Intensive & Critical Care Nursing xxx (2018) xxx–xxx

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Intensive & Critical Care Nursing

journal homepage: www.elsevier.com/iccn

Research article

The communication experience of tracheostomy patients with nurses in

the intensive care unit: A phenomenological study
Angela Tolotti a, Annamaria Bagnasco a,⇑, Gianluca Catania a, Giuseppe Aleo a, Nicola Pagnucci b,
Lucia Cadorin c, Milko Zanini a, Gennaro Rocco d, Alessandro Stievano e, Franco A. Carnevale f,
Loredana Sasso a
a
Department of Health Sciences, University of Genoa, Via Pastore, 1, 16132 Genoa, Italy
b
Department of Clinical and Experimental Medicine, University of Pisa, Italy
c
CRO Aviano National Cancer Institute, Via F. Gallini, 2, 22081 Aviano, Italy
d
Italian Nurses’ National Social Security Council (ENPAPI), Via A. Farnese 3, 00192 Rome, Italy
e
Centro di Eccellenza per la Cultura e la Ricerca Infermieristica, Via G. Cesare 78, 00192 Rome, Italy
f
Ingram School of Nursing, McGill University, Montreal, Quebec, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To describe the experience and sources of comfort and discomfort in tracheostomy patients,
Accepted 4 January 2018 when they communicate with nurses in the Intensive Care Unit.
Available online xxxx Research methodology/design: Benner’s interpretive phenomenology. Data were collected through: a)
semi-structured interviews conducted with the patients after leaving the intensive care unit; b) partici-
Keywords: pant observation; c) situated interviews with intensive care nurses.
Comfort Setting: The intensive care unit of a hospital in Northern Italy.
Communication
Findings: Eight patients and seven nurses were included in this study. Two main themes were identified
Critical care
Discomfort
1) feeling powerless and frustrated due to the impossibility to use voice to communicate; 2) facing continual
Experience misunderstanding, resignation and anger during moments of difficulty and/or communication misunderstand-
Intensive care ings. The main communication discomfort factors were: struggling with not knowing what was
Interpretive phenomenology happening, feeling like others had given up on me, living in isolation and feeling invisible. The main
Nurses comfort factors were: being with family members, feeling reassured by having a call bell nearby and
Patient nurses’ presence.
Tracheostomy Conclusions: This study highlights the important role of communication in tracheostomy patients in
intensive care and how closely it is linked to all the aspects of a person’s life, which cannot be underes-
timated as just not being able to use one’s voice.
Ó 2018 Elsevier Ltd. All rights reserved.

Implications for Clinical Practice

 The impact of nurse-patient communication in intensive care and the sources of comfort and discomfort are highlighted.
 The results of this study could inform strategies and actions to improve the nurse-patient communication in intensive care.
 This study increases nurses’ awareness about the importance of communication for patients and the meaning they give to it.

Introduction

The number of patients who undergo tracheostomy each year is

⇑ Corresponding author.
E-mail addresses: angela.tolotti@unipv.it (A. Tolotti), annamaria.bagnasco@
unige.it (A. Bagnasco), gianluca.catania@edu.unige.it (G. Catania), giuseppe.aleo@
edu.unige.it (G. Aleo), gamma97@tin.it (N. Pagnucci), lcadorin@cro.it (L. Cadorin),
milko.zanini@edu.unige.it (M. Zanini), Franco.carnevale@mcgill.ca (F.A. Carnevale),
l.sasso@unige.it (L. Sasso).
unknown, however this procedure is widespread and has become
common practice (Scherlock et al., 2009). Technological improve-
ments and decreased invasiveness of the tracheostomy procedure
have encouraged its more liberal use (Hosokawa et al., 2015). Par-
ticularly in Europe, when clinical conditions of the mechanically

https://doi.org/10.1016/j.iccn.2018.01.001
0964-3397/Ó 2018 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Tolotti, A., et al. The communication experience of tracheostomy patients with nurses in the intensive care unit: A phe-
nomenological study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.01.001
2 A. Tolotti et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx

