ORIGINAL ARTICLE

Transitions in the communication experiences of tracheostomised patients in intensive care: a qualitative descriptive study Stine Irene Flinterud and Birgitta Andershed

Aims and objectives. To describe how tracheostomised patients in intensive care experience acts of communication and to better understand their experiences in the context of the transitions theory. Background. Waking up in an intensive care unit unable to speak because of mechanical ventilation can be challenging. Communication aids are available, but patients still report difficulties communicating. Investigating how mechanically ventilated patients experience communication in the context of the transitions theory might elucidate new ways of supporting them during their transitions while being ventilated. Design. A qualitative, descriptive design. Methods. Eleven patients who had previously been tracheostomised in an intensive care unit were included in this quality improvement project conducted in a university hospital in Norway. Participants were tracheostomised from 3–27 days. Semistructured interviews were conducted from June 2013–August 2013, 3– 18 months after hospital discharge. Transcripts were analysed using inductive content analysis. Results. Participants reported a great diversity of emotions and experiences attempting to communicate while being tracheostomised. One overarching theme emerging from the analysis was the ‘Experience of caring and understanding despite having uncomfortable feelings due to troublesome communication.’ The theme consists of three categories. The category ‘Emotionally challenging’ shows that patients struggled initially. With time, their coping improved, as revealed in the category ‘The experience changes with time.’ Despite difficulties, participants described positive experiences, as shown in the category ‘Successful communication.’ Conclusion. The importance of patients experiencing caring and understanding despite their difficult situation constitutes the core finding. The findings suggest that participants went through different transitions. Some reached the end of their transition, experiencing increased stability. Relevance to clinical practice. Despite challenges with communication, participants reported that caring and safety provided by health care professionals were significant experiences. They viewed nonverbal communication as being very important.

Authors: Stine Irene Flinterud, MSc, RN, Lecturer, Haukeland University Hospital, and Haraldsplass Deaconess University College, Bergen, Norway; Birgitta Andershed, PhD, RNT, Professor, Department of Nursing, Gjøvik University College, Gjøvik, Norway, and Department of Palliative Research Centre, Ersta Sk€ ondal University College and Ersta Hospital, Stockholm, Sweden

© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing, doi: 10.1111/jocn.12826

What does this study contribute to the wider global clinical community?

• Supporting





patients as they undergo different kinds of transitions will help them achieve increased stability, help them cope better and help them navigate successfully through their difficult situation. Tracheostomised patients in intensive care experience caring and understanding despite having uncomfortable feelings due to troublesome communication. The importance of healthcare professionals use of nonverbal communication such as eye contact and physical contact to promote feelings of safety and security.

Correspondence: Stine Irene Flinterud, Lecturer, Haraldsplass Deaconess University College, Ulriksdal 10, 5009 Bergen, Norway. Telephone: +47 90149286. E-mail: [email protected]

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Key words: communication, inductive content analysis, intensive care, mechanical ventilation, patients’ experience, tracheostomy, transition Accepted for publication: 25 February 2015

Introduction Communication is an integral part of daily living, and it is something most people take for granted. Critically ill patients undergoing intensive care treatment may experience constrained communication caused by factors such as mechanical ventilation, sedatives or muscle weakness (Fisher et al. 2009, Griffiths & Hall 2010, Latronico & Bolton 2011), among other reasons. If patients need prolonged mechanical ventilation, they are often tracheostomised (Marinaro et al. 2012). This bypasses the discomfort of an endotracheal tube through their nose or mouth. However, as these patients breathe, air goes through the tracheostomy tube rather that passing over the vocal cords. Thus, they are unable to produce sounds or utter speech. Tracheostomised patients can communicate through gestures and lip reading, or using low-tech aids such as writing or spelling words by pointing at letters of an alphabet or picture board (Patak et al. 2006, Fisher et al. 2009, Grossbach et al. 2011). The use of communication apps deployed through high-tech aids such as the iPad or other kinds of electronic devices can also facilitate communication (Happ 2001, Finke et al. 2008). Although there are alternative ways to communicate, obstacles may still inhibit or completely prevent functional communication.

