INTRODUCTION

Communication with the critically ill patient is complicated by the environmental, social, physical, and structural barriers that encompass it^1,2. The inability to speak as a consequence of mechanical ventilation, exhaustion, weakness, fear, or anxiety all contribute to need to interpret the movement, gestures, and behavior of the patient^3,4. Poor communication between the nurse and the critically ill patient generate negative emotions, loss of control, misunderstanding, dependency, and alteration of the perception of the patient, with a direct effect on his or her health ^5,6.

The training of nurses in communication techniques has always been at a handicap in the improvement of communication with the patient, and by extension his or her well-being. The first studies made of communication between the nurse and the critically ill patient indicated that nurses relied on verbal communication, with short instructions (less than a minute) concerning the technical procedures to be carried out⁷. Some nurses have used other techniques such as lip-reading and learning by trial and error. Misunderstandings and poor interpretation generated insecurity and frustration in the nurses and worsened their ability to manage pain⁸, provide emotional support, and meet the needs of the patient⁹.

The first quasi-experimental study giving evidence of the effectiveness of communication between the nurse and the patient was carried out by Happ et al.¹⁰, with an intervention called SPEACS. This study measured the frequency, quality, ease, and success rate of communication during nurse-critically ill patient interaction. The first training of nurses in this area was carried out by specialists in Augmentative Alternative Communication (AAC). The results of the study opened up a new line of research examining the analysis, application, acceptance, and effectiveness of AAC. Models of AAC were then constructed^10,11, with nurses receiving training in the different levels of technology associated with AAC: no technology (basic communication skills (BCS)), low technology (blackboards, drawings, international gestures)¹², and high technology (electronic devices and programs)^13,14. Also assessed were the implementation and impact of AAC training, and the impediments to its implementation in the intensive care unit (ICU)^1,15.

In our review of the literature we turned up no studies that contemplated the training of pre-hospital nurses in medicalized ambulances with AAC. The training of pre-hospital nurses (Emergency Medical Systems--SEM) in AAC was therefore put forward for the present study. The adverse conditions represented by the ambulance constitute an additional difficulty in the task of communicating with the critically ill patient^16,17, creating a challenge for the healthcare personnel trying to transmit safety and comfort while accompanying the patient and determining the needs and worries of the individual during transport¹⁸.

MAIN OBJECTIVES

To assess a training program in basic communication skills (BCS) and augmentative alternative communication (AAC), CONCETEM for pre-hospital nurses and to learn both the usefulness of the training program and the level of satisfaction of those participating in it.

METHODS

CONECTEM program and its development

The CONECTEM training program, is aimed principally at nurses treating critically ill patients. It provides tools and resources to nurses to communicate effectively with the aim of improving the quality of the nursing care provided to critically ill patients, limiting the possible psycho-emotional consequences arising from their situation. The program is organized into 4 blocks, as may be seen in Table 1.

Table 1.  Conectem training program 

AVS: Analog Visual Scale, BPS: Behavior Pain Scale, STAI: State-Trait Anxiety Scale, IES: Impact Event Scale

^1.Beukelman, D, K Garret, y K Yorkston. Augmentative Communication Strategies for Adults with Acute or Chronic Medical Conditions.Baltimore: Paul H Brookes Publishing Co,2007.

^2.Carkhuff, R. Helping Human Relations(Vol. 1). New York: Holt, Rineheart and Winston, Inc, 1969.

RESULTS

Sociodemographic characteristics of the nurses

The average age of the participating nurses was 37.5 years. Some 58.3% of the nurses undergoing the communication training were female (n 7). 66.7% were working the day shift. In terms of their work history, 66.7% (n 8) of the nurses had from 5 to 10 years of experience. 75% of them (n 9) had completed a course on basic communication skills during their nursing studies, while 16.7% (n 2) had no prior training in communication (see Table 2).

Table 2.  Nurses' socio-demographic characteristics (n 12) 

MX: Average; SD: Standard Desviation; Typ Er: Typical error; BCS :Basic Communication Skills

Usefulness of CONECTEM training

Prior to the training, only 30% of the participating nurses saw communication with the critically ill patient as being important. In contrast, three months after completing the training, 100% of the same nurses felt that the training had opened up new perspectives regarding communication between the nurse and the critically ill patient. Half of the nurses 50% said that the training had helped them greatly in understanding more fully the psycho-emotional effects felt by the critically ill patient, while another 40% felt that it had helped them somewhat. In terms of expanding knowledge about the techniques of communication, 60% said that the training had done so a great deal, while another 40% said that it had done so somewhat. We find the same percentages with respect to the training and improvement in care quality. Some 60% felt that the training had improved the care they provided the critically ill patient greatly, and 40% said that it had done so somewhat. Therefore, we may conclude that the prehospital nurses saw the CONECTEM training program as ranging between somewhat useful and very much so. See Table 3.