ventilated are favourable, there is the increasing use of light seda-
tion or even no sedation (Karlsson et al., 2012) because this
reduces time required for patients to wean from mechanical venti-
lation and consequently length of stay in the intensive care unit
(ICU) and ensures improved health outcomes (Samuelson, 2006).
This reduces complications and problems caused by immobility,
as shown by Strøm et al. (2010), who compared clinical-
healthcare results obtained through deep sedation with those
using light sedation. Karlsson and Bergbom (2014) described the
main sources of stress and difficulty in mechanically ventilated tra-
cheostomy patients, including the impossibility to communicate.
Various studies have described the experiences of these patients
and how communication difficulties generate feelings of vulnera-
bility and helplessness (Lykkegaard and Delmar, 2015; Engström
et al., 2013; Meriläinena et al., 2013; Magnus and Turkington,
2006), becoming sources of anxiety, frustration, and fear (Patak
et al., 2006; Grossbach, 2007).
Nurses are in the position to understand, address and mitigate
the effects of impaired communication (Karlsson and Bergbom,
2014; Slatore et al., 2012; Carroll, 2007, 2004). When communicat-
ing with patients who are not sedated or under light sedation,
nurses are required to have the ability to capture and correctly
interpret patients’ attempts to communicate and their feedback
(Arrigoni et al., 2013). Difficult communication can prevent tra-
cheostomy patients from expressing their needs, symptoms
(Nilsen et al., 2014), emotions and from participating in decisions
regarding their own treatment.
One study, which investigated communication with tra-
cheostomy patients in the ICU, mainly involved the use of commu-
nication tools and their effectiveness (Nakarada-Kordic et al.,
2017). Current studies mainly focus on experiences of endotracheal
intubated patients, but few have explored the communication
experience of tracheostomy patients in the ICU (Flinterud and
Andershed, 2015; Foster, 2010). Moreover, no studies have shown
whether the communication difficulties experienced by
nasotracheal-intubated patients are similar to those of mechani-
cally ventilated tracheostomy patients.
Methods
This study aimed to explore the communication experience of
tracheostomy patients with nurses in the intensive care unit and
identify which situations and factors made patients feel comfort-
able when communicating with nurses and which caused distress.
Research question
What is the lived experience of adult patients with a tra-
cheostomy, who are not under sedation and mechanically venti-
lated, in their communication with nurses during their stay in
the intensive care unit?
To conduct this study, the researchers used the interpretive
phenomenology methodology developed by Benner (1994). The
decision to use interpretative phenomenology is related to the
aim of this study, which is to gain a deeper understanding of what
patients experience when they communicate with nurses. The
focus is on the patient’s subjective experience and on the meaning
each patient gives to this experience. The purpose of interpretive
phenomenological investigation was to expand our knowledge by
describing things and phenomena as they occur and through lived
experience (Polit and Beck, 2014; Holloway and Wheeler, 2012;
Sokolowski, 2000). This enables to capture any concerns or what
matters to a person, by eliciting narratives about daily experience
and observing how each person behaves and how much impor-
tance is given to each communication event (Benner et al., 2009).
Benner (1994) provides a full discussion of the way in which this
form of interpretation is articulated and various strategies and pro-
cess for interpreting human concerns and actions. Therefore, we
selected various methods: in-depth interviews with the patients,
situated interviews with the nurses and participant observation
during the patients’ stay in the ICU.
Sample
We included all the patients admitted to the ICU of a teaching
hospital in Northern Italy between January 1st, 2015 and Decem-
ber 31st, 2015, who met all our inclusion criteria.
Inclusion criteria: subjects aged 18, upon first admission to
ICU, with tracheostomy, intubated for more than five days, under
light sedation (i.e., level 2 of the Ramsay Scale) (Ramsay et al.,
1974).
Exclusion criteria: patients diagnosed with dementia, psychi-
atric problems, neurological disorders, and disorientation during
mechanical ventilation, or patients with language difficulties.
Considering the type of patient population and the difficulty
involved in recruiting them, we decided to use convenience sam-
pling and to recruit about 10 patients. We speculated on this sam-
ple size, understanding that this could become smaller or larger
according to the density of the data we collected and the principle
of saturation (Morse, 1995). We tried to ensure the highest possi-
ble level of heterogeneity in terms of gender, age, and cultural
background to produce a wider range of phenomenological data
for our analysis (Polit and Beck, 2014; Speziale et al., 2011;
Morse, 1995).
Data collection
During the patients’ stay in the intensive care unit, we con-
ducted participant observations to describe the context in which
each communication interaction with the nurses occurred, and
how these interactions took place. The observations were con-
ducted using a guide (Table 1) at different hours of the day and

Table 1
Researcher’s guide on how to conduct the observation of the communication interactions between patients and nurses.

