key: cord-0844306-upgxpnbe authors: Istanboulian, Laura; Rose, Louise; Yunusova, Yana; Dale, Craig title: Barriers to and facilitators for supporting patient communication in the adult ICU during the COVID‐19 pandemic: A qualitative study date: 2022-03-09 journal: J Adv Nurs DOI: 10.1111/jan.15212 sha: 11c7ba76ba933a67b28c86e3825e0608deaef088 doc_id: 844306 cord_uid: upgxpnbe AIM: To explore barriers to and facilitators for supporting communication with and for patients treated with invasive mechanical ventilation in the intensive care unit during the COVID‐19 pandemic. DESIGN: A qualitative descriptive study reported according to the Consolidated Criteria for Reporting Qualitative Research. METHODS: Adult intensive care unit patients treated with an advanced airway for mechanical ventilation, their family members and healthcare providers (nurses, intensivists and allied health) were recruited for interviews between January and April 2021. Interviews were audio‐recorded, transcribed verbatim and analysed using content analysis methods. Reported communication barriers and facilitators were mapped to the theoretical framework of acceptability to identify potentially modifiable clinical and institutional practices. RESULTS: We recruited 29 participants (20 healthcare providers, four patients and five family member). Provider communication barriers included isolation procedures, lack of personal protective equipment and inadequate communication tools/training, which reduced perceived communication frequency and effectiveness. Patients and families reported infrequent proactive provision of communication tools, which contributed to a crisis of unmet needs. Reported facilitators included adequate access to personal protective equipment to mitigate the risk of patient proximity and communication tools/training to improve communication effectiveness. Authentic unit leadership helped to assuage pandemic work stressors and encourage humanistic care. Our analysis indicates low acceptability of existing communication practices during the COVID‐19 pandemic and the importance of leadership to reduce the burden of communication through provision of key necessary resources. CONCLUSION: COVID‐19 conditions have precipitated a communication crisis in the ICU. The results of this study have practice and policy implications and will be used to co‐design a communication intervention for use during and beyond the COVID‐19 pandemic. IMPACT: The study contributes a better understanding of resources necessary to support patient communication. Results apply beyond the pandemic to routine use of infection prevention and control precautions in the intensive care unit. Intensive care unit (ICU) patients and their healthcare providers (HCPs) have persistently reported communication difficulty due to impaired vocalization associated with placement of advanced airways (e.g. endotracheal or tracheostomy tubes) for mechanical ventilation. Globally, ICU survivors have described communication impairment during mechanical ventilation as one of the most stressful and dehumanizing events of hospital admission (Baumgarten & Poulsen, 2015 ; Karlsen et al., 2019) . Communication difficulty can result in the inability to self-report major physical (e.g. pain, dyspnea, thirst) and psychological symptoms (e.g. sadness, fear, confusion) of critical illness and its treatment (Choi et al., 2017; Radtke et al., 2011) . Unrelieved symptoms contribute to long-term patient morbidity including depression, anxiety and post-traumatic stress disorder, rendering communication an important target for practice improvement (Ijssennagger et al., 2018; Inoue et al., 2019; Khalaila et al., 2011) . ICU nurses most frequently interact with critically ill patients and require pragmatic strategies to address communication impairment. ICU nurses may also be required to guide other HCPs including allied health team members and intensivists about communication strategies and tools that match patient abilities and preferences (Istanboulian et al., 2020) . Current recommendations include but are not limited to the use of augmentative and alternative communication (AAC). Defined as alternatives to speech, AAC consists of 'unaided' strategies (e.g. mouthing words and gesturing) or 'aided' strategies such as low-tech (e.g. picture or word boards) and hightech (e.g. computer interface) devices (Augmentative and Alternative Communication, 2019). Prospective use of AAC is demonstrated to be effective in reducing patient communication difficulty and improving HCP satisfaction with care (Carruthers et al., 2017; Karlsen et al., 2019; Ten Hoorn et al., 2016; Zaga et al., 2019) . In support of this evidence, recent research has identified the importance of all ICU HCPs having access to communication tools and training in their use (Happ et al., 2014; Istanboulian et al., 2020; Trotta et al., 2019) to avoid patient and HCP emotional distress (i.e. frustration, anger) over failed communication attempts (Istanboulian et al., 2020) . The burden associated with failed communication may lead to emotional disengagement and reduced communication frequency by both patients and HCPs (Ijssennagger et al., 2018; Istanboulian et al., 2020) . In Canada and the US, to date approximately 18-28% of people with confirmed COVID-19 infection have been reported to require ICU admission (Canada Go, 2022; Nguyen et al., 2021) . Those treated with mechanical ventilation often experience a prolonged ICU admission, thereby increasing the need for consistent and effective communication support (Attaway et al., 2021) . However to date, infection control