Background Patients previously mechanically ventilated report that the inability to communicate is frustrating, stressful and sometimes even terrifying (Magnus & Turkington 2006, Patak et al. 2006, Carroll 2007, Khalaila et al. 2011). In studies describing how patients experience their stay in the intensive care unit (ICU), the inability to communicate efficiently is reported as being one of their most memorable negative experience, leading to fear and distress (Schou & Egerod 2008, Karlsson et al. 2012a). The need to communicate is important (Engstr€ om et al. 2013), and many patients report feeling powerless and helpless when they cannot communicate successfully (Hafsteind ottir 1996, Karlsson et al. 2012a). Critically ill patients may undergo different kinds of transitions throughout their ICU stay (Ludin et al. 2013). Tran-

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sitions theory is a central concept in nursing (Meleis 2010), and understanding patient transitions is an important consideration in nursing care during critical illness (Ludin et al. 2013). Transition can be viewed as a passage from one condition to another; it describes both the process and the outcome of a complex interaction between a person and his or her surroundings (Chick & Meleis 1986). It is often described as a period during which a person goes through a change that causes instability, stress or confusion, arriving at a new beginning characterised by stability and mastery (Ludin et al. 2013). Meleis (2010) describes different types of transitions, with various dimensions. Three types of transitions are relevant for critically ill patients: (1) health–illness transition related to a new, sudden critical illness; (2) developmental transition related to how the critical illness affects the person or family; and (3) situational transition, which can occur in a situation that changes in the patient’s role, one from a healthy person to a sick person (Ludin et al. 2013). The transitions are closely related and critically ill patients may experience multiple transitions during intensive care (Ludin et al. 2013). Adjusting to their new situation as intensive care patients while at the same time being in transition, a patient’s ability to communicate is vitally important. Communication with tracheostomised patients can be challenging for everyone involved. Communication aids can be helpful, but patients still report that communication is difficult. These patients’ communication experiences have been reported for some decades, both in studies investigating communication or as a finding in studies examining the general experience of intensive care patients. Although some studies report on different aspects of patients’ voices, no study, to our knowledge, has directly connected their experiences to the transitions theory. This study originated in an ICU in a university hospital in Norway, where informal clinical observations of patients, their next of kin and healthcare professionals all led to the conclusion that communication is difficult and often unsuccessful after tracheostomy. Based on these observations, a quality improvement project was initiated, which this study is a part of. The aim of the study was to describe the experience of tracheostomised patients in the © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing

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ICU as they attempted communication and then provide an understanding of the results in the context of the transitions theory.

Design and methods A descriptive, qualitative design using semistructured interviews was employed. The design was considered suitable for capturing the participants’ experiences of communication during the period of time they were tracheostomised in the ICU.

Setting The ICU where the study was conducted was a combined surveillance unit and ICU. It has five well-equipped, single rooms for intensive care and five other single rooms containing less equipment for easier monitoring. The unit mainly has medical patients having conditions such as cardiac arrest, septicaemia or other patients with multiorgan failure, and occasionally, surgical patients, for example, those recovering from cardiac bypass with complications.

Participants The participants were patients who had previously been tracheostomised and mechanically ventilated in the ICU. Inclusion criteria were tracheostomised for a minimum of 48 hours, 18 years or older, spoke and understood Norwegian and were discharged from hospital to their own residence. Because the purpose of the study was to better understand their experiences of communication, there were no criteria related to diagnosis or reason for intensive care. Candidate participants were identified by examining the ward’s electronic journal. Eligible participants were identified retrospectively, starting sequentially with contact of patients who were discharged most recently to those discharged earlier until an adequate number of patients had been identified and satisfied the inclusion criteria. The study’s contact person, who was working in the ICU, called eligible patients, asking for permission to send information about the study. Fourteen potential participants were informed about the study, and 11 agreed to participate, eight men and three women, respectively. They ranged in age from 47–72 years, and the duration of their tracheostomy ranged from 3–27 days. Between 3–18 months had passed since they were discharged from hospital. © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing

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Data collection The interviews were conducted from June 2013 through August 2013. Participants selected the interview location. Five interviews took place in participants’ homes, four in the hospital, one in a participant’s workplace and one by phone. To facilitate conversation and to encourage richer, more detailed participant stories, an interview guide was used to direct the interviews through relevant topics (Kvale & Brinkmann 2009). Repeating to the participants that the topic of interest was their experience with communication during the time they were awake but unable to speak because of the tracheostomy initiated the interviews. The opening question was, ‘Can you tell me what you remember best from the time you could not speak?’ The participants were asked to describe situations in which communication was successful and situations in which it failed, how it felt being unable to talk, how they had attempted to communicate and which aids they had used. Different follow-up questions were asked, depending on the answer to the previous question. At the end of the interview, participants were encouraged to describe additional experiences they had trying to communicate while being tracheostomised that were not revealed previously in the guided interview. The nature of the participants’ stories governed the development of the interview, but the interview guide was used to make sure that every topic was covered. During the interview, the researcher verbally verified that she had noted correctly the participants’ statements. The one interview conducted by phone lasted for seven minutes, while the others were completed from between 15–45 minutes, with an average of 25 minutes. The interviews were digitally recorded and transcribed verbatim by the first author. The telephone interview was conducted on loudspeaker and recorded digitally.

Data analysis Inductive content analysis was used to analyse the data (Elo & Kyng€ as 2008). First, the interviews were transcribed, and then while simultaneously listening to the recordings, the transcripts were carefully read to ensure the written text accurately reflected the participants’ verbal expressions. The analysis began by organising the data using open coding. The text was reread several times to get a general sense of the participants’ experiences, and many descriptive notes and headings were recorded in the transcript margins. In the next step, the notes were transferred to a coding sheet where relevant notes and headings were grouped

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under higher-order headings. Each interview’s higher-order headings were transferred to a separate sheet for analysis, similar higher-order headings were collected, and subcategories were identified. Through abstraction, subcategories were collected and main categories generated before one theme became apparent. The authors continuously and iteratively discussed the emerging results during the analysis process.

Ethical considerations The study was part of a quality improvement project, and approval was granted by the management of the ICU and the hospital’s Data Protection Officer. The study was directed at previously critically ill patients, and extra consideration was employed in the context of the riskbenefit principle (Speziale & Carpenter 2011). Informed consent was important in planning and executing the study. The participants received written information via mail a couple of weeks before the researcher called with request for inclusion. Before they signed the consent, all participants received oral and written information about the aim of the study, assurances that all data would be treated confidentially, that participation was voluntary and that they could withdraw from the study at any time.

Results The participants described a variety of both positive and negative experiences, having great diversity of emotions. A common overarching feeling they described was one in which they report waking up in an unfamiliar situation, unable to speak, which complicated communication. Analysis of the participants’ stories revealed one universal theme: Experience of caring and understanding despite having uncomfortable feelings due to troublesome communication. The theme consisted of three categories – Emotionally challenging, Experience changes with time, and Successful communication – each containing three subcategories, respectively, as shown in Table 1. These will be considered in turn, along with each subcategory.

Emotionally challenging The category Emotionally challenging contains a spectrum of difficult, painful and challenging feelings and experiences. It includes a diversity of expressions, from specific emotions they experienced to descriptions of more general experiences of giving up or losing control. The descriptions

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Table 1 Overview of theme, categories and subcategories emerging from analysis of communication experiences of tracheostomised patients in intensive care Experience of caring and understanding despite having uncomfortable feelings due to troublesome communication Emotionally challenging Upsetting emotions Feeling of powerlessness Loss of control The experience changes with time Strenuous communication Most difficult in the beginning Ways of coping Successful communication Caring from healthcare professionals Understanding from the surroundings Methods of communication

are divided into three subcategories: Upsetting emotions, Feelings of powerlessness and Loss of control. Upsetting emotions Most participants experienced feelings of frustration and despair, in particular immediately after waking up. Several described frustration towards the entire situation; others described it in conjunction with difficulties in communicating. Frustration and despair sometimes led to irritation and anger. It was described as difficult, being unable to express emotions and needs. One participant described it as extremely difficult not being able to talk: Yes, it was a really overwhelming feeling when I couldn’t make myself be understood, that they didn’t understand me, and that I couldn’t tell them anything. That, that was just so distressing. . .it was simply my temper that came, when I realized, I couldn’t manage it.

Feelings of powerlessness The difficult situation the participants experienced of being unable to communicate led to feelings of powerlessness. Discouragement, hopelessness and helplessness were some of the emotions reported when their communication was unsuccessful. This is illustrated in the following expression: I did not understand that they didn’t have the wit to understand what I meant, you see. But it wasn’t, it wasn’t, well, yeah, I had given up you see. Given up. Because I couldn’t. But, well then I had to accept it you know. I was forced to accept it.