The observations have the purpose to obtain a more comprehensive understanding of the phenomenon of this study, because the analysis of the data that emerged from
the interviews could be enriched and supported by the observations conducted in setting where the communication event between the tracheostomy patient and the
nurse took place.
Possible observation items:
 The intensive care unit environment
 Conditions of the tracheostomy patient (posture, presence of infusions, sedation and level of sedations, etc.)
 Time of the day
 Care activities each nurse provides to each patient
 Duration of the communication event
 Communication contents
 Communication feedbacks provide by both the nurse and the patient
 Non-verbal communication of both the nurse and the patient (posture, tone of voice, silence, gestures, facial expressions, emotions, etc.)
 Concurrent events

Please cite this article in press as: Tolotti, A., et al. The communication experience of tracheostomy patients with nurses in the intensive care unit: A phe-
nomenological study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.01.001
 A. Tolotti et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx 3

Table 2
Sample questions from the interview guide for tracheostomy patients.

To ensure that questions were as clear as possible, we used a type of language that was adapted to the specific situation and to the interviewee
Communicating without being able to use your voice is something you have experienced. Do you remember if there were any moments in which you were comfortable
when you communicated with the nurse?
Could you tell me what the nurse did in particular and that you thought was useful? What encouraged you?
Do you remember if there were occasions when you felt uncomfortable in the way you communicated with the nurse?

Table 3
Sample questions from the interview guide for nurses.

 Could you describe a situation you experienced where you perceived that a patient was comfortable with communicating?
 Where there any situations in which a patient was uncomfortable when communicating?
 What do you think could have helped patients feel more at ease with communication?

on different days. Participant observation supported the collection
and analysis of qualitative data to enable our researcher to be fully
immerged in that reality to ‘capture’ the qualitative data related to
the ‘things’ observed and ‘heard’ in that particular communication
context (Polit and Beck, 2014). The data collected through our
observations have not been specifically reported as results, but
were used during the interviews to gain a better understanding
of the problems the patients reported in their narrations and dur-
ing data analysis to gain a clearer and wider view of the context in
which the communication event occurred.
The days immediately after discharge from the intensive care
unit, we conducted in depth interviews with the patients, each
interview lasted about 45 minutes (Table 2). The patients were
interviewed in their own room. The purpose of the interview was
to explore the difficulties experienced by the patients during their
communication experience with the nurses and to identify which
elements had facilitated or hindered their communication with
the nurses. During the interviews, we asked the patients which
nurses they remembered in particular.
All the nurses were informed about the aims and how the study
would be conducted. We interviewed only the nurses who the
patients remembered best in relation to their communication
experiences. Short situated interviews were then conducted with
these nurses (Table 3), enabling to identify the patients directly
involved in the communication events and the context. On average,
each interview lasted about 30 min. All the interviews were audio-
recorded and transcribed verbatim (Polit and Beck, 2014; Holloway
and Wheeler, 2012).
Data analysis
Data analysis and interpretation were conducted according to
the processes described by Benner (1994), under the direct super-
vision of an expert qualitative researcher. Moreover, data analysis
and interpretation were continually guided by our research ques-
tion to discern which data and meanings were most significant.
Data analysis included two phases. In phase one, we repeatedly
read the whole transcript of each patient interview and then con-
ducted a line-by-line thematic analysis. We identified the main
themes and grouped them into categories, while noting their
potential meanings. A thematic analysis was conducted on the
transcripts of the nurses’ interviews. For each case, we identified
the similarities and the differences between the patients’ and the
nurses’ transcripts, and focused on the communication difficulties
experienced by the patients, and comfort and discomfort factors
when communicating with the nurses.
Phase one aimed at understanding and interpreting the
patients’ communication experiences and what meaning they
attributed to each experience. In phase two, we analysed all the
cases and situations to identify and describe commonalities and
differences in the experiences reported by the patients. In addition,
we examined which communication comfort and discomfort fac-
tors were considered more important by the patients, and which
by the nurses.
Methodological rigour
The methodological rigour of our study was supported by the
criteria described by Guba and Lincoln (1981) and Carnevale
(2002). With regard to credibility, each researcher spent time with
the patients in their ‘natural setting’ to observe their experiences in
their respective contexts. ‘‘Bracketing” was adopted to avoid prej-
udices. The use of a ‘reflective diary’, synthesis, and reflection was
helpful to differentiate between what participants said and what
researchers understood.
Regarding auditability, all data collection and analysis decisions
made by the researchers were explained to other researchers and
documented using field notes, memos and a reflexivity journal.
The entire process was audited by a supervisor and by an expert
in qualitative research to optimise analytical neutrality.
Fittingness was promoted by various checks with our expert
advisors to ensure that interpretations were consistent with the
experiences of the interviewees.
Ethical considerations
The study was approved by the Research Ethics Board of the Lig-
uria Region: 417REG2014.
Patients and nurses were informed about the aims and how the
study would be conducted.
Written consent was obtained from all participants, patients
and nurses involved in the study, including the authorisation to
audio-record the interviews and take written notes during the
observation phase. Following the recommendations of the
Research Ethics Board, we also obtained written consent from
the patients’ family members with regard to the observation phase
in the ICU, as well as verbal consent from the patients. Both
patients and nurses were informed about the purpose, duration
of the observation and the role of the observer. We specified that
the observer would not be actively involved in any clinical activity.
Confidentiality and anonymity were ensured throughout.
Findings
We enrolled a total of eight patients with a wide range of clin-
ical conditions (Table 4). During the interviews, one patient
wanted his wife to be present. We conducted between three and
five participant observations per patient. Seven interviews were

