This dissertation is available at Iowa Research Online:

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1 University of Iowa Iowa Research Online Theses and Dissertations Spring 2014 The effectiveness of AAC training protocols for acute care Nurses: a randomized controlled trial of an instructional on-line medium for clinical skills teaching Debora Ann Downey University of Iowa Copyright 2014 Debora Downey This dissertation is available at Iowa Research Online: Recommended Citation Downey, Debora Ann. "The effectiveness of AAC training protocols for acute care Nurses: a randomized controlled trial of an instructional on-line medium for clinical skills teaching." PhD (Doctor of Philosophy) thesis, University of Iowa, Follow this and additional works at: Part of the Speech and Hearing Science Commons

2 The Effectiveness of AAC Training Protocols for Acute Care Nurses: A Randomized Controlled Trial of an Instructional On-line Medium for Clinical Skills Teaching by Debora Ann Downey A thesis submitted in partial fulfillment of the requirements for the Doctor of Philosophy degree in Speech and Hearing Science in the Graduate College of The University of Iowa August 2014 Thesis Supervisor: Professor Richard Hurtig

3 Copyright by DEBORA ANN DOWNEY 2014 All Rights Reserved

4 Graduate College The University of Iowa Iowa City, Iowa CERTIFICATE OF APPROVAL PH.D. THESIS This is to certify that the Ph.D. thesis of Debora Ann Downey has been approved by the Examining Committee for the thesis requirement for the Doctor of Philosophy degree in Speech and Hearing Science at the August 2014 graduation. Thesis Committee: Richard Hurtig, Thesis Supervisor JB Tomblin Michael Karnell Dennis Harper LouAnn Montgomery

5 To My Family ii

6 The Effectiveness of AAC Training Protocols for Acute Care Nurses: A Randomized Controlled Trial of an Instructional On-line Medium for Clinical Skills Teaching Debora Ann Downey iii

7 ACKNOWLEDGMENTS I wanted to offer a special thank you to Richard Hurtig, my academic advisor, for his support, encouragement, and guidance throughout my doctoral studies. Also, I would like to thank the other members of my committee: Lou Ann Montgomery for advice and patience over the last several years and Dennis Harper, Bruce Tomblin and Michael Karnell for their time and encouragement. I would like to thank the UIHC nurses and CSD students at my research site. Despite my recruitment of their service, they were still willing to work with me. It was a pleasure to work with each of them. I must acknowledge my deepest thanks to family and friends for their understanding and support. Thank you for the patience and good humor with which you gracefully accepted the numerous unreturned phone calls and s. I must extend special thank you to Claudia Knutson for all her help and support through this process. To my husband Kurt, there is not enough space to describe the ways you have supported me over the last several years. I thank you for it all. To my sons, Nick, Mitch and Matt, for understanding when I was unable to attend an event or have dinner ready on time. They were even more excited than I about my completion. Debora Ann Downey. iv

8 ABSTRACT Acutely ill patients, across the age continuum, often present with complex communication needs (CCN) due to motor, sensory, cognitive and linguistic barriers they may experience during their hospital encounter. While hospital administrators recognize the importance of improving communication among the healthcare team members to increase quality and safety measures, few have focused on improving the patient-provider communication process, especially for patients with CCN. Recent Joint Commission standards mandates hospitals and healthcare providers improve communication for patients with CCN across all points of the care continuum. The study investigated the effectiveness of AAC training protocols for acute care nurses and ancillary healthcare providers using an on-line instructional medium for clinical skills teaching. The study design allowed for the measurement of learning following exposure to the tutorial and the analysis of possible clinical skill application. The current study invited a total of 377 nurses and graduate students to participate. Eight-three participated in the study and were divided randomly into two groups. Seventeen (20.5%) were assigned to in the control group, and 66 (79.5%) participants were into the test group. Both groups were directed to complete a pre-test measure. This was followed by exposure to the tutorial for the test group. The groups then were instructed to complete a post-test measure. For all participants in the test condition, the mean difference score (post-pre) was The average pre-test score was 60.8 with a standard deviation of 12.4 while the average posttest score was 80.1 with a standard deviation of This difference was significant (p<.00001). This suggests the on-line tutorial as a mode of delivery for clinical skills teaching of AAC solutions for patients with CCN was effective. The study also involved the design of a set of scenarios to assess transfer of knowledge from the tutorial to clinical practice in a safe environment. The scenarios targeted three areas for participants to problem solve through: the development of a yes/no response, recognition of sensory v

