Accepted: 2 April 2017

DOI: 10.1111/jocn.13851

ORIGINAL ARTICLE

Implementing augmentative and alternative communication in

critical care settings: Perspectives of healthcare professionals

Charlotte Handberg PhD, MPH, RN, Researcher1,2 | Anna Katarina Voss OT, AAC
Counsellor3

1
Department of Public Health, Section for
Clinical Social Medicine and Rehabilitation,
Aims and objectives: To describe the perspectives of healthcare professionals
Faculty of Health, Aarhus University, caring for intubated patients on implementing augmentative and alternative
Aarhus, Denmark
2
communication (AAC) in critical care settings.
DEFACTUM, Aarhus, Central Denmark
Region, Denmark Background: Patients in critical care settings subjected to endotracheal intubation
3
Technology in Practice, MarselisborgCenter, suffer from a temporary functional speech disorder and can also experience anxiety,
Danish Centre for Rehabilitation – Research
stress and delirium, leading to longer and more complicated hospitalisation and
and Development, Aarhus, Denmark
rehabilitation. Little is known about the use of AAC in critical care settings.
Correspondence
Method: The design was informed by interpretive descriptive methodology along
Charlotte Handberg, Department of Public
Health, Section for Clinical Social Medicine with the theoretical framework symbolic interactionism, which guided the study of
and Rehabilitation, Faculty of Health, Aarhus
healthcare professionals (n = 48) in five different intensive care units. Data were
University, Denmark and DEFACTUM,
Central Denmark Region, Aarhus, Denmark. generated through participant observations and 10 focus group interviews.
Email: [email protected]
Results: The findings represent an understanding of the healthcare professionals’
perspectives on implementing AAC in critical care settings and revealed three
themes. Caring Ontology was the foundation of the healthcare professionals’ profes-
sion. Cultural Belief represented the actual premise in the interactions during the
healthcare professionals’ work, saving lives in a biomedical setting whilst appearing
competent and efficient, leading to Triggered Conduct and giving low priority to
psychosocial issues like communication.
Conclusion: Lack of the ability to communicate puts patients at greater risk of
receiving poorer treatment, which supports the pressuring need to implement and
use AAC in critical care. It is documented that culture in biomedical paradigms can
have consequences that are the opposite of the staffs’ ideals. The findings may
guide staff in implementing AAC strategies in their communication with patients
and at the same time preserve their caring ontology and professional pride.
Relevance to clinical practice: Improving communication strategies may improve
patient safety and make a difference in patient outcomes. Increased knowledge of
and familiarity with AAC strategies may provide healthcare professionals with an
enhanced feeling of competence.

KEYWORDS
alternative and augmentative communication (AAC), communication, communication aids,
healthcare professionals, intensive care units (ICU), interpretive description, nursing care,
rehabilitation, speech impairment, symbolic interactionism

102 | © 2017 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/jocn J Clin Nurs. 2018;27:102–114.
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HANDBERG AND VOSS | 103