Giving up when attempting to communicate was a recurrent expression, but for most of the participants, problems © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing

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with communicating resolved after a short period of time. Feelings of powerlessness could be caused, among other things, by being unable to verbally express the pain they felt. Several participants described how they were screaming inside because of pain, but were unable to communicate their pain to healthcare professionals. One participant described this sentiment well: Then it hurt so much I almost screamed my head off. Well,

Tracheostomised patients and communication

cult to use communication aids such as a picture board or writing, leading to feelings of fatigue. Many described that they were confident that they would be able to use aids such as an iPad or pen and paper, and they became extremely disappointed when they failed in these efforts. Some participants found answering all the questions of the healthcare professionals to be quite tiring, as this participant described:

inwardly. But I didn’t get out a damn thing. It really hurt. So, it

One of them was trying. And then another one would come who

sucks when you can’t say anything.

maybe could manage it. And then you would have to repeat it again, you know. And then [they would say to me]: “But I don’t

Loss of control The subcategory Loss of control, within the main category Emotionally challenging, contained descriptions of how frightening and uncomfortable the participants found losing control. Feelings of stress, anxiety and panic were emphasised. The participants portrayed different emotional aspects, which all led to an intense experience of lack of coping that subsequently led to loss of control. Losing one’s voice was a terrifying experience for some; being unable to talk provoked feelings of panic and distress. One participant recounted one difficult and scary situation: Just then, I struggled a bit. It was so unreal to not be able to make a sound. It turned into a bit of a big deal. Yes, that’s what it was.

For several participants, these feelings prevented them from coping with their new circumstances. Some also mentioned the fear of never being able to speak again as one factor that affected their coping. For a few participants, this fear persisted until they were able to speak again.

The experience changes with time The category The experience changes with time consisted of three subcategories: Strenuous communication, Most difficult in the beginning and Ways of coping. As time passed, the participants’ communication experiences changed. All of the participants described difficult and negative experiences with communication after they first woke up from anaesthesia. In time, however, they found various ways to cope with their new circumstances. Strenuous communication Participants experienced communication as tiresome and laborious, requiring both physical and mental effort. Initially, all of the participants mentioned that physical obstacles, such as muscle weakness or tremors, contributed to their strained communication. These obstacles made it diffi© 2015 John Wiley & Sons Ltd Journal of Clinical Nursing

really understand what you mean.” You know, and then they tried with the board. And then, then you have to try again because you didn’t get it right. It was a bit tiresome.

The healthcare professionals and the participants’ family were eager to find out what the participants were trying to say. However, their suggestions often failed. This caused the participants to become exhausted and discouraged, as they had to try different strategies to communicate the same thing over and over again. For the majority, the ability to communicate improved with time, but some participants reported experiencing this type of ‘strenuous communication’ throughout the tracheostomy period. Most difficult in the beginning The shock of waking up, not knowing what had happened and being unable to speak, evoked feelings of frustration and despair. Some did not understand that they could not speak; thus, they tried to talk louder and louder and became increasingly stressed out. Several participants experienced a confused concept of time. How they experienced the passage of time also varied. Some reported feeling like time stood still and that it took a long time before they could talk. In general, communication improved with time, often because the participants mastered different communication aids or because the healthcare professionals learned to read the participants’ gestures and needs. Ways of coping As time passed, the participants came up with different ways to cope with their new circumstances. Some used humour in difficult situations; others tried to stay calm while waiting for the tracheostomy to be removed. Some of the participants were very committed to monitoring when their tracheostomy could be removed. This can also be seen as a strategy for coping with a difficult situation lasting a limited period of time. One participant who mentioned being easily understood using lip reading and gesticulations

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described how his coping improved after a short period of time.