Please cite this article in press as: Tolotti, A., et al. The communication experience of tracheostomy patients with nurses in the intensive care unit: A phe-
nomenological study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.01.001
4 A. Tolotti et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
Table 4
Patient characteristics (n = 8).
Name* Age
1 Luca 65
2 Gianni 36
3 Maria** 80
4 Francesco 63
5 Giorgio 39
6 Agostino 62
7 Dario 37
8 Lorenzo 38
*
All names are pseudonyms.
**
Maria died before being interviewed.
conducted with the nurses. The nurses were aged between 32 and
43 years, with experience in the ICU ranging between 2 and 16
years.
Interviews
During the interviews, the participants initially said that they
had difficulty remembering part or all of their experience in the
ICU, but eventually they provided an extensive description.
We could not totally exclude that the communication event
reported by the patients might have occurred during a moment
of delirium. However, it is important to consider the patient’s
experience ‘‘true”. In fact ‘‘the measure of truth of Heidegger’s phe-
nomenology is not whether it offers us a correct representation of
who and what we are . . .the description is measured non by crite-
ria of correctness but by criteria pertaining to its consequences of
our lives” (Benner, 1994).
Two themes were identified in relation to their communication
experience with the nurses, four factors related to discomfort dur-
ing communication and three to comfort.
Lived experience of communication
Feeling powerless and frustrated
Patients realised that they could not use their voice to commu-
nicate on various occasions. Some patients said that they tried to
shout to call the nurses even when they knew they could not.
Patients found it hard to communicate and this generated feelings
of frustration.
‘‘I tried hard to use my voice but it obviously never came. . . I could
not talk and I naturally tried to speak, I tried to find a way to com-
municate but I couldn’t. . . I was frustrated. . . Incredible. . .”. (Luca)
Having their voice was described as being very important, when
this was missing the patients felt powerless.
Inability to speak was experienced as ‘being unable to do any-
thing’. It is as if the absence of one’s voice blocked all other human
activities.
‘‘. . .the frustration of not being able to make myself understood. It
was horrible. . . maybe you want something and gestures are not
enough.” (Luca)
‘‘I wanted to talk but I couldn’t. . . my friends said try to write. . . but
I was too weak to write and not sufficiently conscious to write a
whole sentence. . . I couldn’t do anything”. (Francesco)
Patients also felt deeply frustrated. Being unable to speak made
it difficult to communicate and when they tried to say a word they
realised it was difficult. The attempt to explain something required
a great deal of effort, attention, and concentration and it was very
frustrating when others did not understand.
Please cite this article in press as: Tolotti, A., et al. The communication experience of tracheostomy patients with nurses in the intensive care unit: A phe-
nomenological study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.01.001
Gender Reason for ICU admission ICU stay
Male Acute Respiratory Failure 40 days
Male Septic shock 80 days
Female Intestinal perforation 35 days
Male Sepsis 60 days
Male Acute Respiratory Failure 25 days
Male Trauma 43 days
Male Guillain-Barrè Syndrome 65 days
Male Spleen rupture 20 days
‘‘Everything is different. . . eventually my girlfriend understood, but
for the rest it was difficult to make myself understood. . .” (Luca)
Facing continual misunderstanding, resignation and anger
Faced with the impossibility to use their voice, patients
attempted various strategies, such as trying to say the words softly,
using their eyes, and moving their head. Patients could not always
use gestures due to the reduced mobility of their arms. Sometimes,
they tried to use communication boards, but the patients said that
this required a lot of concentration and attention.
‘‘. . . when I wanted to say something, I couldn’t. . ., but then I
understood that I couldn’t talk. . . and I tried to make myself under-
stood in other ways. . . but I became distressed and gave up. . .”.
(Lorenzo)
Patients expected to be understood, as if this was a specific
competence of the ICU nurses. When this did not happen, after var-
ious attempts the patients developed feelings of anger and/or res-
ignation. Sometimes this triggered a state of profound anxiety.
‘‘. . . you take for granted that others would understand you or read
your lips. That’s how it was! . . . often they couldn’t understand. . .
and I got very angry. . .” (Gianni)
On other occasions, when patients were not understood or
misunderstood, this generated strong feelings of resignation and
some patients in the end just gave up because it was no use trying
again.
‘‘. . .very often they didn’t understand me. . . they thought I had a tic
or a problem with my head, instead I was trying to tell them that
something was hurting me there. . . in the end I gave up”. (Lorenzo)
Four sources of discomfort