1 | INTRODUCTION
What does this paper contribute to the wider
Eighty-four countries have signed The UN Disability Convention, global clinical community?
which describes the right for everyone to be able to communicate
and to use compensatory aids when they experience a functional
• Knowledge on how to improve communication strategies
that may enhance critically ill patients’ safety and make a
speech disorder (UN 2010). Temporary or permanent loss of spoken
difference in patient outcomes.
language due to either physical or neurological reasons can be trau-
matic for both the persons affected and their relatives (Beukelman
• Focus on nurses and other healthcare professionals as
playing a central role in ensuring that assessments of
et al., 2007). Endotracheal intubation, a prerequisite for mechanical
communication needs are conducted for all patients in
ventilation, affects the ability to speak in the short or even the long
critical care settings in order to determine whether
run and can therefore have far-reaching implications for the experi-
patients are able to communicate effectively.
ences of both patients and relatives during hospitalisation and on
their lives after discharge (Svenningsen, Egerod, & Dreyer, 2016;
• It is pressing that the healthcare professionals in critical
care settings all learn, use and apply the augmentative
2807–2815). Access to communicate despite an obstructed spoken
and alternative communication strategies in their clinical
language is a right for everybody (UN 2010) and is exceedingly impor-
practices to ensure all patients the ability to communi-
tant, especially for critically ill patients who may be in the very last
cate.
phases of their lives. Nurses and other healthcare professionals taking
care of critically ill patients are therefore the key to the patients’
access to communication, but can at the same time be a hindrance
the patients’ ability to communicate and interact with their surround- in treatment (Schweickert et al., 2009; 1874–1882). The patients can
ings (Mobasheri et al., 2016, 261–271). Augmentative and alternative aid in the prevention of side effects due to being immobilised by par-
communication (AAC) is a communication strategy that includes all ticipating more actively in physiotherapy and occupational therapy
forms of communication (other than oral) and special augmentative and as a consequence they maintain a better level of functioning
aids (Beukelman et al., 2007). Even though AAC is available, it has (physical and psychological) while being bedbound (Schweickert et al.,
not, for some reason, yet been effectively implemented in the care of 2009; 1874–1882). Being conscious has increased the patients’ ability
the critically ill patients (Mobasheri et al., 2016, 261–271). to be actively involved in and informed on their treatment and thera-
peutic decisions (Vincent et al., 2016, 962–971; Schweickert et al.,
2009; 1874–1882; Efstathiou & Clifford, 2011, 116–123; Klein,
2 | BACKGROUND
Mulkey, Bena, & Albert, 2015, 865–873). Conversely, communication
is more than just being able to express a yes or a no, or a nod or a
2.1 | Being awake and unable to speak
blink, it is also a way to show your personality, expresses fear, wor-
For many patients being admitted to an intensive care unit (ICU) can ries or even make funny comments, but this is not possible for intu-
be a traumatic, frightening and unfamiliar experience (Holm & Dreyer, bated conscious patients whose ability to communicate is very
2015; Svenningsen et al., 2016; 2807–2815). Critically ill patients limited (Blackstone & Pressman, 2016, 69–79; Mobasheri et al.,
subjected to endotracheal intubation and therefore not able to speak 2016, 261–271). Patients’ lack of the ability to speak or communicate
often suffer from anxiety, stress, delirium, confusion, delusional mem- properly can easily lead to decreased participation in their own treat-
ories and symptoms related to the post-traumatic stress syndrome ment and rehabilitation (Magnus & Turkington, 2006; 167–180). The
(Croxall, Tyas, & Garside, 2014; 800–804; Holm & Dreyer, 2015). World Health Organization (WHO) defines rehabilitation as:
Patients’ lack of the ability to speak may lead to anger, anxiety and
frustration among other things because many patients in the ICU are a process aimed at enabling them to reach and maintain
unaware of what has happened prior to admission and will have their optimal physical, sensory, intellectual, psychological
many questions and a compelling wish to communicate (Croxall et al., and social functional levels. Rehabilitation provides dis-
2014; 800–804; Holm & Dreyer, 2015). Exposure to high levels of abled people with the tools they need to attain indepen-
stimuli in the ICU may entail sensory overload known to cause fur- dence and self-determination.(World Health Organization
ther problems for the patients such as irritability, headache, severe (WHO) 2011))
anxiety, hallucinations and confusion (Uzar Ozcetin & Hicdurmaz,
2015; 3186–3196). An increasing number of patients are awake dur- Rehabilitation is considered to begin at the time of diagnosis
ing their stay in the ICU and during mechanical ventilation (Vincent (usually at the hospital) and continue in primary care after hospital
et al., 2016, 962–971). The benefits for the patients of not being as treatment (World Health Organization (WHO) 2011). Patients who
heavily sedated as previously are many, and respiratory therapy has suffer from a functional speech disorder, for example due to endo-
therefore shortened over the years and hence also the time in the tracheal intubation or neurological disease, often have a longer and
ICU (Schweickert et al., 2009; 1874–1882). Being awake for instance more complicated hospitalisation and rehabilitation than other
means that patients are able to communicate and take an active part patients, one reason being great difficulties with communication
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104 | HANDBERG AND VOSS

(Magnus & Turkington, 2006; 167–180). Patients describe that see- boards and electronic aids, which are able to help people express
ing how busy the nurses are also affects them, and they therefore themselves (Beukelman et al., 2007; Schlosser, Koul, & Costello,
tend to isolate themselves (Meril€ainen, Kyng€as, & Ala-Kokko, 2013; 2007; 225–238). There are a number of AAC low- and high-tech
78–87). Isolation and being ignored can lead to feelings of anger and communication aids that enable rapid and targeted communication,
low mood, which again can lead to reduced participation in one’s and these solutions are already known and implemented in other
own rehabilitation (Magnus & Turkington, 2006, 167–180). areas (Beukelman et al., 2007; Schlosser et al., 2007; 225–238).
Research has shown that educating staff in the use of AAC can
shorten a patient’s hospital stay and reduce morbidity (Oczkowski,
2.2 | Communication among healthcare
Chung, Hanvey, Mbuagbaw, & You, 2016, 97-016-1264-y; Fawole
professionals and intubated patients
et al., 2013, 570–577). When patients are intubated and not able to
Improving the patients’ possibilities to communicate and interact is communicate, they are dependent on communication strategies like
an important factor in assisting patients to obtain optimal care and AAC being applied, but unfortunately, even though they are easily
rehabilitation and moreover to help patients avoid isolation, confu- available, AAC strategies have not been implemented to a wide
sion and complications due to loss of the ability to speak (Vincent extent in critical care (Mobasheri et al., 2016, 261–271). Interper-
et al., 2016, 962–971; World Health Organization (WHO) 2011). sonal communication is considered an important means of conveying
However, communication for patients subjected to endotracheal information, providing both physical and psychological support for
intubation is a challenge for both patients and staff that sometimes patients without spoken language, and communication is therefore
leads to misunderstanding, misinterpretation or, at worst, a lack of considered an essential part of treatment (Efstathiou & Clifford,
communication (Otuzoglu & Karahan, 2014, 490–498). The challenge 2011, 116–123). Providing quality health care includes effective
of communicating with intubated patients (instead of patients who communication between healthcare providers and their patients, and
can speak) demands a whole different level of awareness by the AAC is known to be effective in this quest, and is further argued to
healthcare professionals, which can be a huge challenge (Magnus & play a unique role for practitioners, educators and researchers, while
Turkington, 2006; 167–180). For instance, it can be difficult to positively affecting patient outcomes across the healthcare contin-
understand what the patient wishes to say, and this may lead to uum (Blackstone & Pressman, 2016, 69–79).
feelings of incompetence, stress and sometimes even despair among
the staff, who may chose to ignore patients’ efforts to communicate
(Magnus & Turkington, 2006; 167–180). Even though nurses and 3 | AIM OF THE STUDY
other healthcare professionals possess a high level of knowledge and
skills regarding communication, this specific area can lead to stress, The aim of the current study was to describe the perspectives of
feelings of incompetence and (intentional or unintentional) a preoc- healthcare professionals caring for intubated patients on implement-
cupation with physical care and technology, leading to poor commu- ing Augmentative and Alternative Communication in critical care.
nication with intubated patients (Llenore & Robin Ogle, 1999; 142–
145). When patients are unable to express themselves verbally, the
4 | METHODS
staff may be reduced to guessing and freely interpreting what the
patient wishes to express, which often results in an impossible or
4.1 | Design
unmanageable process for nurses who have to take care of many
high priority tasks in a busy critical ward (Efstathiou & Clifford, The study design is qualitative using the methodology interpretive
2011, 116–123). Often the staff is confined to using a yes or no, description (Thorne, 2016) and symbolic interaction as the theoreti-
communicated by a squeeze of the hand or a blinking of the eye, cal framework (Blumer, 1969). Interpretive description is a qualitative
but using communication strategies like AAC, patients are able to inductive research methodology to inform practice-oriented research
express needs, thoughts and feelings, and the communication will (Thorne, 2016). Interpretive description is used in research of clinical
consist of fewer misinterpretations and be easier, optimising the relevance and requires clinical, empirical and knowledgeable integrity
time the staff spends at the bedside (Otuzoglu & Karahan, 2014, in the research question (Thorne, 2016). The methodology seeks a
490–498). Therefore, there is a pressing need to provide staff with coherent conceptual description that represents associations, rela-
information about AAC strategies and aids and how to use them to tionships and patterns within the phenomenon that is being
ensure better communication, care and to avoid misunderstandings researched to improve practice (Thorne, 2016). Interpretive descrip-
(Mazzon, Mauri, & Rupolo, 2001; 819–826). tion differs from other methodologies due to the fact that it draws
on a variety of already known research techniques and traditions like
phenomenology, grounded theory and ethnography, rejecting the
2.3 | Augmentative and alternative communication
“tyranny of method” or “methodological orthodoxy” (Thorne, 2016;
(AAC)
Sandelowski, 2000; 334–340; Sandelowski, 2010, 77–84). As an
AAC is strategy of communicating that comprises different forms of accompaniment to the interpretive description methodology, sym-
communication aids, such as pictures and symbol communication bolic interactionism, constituted the theoretical framework, during
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HANDBERG AND VOSS | 105