Table 3.  Assessment of the utility and application of the CONECTEM training 

MX: avarage; SD: Standard desviation;Typ Er: Typical error; Rating: 1 (nothing), 2 (Little), 3 (Sometimes), 4 (Pretty), 5 (Much)

Perceived satisfaction with the CONECTEM program

The general assessment of the training was 58.3% good and 42.4% very good. The items seen most favorably were: encouraging student participation, the response of the teacher to questions that arose during the training, and the structure and organization of the course. Of note, all the other variables averaged better than 4/5. Therefore, we may conclude that the satisfaction of the nurses with their program was good. See Table 4.

Table 4.  Nurses' satisfaction perception of communication training (n12) 

MX: avarage; DS: Standard desviation; Tip Er Typical error; Rating: 1 (Very poor), 2 (Bad), 3 (Fair), 4 (Good), 5 (Very good)

DISCUSSION

At the outset the nurses participating in the study had a relatively low perception of the importance of communication with the critically ill patient; some 70% (n 7) thought it of little importance or somewhat important. The researchers did not dig deeper to uncover the sources or consequences of this lack of interest, but the reviewed literature indicate that the lack of effective communication between nurse and critically ill patient gives rise to frustration and insecurity in healthcare professionals^{20 21 22}.

Regarding satisfaction with the CONECTEM program, the results indicate that the nurses viewed the methodology used in the program positively, as it encouraged participation by the students. Role-playing and practical case study are two of the most commonly used methods in training programs in communication techniques^23,24. The clarification of the concepts and the general evaluation of the program were also very satisfactory (average 4.42/5). It is of note that the training in communication techniques was well received on the part of the nurses. Koszalinski et al.²⁵reported that 41.6% of the nurses in a training program were then able to communicate better with patients, and 100% were inclined to repeat the training experience. Different studies reported that the nurses felt that the training in BCS and AAC was beneficial to them both professionally and personally^{17 25 26 27}.

The results of the present study reveal that the nurses felt that the CONECTEM program was useful (40%) or very useful (60%), in that their improved communication skills meant an improvement in the quality of care provided to critically ill patients. Similar studies in which the nurses participated in in BCT and AAC training also reported that the nurses saw their training as an professional improvement. Koszalinsky et al.²⁸reported that nurses found new techniques learned in their training to be useful, and often used by them. Higginson et al.²⁹concluded in their study that 89% of the nurses participating in the PACE intervention found it to be very useful. Nurses feel greater professional self-confidence when they are able to communicate with their patients. Mehmet et al.²³carried out training with emergency service nurses. After the training, their communicative skills (p 0.001), empathy (p 0.001), respect and understanding (p 0.01), and active listening (p 0.03) vis a visthe patient had increased, while their ineffective interactions with patients had decreased by 66%.

In our study the nurses participating in the CONECTEM training believed that the training had opened up new perspectives for them in terms of communicating with critically ill patients, had improved their communicative skills, and had helped them to comprehend the psycho-emotional effects on the critically ill patient (average 4/5). In contrast, the items related with the implementation of the communication techniques had lower scores (average 3/5). Authors who have studied the difficulty in implementing BCS and AAC with the critically ill patient have described barriers encountered by the nurses, including a shortage of time, unfamiliarity with the technology^1,15, lack of training, and failure of communication despite having used the techniques that were learned, leading to a certain insecurity in using AAC²⁸.

Limitations

The study has two limitations that must be noted: 1) we did not examine the barriers in the implementation of the training, and their causes. A further study should be carried out to this end; and 2) the representativeness of the sample is limited (n 12), although the other studies reviewed that reported training programs for nurses had from 10 to 22 participants^{24 29 30}.

CONCLUSIONS

The SEM nurses who underwent CONECTEM training based on BCT and AAC were then prepared to apply the new communicative model to their professional lives. All of the nurses felt that the training was useful and that it had improved the care provided to critically ill patients transported in ambulance. The nurses were satisfied with the CONECTEM training, thereby aiding in its future implementation.

Prehospital nurses consider training in BCS and AAC to be useful in helping them communicate more effectively with patients.

Communication programs need to be put in place to improve the quality of care provided to critically ill patients transported in ambulance.