Communication Difficulties and

Psychoemotional Distress in Patients

Receiving Mechanical Ventilation
Rabia Khalaila, RN, PhD; Wajdi Zbidat, RN, MPA; Kabaha Anwar, RN, BSN; Abed Bayya,
MD; David M. Linton, MD; Sigal Sviri, MD
Disclosures
Am J Crit Care. 2011;20(6):470-479.
bstract and Introduction
Abstract

Background Difficulties in communication in intensive care patients receiving mechanical

ventilation are a source of stressful experiences and psychoemotional distress.
Objectives To examine the association between communication characteristics and
psychoemotional distress among patients treated with mechanical ventilation in a medical
intensive care unit and to identify factors that may be predictive of psychological outcomes.
Methods A total of 65 critically ill patients, extubated within the preceding 72 hours, were
included in this cross-sectional study. Data were collected by using a structured interview.
Separate regression analysis of data on 3 psychoemotional outcomes (psychological distress,
fear, and anger) were used for baseline variables, communication characteristics, and stressful
experiences.
Results Difficulty in communication was a positive predictor of patients' psychological
distress, and length of anesthesia was a negative predictor. Fear and anger were also
positively related to difficulty in communication. In addition, the number of communication
methods was negatively associated with feelings of fear and anger. Finally, the stressful
experiences associated with the endotracheal tube were positively related to feelings of anger.
Conclusions Patients treated with mechanical ventilation experience a moderate to extreme
level of psychoemotional distress because they cannot speak and communicate their needs.
Nurses should be aware of the patients' need to communicate. Decreasing stressful
experiences associated with the endotracheal tube and implementing more appropriate
communication methods may reduce patients' distress.
Introduction

Studies[16] have clearly established the difficulties in communication among patients treated
with mechanical ventilation in the intensive care unit (ICU). Most patients who remember the
experience of mechanical ventilation remember the discomfort of being unable to speak.[6]
The most common stressful experiences, in order, are being unable to speak, thirst, difficulty
swallowing, and intubation.[36]
Other studies[79] have emphasized the importance of maintaining optimal communication
between nurses and the patients receiving mechanical ventilation. However, evidence[10]
suggests that although critical care nurses are aware of the need for effective patient

communication, such communication often does not occur. Happ et al[11] found that intubated
patients rated 40% of communication sessions with nurses as somewhat to extremely difficult
and that more than one-third of communications about pain were unsuccessful. Researchers
have identified numerous barriers in nurses' communication with patients receiving
mechanical ventilation, such as difficulty in lip reading, patients' inability to write, patients'
personalities,[12] lack of nurses' education on communication,[2] increased workload,[13] and
nurses' perceived insecurities.[8] However, Kacperek[7] suggested that effective
communication depends on the ability to listen and use nonverbal communication skills.
Communication difficulties create great stress for patients treated with mechanical
ventilation,[2,14] leading to psychoemotional distress, including indications of depression,
anxiety,[3,15,16] fear and anger,[17,18] frustration,[15] panic, sleeping disorders, decreased selfesteem,[19] loss of control,[14] and, occasionally, resignation.[20]
Additional stressful experiences associated with the endotracheal tube, which can also
increase psychoemotional distress in the ICU,[3,6,16] include pain or discomfort associated with
the tube fastenings or with suctioning, interference with sleep, feeling choked, insufficient air,
breathing difficulty after extubation, thirst, and difficulty swallowing.[6,16] Recently, Puntillo
et al[21] reported additional symptoms experienced by critical care patients, such as tiredness,
restlessness, anxiety, sadness, hunger, fear, and confusion. The prevalence of distressing
symptoms among these patients was high; thirst was moderately intense, and shortness of
breath, fear, confusion, and pain were moderately stressful.
Rotondi et al[6] found that each endotracheal tube experience was remembered by more than
20% of patients and that the experience was moderately to extremely bothersome for more
than 66% of those who remembered it. For example, the majority of intubated patients
(82.7%) remembered the experience of not being able to speak. About 80% of these patients
were moderately to extremely bothered by this experience.
Although communication with patients receiving mechanical ventilation is challenging for
patients, nursing staff, and patients' families, certain communication behaviors and methods
alleviate these difficulties[22,23] and reduce patients' distress.[12] Such methods include lip
reading, use of pen and paper,[9] positive body language, friendly facial expression, eye
contact and yes-no questions,[12,24] clicking the tongue or using a bell or clicking device,[25]
and even touch.[26] Other low-technology devices that may be helpful include word or picture
charts, alphabet boards, and erasable boards.[4,18,23] More advanced technological devices, such
as communication aids that rely on computerized electronic voice output, are generally used
on the basis of individual patient assessment and evaluation for longer term patients receiving
mechanical ventilation.[2] Additional methods that enable patients to speak are invasive
modified speech approaches for patients on permanent respirator support and a Portex
Vocalaid (a fenestrated endotracheal tube) for patients who require a constantly inflated tube
cuff.[24] However, Menzel[18] found that using a variety of communication methods was not
correlated with less emotional distress.
The most common stressful experience in mechanically ventilated patients is
being nonvocal.

