VOL: 97, ISSUE: 48, PAGE NO: 35
Karen Leigh, BSc, DipHE, RN, is staff nurse, The Royal Surrey County Hospital, Guildford
According to Sisson (1990), hearing is the last sense to go when a person becomes unconscious.
It is, therefore, imperative that health professionals evaluate the way in which they communicate with unconscious patients.
A number of studies have reported that after regaining consciousness some patients said they heard and understood various conversations that took place while they were unconscious (Tosch, 1988; Podurgiel, 1990; Lawrence, 1995).
Theorists such as Dyer (1995) suggest that touch should be recognised as a valuable form of communication as it reassures unconscious patients, thereby reducing psychological anxiety. However, experimental studies have reached different conclusions and Johnson et al (1989) suggest that communication directed at the unconscious patient may actually cause stress and anxiety.
While the definitions of unconsciousness may vary, it is usually based on a patient’s clinical state and is assessed using the Glasgow Coma Scale, which interprets the patient’s level of arousal.
This review explores the issue of how nurses can communicate with unconscious patients.
The literature search covered several electronic databases, including Cinahl, the British Nursing Index and Medline. Other methods were used to broaden the range of data gathered, such as manual searches and accessing websites. Specialist neurological nurses and multidisciplinary teams were also approached.
An assessment of the researchers’ interpretations revealed a number of themes, including psychological distress and the importance of touch and verbal communication.
Verbal communication is an essential part of the nursing process which can reduce anxiety or distress and emotionally stimulate the patient. It is usually a two-way process in which a message is sent and understood, and feedback is given.
When dealing with unconscious patients, who are unable to respond, it is impossible to know whether they have understood what has been said. However, it is important to remember that the need for communication remains.
La Puma et al (1988) believe that unconscious patients may have a normal auditory response, and that not talking to them suggests that they are not likely to recover, which increases their sense of vulnerability.
Studies of patients’ memories of their unconscious state indicate that they heard and understood conversations. Lawrence (1995) found that unconscious patients could hear and respond emotionally to verbal communication. One patient, when being neurologically assessed, understood the nurse’s request to squeeze her hand but was unable to move. Another stated: ‘I could think and I could hear, but I could not move and I could not talk or open my eyes.’
Research has shown that intensive care syndrome, which is also known as intensive care psychosis, causes significant psychological distress in patients in different states of consciousness.
Asbury (1985) and Dyer (1995) highlight the negative impact of an unfamiliar environment and the use of constant monitoring equipment on patient distress. According to MacKellaig (1987), without orientation and reassurance these patients can experience intense feelings of insecurity, anxiety and isolation. Coupled with fluctuating states of consciousness, they may have hallucinations and delusions.
It is important for nurses to recognise that psychological distress does not occur only among patients in intensive care. As Barrie-Shelvin (1987) suggests, psychological distress caused by sensory deprivation can occur in any patient in any part of the hospital.
By communicating with unconscious patients about their environment as well as providing personal care, nurses can help to meet these patients’ psychological needs. This prevents psychosis withdrawal and delirium, which Chew (1986) believes is caused by psychological stress, including disorientation, anxiety and isolation.
Russell (1999) concludes that hospitals are often noisy and that this makes patients anxious, while reassurance and explanations by nurses help them to feel safe, secure and less vulnerable. This study also explored negative communication, where nurses became over-involved with technical equipment and the physical aspects of care, which reduced the level of communication with patients.
This observation perhaps best reflects the reality of most hospital settings. With decreased numbers of qualified staff and increased workloads in clinical practice, the physical element of the patient’s condition, along with the use of technical equipment, are often given priority over the patient’s psychological needs.
Green (1996) stresses the importance of effective communication, during which nurses personalise their care by addressing the patient by name and meeting his or her individual needs.
Ashworth (1980) found that communication problems were closely linked to an emphasis on physical care, which tended to dominate at the cost of orienting patients, giving reassurance and establishing social interaction. This study also revealed that nurses communicate more with conscious patients as they equate increased responsiveness with encouragement for further interaction.
Podurgiel (1990) suggests that if health professionals use patients’ names in an informative and caring situation, the resulting increased levels of conversation might raise patients’ consciousness levels and boost their chances of survival.