the field work and developing of the interview guides and the analy- large hospitals in Denmark in five critical care wards with up to a
ses. The core element in symbolic interactionism is that reality is total of around 3300 patients (potential AAC users) per year and
actively constructed and that meanings are not inherent in “things” around 400 healthcare professionals, primarily nurses but also occu-
but come through engagement between subjects and objects: mean- pational therapists and physiotherapists. The aim of the “Safe
ings are handled in and modified through interpretive processes used Through Communication” project was, using AAC, to create possibili-
by the person dealing with the things he or she encounters (Blumer, ties to communicate for all the patients in the five critical care wards
1969). The approach through symbolic interactionism is relevant in and thereby provide a safe and more positive experience for hospi-
the current study, as intubated patients communicate in an interac- talised patients with a functional speech disorder. Technology in
tive process with the healthcare professionals and act in the light of Practice has broad experience in implementing communication tools
the significance and meaning their condition has for them (Blumer, in a broad range of target groups. Two persons from Technology in
1969). The core premises of Symbolic Interactionism are (1) human Practice were responsible for running that project. All included
beings act towards things on the basis of the meanings the things wards, and all the staff was provided with a thorough education in
have for them; (2) individually or collectively, the meaning one makes the several steps in AAC strategies and communication aids (Fig-
of things arises from the social interaction one has with one’s fel- ure 1).
lows; and (3) meanings are handled in, and modified through, an In addition to learning about the AAC communication strategies,
interpretive process (Blumer, 1969). Patients in critical care live and all wards were provided with a box containing a variety of AAC
experience among other patients, healthcare professionals and rela- communication aids, cf. Figure 2: (a) iPad app: GoTalkNow and Pre-
tives, and the actions of and among the healthcare professionals are dictable, (b) Windows app: On Screen Communicator, (c) Letter
important for the patients’ ability to recover and rehabilitate in the board, (d) Eye tracking board/book, (e) Pain scale, (f) Auditive Part-
best possible way. ner-Assisted board and (g) Eye tracking letter board.

4.2 | Recruitment 4.3 | Data generation

This study was embedded in a large-scale project called “Safe Data generation for the present study was embedded in “Safe
Through Communication” conducted by Technology in Practice Through Communication,” compromising semi-structured focus
[Teknologi i Praksis] at the MarselisborgCenter, Danish Centre for group interviews and participant observation. The data generation
Rehabilitation, Research and Development, Aarhus, Denmark. The was conducted by the first author at the five included hospital wards
project “Safe Through Communication” was being undertaken at five in Denmark from November 2015–May 2016: compromising four

Steering
Project Steering
Group All Staff Steering All Staff
Manager Group
Introduction Test: daily use Group Test: daily use All Staff
start-up Evaluation
(4 hr) around Workshop around Implementation
planning Focus Group
Focus Group (2-5 min) (3 hr) (2-5 min)
(2 hr) Interviews
Interviews

November 2015 – August 2016

FIGURE 1 Project process: implementing augmentative and alternative communication in five critical care settings
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VOSS
AND
HANDBERG