Many baseline factors, such as background variables (patients' age, sex, marital status,
employment status), may be associated with psychoemotional distress. Advanced age is
associated with a decrease in psychological distress, whereas being female is related to

greater distress.[4,16] Employment status and marital status have not been associated with the
level of distress experienced by patients. In addition, certain health factors can be associated
with psychoemotional distress. For example, history of mechanical ventilation, total duration
of mechanical ventilation, number of days in the ICU, and scores on the Acute Physiology
and Chronic Health Evaluation II are positively correlated with psychoemotional distress,[15,18]
whereas use of anxiolytics or sedation is negatively associated with distress.[15,18,27] The effect
of diagnosis at the time of admission has not been associated with the level of distress.
A total of 40% of intubated patients' rate their communication with nurses as
somewhat or extremely difficult.

The problem of communication during mechanical ventilation and patients' distress at being
unable to speak are important to nurses and other health care providers, yet little is known
about the impact of the inability to speak on psychoemotional distress among critically ill
patients treated with mechanical ventilation.[18] In this study, we examined the relationships
between communication difficulties, the number of communication methods used, perceived
stress associated with the endotracheal tube, and selected baseline variables associated with
psychoemotional distress among ICU patients treated with mechanical ventilation.Continue
Reading
Methods
Research Design and Sample

A cross-sectional, correlational study was conducted. After approval by the institutional

review board, a convenience sample of 65 patients was recruited consecutively during the
working week from a 9-bed medical ICU at Hadassah Hospital, Jerusalem, Israel. The ICU
staff includes intensive care specialists, medical residents in training, and ICU-trained and
nonICU-trained nurses, the unit has a nurse to patient ratio of 1 to 2. Data were collected
during a 17-month period from April 2008 to August 2009. During the course of the study,
255 intubated patients were admitted to the ICU. Interviews were mostly conducted in the
ICU, after patients gave informed consent and met the following criteria: age 18 years or
more; orientation to person, place, time, and situation at the time of the interview; and (3)
intubation for at least 24 hours and extubated within 72 hours before the interview. Patients
who underwent tracheotomy insertion, psychiatric patients, and patients who were depressed
were excluded from the study. Sample size was determined by using prior analyses of
communication difficulty and emotional distress,10 with moderate effect size (0.5) and a
significance level of .05. According to these calculations, a sample size of 65 was sufficient
to yield a power of 85%.
Communication depends on the ability to listen and use nonverbal
communication skills.

The principal or secondary investigator recruited patients by first reviewing documentation

on inclusion criteria, such as duration of mechanical ventilation and time of extubation, and
then checked each patient's mental status with the nurses to determine any cognitive or
emotional limitations after extubation. Written informed consent was then obtained from each
patient.

Data were collected from medical charts and via interviews with the patients. Baseline
characteristics included age, sex, marital status, and employment status. Employment status
was divided into 2 categories: working full-time or part-time and unemployed, retired,
homemaker, or never worked. Clinical data included diagnosis at the time of admission and
history of mechanical ventilation; that is, had the patient had a previous experience that had
required intubation and mechanical ventilation. Total duration of mechanical ventilation,
including days intubated before admission to the ICU, was calculated as the number of
calendar days from ICU admission to discharge. Duration of sedation and analgesia was the
total number of days that the patient received a single or combined continuous infusion of
analgesics and sedatives (eg, combinations of narcotics such as morphine or remifentanyl,
benzodiazepines such as midazolam, and other agents such as propofol). The Acute
Physiology and Chronic Health Evaluation II score was determined for each patient at the
first 24 hours of admission. Finally, data on communication characteristics, stressful
experiences, and psychological outcomes (psychological distress, anger, and fear) were
gathered in a face-to-face 20- to 30-minute interview in the ICU. No data were missing on
variables of interest for the analysis presented in this article, and data on all 65 patients were
included in the analysis.
Measures