Successful communication Instances of successful communication address the narratives of positive experiences. Even though communication was difficult, the participants also experienced instances of successful communication, especially as time passed. These experiences encompass three subcategories: Caring from healthcare professionals, Understanding from the surroundings and Methods of communication. These will be considered in turn next. Caring from healthcare professionals The participants listed different factors that led to positive experiences despite their difficult circumstances. Security and safety were highlighted as very important factors. The participants experienced feelings of frustration and despair. Nonetheless, their difficult situation was tempered by healthcare professionals, who made them feel safe and cared for. This is illuminated in the following statement:

healthcare professionals often instinctively knew their needs, even though they were unable to communicate them. Having a family member by their bedside was important for many of the participants. Family members were supportive during this difficult situation. Several of the participants also highlighted the importance of their relatives being familiar with their usual body language and gestures. This familiarity put them in a good position to understand and relay the participants’ concerns to others. Methods of communication The participants described different methods of communicating. Answering to questions by nodding or shaking their heads were common methods of communicating in the beginning. Lip reading and other gestures were also successful for some participants. Using different aids was often described as difficult in the beginning. However, as time passed, the participants gained control over their body, thereby enabling them to use aids, such as pointing at picture boards and writing with pen and paper. Some were able to talk by means of a speak valve, while two participants successfully used an iPad as a communication aid.

The one good thing, even with all the frustration and all this, I did feel well looked after; and that was very comforting. Despite everything.

Several participants mentioned the importance of having eye contact and physical contact: When the anxiety comes, they were there straight away. They tried to calm you down, held your hand, and spoke to you. Communicated even though I didn’t have a voice. And eye contact, that was very important for me then.

Many received information and explanations from healthcare professionals that were essential in order for them to feel safe. The importance of being well informed, in conjunction with eye and physical contact, was noted by several of the participants. This conveyed calmness and was very important in fostering a sense of security and safety in the participants. One participant emphasised this feeling: But they spoke to me, all of them. I understood that, and it was just fantastic. But I recall that she [the nurse] was also very good at holding hands and using touch. And I found that very comforting, so that’s really important, you know.

Understanding from the surroundings Most of the participants stated that they were being understood by various degrees when they used different aids, gesticulations or lip reading. Several also described how the

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Discussion The participants related nuanced and complex stories they had while being tracheostomised, detailing a wide range of emotions and experiences. They reported waking up in an unknown environment, with the shock of suddenly having become critically ill. Their ability to communicate was compromised because of their tracheostomy, which in turn led them to experience uncomfortable feelings. At the same time, despite having difficulties communicating, the participants’ also had positive experiences with those who showed them care and understanding. Various transition processes highlighted different parts of our results, as shown in Fig. 1. The actual period the participants were tracheostomised can in itself be a transition. The tracheostomy was a temporary element that triggered transition. It started when the participants awoke, unable to speak. Through a period of instability, stress and confusion, the participants reported coping with their situation in different ways. Towards the end of the transition, represented by the removal of the tracheostomy, they regained their voice. Our analyses revealed several categories of experience. The category Emotionally challenging encompasses the distressing emotions experienced by the participants when trying to communicate. The feelings of frustration, despair, irritation and anger described by participants correspond to © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing

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Tracheostomised patients and communication

Figure 1 The results in association with the transitional aspect.

those reported in other studies (Hafsteind ottir 1996, Patak et al. 2004, Magnus & Turkington 2006, Engstr€ om et al. 2013). The emotional aspect of this category reflects how the participants experienced being in transition. One of the most profound characteristics of transition is a feeling of disconnectedness, which is associated with disruption of security, loss of reference points and incongruence in a person’s expectations with reference to his past level of functioning (Ludin et al. 2013). The participants ‘lost’ their reference points and usual ways of coping with different events when they ‘lost’ the ability to use their voice and their ability to be understood. In comparison with their past experience, there was now a clear disparity between their expectations and the reality they woke up to. Feelings of powerlessness were described in various ways: feelings of hopelessness, discouragement and giving up when trying to communicate, with no one understanding their attempts at communicating. These feelings were also pointed out by other studies (Hafsteind ottir 1996, Carroll 2007, Karlsson et al. 2012a). Some of our participants related their feelings of powerlessness, sensations experienced because of being unable to communicate their pain. In an observational study performed by Happ et al. (2011), it was reported that one-third of patients’ efforts to communicate their pain was unsuccessful. Remembering pain experienced during their ICU stay is a prominent experience by patients (Stein-Parbury & McKinley 2000, Coyer et al. 2007). Most of our participants described a difficult situation after waking up from anaesthesia. However, as time passed, their experience changes and they adapted to their new circumstances in different ways (Fig. 1). Feelings of shock, confusion and uncertainty can also signal the beginning of a transition. Indeed, both health-to-illness transition and © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing

situational transition apply to this particular circumstance, because before the onset of their critical illness our participants were more or less functional, able to converse normally, but after awakening from anaesthesia, they were suddenly incapacitated, unable to utter even a single word. In effect, they had to deal with a new reality, one threatened by loss of health, or even death. The role changes trigger a transition, for instance, when a normal healthy person suddenly becomes seriously ill. Transition can be complicated by hindered communication. Not only did the participants experience losing who they normally were, but they also lost the ability to communicate who they were. Tracheostomy prevented them from expressing their personality verbally. Although the participants described many negative feelings and situations, they also described positive feelings and experiences. Many participants stated that the way the healthcare professionals delivered care made them feel secure and safeguarded. This was especially important in the difficult situation in which they found themselves. This is consistent with the findings of other studies (Hofhuis et al. 2008, Samuelson 2011, Engstr€ om et al. 2013). Hofhuis et al. (2008) concluded that the caring and sense of security conveyed by healthcare professionals play an important role in allaying patients’ stress and negative emotions under difficult situations. They stated that this is the most important action a healthcare professional can take to minimise patients’ fear and worries. The participants’ descriptions in the category Successful communication reflect an evolving transition. Ludin et al. (2013) emphasised that people in transition are vulnerable and in need of care and support. We observed this also as the participants described their need to feel secure and safe. The participants described a difficult situation initially.

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However, through care provided by healthcare professionals, they coped better and were thus able to begin to accept their situation with greater stability and sense of security. As shown in Fig. 1, they were able to overcome a period of shock and despair, and instead accept their new situation and their new reality. According to Chick and Meleis (1986), to be in transition, a person must have some awareness of the changes that are occurring. In our study, we found that information and knowledge communicated by healthcare professionals was important (Ludin et al. 2013). This factor may influence transition in a positive way. Through the information and knowledge they received from healthcare professionals, the participants became more aware of their situation, were better able to cope and were able to move through the transition process more smoothly. The need for receiving information while communicating through nonverbal means, such as eye contact and touch, is an important finding reported by others also (Henricson et al. 2009, Karlsson et al. 2012b). For several participants, this was essential. As pointed out by Meleis (2010), nurses have an important role in caring for people in transition. When caring and supporting patients in transition, nurses may help them better navigate through the process, so that they can gain stability under their new circumstances. The support and safeguarding conveyed through eye contact and physical contact during communication is an example of how healthcare professionals successfully helped the participants as they transitioned, as illustrated in Fig. 1. To ensure confidence in the validity of our results and conclusions, we used established concepts advanced by Lincoln and Guba (1985). The study findings must accurately reflect the experiences of the participants (Whittemore et al. 2001). To achieve this, we found it important to ask the participants open-ended questions. During the interviews, the first author briefly repeated a participant’s answer, and then he or she was encouraged to elaborate. Eleven participants were included in this study. We considered this sample size sufficiently large for obtaining a wide variety of stories and experiences, which would generate an adequate amount of transcripts to analyse. The length of time the participants were tracheostomised ranged from 3–27 days, which probably increased the likelihood of obtaining a variety of experiences. Between 3–18 months had passed since hospitalisation and when the interviews were performed. Even though the range of times from hospitalisation varied, there did not seem to be a correlation between the timespan and how much the participants remembered. Other research also highlights that memories from intensive care treatment are retained 5–10 years after hospital discharge

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(Storli et al. 2008, & Zetterlund et al. 2012). The interviews lasted for an average of 25 minutes; the shortest was only seven minutes. Because the shortest interview provided some relevant insights into the experience of communication, it was included in the analysis. The first author conducted and transcribed all of the interviews, analysing the data in close cooperation with the second author who has extensive experience in qualitative methods. To analyse the data, we used qualitative content analysis. It is considered to be suitable for use in the sensitive and multidimensional field of nursing (Elo & Kyng€ as 2008), and we viewed it as appropriate for obtaining a broad sample of the participants’ experiences with communication. Credibility is also affected by the choice of different categories and subcategories. During analysis, we continually and iteratively discussed the emerging results to increase the credibility of our results. One should keep in mind, however, that it is not always possible to achieve mutually exclusive categories, because human experience is often intertwined, with some overlap (Graneheim & Lundman 2004). To achieve confirmability and dependability, we endeavoured to describe our methods and findings in detail, making it possible for future researchers to replicate our study. The participants’ ‘voices’ are illustrated richly in the quotations presented in the results. We do not aim for a broad generalisation, but rather suggest that a thorough consideration provides new insight into these patients’ experience of communication in the context of the transitions theory.