(b) Windows app: On Screen Communicator

(f) Auditive Partner-Assisted board

(d) Eye tracking board/book

(g) Eye tracking letter board

(a) iPad app: GoTalkNow and Predictable

Augmentative and alternative communication aids

(c) Letter board

(e) Pain scale

FIGURE 2
|
106
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HANDBERG AND VOSS | 107

intensive care units and one semi-intensive care unit, all using a means to attentively consider what was said and done within the
mechanical ventilation. The first phase of the project ended in context of the research aim. Data were reread, and a critically
August 2016 (Figure 2), and the follow-up phase will start in the appraisal of relationships within data was conducted. Finally, an
spring of 2017. The focus of the data generation was to understand extraction of the main messages arising from key insights within data
the healthcare professionals’ perspectives and behaviours associated was captured in distilling overarching categories and emergent
with implementing AAC in critical care settings; specifically, what themes (Handberg et al., 2015; Thorne, 2016). The authors worked
were the social interactions between the healthcare professionals together on the analysis.
that informed and influenced meanings and choices in relation to
AAC, and how they interpreted these events in their daily work
4.5 | Ethical considerations
(Handberg, Thorne, Midtgaard, Nielsen, & Lomborg, 2014). Aiming
for depth and variety, the data generation strategy was guided by The study was approved by the Danish Data Protection Agency
purposeful sampling (Thorne, 2016). Of all the healthcare profession- Approval [no. 2015-41-4432]. All participants were informed about
als participating in the “Safe Through Communication” project the project by oral and written information. All participants agreed
(around 300), 48 healthcare professionals were included in this study to participate and to allow the first author to be present during field-
and they were primarily nurses, but also occupational therapists and work, workshops and education sessions etc. Written consent was
physiotherapist participated, all working with patients without func- obtained from all participants, and all were guaranteed anonymity.
tional spoken language. Doctors were not included in the first phase Participants are referred to by pseudonyms selected by the first
of the project. author in connection with specific illustrative quotes in the results
Data were generated from participant observation of the 48 section.
healthcare professionals (steering group included) that participated
in the education and workshops (Figure 1) and further through 10
semi-structured, recorded focus group interviews with the steering 5 | RESULTS
groups with 4–6 participants in each interview (n = 23). On each of
the five departments, two focus group interviews were conducted Overall, the findings represent an understanding of the healthcare
(each around 1½ hour), one interview at the introduction to the pro- professionals’ perspectives on implementing AAC in critical care set-
ject and one interview at the end of the second testing period tings and revealed in the succeeding sequence three overall categori-
(Figure 1). Examples of the qualitative questions asked in the inter- cal themes: Caring Ontology, Cultural Belief and Triggered Conduct
views included: “What seems to be of importance when you work (Figure 3). The themes affected each other in a sequential process.
with patients who experience a functional speech disorder?” “What While Caring Ontology was what the healthcare professionals
are your experiences with AAC (now and after the implementa-
tion)?” “In what way have you used AAC and the aids in your clinical
practice? (and if not, why?)” “In what way do you feel that AAC can
have an effect on communication with the patients?” “In what way
do you engage the patients in the process of applying AAC? (and if
not, why?)” “In what way has the possibility to use AAC and the aids
affected your clinical practice?” “What possibilities/barriers do you
experience in applying AAC in your practice?” Additionally, the first
author made observations during workshops, education and evalua- Caring Cultural
tion of all the 48 healthcare professionals participating from the five ontology belief
departments. Field notes were made on observations, conversations
and on general reflections.

4.4 | Data analysis

Drawing upon interpretive description and symbolic interactionism,
Triggered
the data were analysed in an iterative constant comparative manner
(Thorne, 2016). All data were transcribed by a student worker and
conduct
uploaded into the qualitative software program NVivoTM. Data were
read, and a process of discernment of particular circumstances and
generalised patterns in relation to the study aim was identified
(Handberg, Lomborg, Nielsen, Oliffe, & Midtgaard, 2015; Thorne, F I G U R E 3 Healthcare professionals perspectives on
2016). Data were interpretively examined: participant observations implementing augmentative and alternative communication in critical
in comparison with themes arising from the focus group interview as care settings
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108 | HANDBERG AND VOSS

believed in and explained as the foundation of their profession and No. 1 (ICU Nurse, First interview): “I’m sitting here think-
as the core of high quality of care, Cultural Belief represented the ing about what she said during the workshop. . .I’m not
actual premise in the interactions during their work, saving lives in a that good at turning things that way around. . .the
biomedical setting whilst appearing competent and efficient. This led patients right to communicate. . .. No. . .I’m really looking
to a Triggered Conduct, with the healthcare professionals giving low forward to hearing what our colleagues have to say
priority to psychosocial issues like communication, compromising about that approach, because she really argued well-
their professional values or caring ontology. . . .and I’m not sure I can do that.”