conditions, such as those enacted during the COVID-19 pandemic, have not been the primary context for research informing ICU communication guidance (Istanboulian et al., 2020) . COVID-19 infection prevention and control measures including the use of personal protective equipment (PPE) and visiting restrictions may complicate utilization of current guidance to support communication with patients (i.e. AAC) and support of communication for patients (i.e. family education in AAC) in the adult ICU (Freeman-Sanderson et al., 2020; Ontario PH, 2021) . As the pandemic presents a significant change in the global healthcare landscape, exploratory research is needed to understand barriers to and facilitators for communication among nurses, patients, family and other ICU professional stakeholders to inform practice recommendations (Akgun et al., 2020; Barreras-Espinoza et al., 2021; Freeman-Sanderson et al., 2020; Richards et al., 2021; Rose et al., 2021) . Theoretical frameworks are recommended to explore practice barriers and facilitators, and inform the design and implementation of complex interventions, such as patient communication (O'Cathain et al., 2019) . The theoretical framework of acceptability (TFA) defines acceptability as a multifaced construct that reflects the cognitive and emotional responses of people delivering or receiving a healthcare intervention (Sekhon et al., 2017) . The TFA includes seven constructs, namely: affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness and self-efficacy (Sekhon et al., 2017) . The TFA posits that patients, families and HCPs form judgements about the acceptability of an intervention, based on anticipated or actual experience, that will impact their engagement with or commitment to the intervention. Because aspects of an intervention can be modified to increase acceptability, an important element of the present study was to identify dimensions of communication that may be amenable to improvement. Our aim was to explore barriers to and facilitators for supporting communication with and for mechanically ventilated adult patients admitted to ICU during the COVID-19 pandemic according to TFA constructs. We conducted a prospective qualitative descriptive study, which is an approach for exploring participants' perceptions of clinical processes and how they might be improved (Doyle et al., 2020) . We recruited participants from a 17-bed medical-surgical ICU in a community teaching hospital in Toronto, Canada (January-April 2021) admitting COVID-19 patients experiencing hypoxemic respiratory failure. The unit is managed under a closed intensivist model and nurses are assigned to mechanically ventilated patients in a 1:1 or 1:2 ratio. Respiratory therapists (RTs) are also present in the unit to manage ventilator support and weaning. The study unit followed COVID-19 infection prevention and control standards set by the Government of Ontario, including the use of PPE, isolation of patients with suspected or confirmed infection and restricting family visitors except in the case of imminent death (Ontario PH, 2021) . The Consolidated Criteria for Reporting Qualitative Research (COREQ) was used as a guide for reporting this research (Tong et al., 2007) . Eligible participants were: (1) patients (≥18 years of age, discharged from ICU and able to speak English) admitted to the study unit and treated with an advanced airway during the COVID-19 pandemic; (2) family members (≥18 years of age, discharged from ICU and able to speak English) of patients admitted to the study unit; (3) HCPs including registered nurses, intensivists and allied health team members (i.e. RTs, speech and language therapists [SLP], occupational and physical therapists, registered dietitians, pharmacists, social workers, spiritual care providers) employed in the study unit during the COVID-19 pandemic. We used convenience sampling in the study setting to recruit participants. This comprised the use of paper and electronic posters advertising the study. Patients and family were identified by HCPs on discharge from ICU and all participants were approached and consented by the principal investigator (LI). Following informed consent, participants took part in one interview exploring their communication experiences using a semi-structured interview guide (Material S1) previously piloted with an external sample. All interviews were conducted by LI who identifies as a woman and has graduate training in the conduct of semi-structured interviews. LI works professionally as a nurse practitioner with prior clinical experience caring for mechanically ventilated patients and their families in adult ICUs and a long-term ventilation and weaning centre in the study site. Interviews were conducted privately either face to face (in an office), by telephone or video call. Data collection and analysis occurred concurrently and data collection was discontinued when no new information was being identified during interviews (Cope, 2014) . No one refused participation, no participant dropped out and no repeat interviews were carried out. Interviews were digitally audio-recorded and transcribed verbatim. Prior to the interview, LI ensured participants understood the rationale for the study and that participation was voluntary and confidential. Ethics approval for the study was given by the Michael Garron Hospital (820-2010-Mis-347) and the University of Toronto Research Ethics Boards (40495). Written informed consent was obtained from all participants prior to interview. We completed a team-based deductive content analysis with author coders working in pairs together, multiple rounds