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Communication is Critical in ICU Nursing

Continuity of care relies upon the communication skills of nurses.

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Whether it's the way they converse with children, the way they explain discharge instructions to patients or their tone during day-to-day rounds, nurses must adhere to a clear communication strategy designed for better care transitions for all patients. That's especially true on the intensive care unit.

"Communication is one of the key tools that an ICU nurse has to support the patient at the bedside, and is essential to providing care to critically ill patients who typically require constant monitoring and assessment," said Christine Gamlen, MSN, RN, CNO of health IT vendor Vocera, who has managed busy ICU and oncology units at Stanford University Medical Center and UCSF Medical Center, both in California.

"Since ICU nurses are typically tasked with providing vigilant care to just one or two patients, they are in a perfect position to observe any changes to patients' conditions and communicate and document these changes to the other care team members," she said.

Shelley Simkins, MSN, RN, critical care services director at McKee Medical Center in Loveland, Colo., said communication in an ICU setting is imperative because of the high acuity levels of the patients. "ICU nurses are in constant communication with other disciplines and the physicians to ensure continuity of patient care," she said.

"An example of this is interdisciplinary rounds that occur in ICU on a daily basis. During rounds, all ICU staff, the intensivist and all disciplines caring for ICU patients gather together to discuss each ICU patient and establish the plan of care for the patient that particular day. At times, the group invites the patient and family to be part of these rounds so they have a chance to ask questions about the current plan of care."

Technology & Flexibility

Barbara Maffia, RN, nurse manager of the ICU at Long Island College Hospital - SUNY Downstate Medical Center, Brooklyn, N.Y., believes critical care nurses can improve patient care by being flexible in their thinking of what constitutes communication and adaptable when it comes to new technology.

"One of the ways is to permit the patient to communicate by texting. Many ICU patients are intubated and cannot verbalize their needs, but they are extremely comfortable texting," she said. "Hospitals often have standing restrictions against cell phone use in the ICU, but if this is the best way to communicate with the patient then the nurse should be accommodating."

Non-verbal communication is just as important. Patients on multiple medications may not be fully aware of their surroundings and thus may be incapable of comprehending oral instructions or remarks. However, they often respond demonstrably well to non-verbal methods of communication, such as a smile or a therapeutic touch.

"In large urban areas, many people do not communicate sufficiently well in English. Other non-English speaking patients who normally can communicate in English, revert to their native language under stress of the ICU," Maffia said.

"Language issues do not need to be a barrier between ICU nurses and their patients. Judicious use of existing tools, such as dual-receiver telephone handsets and other language line tools can allow the nurse to communicate directly with the patient or the family member."

Children & Communication

When it comes to pediatric patients, with their limited knowledge of the hospital setting, the slightest variation in noise, site, smell or activity may provoke fear and curiosity in a child.

Therefore, a nurse is in a pivotal position to set the tone for the entire hospitalization and establish a trusting, therapeutic relationship.

"Naturally, a parent or caregiver needs to understand the condition and prognosis of the patient in its entirety," Maffia said. "But the patient does, as well.

"A good ICU nurse communicates with a pediatric patient at the level of his/her comprehension, which will reduce fear and anxiety."

Emily Weber, RN, director of nursing at Newborn Center at Texas Children's Hospital in Houston, said in the NICU, communication is key in providing safe and effective care.

Some of the common disciplines that the neonatal nurse communicates with include physicians, respiratory therapists, dietitians and pharmacists. However, the most important communication is with the family.

"As communication between care providers is improved, better care is delivered to the patients," Weber said. "For example, in a negative or punitive work environment, a nurse might be hesitant to bring up a concern with a provider about a patient. In an environment that has mutual trust and respect, a nurse would easily bring up concerns that could assist with an early intervention of a patient problem."

Technology is also important with children. From cell phone texting to handheld game devices, technology plays an enormous role in the life of the modern child. If the ICU nurse can accommodate the pediatric patient, then the child will be in a better frame of mind to respond to care.

Hospital Occupancy

Poor communication also causes poor care transitions and patient throughput, which leads to overbooked hospitals.

"ICU nurses should take the time to huddle with the physician and other clinicians providing care to ensure that all parties, including patients and their families, understand their care plan and can move seamlessly through the hospital," Gamlen said. "Once patients are ready to leave the ICU, it is also vital that nurses effectively communicate hand-off information to caregivers or discharge information to patients and their families to reduce the likelihood of readmission."

Simkins offers that daily bed huddles are a great communication method for discussing hospital occupancy in real time.

"Each day nursing leadership and the unit charge nurses gather to discuss activity on the units, and how beds will be managed throughout the day," she said. "If the hospital gets close to capacity, another emergency meeting is established so the flow of the hospital is being addressed in real time."

Post Discharge

As today's patients leave the hospital, they have more acute healthcare needs, so the information they receive at discharge can be overwhelming.

"The most successful model we have seen is having a discharge RN call the patient 24-48 hours after the patient leaves the hospital to review the discharge information again and allow the patient to ask questions," Simkins said. "The discharge nurse can assess over the phone if the patient needs further resources or may need some further explanation of their home care instructions."

ICU nurses can teach and affirm positive behavior and proper communication can impact successful post-discharges.

For example, a patient who ended up in the ICU because of a neglected decayed tooth can be reminded that visits to a dentist could have prevented an infection severe enough to require an ICU stay, and offer literature about preventive dental care as they leave.

High-risk and premature infants often need complex arrangements for their care needs after discharge as there is often multiple follow-up appointments, home care, medication and equipment/supplies that need to be coordinated.

"The discharge plan for these medically complex children requires planning upon admission from several care providers," Weber said. "The NICU nurse is the overall coordinator of care for discharge needs. Engaging in early and frequent communication of these needs ensures families are ready for discharge when medically appropriate."

Evolution of Nurse Communication

Patient-centered communication has evolved over the years. The communication with families has transitioned from informing the families to engaging the families as partners in care delivery decisions.

"As far as nurses are concerned, the ICU has always been a very intense and patient-centered unit," Maffia said.

"The multidisciplinary approach, now the standard of patient care, has enabled nurses to forge stronger bonds with the other health professionals who are involved in the entirety of the patient experience, such as attending physicians, medical staff, respiratory therapists and pharmacists," she said.

This, in turn, has expanded the nurse's knowledge of the patient's case, knowledge that allows her to communicate more fully with the patient and family.

Keith Loria is a freelance writer.

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