Promoting a nursing team’s ability to notice intent to communicate in lightly sedated mechanically ventilated patients in an intensive care unit: An action research study

Abstract

Objectives

This study aimed to examine changes in the practice of nurses who received an intervention designed to increase their awareness of endotracheally intubated, lightly sedated mechanically ventilated patients’ intent to communicate.

Research methodology

Action research was applied. Specifically, three interventions promoting awareness of patients’ intent to communicate were administered and pre- and post-intervention, observations of patient-nurse interactions, unstructured interviews with nurses and a patients’ satisfaction survey were conducted. The pre- and post-intervention patient-nurse interactions and patients’ survey results were then compared and a content analysis of the interviews and field notes was performed.

Setting

The intensive care unit of a university hospital.

Main outcome measure

Nurses’ awareness of lightly sedated mechanically ventilated patients’ intent to communicate.

Findings

After the intervention, the incidence-rate ratios for nurses noticing of patients’ intent to communicate were 1.53; there was no change in the frequency of patients’ intent to communicate. Further, nurses became more aware of and reflected on their own practices, showed increased interest in co-workers’ practices and considered their actions from patients’ perspectives. Patients’ satisfaction with nurses’ respect for their wishes and dignity also increased.

Conclusions

Action research can induce a change in intensive-care-unit-based nursing practice towards patient-centred care.

Introduction

In intensive care units (ICUs), severely ill patients who are under mechanical ventilation (MV) have traditionally been administered heavy sedation to alleviate the associated pain and discomfort. Recently, however, it has been recommended that light sedation be used in such cases, as this can lessen the risk of adverse effects associated with excessive use of sedatives (Balas et al., 2012, Balas et al., 2018). Maintaining patients’ cognitive functions by decreasing their degree of sedation facilitates early mobilisation and allows even endotracheally intubated MV patients to communicate through writing (Barr et al., 2013, Vincent et al., 2016).

Several studies have consulted with MV patients post extubation, consequently clarifying their experiences while under MV (Engström et al., 2013, Samuelson, 2011, Karlsson et al., 2012a). In particular, the patients reported experiencing anxiety, fear, loneliness and physical suffering, as they were dependent on healthcare professionals and did not have access to sufficient means of communication (Baumgarten and Poulsen, 2015, Cutler et al., 2013, Fink et al., 2015, Finke et al., 2008, Guttormson et al., 2015, Tembo et al., 2015). One limitation to these studies is that 33–57% of those approached did not remember their experience in the ICU (Myhren et al., 2009, Rotondi et al., 2002). However, with the current practice of using less sedation, real-time surveys of endotracheally intubated patients have become possible; lightly sedated mechanically ventilated (LSMV) patients have demonstrated that they can interact with their surroundings even while in a critical condition, physically dysfunctional and dependent on technology (Laerkner et al., 2017, Noguchi and Inoue, 2016, Prime et al., 2016). As a consequence, it has been found that LSMV patients desire to remain conscious and to be able to maintain their self-image by communicating with others; in fact, they reported a willingness to experience pain in order to maintain consciousness and communication abilities (Noguchi and Inoue, 2016, Prime et al., 2016). However, the patients also reported that they generally did not receive opportunities to initiate communication and were ignored when they attempted to communicate (Karlsson et al., 2012b, Karlsson et al., 2012c, Samuelson, 2011). Further, they revealed that they experienced existential suffering as a result of their unidirectional communication with medical personnel (Holm and Dreyer, 2017, Noguchi and Inoue, 2016).

Until recently, communication between MV patients and nurses was brief, lasting approximately one minute (Ashworth, 1980), during which the nurse spoke for approximately 35 seconds (Nilsen et al., 2013) and initiated most of the exchanges (Happ et al., 2011). ICU nurses prioritise reducing patients’ burden and emphasise efficient, task-oriented methods of communication; with MV patients, ICU nurses control the timing of such communication, the topics covered and the communication methods (Bergbom-Engberg and Haljamäe, 1993, Hall, 1996, Happ et al., 2011, Nilsen et al., 2013). Thus, to enable LSMV patients to appropriately influence these exchanges and to ensure that their human dignity is respected, changes in practice that support two-way communication are needed.

In the present study, action research (AR) is employed, involving the application of an intervention designed to encourage nurses to develop greater awareness of LSMV patients’ desire to communicate. The specific goal was to effect changes in nurses’ practice that would result in greater respect for the human dignity of LSMV patients in ICUs. This AR emphasised the initiative of both parties (nurses and patients), focusing on specific events in a specific setting, and aimed to foster improvements in the current situation while also obtaining and considering the perspectives of both parties (nurses and patients); this method is based on the social process of collaborative learning (Chenail et al., 2010, Cooper, 2000, Greenwood, 1999, Kemmis, 2007, Kemmis and McTaggart, 2005). Further, situated learning, which involves a more active approach than traditional systematic or passive learning, was set as the theoretical foundation of this study; this entailed the nurses improving their care practices through active participation in the daily practices (Lave and Wenger, 1991).