The healthcare professionals explained the importance of com-

5.1 | Caring ontology
munication, but at the same time explained (in the second interview)
Almost all the healthcare professionals showed high motivation and that after getting back to their practices after the educational sittings
commitment when introduced to the concept and idea of AAC dur- and the workshops that they actually had only used AAC a little in
ing workshops. They addressed it as a wonderful concept and some- some wards and in one not at all. They had a hard time explaining
thing that they had needed for years, and in the workshops, they this and kept mentioning that communication was considered an
were very active and enthusiastic. They explained that they often important part of the patients’ well-being, recovery and rehabilita-
had experienced challenges, troubles and frustrations related to tak- tion. They were disappointed that the AAC had not gained accep-
ing care of intubated patients that were not able to communicate tance among a larger number of their colleagues, and they all stated
very well. The healthcare professionals explained and described that that the need was there but the implementation had failed. There
they had often wanted to focus much more on communication and seemed to be an anticipation that the implementation would happen
that they had a clear comprehension that the patients were in need automatically, and they found it difficult because the staff in the ICU
of this and often tried to communicate things that the healthcare consisted of so many people:
professionals could not understand or interpret. They illuminated
how they considered it one of their core values, the ontology of No. 38 (ICU Nurse. First interview): “Well. . .we haven’t
care and a central element of high quality care to provide the been that successful yet. . .right now we need to get
patient with possibilities to communicate by better means than going. . .and do we feel comfortable with that? Well it is
before this project. During education sessions and training in the much easier to hand it [the AAC aids] over to the rela-
use of AAC, the staff explained that they were surprised at how tives and tell them that this is a communication aid that
much the patients were able to communicate with aid of AAC. The can function well. . .then you can communicate with your
staff explained that it was a great motivator that the need was so husband or wife. . .eh in that way you can push a lit-
obvious among the patients, a right for the patients and themselves, tle. . .get it going. . .but I know that we as staff need to
and that using AAC made it possible to provide high quality care, be the ones using it. . .we need to get going.”
but at the same time however they found it challenging:
Some of the healthcare professionals tried using the AAC aids
No. 36 (Occupational Therapist. Second interview): “ I and succeed at times. They told their colleagues about it and
don’t know. . .I think the patients. . .they kind of take it explained that they had only tried to use the AAC aids as a last
for granted being able to communicate. They’re like this: resource because of frustration over not being able to understand
They stuck this tube into my throat making it impossible and communicate with the patient. The staff explained that the
for me to speak. . . well of course they will provide me patients once able to speak again after being extubated always
with some means to communicate. But to us it’s new - mentioned what was the most important for them like: “Will I live?”
these strategies - and the patients they just take it for “What happened?” “How long?” “What will happen next?” “What
granted. . .this possibly [AAC] you know”. are my chances?” These were very important issues for the patients
and acknowledged greatly by the healthcare professionals. Being
No. 35 (ICU Nurse): “The more natural it becomes for us
afraid or scared or affected in more physically related areas like
the more we may take it for granted as well”.
being thirsty, needing to be turned over, needing to go to the bath-
No. 37 (ICU Nurse): “Yes, yes I know and if we used the room or craving air were also mentioned by the staff as areas in
strategies then it’ll become natural right?” which the patients wanted to communicate, all areas of fundamen-
tal care considered of high relevance for the healthcare profession-
The staff mentioned that AAC could help them involve patients als. However, the staff explained that unfortunately they were
in the care to a much greater extent than they had before, and they often not able to guess what the patients wanted to communicate
explained that they agreed, but were surprised that communication if it was not related to care. Although the healthcare professionals
was a right. This made communication even more important for perceived communication as the core of their caring ontology and
them but still challenging: all the benefits it implied, it surprised them that they did not use
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HANDBERG AND VOSS | 109

the AAC strategies more, which they explained as being related to No. 1 (ICU Nurse): “Yes they’re afraid of doing something
Cultural Beliefs, the next finding. wrong. . .even though we’re told that’s not possible
[laughs] maybe we should just try it?”

5.2 | Cultural belief No. 2 (ICU Nurse): “But in the ICU we’re brought up
using procedures and things have to be conducted in a
The healthcare professionals in the critical wards perceived the certain way. . .you know. . .it matters you know in our
biomedical paradigm as paramount for their work, which they field of work, don’t you think so? All the care-related
explained both during the educational sittings but also during the tasks we conduct are written down. We teach each
interviews. According to the healthcare professionals, saving lives other, the old ones teach the new ones and so on. It is
and treatment came first, and they stated that they did not priori- hard to implement this and difficult to get introduced to
tise communication in relation to this. They described that the something new. . .so I don’t think they [the colleagues]
most important issues needing attention and focus were the actual will go on and use the strategies. I’m sorry I just don’t.”
treatment and physical needs of the patient or issues that played
a prominent role for patients in general like being able to breathe Many of the healthcare professionals explained that they missed
and prioritising vital organs. The staff explained that the biomedi- instructions and directions and therefore felt uncertain about how to
cal paradigm was of high priority, and the healthcare professionals’ use AAC. In relation to this, they argued that the AAC strategies
(especially the nurses) attitudes and behaviour were specifically were time-consuming and that there were so many other things that
affected in that direction. Even though communication could help needed to be done:
the patient maintaining their functioning (which was addressed as
important by the nurses), this seemed to be constantly overruled No. 40 (Occupational Therapist. First interview): “Yes
by their biomedical way of thinking. The cultural belief seemed to sometimes it’s related to being busy if I have to be com-
be securely anchored and difficult to change for the staff, and pletely honest. The first few times it can be very time
they explained over and over that they were stuck in old habits, consuming and you feel you’re affected by time pres-
but also in what they explained as more important tasks than sure. . .there’s simply no time and it is suddenly easier to
communication: just try to lip read in order to save time and escape
instead of having to explain about communication
No.3 (ICU Nurse. Second interview): “The patients don’t
strategies.”
have the energy to communicate. . .and they are not able
to. . . We’re sort of used to communicate on how they
The staff did nevertheless address the fact that in the long run,
are placed in the bed, are they able to breathe, are they
AAC would probably help them and save time. They addressed the
in pain and stuff like that. We’re used to asking things
importance of remembering to use the AAC strategies and keep on
like that and they can either nod a yes or no. . .and I
training, but in the same sentence mentioned how strong the force
think it’s so difficult to change my priorities and my con-
of habit was. What frustrated the healthcare professionals the most
duct. . .a conduct I have had for many years and now
was that when they actually did succeed in communicating with the
suddenly I have to carry something visual with me [the
patients using AAC, they were surprised at what the patients
AAC aids]. . ..that does not suit me well [laughs].
expressed, things they could never have guessed, which leads to the
final theme Triggered Conduct.
The staff expressed several times that they had a cultural belief
that it was important to radiate competence and calmness to the
patients. A very important factor mentioned by many of the nurses 5.3 | Triggered conduct
was their need to show both patients and relatives that they were in During the follow-up education, workshops and interviews the staff
control and that the patient could feel safe. Using AAC was however described, and it could also be observed, that they became frus-
new to the staff, and they found it very difficult and demanding, trated when they could see the patients trying to communicate and
leading to the staff giving low priority to the AAC strategies. The they could not understand. This triggered a conduct where some of
staff explained that when they were insecure about to use of the the staff stated that they chose to ignore signs of communication
AAC strategies, they felt incompetent and left the communication because they could not understand the patient and they did not
strategies and aids untouched: have the time it would take to use the AAC strategies. The staff
explained that they had a clear comprehension and had experienced
No. 7 (ICU Nurse 2. interview): I think maybe in time we that the patients had more communication needs than what they, as
will use it [AAC] more, but it’s just. . .when you feel inse- their healthcare provider, could or did cover. The staff, for instance,
cure and that’s what my colleagues say they do. . . then told about a patient that had been very frustrated and had tried to
you don’t use it”. communicate with them throughout the whole day. They could not
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110 | HANDBERG AND VOSS

