September 5, 2022
I Need This By Saturday, Under 20% Plagiarism
September 5, 2022

Mental Health Factors

Mental Health Factors

©2021 American Association of Critical-Care Nurses doi:

Background Communication is key to understanding the emotional state of critical care patients.

Objective To analyze the effectiveness of the communi- cative intervention known as CONECTEM, which incorpo-

rates basic communication skills and augmentative

alternative communication, in improving pain, anxiety,

and posttraumatic stress disorder symptoms in critical

care patients transported by ambulance.

Methods This study had a quasi-experimental design with intervention and control groups. It was carried out at 4

emergency medical centers in northern Spain. One of the

centers served as the intervention unit, with the other 3

serving as control units. The nurses at the intervention cen-

ter underwent training in CONECTEM. Pretest and posttest

measurements were obtained using a visual analog scale to

measure pain, the short-version State-Trait Anxiety Inven-

tory to measure anxiety, and the Impact of Event Scale to

measure posttraumatic stress disorder symptoms.

Results In the comparative pretest-posttest analysis of the groups, significant differences were found in favor of

the intervention group (Pillai multivariate, F 2,110

= 57.973,

P < .001). The intervention was associated with improve-

ments in pain (mean visual analog scale score, 3.3 pre-

test vs 1.1 posttest; P < .001) and posttraumatic stress

disorder symptoms (mean Impact of Event Scale score,

17.8 pretest vs 11.2 posttest; P < .001). Moreover, the per-

centage of patients whose anxiety improved was higher

in the intervention group than in the control group (62%

vs 4%, P < .001).

Conclusion The communicative intervention CONECTEM was effective in improving psychoemotional state among

critical care patients during medical transport. (American

Journal of Critical Care. 2021;30:45-54)

A COMMUNICATIVE INTERVENTION TO IMPROVE THE PSYCHOEMOTIONAL STATE OF CRITICAL CARE PATIENTS TRANSPORTED BY AMBULANCE By Marta Prats Arimon, PhD, BD, RN, Montserrat Puig Llobet, PhD, BD, RN, Juan Roldán-Merino, PhD, MSN, RN, Carmen Moreno-Arroyo, PhD, MSN, RN, Miguel Ángel Hidalgo Blanco, PhD, MSN, RN, and Teresa Lluch-Canut, PhD, BD, RN AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 45



46 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1

E ffective communication is key to understanding the difficulties implicit in critical ill- ness.1,2 Critically ill patients often experience psychoemotional symptoms such as sadness, anger, nervousness, worry, fear, stress, anxiety, and pain,3-5 which are related to their inability to communicate.6,7 In addition, the reduced level of awareness of these patients can lead to states of confusion or delirium,8,9 which alter their perceptions

of reality.10 The negative feelings contribute to the frustration generated by the lack of commu- nication and can affect the patient’s perception of the quality of nursing care received.1,2,11 The most prevalent negative psychoemotional states among critically ill patients are pain (experi- enced by 70%-89% of patients),12,13 anxiety (30%-60%), and posttraumatic stress (27%).3,14-16

Research on in-ambulance communication between critical care patients and nurses first emerged in Europe.17-19 In the United States, effective commu- nication has been a quality standard for the treatment of critical care patients for several years.20 An increas- ing amount of research on the topic has been per- formed in Spain.21

Inadequate communication due to physical, cognitive, and psychological barriers is one of the main problems affecting critical care patients.10,22,23 Misunderstandings and/or misinterpretations gen- erate insecurity and frustration among nurses and

reduce their effectiveness in treating pain, providing emotional support, and meeting patients’ needs.24,25 Research on patient-nurse communication should involve measurement of pain as well as psychoemo- tional variables such as anxiety and the effects of trauma, which can lead to symptoms of posttraumatic stress disorder (PTSD) in critically ill patients.26

Patak et al27 and Happ et al28 were among the first authors to propose a set of communicative inter- ventions based on augmentative alternative commu- nication (AAC) and basic communication skills (BCS) for use with critical care patients. These recommenda- tions led to the development of various AAC mod- els.29,30 Nurses received training based on these models,31,32 with the impact assessed in terms of improvement in the treatment of critically ill patients. However, few studies have been conducted in which these techniques have been applied outside of the hospital intensive care unit (ICU).33-35 The adverse conditions prevailing in an ambulance setting, such as limited space and vehicle movement with result- ing discomfort, further hinder communication with the critical care patient36,37 and negatively affect the patient’s physical, psychological, and emotional well- being.38,39 Therefore, additional research on nurse- patient communication in this context is needed. This study was conducted to analyze the effect of implementation of AAC and BCS on the psychoemo- tional state of critical care patients being transported by ambulance.

Methods This study had a quasi-experimental design with

a control group and an intervention group and involved preintervention and postintervention measurements of pain, anxiety, and PTSD symp- toms. The CONECTEM communicative intervention was used in critical care patients in the intervention group transported by ambulance, whereas the tra- ditional care process was used for control group patients (Table 1).