of group discussions and NVIVO 12 software to identify, code and categorize barriers and facilitators to supporting patient communication (Bengtsson, 2016) . The four stages of content analysis (i.e. decontextualization, recontextualization, categorization and compilation) were used (Bengtsson, 2016) . In the categorization phase, barriers and facilitators were mapped to the TFA's seven constructs. Definitions for the TFA constructs were adapted to communication with adult ICU patients (Table 1) . To enhance credibility of the analysis a code book was constructed and modified using an audit trail through the multiple rounds of coding and discussions among the research team (Cope, 2014; De Cuir-Gunby et al., 2011) . Further meanings in and across the acceptability constructs and participant groups were elaborated during the compilation stage. We conducted 29 semi-structured telephone (15, 52%), face to face (9, 31%) and video call (5, 17%) interviews. Most interviews (23, 79%) were between 30 and 60 min (average 35 min) and six (21%) lasted between 15 and 30 min. Data were collected from nurses and other HCPs (20, 69%) and patients/family (9, 31%). HCPs were primarily women (17, 85%); patient participants were mostly men (3, 75%). Family members largely identified as women (4, 80%) and spouses (2, 40%) and included both members of surviving and deceased ICU patients (Table 2 ). Patient and family interviews occurred from 11 to 305 days post discharge from ICU, and all participants were able to recall communication experiences in ICU during COVID-19 pandemic conditions. Patient and family interviews were conducted in dyads (4, 44%) or stand alone when only a patient or family member was available (5, 56%). Though a variety of interview modes were used, each in accordance with participant preference, the quality of data collected afforded by video and face to face methods offered better access to non-verbal communication for all participants, and in the case of HCPs time constraints in the form of interruptions were observed. Participant checking did not occur after data collection was complete, however, clarification with participants was sought throughout each interview. Participants largely expressed gratitude for the opportunity to share their experiences. HCPs described using a range of communication strategies with patients individualized to each person's level of consciousness and functional capacities. The primary method described was lip reading/ gesture interpretation. Examples of AAC use for awake patients included alphabet boards found online and printed locally or a clipboard and paper if available. For patients who were not awake, some HCP participants described explaining procedures, that is, step-by-step guidance. Patient participants recalled more extensive communication efforts by individual providers as the exception rather than the norm. (Table 3) and facilitator (Table 4 ) categories and described with theoretical concepts from the TFA (identified by italics). In the barrier and facilitator categories, HCP results are separated from patient and family results, permitting comparison across these groups. The source of HCP quotes from members of the allied team were not separated by profession to protect the privacy of participants for whom there were one or few from each class in the study setting. Additional quotes are included as Table S1A-D). Also, sometimes you're wearing an N95 mask and you're wearing a shield on top of that, and you know, and you're wearing a gown and hairnet and everything, you have to speak really loudly. And, and your words don't come out as clear. Nurse HCPs described communication with mechanically ventilated patients as a time-intensive endeavour under normal or non-pandemic circumstances. This is because a process of trial and error is required to The aim of this qualitative study was to explore barriers to and fa- (Reidy et al., 2020) . Our analysis indicates low acceptability of existing communication practices for mechanically ventilated patients in the adult ICU during COVID-19 restrictions from the perspective of diverse ICU stakeholders. Barriers aligned with the TFA constructs burden, affective attitudes, effectiveness, ethicality and intervention coherence suggest a need to ad- IstanboulIan et al. Strengths of this study include the use of a theoretical framework and the inclusion of patient, family and professionally diverse stakeholders. The TFA provided a systematic and multilevel approach to exploring acceptability that may inform the design and implementation of communication interventions. In addition, we employed an interprofessional team approach to analysis to expand interpretive insights and implications. Limitations include a single study site and limited numbers of patients, which may impact transferability of the results. Time constraints in the pandemic context contributed to some shorter interviews for some HCPs. The researcher conducing the interviews is an NP working in the same institution, which may have influenced stakeholder reporting during interviews. will be used to co-develop with patient, family and clinician stakeholders, an intervention for this context that will undergo further acceptability evaluation. The authors thank the patients, families and healthcare provider participants of this study for their generous participation. LI, LR, YY, CD: made substantial contributions to conception and design, acquisition of data, and analysis and interpretation of data. The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15212. 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