understand what he was trying to communicate and tried with all explained that they reckoned that the use of the AAC strategies
the usual means to help him. Finally, the staff resorted to AAC and may disappoint the patients and that they might set their hopes up
the patient was able to ask, using the eye tracking letter board, only to be disappointed:
whether he was getting worse because they had not extubated him
in the morning as they had promised the day before. The staff was No. 43 (ICU Nurse. Second interview): “Let’s be honest,
now able to tell him that he was okay, and they had just postponed there are several barriers related to us as
the extubation until the next day. The staff gave another example staff. . ..eh. . .we’re not good at introducing the communi-
where they had to leave a patient with an iPad due to an acute situ- cation strategies to our patients, and it often depends
ation, and when they got back to him, the patient had written on on who’s taking care of the patient. Some of our col-
the iPad: “This is really clever.” Another patient had written a list of leagues are better at using the AAC strategies. . .maybe
things that he wanted addressed at rounds. The experience of know- due to the patient being in better shape and able to
ing that AAC worked well and that it was not used as much as pos- write and communicate to some degree. But we also
sible to communicate with the patients lead to frustration and have to acknowledge that we have to give the patients
disappointment among healthcare professionals as they were not a choice. . ..eh. . .we just take for granted that they are
able to live up to their believed caring ontology. The staff related content and then. . ..we just go along with what we think
that they knew that the AAC strategies were applicable, and never- is the best way to do things.”
theless, they explained at the same time that they avoided using
them for several reasons. The reasons the healthcare professionals Even though finding it difficult to communicate, some members of
gave for not using the AAC strategies and repressing communication the staff did try to implement the AAC strategies and communication
were, for instance, that the AAC strategies were too complicated, aids (as described above) in their practice and mentioned the iPad app:
the communication aids needed developing, were never there when GoTalkNow and Predictable, Auditive Partner-Assisted board, Letter
you needed them, and that the patients were too ill, too sedated, board, Eye tracking letter board/book and pain scale as the most appli-
too old, too disorientated, only intubated for a short period of time, cable communication aids. However, the healthcare professionals’
etc. conduct and actions with regard to neglecting AAC strategies and
communication aids in daily practice resulted in demotivation among
No. 1 (ICU Nurse. Second interview): “You tend to get the staff because they had had high hopes regarding the new possibili-
easily interrupted and maybe you don’t have. . .that’s ties in AAC. They found it hard and challenging to implement the AAC
when I think that this [AAC] is not a need for me right strategies in their daily practice and specifically mentioned that they
now. . .to be able to communicate with the patient. needed more success stories, but at the same time acknowledged that
Actually all I need is to be done and able to wrap things these stories required their use of the AAC strategies.
up and get going onward to the next patient”.

[Goes on] ”Communication is really being narrowed down

in our practice. . .down to almost no communication. . .I 6 | DISCUSSION
think it’s due to the force of habit. . .we go along as we
usually do. The patients’ needs are being narrowed down The successive sequences of the findings Caring Ontology, Cultural
as a consequence. I realise that and it is all because I Belief and Triggered Conduct represent an understanding of the per-
tend not to invite the patient to communicate. I sort of spectives of the healthcare professionals caring for intubated
ignore any signs from the patients. . ..there is so much I patients with regard to implementing AAC in critical care settings.
need to do.” According to these findings, the healthcare professionals follow an at
times unfortunate circle of sequences (Figure 3). The circle starts
A conduct of leaving out communication knowing that the with the ontology of caring, which motivates the healthcare profes-
patients send out signals trying to communicate entailed an underly- sionals in their quest for better communication options for the
ing on-going guilty conscience in the daily practice of the staff. They patients in critical care settings and which they consider to be of
described that they wanted to involve the patient more through great importance. The cultural belief in a biomedical setting, how-
communication but omitted this due to problems and challenges ever, draws the healthcare professionals away from their ontological
with communicating. The staff explained that they primarily commu- values. The belief that saving lives is the most important job for
nicated with the patient by a nod for yes or no, or a squeeze of the them is impossible to argue with (for anyone), and their priorities are
hand, and that they found communication rather challenging, difficult understandable. However, the conduct that this culture entails is not
and time-consuming and therefore often chose to deliberately consistent with the staffs’ profound ontology, and this leads to
neglect it. Still the healthcare professionals had a feeling that they demotivation and resignation among the staff in relation to using
had left something out, which caused them to reflect on their prac- AAC in daily clinical practice. So the core issue seems to be how the
tice and what the consequences were for the patients. They staff can carry out a clinical practice that meets their own
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HANDBERG AND VOSS | 111