About the Authors Marta Prats Arimon is an associate professor, School of Nursing, Faculty of Medicine and Health Sciences, Univer- sity of Barcelona, Barcelona, Spain; a collaborating pro- fessor, School of Nursing, Faculty of Medicine and Health Sciences, University Ramon Llull, Barcelona, Spain; and a registered nurse, Emergency Department, Hospital Transfronterer de Cerdanya, Puigcerdà (Girona), Spain. Montserrat Puig Llobet is a professor and director of the Mental and Public Health Department and director of the master’s program in nursing interventions in complex chronic patients, School of Nursing, Faculty of Medi- cine and Health Sciences, University of Barcelona and a researcher in the CARINGCF Research Group, Tarrag- ona, Spain and the GIRISAME Research Group, Madrid, Spain. Juan Roldán-Merino is a professor, Campus Docent, Sant Joan de Déu-Fundació Privada, School of Nursing, University of Barcelona; a researcher in the GIESS Research Group and the GEIMAC Research Group, Barcelona, Spain; and coordinator of the GIRISAME Research Group and the REICESMA Research Group, Madrid, Spain. Carmen Moreno-Arroyo and Miguel Ángel Hidalgo Blanco are professors in the Department of Fundamental and Medical- Surgical Nursing and directors of the master’s program in critical care nursing, School of Nursing, Faculty of Medicine and Health Sciences, University of Barcelona. Teresa Lluch- Canut is a professor of psychosocial and mental health, School of Nursing, Faculty of Medicine and Health Sci- ences, University of Barcelona; and a researcher in the GEIMAC Research Group, Barcelona, Spain.

Corresponding author: Montserrat Puig Llobet, PhD, BD, RN, Director, Mental and Public Health Department, School of Nursing, Faculty of Medicine and Health Sciences, Univer- sity of Barcelona, C/ Feixa Llarga s/n 08870–Hospitalet de Llobregat, Barcelona, Spain. (email: AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 47

Setting and Sample The study was carried out at 4 emergency medical

system centers in Catalonia, a region of northeastern

Spain. Selection of the centers was based on their similar characteristics: location in a rural area with a geographically dispersed population, transfers that

Intervention group: CONECTEM communicative intervention

Table 1 CONECTEM communicative intervention and routine communicative action of nonhospital nurses

STRATEGY 1 Communication with the patient according to the training and

guidelines established in the communicative intervention, focusing

mainly on the following:

• Initiate the patient-nurse interaction

• Continuous communication during the journey

• The frequency and duration of the interaction depend on the

patient’s requirements at the time of transportation

• Always maintain eye contact during the interaction

• Pause to allow the patient to process the information

• Clarify and double-check all messages from the patient in

order to avoid misinterpretations

• Show empathy, be assertive, and use active listening techniques

• Refrain from making value judgments about patients and/or

their family situation

• Pay attention to nonverbal communication: gestures of pain,

restlessness, or sighing

STRATEGY 2 Communication with the patient according to the training and

guidelines established in the communicative intervention, focusing

mainly on the following:

• Perform the communication actions in Strategy 1

• Highly precise and specific language, using short sentences to

facilitate effective communication

• Establish a signal for yes, one for no, and one for “I don’t understand”

• Use the CONECTEM support material

Boards for conveying emotions

Boards for conveying requirements

International dictionary symbols

• The patient is asked to point or indicate what they wish to com-

municate. If they are unable to do this, the nurse asks them

• Nonverbal communication

Pay attention to gestures of pain, restlessness, or sighing

Physical contact

Relaxing music (use of the CONECTEM musical support material)

STRATEGY 3 Communication with the patient according to the training and

guidelines established in the communicative intervention, focusing

mainly on the following:

• Ensure a peaceful atmosphere, ensuring that devices are silenced and

their alarms are off, and dim the lighting to help the patient to rest

• Be on the lookout for changes in physical signs

• Observe facial expressions and motor movements

• Verbal communication

Initiate the interaction

Explain any relevant and suitable procedures and information to

the patient

Soothing and unhurried tone of voice

• Suitable training on physical contact

• Relaxing music (use of the CONECTEM musical support material)

Communication with the patient in accordance with the

social and communication skills of nurses who have

received no training or guideline(s)

Introduction of the nurse to the patient and explanation of

the transportation procedure

Interaction at the beginning and end of the transportation

Communication at the patient’s request

Short patient-nurse interactions related to the patient’s physical

condition or the progress of the journey

Clichéd questions and sentences

How are you doing?

We’re almost there.

There are x km left.

If there is any problem, let me know.

Communication with the patient in accordance with the

social and communication skills of nurses who have

received no training or guideline(s)

Lack of verbal communication due to lack of resources

Use of nurse’s own resources

Lip reading

Gesticulation or signs

Writing on paper

Nonverbal communication at the nurse’s discretion

Communication with the patient in accordance with the social

and communication skills of the nurses

Ensure a peaceful atmosphere to facilitate patient rest

Be on the lookout for changes in physical signs

Observe patient motor movements

No verbal communication with the patient

Physical contact and nonverbal communication at the

nurse’s discretion

Control group: routine communicative action

Glasgow Coma Scale score 15 (patients with no communicative difficulties)

Glasgow Coma Scale score 9-14 (patients with communication difficulties regarding comprehension and/or expression)

Glasgow Coma Scale score ≤8 (sedated or intubated patients, unconscious patients, patients with no verbal response)



48 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1

are lengthy in both time and distance, and narrow, winding roads in their territory.

The study population consisted of all critically ill patients transferred by ambulance to the 4 emer- gency medical centers chosen. One of the centers (most convenient for the principal investigator) was selected for implementation of the CONECTEM com- municative intervention (the intervention group), with patients from the other 3 centers constituting the control group. The nurses caring for the inter- vention group were previously trained in BCS and AAC to prepare them for the CONECTEM interven- tion in the ambulance.

The study sample, recruited from consecutive cases, was nonprobabilistic. Critically ill patients were included in the study if they were aged 18 or

older and required transfer by ambulance to a secondary or tertiary hospital for either diag- nosis or treatment. Patients were excluded if they were transferred by helicopter.

The sample size was esti- mated on the basis of the prev- alence of anxiety in critical care patients, which is 60%, accord- ing to the literature.40 With an

of .05 and a power of 80% to detect a difference of 25% between the 2 groups and with estimated losses of 10%, 69 patients were needed in each

group. (Ultimately, 68 patients participated in the intervention group and 52 patients in the control group—see Results.)