Conclusion and relevance to clinical practice The importance of patients experiencing caring and understanding despite having uncomfortable feelings due to troublesome communication constitutes the core finding of our study. The participants expressed a wide spectrum of emotions associated with their inability to speak while being tracheostomised. When awakening from anaesthesia, their experiences were characterised by feelings of frustration, panic and anger, which often led to pervasive feelings of powerlessness, despair and loss of control. As time passed, they developed different ways to cope with their circumstances, and communication became easier. Another important finding was the significance participants placed on nonverbal communication, such as eye contact and physical contact. This promoted feelings of safety and security, and it was valued tremendously in their ability to deal with a difficult and demanding situation. The implication of this finding is that it can also be applied in other © 2015 John Wiley & Sons Ltd Journal of Clinical Nursing

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settings, and it is certainly relevant for everyone working in health care. The caring and safeguarding attitude communicated by healthcare professionals helped participants to cope with their situation. This can be understood in the context of transition. The transition process begins when a patient wakes up in an unfamiliar environment, not knowing what had happened previously and experiencing difficulties communicating. Through the caring and safeguarding provided by healthcare professionals, patients slowly begin to cope with their new circumstances, and the transition process evolves. Being aware of the different kinds of transitions that the tracheostomised intensive care patients might experience is important. Supporting patients as they undergo these transitions will help them navigate successfully through their situation, will help them achieve increased stability and will help them cope better with their difficult situation.

Our findings indicate that some participants reached the end of their transition, experiencing increased stability even though they were still tracheostomised. Others, however, experienced a difficult time with stress and instability, which persisted until they could speak again. This possibly means that they entered a transition but failed to reach its end before they were decannulated and able to speak again.

Contributions Study design: SIF, BA; Data analysis: SIF, BA and Manuscript preparation: SIF, BA.

Funding This research received no specific grant from any funding agency.

References Carroll SM (2007) Silent, slow lifeworld: the communication experience of nonvocal ventilated patients. Qualitative Health Research 17, 1165–1177. Chick N & Meleis AI (1986) Transitions: a nursing concern. In Transitions Theory-middle Range and Situationspecific Theories in Nursing Research and Practice. (Meleis AI ed.). Springer, New York, NY, pp. 24–37. Coyer FM, Wheeler MK, Wetzig SM & Couchman BA (2007) Nursing care of the mechanically ventilated patient: what does the evidence say? Part two. Intensive and Critical Care Nursing 23, 71–80. Elo S & Kyng€as H (2008) The qualitative content analysis process. Journal of Advanced Nursing 62, 107–115. Engstr€ om A, Nystr€ om N, Sundelin G & Rattray J (2013) People’s experience of being mechanically ventilated in an ICU: a qualitative study. Intensive and Critical Care Nursing 29, 88–95. Finke EH, Light J & Kitko L (2008) A systematic review of the effectiveness of nurse communication with patients with complex communication needs with a focus on the use of augmentative and alternative communication. Journal of Clinical Nursing 17, 2102–2115. Fisher CA, Charlebois DL, Tribble SS & Merrel PK (2009) Patient manage-

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ment: respiratory system. In Critical Care Nursing: A Holistic Approach, 9th edn (Morton PG & Fontaine DK ed.). Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia, PA, pp. 567–625. Graneheim UH & Lundman B (2004) Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Education Today 24, 105–112. Griffiths RD & Hall JB (2010) Intensive care unit-acquired weakness. Critical Care Medicine 38, 779–787. Grossbach I, Stranberg S & Chlan L (2011) Promoting effective communication for patients receiving mechanical ventilation. Critical Care Nurse 31, 46–61. Hafsteind ottir TB (1996) Patient’s experience of communication during the respirator treatment period. Intensive and Critical Care Nursing 12, 261– 271. Happ MB (2001) Communicating with mechanically ventilated patients: state of the science. American Association of Critical-Care Nurses Advanced Critical Care 12, 247–258. Happ MB, Garrett K, Thomas DD, Tate J, George E, Houze M, Radtke J & Sereika S (2011) Nurse-patient communication interactions in the intensive