Struggling with not knowing what is happening
The patients often reported that they did not know what was
happening, what were their clinical conditions, and the therapeutic
decisions. Some patients did not remember receiving any
information.
‘‘. . .not even knowing that you have been operated. . . not knowing
what the others were doing. . . it was really horrible. . .” (Agostino)
Others remembered receiving only fragmentary information, so
some patients felt ‘desperate’ and this was described as one of the
worst moments in which ‘your mind goes back and forth’. Some
patients thought that they received very little information due to
the lack of ‘time’ or because nurses had to attend to other more
urgent situations.
‘‘. . .above all I didn’t know what was wrong with me. . . what they
were doing to me. . . but probably they also didn’t have the
time. . .there are urgent situations and have to save other people’s
lives” (Francesco)
 A. Tolotti et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
Feeling like other people have given up on me
Patients perceived a sense of resignation in those surrounding
them due to the difficulties in understanding and when others
thought that there was little hope that the patient’s clinical condi-
tions would improve.
This perception generated in patients feelings of grief, espe-
cially when their family members were unable to understand.
Faced with this problem, some patients tried to reduce their
family members’ feelings of inadequacy by involving them in
other activities. In the latter case, some patients gave up on trying
to communicate.
‘‘. . . with my parents it was like taking part in a TV game show. . . I
felt sorry for them because they felt a little inadequate. . . you know
they didn’t always get the answer right. . . I felt sorry so I invented
other games so that they would calm down. . .” (Dario)
When patients perceived that their family members were wor-
ried or sad about their clinical condition, they found the strength to
react, as if the suffering of their beloved ones induced them to
‘react’.
‘‘. . . I wasn’t ready to leave my wife. . . I saw that she was very
sad. . . and so I reacted. . .” (Luca)
‘‘my wife was told. . . look we are not absolutely sure . . . instead I
reacted and I managed to recover. . .” (Agostino)
Other patients experienced moments of profound resignation
and ‘let themselves go’. What gave them the strength to keep going
was the presence of their beloved ones, who represented the ‘tran-
sition from darkness to light”
‘‘. . . when I saw my beloved ones again and having them near
me, it was as if darkness had gone away and light had come
back. . .” (Francesco)
Living in isolation
The inability to speak made it difficult to interact with other
people, and this generated in patients a sense of isolation linked
to a feeling of ‘counting for nothing’ (i.e., worthlessness).
‘‘. . . I felt as if I counted for nothing. . . I could not say anything. . . I
couldn’t interact. . .” (Lorenzo)
Patients described time as ‘infinite’ during which they were
alone, with nothing to do, except sleep or observe what was hap-
pening. Not having anyone nearby was another common theme
that caused suffering and sometimes despair.
‘‘. . .endless, even because you had nothing to do. You just gazed at
the people who went back and forth. . .” (Giorgio)
‘‘. . . you go crazy . . . you really go crazy. . . because it is endless . . .
really if it hadn’t been for my partner I wouldn’t have . . . (Gianni)
Sleeping was described as a way of reducing suffering and they
got angry when their sleep was interrupted. They did not under-
stand why they had to stay awake and alone. This loneliness made
them feel abandoned and forsaken.
‘‘. . .nobody came. . . nobody was near me (surely they did come)
. . .nobody ....no, there wasn’t anybody and then my desperation
grew more and more. . .” ‘‘. . . but . . . probably they also didn’t have
the time. . .” (Francesco)
Feeling invisible
Patients reported that they ‘felt invisible’ in relation to the
inability to communicate with others and not being involved in
the care plan, as if they did not exist. Some patients felt uneasy
when the physicians did not speak directly to them as if the
Please cite this article in press as: Tolotti, A., et al. The communication experience of tracheostomy patients with nurses in the intensive care unit: A phe-
nomenological study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.01.001
5
absence of their voice blocked any form of communication, includ-
ing information.
‘‘. . .the doctors . . .never spoke to me. Until recently, they just didn’t
speak to me. . . now if I ask a question they give me an answer. All
was well with the nurses, I didn’t have any problems.” (Giorgio)
Decisions that regarded them were being made and the patients
were not informed or involved in the decision-making process. The
patients had negative feelings when they were deprived of the pos-
sibility to know and decide. Patients would have preferred to
receive more reassurance.
‘‘. . .I don’t know why . . . you shouldn’t treat a sick person that way,
there ought to be somebody who stays close to that person, and