Data Collection The emergency medical team nurses from each of

the 4 participating sites were tasked with data collec- tion. The nurses working at the center where the inter- vention was carried out collected the data for the intervention group. Nurses working at the other 3 cen- ters collected the data for the control group. Data col- lection began once the patient was in the ambulance and concluded upon their arrival at the destination. The mean transfer duration was 1.5 to 2 hours. Three psychoemotional responses typical in this situation were assessed: pain, anxiety, and symptoms of PTSD. The nurses assessed the study variables using validated scales before and after the CONECTEM intervention in the intervention group, and before and after trans- port in the control group. Sociodemographic and health variables were also collected (sex, age, type of

disease, degree of consciousness, and whether or not the patient was fitted with an endotracheal tube). The data collection process lasted 6 months.

Instruments The Glasgow Coma Scale (GCS)41 was used to

identify the most suitable CONECTEM intervention strategy for each patient based on their degree of con- sciousness. This tool was chosen because it is com- monly used by nurses working outside the hospital, permitting quick assessment and taking into account a person’s verbal and motor responses, which influ- ence communication.

The following instruments were used to assess the psychoemotional variables of pain, anxiety, and PTSD symptoms, respectively:

Visual Analog Scale. The visual analog scale (VAS)42 was used to measure the intensity of the pain described by the patient. The VAS can take the form of centime- ters or numbers from 0 to 10. Pain was also dichoto- mized into 2 categories: absence (VAS score of 0) and presence (VAS score of 1-10).

State-Trait Anxiety Inventory. A modified version of Spielberger’s State-Trait Anxiety Inventory43 was used to measure anxiety. This scale consists of 6 items divided into 2 categories for anxiety: present (anx- ious, nervous, worried) and absent (calm, comfort- able, “I feel calm”).

Impact of Event Scale. The Impact of Event Scale44 comprises 15 items: 6 measures of intrusion, 8 of avoidance, and 1 of hyperactivity. The score for each item ranges from 0 to 5, with 0 indicating never, 1 rarely, 3 sometimes, and 5 often. A total score is cal- culated, with higher values indicating greater stress levels. A total score of less than 8.5 indicates mild stress; 8.5 to 19, moderate stress; and greater than 19, severe stress.

If the patient has a GCS score of less than 9 and is receiving mechanical ventilation, it has been recom- mended that the patient’s pain be measured using the Behavioral Pain Scale45 and the patient’s agitation- sedation state be measured using the Ramsay Sedation Scale and the Richmond Agitation-Sedation Scale.46 A case report form was used to collect data on sociode- mographic and health variables.

Intervention and Intervention Protocol The CONECTEM intervention consists of BCS

such as visual contact, message clarification, empa- thy, and active listening47 and uses AAC techniques such as panels with icons representing requirements and emotions and the international dictionary signs. 29,48 Other AAC techniques such as writing

The impact of the communicative inter-

vention on critically ill patients transported

by ambulance was evaluated in relation to pain, anxiety, and

symptoms of posttrau- matic stress disorder. AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 49

on a board or using advanced technology were ruled out because of the difficulty and complexity of per- forming them during the ambulance transfer (ie, vehicle movement, narrow roads, the time needed to show the patient and nurses how an electronic device works, and the patient’s condition). The inter- vention was designed by a group of experts who approved its application during ambulance trans- port. Before use of the CONECTEM intervention, the nurses who wished to participate in the study underwent a training program that qualified them to carry out the intervention in the ambulance. The training was organized into 3 modules: the anthro- pology of communication, the psychoemotional state of the critically ill patient, and the BCS and AAC used in CONECTEM. The training lasted 6 hours spread over 2 days. The training methods used were role playing and case management. To be able to per- form the CONECTEM intervention, nurses were required to pass a theoretical-practical posttraining test with a score of at least 70%.

The intervention was split into 3 different strate- gies according to the patient’s level of consciousness. Each strategy entailed a certain level of verbal and non- verbal communication. In contrast, nurses caring for patients in the control group used routine communi- cative action that relies on the nurse’s social and com- munication skills. The CONECTEM intervention and the routine communicative action are described in greater detail in Table 1.

Statistical Analysis In the descriptive analyses, number and percentage

were used for categorical variables, whereas median and SD were used for quantitative variables. The normality of the quantitative variables was verified with the Kolmogorov-Smirnov test. Either the t test or the Mann- Whitney U test was used for analysis of the quantitative variables, depending on the data distribution. Either the

2 test or the Fisher exact test was used for analysis of the categorical variables. To analyze the impact of the intervention on the dependent variables (pain and PTSD symptoms), we performed multivariate analysis of covariance of the pretest-posttest differences between the intervention group and the control group (intro- ducing the pretest score as a covariable). Finally, we conducted repeated-measures analysis of variance for the pain and PTSD symptom variables. The Pearson product-moment correlation was used to calculate the relationships between pain, anxiety, and PTSD symp- toms. A P less than .05 was considered to indicate statis- tical significance. IBM SPSS Statistics, version 17.0, was used for the statistical analysis.

Ethical Considerations The project was approved by the independent

ethics committee of Spain’s regional university (INF-2014-17) and by the board of directors of Spain’s emergency medical system (20150120_21). The study was guided by the Helsinki Declaration on ethical principles for medical research involving human participants. Each patient or guardian and each nurse working in the intervention and control groups signed an informed consent form to partici- pate in the study and was assured of confidentiality and data anonymity.

Results Participant Flow

Twelve nurses of the 22 eligible for work with the intervention group were enrolled and trained in the CONECTEM intervention. All nurses in this group carried out the intervention in the ambulance. A total of 138 critically ill patients were consecutively enrolled in the study: 69 patients in the intervention group and 69 in the control group. Seventeen patients were excluded from the control group because of missing information on the measurement scales, and 1 patient was excluded from the intervention group because of not being an interhospital transfer (see Figure).