Helwick (1994) reasons that verbal communication helps to stimulate the brain’s reticular activating system, which is a complex network centred on a person’s arousal, thus maintaining a conscious state.
There are two main types of touch, often referred to as task-orientated - where a patient is touched when being turned or washed - and caring touch - where touch is used to enhance communication and provide reassurance. Verity (1996) emphasises that caring touch, used with speech, can enhance the messages patients receive.
Talton (1995) criticises nurses who assume it is acceptable to touch all patients, while Dyer (1995) emphasises that touch involves a two-way process and that permission to touch should be sought before a nurse invades a patient’s personal space. When caring for unconscious patients, nurses could ask relatives to find out if touch would be welcomed.
Studies by Tosch (1988), Podurgiel (1990) and Lawrence (1995) emphasise that tactile stimulation conveys emotional support. Tosch (1988) points out that pinching, which some nurses had used to gain a response during a Glasgow Coma Score assessment, was remembered as painful.
Ashworth (1980) found that touch has the potential to stimulate a response from patients when other methods of interaction have failed. However, she noted that nurses were often afraid to get too emotionally involved with patients and tended to use a task-oriented form of touch.
Despite some evidence showing that unconscious patients can remember conversations, little experimental research has been done. Walker et al (1998), Treloar et al (1991) and Johnson et al (1989) are among the few researchers to have investigated the effect of verbal communication on severely unconscious patients. These studies set out to determine whether verbal communication could change a patient’s physiological response. Blood pressure, heart and respiratory rate, oxygen saturation, intracranial pressure and levels of restlessness were examined.
Walker et al (1998) and Treloar et al (1991) found no physiological changes and an absence of negative effects, suggesting that nurses and families should continue to communicate verbally. However, Johnson (1989) shows that emotionally referenced conversation can increase intracranial pressure, which indicates possible feelings of anxiety and stress, whereas unrelated and depersonalised conversation decrease intracranial pressure. These conflicting results support the need for further research.
The nurse’s role
One-way communication from nurse to patient can be enhanced if the nurse is closely involved with the unconscious patient’s family. Gaining an insight into the patient’s background and personality also allows the nurse to communicate more effectively.
Podurgiel (1990), Dyer (1995) and Green (1996) all strongly recommend that care should be personalised through the use of effective communication strategies, such as by talking directly to the patient and using touch to enhance communication and convey emotional support.
Individualised care can be achieved by addressing unconscious patients by their preferred name, encouraging family and friends to contribute to the sound of familiar voices and discussing subjects of interest to the patient. According to Ashworth (1980), this type of communication could improve sensory input to the patient.
Podurgiel (1990) emphasises the importance of nurses gaining historical information on their patients. One patient in her study was seen to withdraw into unconsciousness when her husband visited and staff later discovered that the couple had an unhappy relationship. This highlights the need for nurses to be aware of the effect visitors may have on patients.
Treloar et al (1991), Dyer (1995), Verity (1996) and Gelling and Previst (1999) suggest that nurses should encourage unconscious patients’ families to interact with them. This helps to maintain social normality and address the patient’s psychological needs. For example, families should be included in the orientation process, communicating information such as the time of day and telling the patient about social family events.
Treloar et al (1991), Dyer (1995) and Verity (1996) all suggest that nurses need to recognise that they are often regarded as role models. If they demonstrate good standards of practice when communicating with unconscious patients they may encourage others to become more fully involved in the process.
As Ashworth (1980) recognises, nurses often experience difficulties in communicating with unconscious patients, primarily because the patient is unable to respond. However, Lawrence (1995), Podurgiel (1990) and Tosch (1988) indicate that unconscious patients have been reassured by the communication process and that this helps to meet their psychological needs and prevents unnecessary distress, thus aiding their recovery.
It is recommended that nurses evaluate such studies and aim to strike a balance in providing physical and psychological care by focusing on touch and verbal communication while ensuring that any clinical needs are met. Nurses need to analyse their patients’ responses to communication and be aware of physiological signs that may indicate stressful reactions.
Nurses who are involved in the care of unconscious patients should identify further evidence to ensure best practice. As Shuldham (1984) concludes, further education could help to improve the communication process by enabling them to evaluate and enhance their practice.