care unit. American Journal of Critical Care 20, 28–40. Henricson M, Segesten K, Berglund AL & M€ a€ att€ a S (2009) Enjoying tactile touch and gaining hope when being cared for in intensive care – a phenomenological hermeneutical study. Intensive and Critical Care Nursing 25, 323–331. Hofhuis JGM, Spronk PE, van Stel HF, Schrijvers AJP, Rommes JH & Bakker J (2008) Experience of critically ill patients in the ICU. Intensive and Critical Care Nursing 24, 300–313. Karlsson V, Bergbom I & Forsberg A (2012a) The lived experience of adult intensive care patients who were conscious during mechanical ventilation: a phenomenological-hermeneutic study. Intensive and Critical Care Nursing 28, 6–15. Karlsson V, Forsberg A & Bergbom I (2012b) Communication when patients are conscious during respirator treatment – a hermeneutic observation study. Intensive and Critical Care Nursing 28, 197–207. Khalaila R, Zbidat W, Anwar K, Bayya A, Linton DM & Sviri S (2011) Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation. American Journal of Critical Care 20, 470–479.

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SI Flinterud and B Andershed Kvale S & Brinkmann S (2009) Interviews, 2nd edn. SAGE publications, Los Angeles, CA. Latronico N & Bolton CF (2011) Critical illness polyneuropathy and myopathy: a major cause of muscle weakness and paralysis. The Lancet. Neurology 10, 931–941. Lincoln YS & Guba EG (1985) Naturalistic Inquiry. SAGE publications, Beverly Hills, CA. Ludin SM, Arbon P & Parker S (2013) Patients’ transition in the Intensive Care Units: concept analysis. Intensive and Critical Care Nursing 29, 187– 192. Magnus VS & Turkington L (2006) Communication interaction in ICU – patient and staff experiences and perceptions. Intensive and Critical Care Nursing 22, 167–180. Marinaro JL, Mistra RP & Hale D (2012) Percutaneous tracheostomy for the intensivist. In Critical Care – Emergency Medicine. (Farcy DA, Chiu WC, Flaxman A & Marshall JP eds). McGraw-

10

Hill Medical, New York, NY, pp. 529–540. Meleis AI (2010) Transitions Theory-middle Range and Situation-specific Theories in Nursing Research and Practice. Springer, New York, NY. Patak L, Gawlinski A, Fung NI, Doering L & Berg J (2004) Patients’ reports of health care practitioner intervention that are related to communication during mechanical ventilation. Heart and Lung 33, 308–320. Patak L, Gawlinski A, Fung NI, Doering L, Berg J & Henneman EA (2006) Communication boards in critical care: patients’ views. Applied Nursing Research 19, 182–190. Samuelson KA (2011) Unpleasant and pleasant memories of intensive care in adult mechanically ventilated patients-findings from 250 interviews. Intensive and Critical Care Nursing 27, 76–84. Schou L & Egerod I (2008) A qualitative study into the lived experience of post-CABG patients during mechani-

cal ventilator weaning. Intensive and Critical Care Nursing 24, 171–179. Speziale HJ & Carpenter DR (2011) Qualitative Research in Nursing. Lippincott Williams & Wilkins, Philadelphia, PA. Stein-Parbury J & McKinley S (2000) Patients’ experience of being in an intensive care unit: a select literature review. American Journal of Critical Care 9, 20–27. Storli SL, Lindseth A & Asplund K (2008) A journey in quest of meaning: a hermeneutic-phenomenological study on living with memories from intensive care. Nursing in Critical Care 13, 86– 96. Whittemore R, Chase SK & Mandle CL (2001) Validity in qualitative research. Qualitative Health Research 11, 522– 537. Zetterlund P, Plos K, Bergbom I & Ringdal M (2012) Memories from intensive care unit persist for several years – a longitudinal prospective multi-centre study. Intensive and Critical Care Nursing 28, 159–167.

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Transitions in the communication experiences of tracheostomised patients in intensive care: a qualitative descriptive study.

To describe how tracheostomised patients in intensive care experience acts of communication and to better understand their experiences in the context ...
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