Baseline Data The mean (SD) age of the 120 patients in the final

sample was 63.4 (17.7) years. Of the 120 patients, 48 (40.0%) were female. The most common disease

Assessed for eligibility

Patients (n = 332)


(n = 52) Analyzed

(n = 68)

Selected for

control group

(n = 69)

Excluded (n = 192)

Did not meet inclusion

criteria (n = 190)

Declined to participate

(n = 2)

Figure Flow diagram of study participants.



(n = 138)

Selected for

intervention group

(n = 69)

Excluded because

forms were

incomplete (n = 17)

Excluded because

not an



(n = 1)

E n

ro ll m

e n

t S

e le

ct e d

F o

ll o

w -u

p A

n a ly

ze d



50 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1

types were heart condition (55 patients [45.8%]) and neurological disease (25 patients [20.8%]). Ninety-eight (81.7%) of the patients were conscious and oriented (GCS score, 15), 18 (15%) were con- scious and disoriented (GCS score, 9-14), and only 4 (3.3%) were intubated and receiving mechanical ventilation (GCS score, ≤8) (Table 2). The psychoemo- tional variables were analyzed for patients with a

GCS score of greater than 9 (n = 115), as intubated patients were somewhat underrepresented.

The prevalence of pain was 68.7% (95% CI, 59.8%-76.7%), with a mean score of 2 of 10 on the VAS scale. A total of 80.9% (95% CI, 72.9%-87.3%) had anxiety. Regarding PTSD symptoms, 68.7% (95% CI, 59.8%-76.7%) of patients had moderate to severe symptoms, and 31.3% (95% CI, 23.3%-40.2%) had

Variable Total sample

(N = 120) Intervention group

(n = 68) Control group

(n = 52)

Table 2 Baseline characteristics at pretest for intervention and control groups

Age, mean (SD), y




Type of disease







Glasgow Coma Scale score, mean (range)

Glasgow Coma Scale score distribution






Orotracheal intubation



Score on visual analog scale for pain, median (range)


Present (score 1-10)

Absent (score 0)

Behavioral Pain Scale

No pain

Pain present

State-Trait Anxiety Inventory



Score on Ramsay Sedation Scale, median (range)

Score on Impact of Event Scale, median (range)

Impact of Event Scale

No or few symptoms

Moderate symptoms

Severe symptoms

Score on Richmond Agitation-Sedation Scale, median (range)

.76 a

.85 b

.85 b

.46 c

.75 b

.58 b

.08 c

.42 b

>.99 b

.05 b

>.99 c

.06 c

.007 b

>.99 c

63.9 (17.8)

20 (38)

32 (62)

28 (54)

3 (6)

12 (23)

1 (2)

3 (6)

5 (10)

15 (3-15)

44 (85)

6 (12)

0 (0)

0 (0)

2 (4)

2 (4)

50 (96)

2 (0-7)

32 (64)

18 (36)

2 (100)

0 (0)

36 (72)

14 (28)

5.5 (5-6)

23 (0-50)

8 (16)

13 (26)

29 (58)

−4.5 (−5 to −4)

62.9 (17.8)

28 (41)

40 (59)

27 (40)

6 (9)

13 (19)

1 (1)

7 (10)

14 (21)

15 (3-15)

54 (79)

9 (13)

2 (3)

1 (1)

2 (3)

2 (3)

66 (97)

3 (0-10)

47 (7)

18 (28)

2 (68)

1 (33)

57 (88)

8 (12)

6 (3-6)

14 (0-59)

28 (43)

11 (17)

26 (40)

−5 (−5 to −1)

63.4 (17.7)

48 (40.0)

72 (60.0)

55 (45.8)

9 (7.5)

25 (20.8)

2 (1.7)

10 (8.3)

19 (15.8)

15 (3-15)

98 (81.7)

15 (12.5)

2 (1.7)

1 (0.8)

4 (3.3)

4 (3.3)

116 (96.7)

2 (0-10)

79 (68.7)

36 (31.3)

4 (80.0)

1 (20.0)

93 (80.9)

22 (19.1)

6 (3-6)

18 (0-59)

36 (31.3)

24 (20.9)

55 (47.8)

−5 (−5 to −1)


No. (%) of patients

a Independent t test.

b 2 analysis.

c Mann-Whitney U test. AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 51

mild symptoms. The pretest sociodemographic and psychoemotional variables did not differ significantly between the 2 groups, with the exception of PTSD symptoms, with a greater percentage of patients in the intervention group having few or no symptoms (P = .007) (Table 2).

Effectiveness of the CONECTEM Intervention in Improving Psychoemotional State

The results of multivariable analysis of covari- ance with pretest-posttest differences showed statis- tically significant differences between groups (Pillai multivariate, F

2,110 = 57.973, P < .001). The univariate

analysis of variance results showed an association between the intervention and improvement in pain and PTSD symptoms in the intervention group (P < .001; Table 3).

In the comparison of anxiety (improvement or nonimprovement) between the 2 groups, a greater percentage of patients with improvement was found in the intervention group (62% vs 4%), with the difference being statistically significant (P < .001; Table 4).

Correlations Among Pain, Anxiety, and PTSD Symptoms in the Posttest Period

The Pearson product-moment correlation test indicated significant correlations among the 3 psy- choemotional variables: pain and anxiety (r = 0.37), pain and PTSD symptoms (r = 0.33), and PTSD symp- toms and anxiety (r = 0.51) (P < .05 for all). These correlation coefficients demonstrated moderate cor- relation among the 3 variables.