before that person loses consciousness . . .reassure that person by
saying don’t worry, we are here. . . instead absolutely nothing, . . .
it was really horrible. . .” (Francesco)
The three sources of comfort
Comforted by being with significant people
The presence of a family member was so important that a par-
ticipant talked about ‘transition from darkness to light’, where
darkness meant isolation and loneliness, whereas light was used
to describe hope associated with the end of isolation.
Family members played a key and crucial role, because they
were a source of comfort, encouragement, hope, and protection.
‘‘. . . when I saw my beloved ones again and having them near
me, it was as if darkness had gone away and light had come
back. . .” (Francesco)
‘‘. . .I was afraid, I trembled, I waited for my dad to arrive. . . I felt
calmer only when he was there. . .” (Gianni)
Family members also acted as intermediaries with the nurses.
They played a key role in building a relationship of trust with the
nurses. Sometimes, patients asked their family members to be
their ‘voice’ and communicate with nurses.
‘‘I got a lot of help because Stefano was with me all day, so since he
knew me he could act a little as an intermediary. . . also in terms of
communication, he knew me and understood me more quickly. . .”
‘‘. . .I never would have made it without him. . .” (Dario)
Family members knew the patients, their habits, and better
understood what they needed, providing them with the necessary
support and help, and helped nurses understand what they
needed.
‘‘yes, for me my wife was very important. . . moreover, I couldn’t
wait to see her, because she was a source of comfort for me and
she helped me if I needed something. . .” (Agostino)
Reassured by having my call bell nearby
Not being able to use their voice and sometimes the reduced
mobility made it difficult for patients to communicate when they
needed to call the nurses. These difficulties led to experiences of
deep concern.
‘‘. . . knowing that I could call them at any time was one of the
problematic things. . . instead other things were not. . . I must say
that they always understood what I was asking for. . .” (Giorgio)
The patients described having a call bell nearby as a source of
great reassurance, because it substituted their voice, and it was a
safe and quick way of calling for help.
6 A. Tolotti et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
‘‘. . . the call bell reassured me because every time I rang it they
came. . . instead that evening I didn’t have it and it was a tragedy. . .
because I thought I would die and instead the nurse saw that I was
in a bad condition and she immediately helped me and I asked her
to give me a call bell and also my wife can tell you that since then I
never let go of the call bell. . .” (Agostino)
Feeling comforted by the nurses’ presence
Patients reported that they felt reassured by the presence of the
nurses. They acknowledged their specialized competence, and
knew they were trustworthy.
‘‘. . .I really trusted them, the nurses don’t know how good they are,
. . .they don’t realize how important they are. . .” ‘‘. . . they treated
me like a baby, they reassured me. . .” (Dario)
What mostly comforted the patients was the awareness that
nurses showed interest in them. They perceived this interest
through the nurses’ gestures, words, smiles, and the time they ded-
icated to them.
‘‘. . .I must say that the nurses were really good and I will always
say this, they were very professional. . . then we would also joke
and laugh. . . look I say it from the bottom of my heart, because
when they passed they said hello and asked how I was feeling
and this was comforting for me. . . there were these people who
really cared about me. . .” (Agostino)
Also when nurses took care of their well-being, such as body
hygiene, was perceived to be reassuring. Listening and dialogue
were very important elements of comfort for the patients.
‘‘. . .they did all the cleaning they were supposed to do. . . I was
happy because I am used to having a shower every morning, this
was positive for me and made me feel very comfortable. . .”
(Agostino)
Integrative analysis
Themes in common with patients and nurses: similarities and
differences
Frustration due to difficulty with communication
Communicating with patients who could not use their voice is
difficult. Some nurses said that thanks to their experience they
had improved their ability to read the patients’ lips and most of
the time they understood what the patients wanted to say. Also
the patients reported that some nurses managed to understand
better what they were trying to say compared to other nurses.
The anger and/or frustration reported by the patients when they
are not understood, was also reported by the nurses. Anger and
frustration were feelings that also nurses had when they could
not understand what the patients were trying to say. These feelings
were strong and exacerbated by the nurses’ willingness to ‘be there
to help them’, but the inability to understand them did not let them
do this. Repeating frequently ‘I don’t understand’ becomes unbear-
able, and sometimes led nurses to implement avoidance strategies,