Psychological distress from being unable to speak was measured by using the Hospital
Anxiety and Depression Scale,[28,29] a 14-item, self-reporting screening scale that consists of
two 7-item Likert scales, 1 scale for anxiety and 1 scale for depression. Each scale has scores
from 0 to 21. Patients were asked to choose a single response from the 4-point Likert scale,
from 0 to 3. One example from the depression scale is "I feel as if I am slowed down."
"Worrying thoughts go through my mind" is from the anxiety scale. Higher mean scores
indicate greater psychological distress. The score achieved in the study reported here was .
89.
Emotional distress at being nonvocal was measured by using 2 analog scales: the fear scale
and the anger scale.[18] Patients rated their fear response during mechanical ventilation from 0
(no fear) to 10 (extremely fearful). The anger scale ranged from 0 (calm) to 5 (enraged).
Higher scores indicate greater emotional distress.
Perceived difficulty with communication was measured by using the Ease of Communication
Scale developed by Menzel.[18] This 6-item Likert-type instrument was used to measured
patients' perceived difficulty in communication when they were unable to speak. Patients
rated their experienced communication difficulty in general, with nurses about physical
needs, with questions about the care, with questions about the patients' condition, and in
making themselves understood. A 5-point Likert format was used, from 0 (not difficult at all)
to 4 (extremely difficult). Higher scores indicate greater difficulty. The reliability coefficient
( = .89) in the study was high.
The number of communication methods used was measured by means of the Menzel
communication checklist,[18] which consists of 8 methods commonly used in the critical care
unit at Hadassah Hospital: squeezing hands, lip reading, pen and paper, facial expression,
shaking or nodding the head, word or picture charts, alphabet boards, and electronic voice
output. Patients were asked to select the methods they used to communicate when intubated;
the results were a score from 0 to 8.

Stressful experiences associated with use of an endotracheal tube and mechanical ventilation
were measured by using the ICU-Stressful Experiences Questionnaire,[6] which consists of 32
items about potentially stressful experiences associated with the ICU and the endotracheal
tube. Only the 10 items on endotracheal tubes in the questionnaire were used. Patients were
asked if they remembered the experience, and then they ranked how much it bothered or
upset them on a 5-point scale: 1 (not at all), 2 (a little bit), 3 (moderately), 4 (quite a bit), and
5 (extremely). Examples include "Remember not being able to speak" and "Remember pain
or discomfort associated with endotracheal tube." A higher score indicates greater stressful
experiences related to use of an endotracheal tube. The coefficient for this scale in this
study was .90.
Statistical Analysis

SPSS, version 17 (IBM SPSS Statistics, Armonk, New York) was used for all data analysis.
Variables were analyzed on 3 levels. Univariate examination was used for means, standard
deviations, and ranges. For the bivariate level, Pearson product moment correlations, and
independent t tests were used to clarify the associations between the independent variables
and 3 outcome variables. Finally, multivariate linear regression analysis (enter method) was
used to detect factors that could have influenced each outcome. All tests of significance were
2-tailed; P values less than .05 were considered significant.
Patients had moderate feelings of depression and anxiety, anger and fear.
Results

Table 1 gives the patients' baseline characteristics. Most of the patients were men, were
married, and were unemployed. The age range was 18 to 92 years (mean, 59.7; SD, 18). The
most common diagnoses at admission were respiratory insufficiency and infection. Patients
had moderate scores on the Acute Physiology and Chronic Health Evaluation II (mean, 24.1),
and the mean duration of mechanical ventilation was 6.8 days. One-fourth of the patients had
had mechanical ventilation in the past. Half of the patients received anesthesia and analgesic
drugs during the period of mechanical ventilation, for a mean of 3 days. The mean length of
stay in the ICU before the interview was 8 days.
Bivariate analysis was used to explore the associations between the baseline variables and
each of the outcome variables. However, no associations were significant (data not shown).
The vast majority rated communication as quite difficult to extremely difficult.

Table 1 also gives the descriptive statistics of the communication characteristics, stressful
experiences associated with use of an endotracheal tube, and the 3 outcomes. The mean
scores for the outcomes indicate that patients had moderate feelings of depression and
anxiety, anger, and fear. In addition, patients had high scores for stressful experiences with
use of an endotracheal tube, and variance between the patients was low. Mean scores on the
communication items indicate a moderate difficulty with communication. Figure 1 is a
histogram of the general communication rating. The majority of the patients (82%) rated
general communication as quite difficult to extremely difficult, whereas 18% rated
communication as not difficult at all to somewhat difficult. Figure 2 shows the
communication methods used by intubated patients. Each patient used about 3
communication while unable to speak, including squeezing hands (92%), shaking or nodding

the head (86%), lip reading (83%), facial expressions (83%), pen and paper (57%), word or
picture charts (17%), alphabet boards (6%), and electronic voice output (5%).