Discussion Effectiveness of CONECTEM Communication Strategies

The ability of nurses and critical care patients to interact is fundamental to their effective communi- cation.20,30 The results of this study demonstrate that the actions constituting the various CONECTEM communication strategies were effective in improv- ing the psychoemotional state of the critical care

patients transported by ambulance. Other studies based on BCS have also indicated improvement in patient communication and level of satisfaction with care.49-51 In addition, the use of AAC techniques with critical care patients facilitates nurse-patient communication52 and relieves pain53 and psychoemo- tional symptoms such as anxiety54 and depression,55 helping to improve nursing treatment.6,11,56 However, we found no studies on critical care patient–nurse AAC in the nonhospital setting, making it impossible to compare the effects of AAC on patients in this set- ting with the effects on patients subsequently admit- ted to the ICU. Although Eadie et al34 reported that AAC in the ambulance improved communication between paramedics and patients, the literature is still insufficient to compare the scope of AAC in this field and what effects it might have on a patient who is later admitted to a hospital ICU.

Effectiveness of the CONECTEM Intervention in Improving Pain, Anxiety, and PTSD Symptoms

Pain. Pain is one of the most common symptoms in critical care patients, regardless of their disease, with a prevalence of 70% to 87%.57-59 In this study, the prevalence of in-ambulance pain in critical care patients was 68.7%. Given the difficulty of measuring pain in critically ill patients, several studies have been conducted on how to increase the effectiveness of the communication of pain between patient and nurse.60,61 Nurses’ training in communication skills affects their ability to accurately gauge the patient’s degree of pain and determine whether or not the patient needs anal- gesic treatment.32,54,62 In the same vein, the results of


Table 3 Pretest-posttest differences in scores on the visual analog scale for pain (VAS) and the Impact of Event Scale (IES)



a ”Pretest” and “posttest” refer to before and after the intervention.

b ”Pretest” and “posttest” refer to before and after transport.

c From pretest to posttest analysis of variance.





0.1 (1.1)

0.3 (4.1)

2.1 (1.9)

22.7 (12.2)

2.2 (2.2)

22.4 (13.1)

1.9 (1.9)

6.6 (6.4)

3.3 (2.6)

17.8 (15.1)

1.1 (1.6)

11.2 (10.5)

PF 1 , 11 3 cDifferenceDifferencePretesta PretestbPosttesta Posttestb

Score in control group (n = 50), mean (SD)Score in intervention group (n = 65), mean (SD)


Table 4 Comparison of anxiety between groupsa

No change or worsening




48 (96)

2 (4)

25 (38)

40 (62)

Pb Control group

(n = 50) Intervention group

(n = 65)

a Data are number (%) of patients.

b From

2 test.



52 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1

this study show that the pain felt by critically ill patients transported by ambulance decreased by 67% after performance of the CONECTEM interven- tion and that the pain that most patients continued to feel was mild. Less sedation and better pain treatment contribute to improvements in patients’ health and recovery.2,14,53,63

Anxiety. Anxiety was the psychoemotional vari- able with the highest incidence in this study, with 93 (80.9%) of the patients transported by ambulance exhibiting this symptom. In contrast, the prevalence of anxiety in critical care patients in ICUs is 30% to 60%.40,64 Previous studies involving conscious and oriented critical care patients indicate that the cramped vehicle space, constant noises and movements, and uncertainty and urgency of the situation make trans- portation by ambulance stressful for patients, which may induce or exacerbate anxiety.65 In addition, stud- ies using music therapy or AAC to reduce anxiety in

ICU patients have yielded positive results,66,67 con- sistent with this study (intervention group: 62% anxiety improved vs 38% anxiety not improved [P > .05]).

PTSD Symptoms. The results of this study show that 68.7% of the total sample had moderate to

severe symptoms of PTSD. This prevalence is higher than that reported in the literature for ICU patients (20%-27%).3,68,69 This difference may be due in part to the immediacy of the traumatic event. Other stud- ies on PTSD have indicated that psychoemotional interventions are more effective if they are initiated at the onset of symptoms, which may prevent the need for short- or long-term psychiatric treatment.26,70,71

Limitations This study has limitations. One is the noninde-

pendence of the sample. Another is that the same nurses who delivered the intervention to patients also collected the symptom outcome data, which may have introduced bias. Moreover, we did not per- form interstrategy comparison owing to the sample size. Finally, the cross-sectional design of the study did not allow evaluation of PTSD symptoms in the medium and long terms or measurement of the ongoing adherence of the nurses to the interven- tion. Therefore, additional studies with larger sam- ples and longitudinal designs are needed to confirm the results obtained in this study.

Conclusion The CONECTEM intervention demonstrated

effectiveness in improving the psychoemotional state of critical care patients during ambulance transport. Furthermore, this type of intervention involves no additional cost and is easy to imple- ment, making it highly cost-effective. We therefore recommend that it be introduced as part of the treatment of critical care patients transported by ambulance in emergency medical systems.

ACKNOWLEDGMENTS This work was performed in the emergency medical system of Catalonia and the Hospital Transfronterer de Cerdanya, Puigcerdà (Girona), Spain. It was part of the doctoral thesis of the first author (M.P.A.), which was supervised by the second and last authors (M.P.L. and T.L.C.). We thank all of the emergency nurses who par- ticipated in this study.


REFERENCES 1. Norouzinia R, Aghabarari M, Shiri M, Karimi M, Samami E.