expectations in regard to their caring ontology and where they still not want to appear incompetent while using AAC. They tend to
do not have to compromise in relation to their cultural beliefs. We refer much more to the actual AAC aids rather than to the AAC
argue that prioritising treatment and saving lives should not entirely strategy and this could be a core element, whereas AAC should
leave out the possibility for the patients to communicate, especially actually be thought of more as a strategy than just physical aids
when it might be the last chance for some patients to communicate (Beukelman et al., 2007). Fundamentally, it is therefore important to
before dying. The first step is nevertheless to understand the health- inform and educate the healthcare professionals on the importance
care professionals’ perspectives in order to be able to change or of an overall understanding of AAC communication as a strategy
improve practice. more than an actual aid (Beukelman et al., 2007). Asking well-built
Research has shown that patients with a functional speech disor- questions is often the first stumbling block for practitioners and can
der are at greater risk of getting poorer treatment and rehabilitation, be a barrier for the healthcare professionals, leading to a feeling of
exposed to more accidental incidents and having poorer treatment incompetence (Schlosser et al., 2007; 225–238). To facilitate the ask-
outcomes (Patak et al., 2009, 372–376). Knowing how important it ing of well-built questions, it may be helpful to follow a template
is for patients to be able to express themselves during a critical per- (Schlosser et al., 2007; 225–238), but the healthcare professionals in
iod of their lives (Patak et al., 2009, 372–376), for example be able this study argued that using templates might affect their striving to
to have influence on their own treatment or rehabilitation and com- appear as competent and radiate safety to the patient. If it is possi-
municate with relatives and further that communication is a right, ble for the staff to learn the strategies well, then they do not neces-
makes it a compelling necessity to address this area, also in a critical sarily have to use the aids but apply them only as support for the
care setting. Research, however, has shown that it is often a chal- strategy (Beukelman et al., 2007). This approach might help change
lenge to change communication culture in healthcare settings the staff’s view that the aids are the central element and thereby
(Magnus & Turkington, 2006; 167–180; Patak et al., 2009, 372–376; eliminate the feeling of being incompetent while trying to apply AAC
Beukelman et al., 2007; Fawole et al., 2013, 570–577), which was in their practice.
also illustrated in the present study where the healthcare profession- Changing culture and implementing new ways of working like
als’ sometimes chose to neglect communication even though they with AAC requires a comprehensive vision with simultaneous, inter-
knew about AAC. The staff explained, and it was observed, that they connected strategies targeting clinician training (Reidy et al., 2016).
did not give AAC and communication high priority. This conduct Research has shown how communication in the care of patients with
may be explained by an old habit or culture in hospitals where there advanced and serious illnesses can be improved using interventions,
used to be speech and language therapist present and where com- particularly with regard to healthcare use (Fawole et al., 2013, 570–
munication used to be their professional area. Speech and language 577). AAC can be considered such an intervention in clinical practice,
therapists are used to working with challenges related to communi- and the staff needs to be trained more thoroughly, so that they are
cation, but the area of communication is not owned by the speech comfortable with the AAC strategies (Beukelman et al., 2007). Fur-
and language therapists, and often they are no longer available in ther there should be focus on those healthcare professionals who
hospitals. Therefore it is pressing that all staff on wards with actually do use AAC and on sharing their successful stories. Nurses
patients with a functional speech disorder address the needs related and other healthcare professionals play a central role in ensuring
to communication and thereby make communication everybody’s that assessments of communication needs are conducted as a central
business (Beukelman et al., 2007). It is critically relevant for all health element of the caring ontology. Assessment of communication needs
professions to be concerned about communication possibilities for should be carried out for all patients in critical care settings in order
their patients (Magnus & Turkington, 2006; 167–180; Patak et al., to determine whether patients are able to communicate effectively
2009, 372–376; Beukelman et al., 2007; Fawole et al., 2013, 570– or not and to uncover needs and challenges in order for the staff to
577); for instance, for the nurse during care, treatment and rehabili- direct their actions towards the implementation of successful strate-
tation; for the doctor during diagnosis, treatment and rounds; for the gies (Patak et al., 2009, 372–376).
therapists during training, etc. But most important is that the Lastly, an area that was not extensively covered in this article
patients are able to have an influence on their own treatment and is the effort to involve for instance family members, who often
can express thoughts, anxieties and reflections on being in an often have a difficult time because of their relatives’ critical illness
life-threatening situation in the critical ward (Schweickert et al., entailing functional speech disorder. The relatives should therefore
2009, 1874–1882). be provided with the possibility to communicate with their rela-
As the healthcare professionals in the present study, as a part of tives (the patients) through AAC strategies and aids (Agard &
the circle, express interest in communication and are motivated for Lomborg, 2011; 1106–1114). Relatives can provide information on
implementing AAC, the important issue seems to be how the circle or pictures of the patient from time before they were admitted,
of sequences can be broken in order to hinder the unfortunate con- and research shows that for instance patient photographs dis-
sequences of especially the triggered conduct. However the findings played at the bedside may assist the healthcare professionals to
point towards possible reasons as to why the staff does not apply personalise the care of the patients, which might strengthen the
AAC to their practice even though they find it relevant. For instance caring ontology and improve communication (Neto, Shalof, & Cost-
many of the healthcare professionals point to the fact that they do ello, 2006; 198–204).
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112 | HANDBERG AND VOSS