such as moving away to do other things, or saying that other
nurses were calling them. Sometimes, nurses interrupted their
communication with the patients and resumed it afterwards when
the patient had calmed down. These strategies were adopted
because of the distress and powerlessness that also nurses experi-
ence when they cannot understand what the patients are trying to
communicate.
Please cite this article in press as: Tolotti, A., et al. The communication experience of tracheostomy patients with nurses in the intensive care unit: A phe-
nomenological study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.01.001
Comfort factors
Both patients and nurses included the ‘presence of caring
nurses’ among the comfort factors. Everyone described this as an
important factor. Patients viewed this factor as a sign of respect
and recognition of their suffering, and their sense of ‘uniqueness’.
They felt reassured and comforted.
Nurses reported that dedicating time and showing that they
cared for the patients were very important. In some cases, nurses
reported that they had little time to dedicate to their patients
due to their heavy workload. Other nurses reported the need to
protect themselves from excessive emotional involvement in
patients’ suffering, although they recognised the importance of
being at their bedside.
Another important comfort factor for both patients and nurses
was the presence of family members. For patients, family members
were extremely important because they provided hope, comfort
and reassurance. Nurses in some cases had an ambivalent attitude
towards family members. On one hand, they recognised how
important family members were for the patients and their role in
facilitating the nurses’ relationship of trust with the patients, and
their involvement in meeting some of the patients’ needs, such
as eating and drinking and personal care. On the other hand, family
members were perceived as an element of complexity that could
potentially cause interferences with the nurses’ work.
Discomfort factors
Both patients and nurses described the lack of information as a
source of discomfort. Patients reported that they received incom-
plete information and that they did not know what was happening.
They did not feel actively involved in decision-making processes
due to the lack of information and the communication difficulties
they had when they could not use their voice.
For nurses, information problems were mainly due to commu-
nication difficulties, because talking to a patient with a tra-
cheostomy is not easy and in their view this compromises the
possibility to provide correct and complete information.
‘Isolation’ was also reported by nurses as a discomfort factor.
This factor was exacerbated by an organizational problem, which
nurses identified as the ‘time factor’: the impossibility to have a
one-to-one nurse/patient ratio also compromised the level of com-
munication and the possibility to stay at the patient’s bedside.
Another discomfort factor reported by patients was the impos-
sibility to call nurses in case of need when a call bell was not avail-
able. This element was not reported by the nurses. The presence of
monitors and open spaces was reassuring for nurses because they
could constantly see which patients needed help or assistance and
could intervene immediately.
Discussion
Our study highlighted the patients’ communication experi-
ences, the respective meanings and factors that made patients feel
at ease and increased their communication comfort with the
nurses.
Communicating with nurses is a key element of the patient’s
experience, it is the means through which a relationship is estab-
lished, which can lead to positive feelings, such as feeling reas-
sured, or to negative feelings, such as ‘counting for nothing’, and
being just a ‘body’ on which other people act. According to some
studies (Cypress, 2011; Vouzavali et al., 2011) nurses and patients
in the ICU find themselves immersed in a mutual relationship, in a
highly technological environment, extremely important for the life
 A. Tolotti et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
of the patients (Olausson et al., 2014), but where there is also the
risk of objectifying patients (Almerud et al., 2008).
Not being understood when patients try to communicate gave
rise to anger and frustration, as reported in other studies with intu-
bated patients (Happ et al., 2011; Hofhuis et al., 2008). Also nurses
experienced this frustration because it was hard to understand the
patients, generating feelings of distress. In some cases, specific
behaviours are adopted, ranging from objectification of care, as
reported by Martinsen and Dreyer (2012), to strategies of
avoidance.
The patients’ feelings of solitude were mitigated by the pres-
ence of nurses and family members. Patients felt reassured by
the presence of nurses who paid attention to them and showed
that they cared for them. This perception led patients to describe
them as ‘good nurses’, as reported by Wysong and Driver (2009),
where patients described nurses as being unskilled and ‘uncaring”
when nurses did not establish a relationship with them.