Communication barriers perceived by nurses and patients. Glob J Health Sci. 2015;8(6):65-74. doi:10.5539/gjhs.v8n6p65

2. Kleinpell RM. Improving communication in the ICU. Heart Lung. 2014;43(2):87. doi:10.1016/j.hrtlng.2014.01.008

3. Fumis R, Martins P, Schettino G. Incidence of post-traumatic stress, anxiety and depression symptoms in patients and rel- atives during the ICU stay and after discharge. Crit Care. 2012; 16(suppl 1):P497. doi:10.1186/cc11104

4. Rattray J, Crocker C, Jones M, Connaghan J. Patients’ percep- tions of and emotional outcome after intensive care: results from a multicentre study. Nurs Crit Care. 2010;15(2): 86-93. doi:10.1111/j.1478-5153.2010.00387.x

5. Wiencek C. Symptom Burden and Its Relationship to Func- tional Status in the Chronically Critically Ill. Dissertation. Case Western Reserve University; 2008. Accessed April 3, 2018.!etd.send_file?accession= case1207241196&disposition=inline

6. Modrykamien AM. Strategies for communicating with con- scious mechanically ventilated critically ill patients. Proc (Bayl Univ Med Cent). 2019;32(4):534-537. doi:10.1080/0899 8280.2019.1635413

7. Choi JY, Campbell ML, Gélinas C, Happ MB, Tate J, Chlan L. Symptom assessment in non-vocal or cognitively impaired ICU patients: implications for practice and future research. Heart Lung. 2017;46(4):239-245. doi:10.1016/j.hrtlng.2017.04.002

8. Griffiths RD. Sedation, delirium and psychological distress: let’s not be deluded. Crit Care. 2012;16(1):109. doi:10.1186/cc11176

9. Jones C, Griffiths RD, Humphris G, Skirrow PM. Memory, delusions, and the development of acute posttraumatic stress disorder–related symptoms after intensive care. Crit Care Med. 2001;29(3):573-580. doi:10.1097/00003246- 200103000-00019

10. Carroll SM. Nonvocal ventilated patients’ perceptions of being understood. West J Nurs Res. 2004;26(1):85-103. doi:10.1177/0193945903259462

11. Guttormson JL, Bremer KL, Jones RM. “Not being able to talk was horrid”: a descriptive, correlational study of communi- cation during mechanical ventilation. Intensive Crit Care Nurs. 2015;31(3):179-186. doi:10.1016/j.iccn.2014.10.007

12. Puntillo KA. Pain experiences of intensive care unit patients. Heart Lung. 1990;19(5 Pt 1):526-533.

13. Puntillo KA, White C, Morris AB, et al. Patients’ perceptions and responses to procedural pain: results from Thunder Project II. Am J Crit Care. 2001;10(4):238-251.

14. Bender BG. Pain control in the intensive care unit: new insight into an old problem. Am J Respir Crit Care Med. 2014;189(1): 9-10. doi:10.1164/rccm.201311-2059ED

Use of augmentative alternative communica-

tion (AAC) techniques with critical care patients

facilitates nurse-patient communication. AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1 53

15. Myhren H, Ekeberg Ø, Tøien K, Karlsson S, Stokland O. Posttraumatic stress, anxiety and depression symptoms in patients during the first year post intensive care unit dis- charge. Crit Care. 2010;14(1):R14. doi:10.1186/cc8870

16. Ringdal M, Plos K, Lundberg D, Johansson L, Bergbom I. Outcome after injury: memories, health-related quality of life, anxiety, and symptoms of depression after intensive care. J Trauma. 2009;66(4):1226-1233.

17. Aronsson K, Björkdahl I, Wireklint Sundström B. Prehospital emergency care for patients with suspected hip fractures after falling—older patients’ experiences. J Clin Nurs. 2014; 23(21-22):3115-3123. doi:10.1111/jocn.12550

18. Holmberg M, Fagerberg I. The encounter with the unknown: nurses lived experiences of their responsibility for the care of the patient in the Swedish ambulance service. Int J Qual Stud Health Well-being. 2010;5(2). doi:10.3402/qhw.v5i2.5098

19. Wireklint Sundström B, Dahlberg K. Caring assessment in the Swedish ambulance services relieves suffering and enables safe decisions. Int Emerg Nurs. 2011;19(3):113-119. doi:10.1016/j.ienj.2010.07.005

20. The Joint Comission. Approved: new and revised hospital EPs to improve patient-provider communication. Jt Comm Perspect. 2010;30(1):5-6.

21. Romero-García M. Diseño y Validación de un Cuestionario de Satisfacción con los Cuidados Enfermeros desde la Per- spectiva del Paciente Crítico. Dissertation. University of Barcelona; 2016. Accessed March 15, 2018. http://diposit.

22. Campbell GB, Happ MB. Symptom identification in the chron- ically critically ill. AACN Adv Crit Care. 2010;21(1):64-79. doi:10.1097/NCI.0b013e3181c932a8

23. Tate JA, Seaman JB, Happ MB. Overcoming barriers to pain assessment: communicating pain information with intubated older adults. Geriatr Nurs. 2012;33(4):310-313. doi:10.1016/j. gerinurse.2012.06.004

24. Meriläinen M, Kyngäs H, Ala-Kokko T. Patients’ interactions in an intensive care unit and their memories of intensive care: a mixed method study. Intensive Crit Care Nurs. 2013;29(2): 78-87. doi:10.1016/j.iccn.2012.05.003

25. Radtke JV, Tate JA, Happ MB. Nurses’ perceptions of commu- nication training in the ICU. Intensive Crit Care Nurs. 2012; 28(1):16-25. doi:10.1016/j.iccn.2011.11.005

26. Peris A, Bonizzoli M, Iozzelli D, et al. Early intra-intensive care unit psychological intervention promotes recovery from post traumatic stress disorders, anxiety and depres- sion symptoms in critically ill patients. Crit Care. 2011;15(1): R41. doi:10.1186/cc10003

