse’s questions unequivocal and easy to understand?
Can the picture board support a systematic approach where feelings and needs are examined?
Selection of appropriate communication tool(s) Does the ICU have the required communication tools (eg, pen/paper, laminated communication
book and tablet with communication program)?
Which low- or high-tech tools can the patient use?
Should several tools be presented, or is one particular tool most suitable?

402 CIN: Computers, Informatics, Nursing August 2018

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

significantly complicated nurse-patient communication in
the ICU. Happ et al17 stated that 53.9% of mechanically
ventilated patients meet communication criteria, because
they are awake, alert, and responsive to verbal communica-
tion. However, we argue that “awake, alert, and responsive”
are not the only criteria relevant to patients’ ability to com-
municate. Psychological and cognitive aspects described by
Happ et al17 are important, but our study shows that phys-
ical factors like fatigue, impaired muscle strength, and re-
duced vision must also be taken into account. Garry et al29
suggested that an eye-tracking device may enhance commu-
nication, and this could be useful for patients with reduced or
impaired muscle strength. An eye-tracking device was pur-
chased for use in this study, but it required cognitive abilities
and concentration skills that participants did not have. Sii
and Swann15 reported that communication tools may be
beneficial but that patients still use nonverbal communica-
tion like mouthing words and nodding; communication tools
require more alertness and dexterity than patients in the
ICU may have. This is consistent with findings in our study.
In accordance with Hoorn et al,3 our findings suggest that a
combination of several communication methods may be ad-
visable. The communication tools were not always neces-
sary, and other strategies were required. Hoorn et al3 also
developed an algorithm to standardize the approach for se-
lection of communication techniques. Our findings suggest
that this algorithm may be useful, and it complies with the
strategy shown in Table 1.
Some nurse-related challenges were identified, and might
be addressed by a systematic implementation strategy, al-
though there may be several barriers to implementation.30
The Danish study of Handberg and Voss31 was conducted
in a very similar context, and focused on implementing
AAC in the ICU. One of the challenges described in relation
to implementation was that healthcare professionals were
stuck in old habits, which was also the case in our study. Sev-
eral studies argue for the importance of a good education
program when teaching healthcare professionals to commu-
nicate with intubated patients, which could influence the
implementation process.8,9,13,30,32 Handberg and Voss31 es-
pecially emphasized learning how to formulate precise ques-
tions and understanding that AAC is not only the use of tools
but is also about applying the correct strategy for each pa-
tient. This is consistent with the findings in both this study
and our baseline study,23 where it became clear that AAC,
defined only as tools or technological devices, is not always
the best way to facilitate communication. There may be sit-
uations in which low- or high-tech tools are not useful, for ex-
ample when the patient is in the most acute phase of critical
illness, or when communicating about practical or basic
physical issues. A simple yes/no questioning technique may
be sufficient. It is therefore important to inform nurses about
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the fact that AAC is more than using tablets, alphabet boards,
or pictograms; it is also vital to know when to use which
strategy, and have the skills to apply the correct technique
(eg, formulating precise questions).23,31 This may ease the
process of introducing communication tools and techniques
in clinical practice.
The technical difficulties described in this study can be
resolved, and literature shows that more and more techno-
logical solutions that can enhance communication are avail-
able.10,14,15,29,33,34 Most articles, however, report on pilot
studies, and more extensive testing is needed.34 Handberg
and Voss31 also tested OSC, along with other low- and high-
tech solutions. In that study, healthcare professionals gave
opinions on the applicability of communication aids, and
they mentioned many other solutions, but failed to mention
OSC. They may have experienced some of the same chal-
lenges as we did (eg, latency), but unfortunately did not de-
scribe barriers in detail.31 Our study clearly shows that it is
important to choose the right technological solution(s), be-
cause difficulties in use due to latency or complexity may
be a barrier to implementation, which was also a finding of
the review by Carruthers et al.34 In a study by Koszalinski
et al,14 the authors’ conclusion was “Technology is going
to be a significant game changer in communication.” Al-
though we cannot argue against the potential future truth
of this statement, in the present, as many other studies
found,3,9,13 we suggest that using and combining a variety
of AAC strategies and tools may better meet the various
needs of heterogeneous patients in the ICU and help to make
each nurse-patient interaction a successful communication.
LIMITATIONS
We believe that the findings contribute to understanding
how the use of communication tools in the ICU can affect
nurse-patient communication; however, there are some lim-
itations. Because of difficulties in recruiting participants for
the study, the sample is relatively small, which was primarily
due to patient-related characteristics, as described in the
analysis. Thus, it was difficult to recruit patients. Conducting
complex intervention studies in the ICU can be especially
difficult because of the patients’ critical condition and vul-
nerability; ethical considerations must be addressed when
recruiting participants.35 However, since this was a pilot
study, we believe that the sample size is acceptable, and the
findings have contributed to knowledge in the field of AAC
in the ICU setting.
The original intention of the study was to test communi-
cation tools based on health technologies. However, the
nurses participating in the study believed that it was impor-
tant to include a nonelectronic tool, ensuring that more pa-
tients could use it. This turned out to be an advantage
from a practical point of view, but from a methodological
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FEATURE ARTICLE
perspective, it would have been preferable to separate these
two. This perspective underlines the importance of having a
variety of communication tools available, both high-tech and
low-tech, because each patient has individual communica-
tion difficulties, needs, and preferences.
The data collection method, inspired by Spradley,24
which allowed for informal interviews in connection with
participant observations, gave richness to the data. During
data analysis, further rigor and transparency were obtained
by both researchers contributing to the analysis and using
NVivo 10, which enabled the analysis to go forward and
back between the parts and the whole in a hermeneutic cir-
cle. The phenomenological-hermeneutic approach was an
excellent way to gain understanding of the lived experiences
of the nurse-patient interaction in relation to communication
tools. Findings show that mechanically ventilated patients
have individual challenges, influencing their ability to use
communication tools; however, the number of patients able
to use communication tools in the ICU was not addressed in
this study. A study design with mixed methods would have
allowed for a quantitative part of the study, and screening
all patients could have been profitable in answering this
question: “How many mechanically ventilated patients can
use communication tools in the ICU?” This would provide
a deeper understanding of which tools to purchase, and be
relevant in evaluating the cost-effectiveness of various com-
munication tools and strategies.
CONCLUSION
The communication tools that were tested in this study pre-
sented some challenges, primarily patient related. Physical,
psychological, and cognitive conditions and impairments like
fatigue, reduced muscle strength, and delirium have an im-
pact on patients’ abilities to use communication tools. Be-
cause this is part of the acute and critical illness trajectory,
these obstacles are difficult to eliminate and will always be
present in an ICU context. However, patients who are able
to use communication tools find them very helpful. Various
communication tools, both high- and low-tech, should be
present in the ICU to accommodate the needs of a het-
erogeneous group of patients. Meanwhile, nurse-related
challenges may be dealt with through a systematic imple-
mentation strategy. Technical difficulties can be resolved,
and as this field rapidly develops, new hardware and
software may present communication solutions for the
mechanically ventilated patient. The nurse-patient com-
munication process, however, does not depend only on
technical solutions, but also on a systematic communication
strategy containing both nontechnological and technologi-
cal approaches that can address the many needs of patients
in the ICU.
404 CIN: Computers, Informatics, Nursing
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
Acknowledgments
The authors thank The Novo Nordisk Foundation for giving funding to
this study. They also thank Aarhus University Hospital for its contribu-
tion, especially the two ICUs OVITA and ITA.
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