(Enlarge Image)

Figure 1.
In general, how difficult it was to communicate (N = 65).

(Enlarge Image)

Figure 2.
Communication methods used by intubated patients (N = 65)
Table 2 presents the stressful experiences associated with use of an endotracheal tube during
mechanical ventilation. Each experience was remembered by about 50% or more of the
patients. At least 62% were bothered moderately to extremely. For example, more than 75%
of those who remembered their experience with the endotracheal tube were bothered
moderately to extremely by not being able to speak (90%), feeling thirsty (87%), pain during
suctioning (82%), pain associated with the tube (78%), and interference with swallowing
(77%).
Table 3 is the bivariate correlation matrix between the main study variables. Higher
psychological distress scores were correlated with greater feelings of fear and anger, more
stressful experiences with the endotracheal tube, and more difficulty with communication, but
not with the number of communication methods. A greater level of fear was correlated with
higher anger levels and greater difficulty with communication as well as with fewer
communication methods, but not with stressful experiences associated with the endotracheal
tube. Anger was positively correlated with stressful experiences associated with the
endotracheal tube and with difficulty in communication, but negatively correlated with the
number of communication methods. The stressful experiences associated with the
endotracheal tube were also positively correlated with communication difficulty. Finally, the
results showed no correlation between the number of communication methods and
communication difficulty.

Table 4 displays the hierarchical regression for each outcome. All of the independent
variables in these analyses were entered. The regression analyses for each outcome were
significant. The first linear regression revealed 2 significant predictors of psychological
distress, with an adjusted R2 of 0.47 (P = .02). The analysis indicated that duration of
anesthesia was negatively associated with psychological distress. However, communication
difficulty was positively associated with the same outcome.
The results of the second regression analysis revealed 2 predictors of fear, with an adjusted
R2 of 0.59 (P = .01). Communication difficulty was a positive predictor of fear. The results
also indicate that the number of communication methods was independently associated with a
low level of fear.
The final regression analysis revealed 4 significant predictors of anger,
with an adjusted R2 of 0.72 (P < .001). The results show that
difficulty with communication and the stressful experiences
associated with the endotracheal tube were independently
associated with higher anger levels during mechanical ventilation.
However, the number of communication methods was negatively
related to anger. Married patients reported higher levels of anger
than did the unmarried patients. Discussion

Although difficulty with communication among patients treated with mechanical ventilation
has been well studied, the interrelationships between this difficulty and psychoemotional
distress have rarely been investigated.[18] Our analysis is one of the few efforts to examine the
responses of critically ill patients receiving mechanical ventilation to the negative
experiences of having an endotracheal tube and being unable to speak. Our results indicate
that patients treated with mechanical ventilation experience moderate to high levels of
psychoemotional distress at being unable to speak, these results are congruent with previous
research[3,1518] that indicated that patients treated with mechanical ventilation who cannot
speak experience a variety of negative feelings, such as depression, anxiety, fear, and anger.
Our findings also indicate that patients' communication difficulties were the strongest
predictor, explaining the variance of patients' psychological and emotional distress at being
unable to speak, as reported elsewhere.[15,16,18] Our results suggest that interventions to prevent
psychoemotional distress among patients treated with mechanical ventilation should target
patients with communication difficulties. The reason so many of our patients expressed their
frustration with being unable to speak while being treated with mechanical ventilation may be
related to the discomforts of communication difficulties associated with periods of increased
awareness and alertness during weaning from the treatment.
The number of communication methods used by our patients was negatively correlated with
the level of fear and anger at being unable to speak. A possible explanation of these findings
is that patients with a lower level of emotional distress used more effective communication
methods in expressing their needs. However, we cannot yet confirm whether a using a high
number of communication methods reduces negative emotional feelings or vice versa,
although this finding suggests that facilitating effective and appropriate communication
methods may protect patients treated with mechanical ventilation from negative emotional
distress. Our results parallel those from other studies regarding the association between the
nurses' use of some physical methods to communicate (eg, squeezing hands, shaking the