27. Patak L, Gawlinski A, Fung NI, Doering L, Berg J. Patients’ reports of health care practitioner interventions that are related to communication during mechanical ventilation. Heart Lung. 2004;33(5):308-320. doi:10.1016/j.hrtlng.2004. 02.002

28. Happ MB, Roesch TK, Garrett K. Electronic voice-output communication aids for temporarily nonspeaking patients in a medical intensive care unit: a feasibility study. Heart Lung. 2004;33(2):92-101. doi:10.1016/j.hrtlng.2003.12.005

29. Happ MB, Sereika S, Garrett K, Tate J. Use of the quasi- experimental sequential cohort design in the Study of Patient- Nurse Effectiveness with Assisted Communication Strategies (SPEACS). Contemp Clin Trials. 2008;29(5):801-808. doi:10.1016 /j.cct.2008.05.010

30. Patak L, Wilson-Stronks A, Costello J, et al. Improving patient- provider communication: a call to action. J Nurs Adm. 2009; 39(9):372-376. doi:10.1097/NNA.0b013e3181b414ca

31. Ganz JB, Sigafoos J, Simpson RL, Cook KE. Generalization of a pictorial alternative communication system across instructors and distance. Augment Altern Commun. 2008; 24(2):89-99. doi:10.1080/07434610802113289

32. Happ MB, Baumann BM, Sawicki J, Tate JA, George EL, Barnato AE. SPEACS-2: intensive care unit “communication rounds” with speech language pathology. Geriatr Nurs. 2010;31(3):170-177. doi:10.1016/j.gerinurse.2010.03.004

33. Alm-Pfrunder AB, Falk AC, Vicente V, Lindström V. Prehospital emergency care nurses’ strategies while caring for patients with limited Swedish-English proficiency. J Clin Nurs. 2018; 27(19-20):3699-3705. doi:10.1111/jocn.14484

34. Eadie K, Carlyon MJ, Stephens J, Wilson MD. Communicat- ing in the pre-hospital emergency environment. Aust Health Rev. 2013;37(2):140-146. doi:10.1071/AH12155

35. Weiss NR, Weiss SJ, Tate R, Oglesbee S, Ernst AA. Language disparities in patients transported by emergency medical

services. Am J Emerg Med. 2015;33(12):1737-1741. doi:10.1016 /j.ajem.2015.08.007

36. Ahl C, Nyström M. To handle the unexpected—the meaning of caring in pre-hospital emergency care. Int Emerg Nurs. 2012;20(1):33-41. doi:10.1016/j.ienj.2011.03.001

37. Togher FJ, Davy Z, Siriwardena AN. Patients’ and ambulance service clinicians’ experiences of prehospital care for acute myocardial infarction and stroke: a qualitative study. Emerg Med J. 2013;30(11):942-948. doi:10.1136/emermed- 2012-201507

38. Drury J, Kemp V, Newman J, et al. Psychosocial care for persons affected by emergencies and major incidents: a Delphi study to determine the needs of professional first responders for education, training and support. Emerg Med J. 2013;30(10):831-836. doi:10.1136/emermed-2012-201632

39. Iqbal M, Spaight PA, Siriwardena AN. Patients’ and emer- gency clinicians’ perceptions of improving pre-hospital pain management: a qualitative study. Emerg Med J. 2013; 30(3):e18. doi:10.1136/emermed-2012-201111

40. Castillo MI, Cooke ML, Macfarlane B, Aitken LM. Trait anxiety but not state anxiety during critical illness was associated with anxiety and depression over 6 months after ICU. Crit Care Med. 2016;44(1):100-110. doi:10.1097/CCM. 0000000000001356

41. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. Lancet Neurol. 1974;304(7872):81-84. doi:10.1016/s0140-6736(74)91639-0

42. Knop C, Oeser M, Bastian L, Lange U, Zdichavsky M, Blauth M. Development and validation of the visual analogue scale (VAS) spine score. Unfallchirurg. 2001;104(6):488-497. doi:10.1007/s001130170111

43. Chlan L, Savik K, Weinert C. Development of a shortened state anxiety scale from the Spielberger State-Trait Anxiety Inventory (STAI) for patients receiving mechanical ventila- tory support. J Nurs Meas. 2003;11(3):283-293. doi:10.1891/ jnum.

44. Horowitz M, Wilner N, Alvarez W. Impact of Event Scale: a measure of subjective stress. Psychosom Med. 1979;41(3): 209-218. doi:10.1097/00006842-197905000-00004

45. Ahlers SJGM, van Gulik L, van der Veen AM, et al. Compari- son of different pain scoring systems in critically ill patients in a general ICU. Crit Care. 2008;12(1):R15. doi:10.1186/cc6789

46. Tobar E, Romero C, Galleguillos T, et al. Método para la evaluación de la confusión en la unidad de cuidados inten- sivos para el diagnóstico de delírium: adaptación cultural y validación de la versión en idioma español. Med Intensiva. 2010;34(1):4-13. doi:10.1016/j.medin.2009.04.003

47. Carkhuff R. The Art of Helping. 9th ed. HRD Press, Inc; 2009. 48. Beukelman DR, Fager S, Ball L, Dietz A. AAC for adults with

acquired neurological conditions: a review. Augment Altern Commun. 2007;23(3):230-242. doi:10.1080/07434610701553668

49. Sulmasy DP, McIlvane JM, Pasley PM, Rahn M. A scale for measuring patient perceptions of the quality of end-of-life care and satisfaction with treatment: the reliability and valid- ity of QUEST. J Pain Symptom Manage. 2002;23(6): 458-470. doi:10.1016/S0885-3924(02)00409-8

50. Wanzer MB, Booth-Butterfield M, Gruber K. Perceptions of health care providers’ communication: relationships between patient-centered communication and satisfaction. Health Com- mun. 2004;16(3):363-383. doi:10.1207/s15327027hc1603_6

