As discussed throughout this book, effective communication is essential to the relationship between the nurse and client. The ability to communicate is often taken for granted, and it is not appreciated until the nurse finds him- or herself in a situation in which the traditional means of communication are not possible. Nurses who practice in an intensive care unit provide care to clients who are unable to communicate verbally or nonverbally. For the client who is mechanically ventilated without cognitive impairment, the ability to speak is lost, but nonverbal communication remains possible. In contrast, the client who has a cognitive impairment (e.g., unconsciousness) and is mechanically ventilated has lost both verbal and nonverbal communication.

Voicelessness has been identified as the inability to speak resulting from respiratory tract intubation and/or mental status changes (permanent or transient).¹ Clients who have experienced voicelessness describe feelings of insecurity, frustration, anxiety, fear, anger, agony, and panic.², ³, ⁴, ⁵ Asking a question or expressing a need is a challenge for the intubated client. In one study 29 clients were interviewed about their experience while intubated. Sixty-two percent of the clients reported high levels of frustration associated with their inability to communicate. Only 14% reported their experiences in communicating as not frustrating.⁶ Trying to get the nurse to understand what the client is asking for can be an exhausting and frustrating experience. This sense of frustration can be seen in the following client’s statement: “I can remember getting cross with everybody, getting cross with … my husband, my sister, my mum and dad because they couldn’t understand what I was to say to them.”⁵ In another study, 13 of the 22 clients interviewed felt the registered nurse caring for them was able to understand their needs and wishes.⁷

Other frustrations arise from insufficient explanations and inadequate understanding of conversations with caregivers. Explanations related to the client’s care and treatments are not clearly understood, and the client is unable to communicate the need for additional information and clarification. Also frustrating is the inability of the nurse to interpret the client’s nonverbal cues, which result in misunderstanding of the client’s request or continued attempts to communicate.¹,⁵,⁸ One nurse stated “I think it is one of the most frustrating things that can happen to a patient. The patient is lying there, completely helpless, trying to communicate desperately with you, and you have to say, ‘No, I don’t understand, sorry.’”⁹

The intensive care unit presents many barriers to effective nurse-client communication. Bassett⁹ placed the various barriers in two categories: mechanical and psychological. Included in the mechanical category is the client’s inability to speak or communicate. Factors that influence this category include the client’s medical condition, the administration of sedating and neuromuscular blocking agents (NMBAs), presence of an artificial airway, and the noise generated by the various pieces of equipment and personnel in the intensive care unit.

Communication is an active process that requires energy. The client who is critically ill may not have the energy necessary to communicate or may only have a limited reserve that becomes depleted with repeated attempts to communicate. This is seen in a statement by a client: “He [nurse] tried very hard to communicate. He would watch my lips and mouth, because I couldn’t use the [alphabet] board very well. I was so weak, and I forgot how to spell, just couldn’t seem to get it all together, I was so groggy.”³

The medications utilized also influence the ability to communicate. NMBAs are frequently employed in the care of the critically ill client. These agents paralyze the skeletal muscles and render the individuals unable to move or even open their eyes. For these clients, verbal and nonverbal communication is lost. The administration of sedating agents to mechanically ventilated clients also affects their ability to communicate by altering their mental status.¹⁰

There are factors that may both limit and facilitate communication with intubated clients depending on the situation. Some of the factors identified by critical care nurses that limit their ability to communicate include:¹,³,⁸,¹⁰, ¹¹, ¹²

Additional factors were identified when the client was comatose or unresponsive due to NMBAs. These factors included self-consciousness on the part of the nurse, lack of privacy, and the circumstances surrounding the injury. The nurses who were interviewed described feeling self-conscious talking to a client who was unable to talk back or use nonverbal methods. The majority of communication with clients consisted of informing them of upcoming procedures or activities. Rarely were nonprocedural topics discussed.¹⁰

The experience level of the nurse is a factor that can also inhibit communication. A grounded theory study by Villanueva¹⁰ explored the experiences of critical care nurses caring for clients who were comatose due to a traumatic head injury or receiving NMBAs. As novices, the nurses described themselves as being task oriented, overwhelmed, and intimidated. Their focus was on managing the complex equipment and required nursing responsibilities. It was not until novices achieved a comfort level with the technical aspects of their role that they were able to focus on talking to clients. The client’s acuity was also a factor in inhibiting communication even for experienced nurses. The higher the client’s acuity, the greater the intensity required for monitoring physiological and neurological status, maintaining the complex equipment, and performing the numerous nursing responsibilities. As a result, the nurses talked less to their clients, and when they did talk, the conversation was limited to information about upcoming procedures or activities.

In a study by Patak,⁶ practitioner interventions and attributes that promoted or inhibited communication were identified by previously mechanically ventilated patients. Attributes that were found to be helpful were being kind and patient, offering verbal reassurance and important information, and being present and available at the bedside. Characteristics and attributes that negatively impacted communication were providers who were described as mechanical, nonpersonal, inconsistent, inattentive, and “absent.”