head, lip reading, and facial expression) and low levels of patients' distress,[12] even though
some studies[18] dispute this association.
Our results further show that stressful experiences associated with the endotracheal tube were
a positive predictor of emotional distress among patients treated with mechanical ventilation,
as reported in other studies.[3,6,16] This finding suggests that negative experiences, such as pain
or discomfort associated with suctioning via the endotracheal tube, interference with sleep,
thirst, and difficulty swallowing, also increase emotional distress. These findings lead us to
conclude that purposive interventions designed to affect emotional distress in patients treated
with mechanical ventilation should focus on the preventable stressful experiences associated
with use of an endotracheal tube.
The duration of analgesia and sedation (number of days) was inversely related to
psychological distress but was not related to emotional outcomes. This result corresponds
with the findings of another study[15] in which patients treated with mechanical ventilation
who received anxiolytic medication had a lower level of frustration than did patients who
were not given an anxiolytic agent. However, the use of sedatives, particularly
benzodiazepines, has been associated with delirium and other cognitive side effects in
critically ill patients,[30] necessitating the implementation of carefully planned sedation and
awakening bundles. These findings[30] suggest that careful administration of sedative and
analgesic agents and appropriate monitoring of cognitive side effects may protect patients
treated with mechanical ventilation from psychological distress.
An additional factor that appeared to be related to emotional distress was marital status. In
our study, married status was related to greater feelings of anger, suggesting that married
patients treated with mechanical ventilation were more vulnerable than unmarried patients to
emotional distress. Additional analysis between each item of the Ease of Communication
Scale and anger revealed that greater difficulty in communicating with family members is
correlated with greater feelings of anger among patients treated with mechanical ventilation.
Perhaps, patients' families are less equipped or skilled in communicating with nonvocal
persons and/or are less able to discern nonvocal messages from the patients.
We found no statistical relation between severity of illness and duration of ventilation with
psychoemotional distress, contradicting findings from other studies.[18] A possible explanation
is our small sample size and the consequent low statistical power. Furthermore, unlike
previous results,[12] our findings did not reveal a significant association between the number
of communication methods and psychological distress. Our results suggest that the
communication methods used were perhaps more effective in reducing fear and anger but not
effective in addressing depression and anxiety.
Similar to previous reports,[18] our results did not show a significant association between other
baselines variables, such as history of mechanical ventilation and diagnoses at the time of
admission. A possible explanation of these findings is the small sample size
Limitations

Despite the strengths of our study, a few limitations should be noted. The first is the crosssectional design, which does not allow confirmation of causal inferences about the
association between the communications characteristics and psychoemotional distress. The
second limitation is the use of a small sample from a single site and nonrandom selection of

the convenience sample; generalizing our results beyond our sample of patients may be
difficult, and our findings may not apply to other intubated patients in other ICUs, such as
surgical and cardiac units. The third limitation is the lack of a control group of patients
treated with mechanical ventilation who had no experience of being unable to speak. The last
limitation is the potential bias of repeated testing, which we did not make statistical
adjustments for. Despite these limitations, however, our results provide initial insights into
the correlation between difficulty with communication, stressful experiences associated with
the endotracheal tube, and psychoemotional distress among critically ill patients treated with
mechanical ventilation.
Higher psychological distress was not associated with the number of
communication methods.
Conclusions

Patients treated with mechanical ventilation reported moderate to high levels of psychological
and emotional distress in trying to communicate their needs during the treatment. The
findings suggest that ICU nursing staff should be aware of and sensitive to communication
difficulties among patients treated with mechanical ventilation who are unable to speak. We
recommend interventions to reduce psychoemotional distress and difficulty with
communication among patients treated with mechanical ventilation. These interventions
include optimal analgesia and sedation protocols to decrease the stressful experiences
associated with the endotracheal tube and development of more appropriate communication
methods easily used by patients treated with mechanical ventilation, such as low-technology
devices (eg, word or picture charts, alphabet boards, squeezing hands, shaking the head, lip
reading, and facial expressions). These interventions will enable the medical and nursing staff
to better meet the needs of these patients.
Mechanically ventilated patients experience moderate to high levels of
psychoemotional distress at being unable to speak.

Future investigators should examine psychological and emotional distress during mechanical
ventilation, after extubation, and after discharge from the ICU. Additional studies are needed
to evaluate the effectiveness of interventions to facilitate communication with patients treated
with mechanical ventilation. An examination of the effect of stressful experiences associated
with an endotracheal tube and difficulty with communication on other psychoemotional
responses, such as frustration, panic, loss of control, and satisfaction with the quality of care,
would be useful.