51. Williams KN, Herman RE. Linking resident behavior to dementia care communication: effects of emotional tone. Behav Ther. 2011;42(1):42-46. doi:10.1016/j.beth.2010.03.003

52. Otuzoğlu M, Karahan A. Determining the effectiveness of illustrated communication material for communication with intubated patients at an intensive care unit. Int J Nurs Pract. 2014;20(5):490-498. doi:10.1111/ijn.12190

53. Happ MB, Garrett KL, Tate JA, et al. Effect of a multi-level intervention on nurse-patient communication in the inten- sive care unit: results of the SPEACS trial. Heart Lung. 2014; 43(2):89-98. doi:10.1016/j.hrtlng.2013.11.010

54. Maringelli F, Brienza N, Scorrano F, Grasso F, Gregoretti C. Gaze-controlled, computer-assisted communication in Intensive Care Unit: “speaking through the eyes.” Minerva Anestesiol. 2013;79(2):165-175.

55. Koszalinski RS, Heidel RE, Hutson SP, et al. The use of com- munication technology to affect patient outcomes in the inten- sive care unit. Comput Inform Nurs. 2020;38(4):183-189. doi:10.1097/CIN.0000000000000597

56. Nilsen ML, Sereika SM, Hoffman LA, Barnato A, Donovan H, Happ MB. Nurse and patient interaction behaviors’ effects on nursing care quality for mechanically ventilated older



54 AJCC AMERICAN JOURNAL OF CRITICAL CARE, January 2021, Volume 30, No. 1

adults in the ICU. Res Gerontol Nurs. 2014;7(3):113-125. doi:10.3928/19404921-20140127-02

57. Joffe AM, Hallman M, Gélinas C, Herr D, Puntillo K. Evalua- tion and treatment of pain in critically ill adults. Semin Respir Crit Care Med. 2013;34(2):189-200. doi:10.1055/s-0033-1342973

58. Puntillo K. Pain assessment and management in the critically ill: wizardry or science? Am J Crit Care. 2003;12(4):310-316.

59. Skrobik Y, Chanques G. The pain, agitation, and delirium practice guidelines for adult critically ill patients: a post- publication perspective. Ann Intensive Care. 2013;3(1):9. doi:10.1186/2110-5820-3-9

60. Arbour C, Gélinas C. Behavioral and physiologic indicators of pain in nonverbal patients with a traumatic brain injury: an integrative review. Pain Manag Nurs. 2014;15(2):506-518. doi:10.1016/j.pmn.2012.03.004

61. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013; 41(1):263-306. doi:101097/CCM0b013e3182783b72

62. Nilsen ML, Happ MB, Donovan H, Barnato A, Hoffman L, Sereika SM. Adaptation of a communication interaction behavior instrument for use in mechanically ventilated, nonvocal older adults. Nurs Res. 2014;63(1):3-13. doi:10.1097 / NNR.0000000000000012

63. Varndell W, Fry M, Elliott D. A systematic review of observa- tional pain assessment instruments for use with nonverbal intubated critically ill adult patients in the emergency depart- ment: an assessment of their suitability and psychometric prop- erties. J Clin Nurs. 2017;26(1-2):7-32. doi:10.1111/jocn.13594

64. Nikayin S, Rabiee A, Hashem MD, et al. Anxiety symptoms in survivors of critical illness: a systematic review and meta- analysis. Gen Hosp Psychiatry. 2016;43:23-29. doi:10.1016/ j.genhosppsych.2016.08.005

65. Weber U, Reitinger A, Szusz R, et al. Emergency ambulance transport induces stress in patients with acute coronary

syndrome. Emerg Med J. 2009;26(7):524-528. doi: 10.1136/ emj.2008.059212.

66. Hosseini SR, Valizad-Hasanloei MA, Feizi A. The effect of using communication boards on ease of communication and anxiety in mechanically ventilated conscious patients admitted to intensive care units. Iran J Nurs Midwifery Res. 2018;23(5):358-362. doi:10.4103/ijnmr.IJNMR_68_17

67. Sanjuán Naváis M, Via Clavero G, Vázquez Guillamet B, Moreno Duran AM, Martínez Estalella G. Efecto de la música sobre la ansiedad y el dolor en pacientes con venti- lación mecánica. Enferm Intensiva. 2013;24(2):63-71. doi:10.1016/j.enfi.2012.11.003

68. Bienvenu OJ, Colantuoni E, Mendez-Tellez PA, et al. Co-occurrence of and remission from general anxiety, depression, and posttraumatic stress disorder symptoms after acute lung injury—a 2-year longitudinal study. Crit Care Med. 2015;43(3):642-653. doi: 10.1097/ CCM.0000000000000752

69. Parker AM, Sricharoenchai T, Raparla S, Schneck KW, Bien- venu OJ, Needham DM. Posttraumatic stress disorder in critical illness survivors: a metaanalysis. Crit Care Med. 2015;43(5):1121-1129. doi:10.1097/CCM.0000000000000882

70. Hatch R, McKechnie S, Griffiths J. Psychological intervention to prevent ICU-related PTSD: who, when and for how long? Crit Care. 2011;15(2):141. doi:10.1186/cc10054

71. Wade DM, Hankins M, Smyth DA, et al. Detecting acute dis- tress and risk of future psychological morbidity in critically ill patients—validation of the intensive care psychological assessment tool. Crit Care. 2014;18(5):519. doi:10.1186/s13

To purchase electronic or print reprints, contact American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362- 2050 (ext 532); fax, (949) 362-2049; email,



Copyright of American Journal of Critical Care is the property of American Association of Critical-Care Nurses and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.