Another key element for both patients and nurses was the pres-
ence of family members, who are sources of comfort, hope, and help
for patients (Cutler et al., 2013). A low level of family member
involvement in the patient-nurse relationship has a negative impact
on the patient’s experience (Cypress, 2014). For patients, family
members are often also a means to communicate with the nurses.
Therefore, when nurses involve family members in the patient care
process, it is much easier to develop a relationship of trust between
patients and nurses. In fact, the role of the family members in the ICU
depends on the interactions and relationships that are established
between nurses and patients’ family members (Cypress, 2011).
Our study highlighted the ambivalent feelings of the nurses in
relation to the presence of the family members, who on one hand
were considered to be instrumental and important for patients and
useful for healthcare processes, but on the other they were consid-
ered as a potential interference for their work. Nurses highlighted
how the presence of family members was useful for patients, not
only in terms of comfort and encouragement, but also for their par-
ticipation in the care process by improving the patients’ well-being
(Benner et al., 2011). We also showed how a good relationship with
family members had a positive influence on the relationship with
patients. Therefore, if family members are actively involved in
the nurse-patient relationship, everything is easier and patient
care is promoted. This leads to the development of positive feelings
so that patients consider nurses as part of their family, as people
who really care for them. Nurses’ experiences were similar. In fact,
nurses, patients and family members have been conceptually
described as a single whole (Cypress, 2013).
Limitations
A limitation of our study was the fact that all patients were
males. It would be interesting to expand this study and include
female patients.
This study did not explore how nurses experienced the commu-
nication events. Important results could be obtained thanks to
studies that explore how health professionals experience commu-
nication with patients. The thematic analysis of our study high-
lighted some issues linked to their communication with these
patients, which would deserve further investigation. In addition,
this study focused on the patient-nurse dyad, but it would be inter-
esting to conduct a similar study that also includes the viewpoint
of family members and other health professionals.
Conclusions
In this study, we described patients’ communication experi-
ences when they interacted with nurses, the comfort and discom-
Please cite this article in press as: Tolotti, A., et al. The communication experience of tracheostomy patients with nurses in the intensive care unit: A phe-
nomenological study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.01.001
7
fort factors, the similarities and differences between what patients
and nurses perceived. Our results highlighted the importance of
communication for tracheostomy patients and showed how com-
munication is intrinsically linked to many aspects of the patient’s
experience, which cannot be reduced merely to the inability to
use their voice. Our findings added new elements to the existing
knowledge on the communication experience of tracheostomy
patients in the ICU.
Funding
This study was funded by the Centre of Excellence for Nursing
Scholarship, Rome, Italy
Conflict of interest
The authors declare that there is no conflict of interest.
They also declare that they agree with the content of this manu-
script, which has not been published or submitted for publication
elsewhere.
Ethical statement
The study was approved by the Local Research Ethics Board of
the Liguria Region.
The unit nurse manager asked patients who met the inclusion
criteria if they were willing to meet our researcher so that they
could be informed about the study and decide whether to partici-
pate or not.
After discharge from the ICU, written consent was obtained
from all participants who accepted to take part in the study,
including the authorisation to audio-record the interviews and
take written notes. Following the recommendations of the
Research Ethics Board, we also obtained written consent from
the patients’ family members with regard to the observation phase,
as well as verbal consent from the patients when they were already
admitted to the ICU.
All participants were informed and aware that they could with-
draw from the study at any time.
Confidentiality and anonymity were ensured throughout.
Acknowledgements
We thank the Centre of Excellence for Nursing Scholarship in
Rome for funding this study.
We thank the patients and nurses who took part in this study,
and the nurse managers for their collaboration.
We thank the students who participated in this study: Davide
Ulivieri, Ilenia Gallo, Lorenza Fabris, Alessandra Barontini, and
Ilaria Cavicchioli.
A special thanks goes to our colleague Dr. Dario Valcarenghi
who proofread the article.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at https://doi.org/10.1016/j.iccn.2018.01.001.
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