The study has, however, some limitations that need to be men-

6.1 | Methodological considerations
tioned. It is an obvious weakness that this study only concerns the
Before the study, we knew that communication was important and perspectives of healthcare professionals. It would have been inter-
that AAC could be a relevant strategy for communication with peo- esting and very relevant to have focused on the patients’ perspec-
ple suffering from a functional speech disorder. We were interested tives as well and interviewed patients after their discharge from the
in in-depth knowledge to create new insights regarding the perspec- critical care wards and further have made observations of healthcare
tives of the healthcare professionals caring for intubated patients on professionals during care and treatment of the patients. We reckon
implementing AAC in critical care settings. A qualitative approach that hearing the patients’ perspectives and being able to observe the
with interviews as a research strategy allowed for us to produce this staff and patients in interaction could give us an even broader
new knowledge on communication in critical care settings. Through- understanding as to why there seem to be barriers in applying AAC
out the project, we have sought to secure the validity which ought in clinical practice. Lastly, it would also have been interesting to
to be considered in relation to our study findings: “Is the new knowl- include other wards and not just critical care settings in order to be
edge valid and transferable?” (Malterud, 2001, 483–488). Even able to compare the results and to assess how much the “critical
though we did not aim primarily for transferability in qualitative factor” influences the staff attitudes.
studies, these study findings point out the relevance of AAC strate-
gies and aids being implemented in clinical practice because of the
many groups of patients suffering from a functional speech disorder. 7 | CONCLUSION
Groups of people who might benefit from AAC may be, for instance,
people who suffered from a stroke, people with aphasia, people with Communication is a right for all persons, also those who suffer from a
progressing neurological diseases and temporary medical conditions functional speech disorder. Knowing that a lack of the ability to com-
in which spoken language is affected. municate puts the patients at greater risk of getting poorer treatment
In regard to validity, doing both observations and interviews and rehabilitation, being exposed to more accidental incidents and
made it possible to gain further depth and elaborate on the health- having a poorer treatment outcome supports the pressuring needs to
care professionals’ perspectives regarding actually using the AAC to implement and use AAC in critical care. This study provides insight
a lesser extent than expected prior to the project. Further observa- into the importance of providing all patients in critical care with the
tions during the sessions on education in the different steps of the ability to communicate using AAC strategies while they are intubated.
project were conducted, and the observation and interview guides It is documented how culture in a biomedical paradigm can be a domi-
provided structure during the data generation and ensured that we nant factor and represent barriers that hinder healthcare professions
got to touch upon certain important areas. The guides (interview and in implementing and using AAC with their patients. The findings can
observation) were developed on the basis of the principle of open- guide practice to develop communication based in the AAC strategies
ended questions that allowed spontaneous, surprising and fluctuating while still preserving the caring ontology, professional pride and com-
answers from the healthcare professionals, even though they did petence, leading to better care and more communicative patients. The
contain “raw” topics that outlined what was attempted to be cov- healthcare professionals can play an important role in promoting AAC,
ered during the interview. but further education, training and follow-up are needed. Further
We experienced an overall consensus in the healthcare profes- research is required to explore the patients’ experience of being able
sionals’ perspectives, which is also reflected in the findings. There to communicate with the aid of AAC.
were nevertheless a few contradictions in the data material. Some of
the healthcare professionals actually tried to use AAC as described,
whereas others chose to completely neglect the AAC strategies. 8 | RELEVANCE TO CLINICAL PRACTICE
These contradictions and variations were few, and were typically
expressed by one healthcare professional, in conversation with a
colleague or during focus group interviews. 1. Improving communication strategies can improve patient safety
In relation to sampling, we aimed to include healthcare profes- and make a difference in patient outcomes, and an increased
sionals of various age, education and experience in the included knowledge on and familiarity with AAC strategies can provide
wards to ensure variation in data. Interpretive description (Thorne, the healthcare professionals with an enhanced experience of
2016) does recommend bigger sample sizes and a variation of sam- being competent.
ples, and we wanted to be able to gain knowledge from a broad 2. Nurses and other healthcare professionals play a central role in
range of healthcare professionals. The purposive sampling strategy ensuring that assessments of communication needs are con-
(Thorne, 2016) of including healthcare professionals from five differ- ducted as a central element of the caring ontology, and an
ent hospital settings for the data generation turned out to be com- assessment of communication needs should be carried out in all
prehensive but also rewarding in terms of representation and patients in order to determine whether patients are able to com-
variation in data. municate effectively.
 13652702, 2018, 1-2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocn.13851 by Cochrane Saudi Arabia, Wiley Online Library on [05/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
HANDBERG AND VOSS | 113

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CONTRIBUTIONS
https://doi.org/doi: 10.1016/j.iccn.2012.05.003
Study design: CH & AV; Data collection and analysis: CH & AV; Mobasheri, M. H., King, D., Judge, S., Arshad, F., Larsen, M., Safar-
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