9 issues displayed by patients with CCN; and, candidacy for AAC use in an acute care setting. The scenarios were presented to both groups after completion of the post-test measure. No significant difference across the groups was noted. However, findings suggested that the use of scenarios may be a viable method for assessing the application of clinical skills when the participant had to generate a narrative outlining clinical practice as opposed being scaffold by the selection of correct and incorrect clinical skill strategies presented. The study emphasizes the need to enhance the patient-provider communication experience for patients with CCN and outlines basic elements for nurse training modules. vi

10 TABLE OF CONTENTS LIST OF TABLES... ix LIST OF FIGURES... x CHAPTER 1. INTRODUCTION... 1 A Review of the Literature on Patient-Nurse Communication... 6 A Review of Nurse-Patient Communication for Hospitalized Patients with CCN... 9 A Review of the Literature on AAC Solutions for Patients with CCN Nursing Understanding of AAC The State of Online Training Statement of the Problem Elements of the Study CHAPTER 2. METHODS Description of Tutorial Content Component 1: The Problem Component 2: The Communication Parameters Associated with CCN Patients Component 3: The Yes/No Response Component 4: Low-tech to High-tech Options The Use of Videos as Means of Learning Enhancement Learning Assessment and Instruments Pre-& Post-Test Measures The Rational for Pre-test Question Probes Scenario Assessment Reconstruction of the Scenarios Assessment Tool Institutional Review Board Approval Delivery Medium for the Tutorial Online Live Participants Pilot Participants UIHC Nurses Communication Science & Disorders Students Procedure Basic Procedure Outline for All Participant Groups Statistical Analysis vii

11 CHAPTER 3. RESULTS Subject Participation Baseline Measure Measure of Knowledge Learned Pre- & Post-Test Comparison Measure of Transfer of Knowledge CHAPTER 4. DISCUSSION The Effectiveness of the Tutorial Subject s Ability to Complete the Performance Elicitation Tasks Baseline Measure of Prior Knowledge Measure of Knowledge Learning Condition 2 Scenario Probes Tutorial Evaluation Notable Study Findings Subject Recruitment and Design Incentives and rewards for subjects Administrative Barriers Possible Lack Of Awareness Of The Need For Clinical Training Personal And Practical Obstacles Future Tutorials: Components for Consideration Which Embrace Patient Provider Communication Strategies Useful to the Patient-Provider Communication Process Conclusion APPENDIX A ORIGINAL SCENARIO SETS APPENDIX B REVISED SCENARIO SETS REFERENCES viii

12 LIST OF TABLES Table 1.1 UIHC AAC Nursing Needs Assessment Quieres Table 1.2 Years of Nursing Experience Table 1.3 UIHC Response Rate Table 1.4 Breakdown of Critical Care Units Use of Varying Forms of AAC Table 2.1 Pretest Questionaire Table 2.2 Post-test Questionaire Table 2.3 Reaserch Protocol Used With Research Cohorts Table 2.4 AAC Tutorial Evaluation for CSD Groups Table 3.1 Subjects Level of Participation by Groups Table 3.2 Pre-test Question Statistics for All Groups: Question Mean Scores Table 3.3 Post-test Question Statistics for All Groups: Question Mean Scores Table 4.1 Control & Test Groups Comparison: Changes Noted Between Pre- and Post-test Measures Table 4.2 Scenario Tarteted Knowledge Areas Table 4.3 CSD Group 1 (Audilogy Graduate Students): Tutorial Evaluation Table 4.4 CSD Group 2 (Speech Pathology Graduate Students): Tutorial Evaluation. 106 ix

13 LIST OF FIGURES FIGURE 2.1 Tutorial Navigation Example...61 FIGURE 3.1 All Groups Pre-Test Mean Scores...76 FIGURE 3.2 Pre- & Post-Test Comparison: Group Mean Scores FIGURE 3.3 Lend Groups Sceanrio Mean Scores FIGURE 3.4 Sceanrio Group Mean Scores: UIHC Nursing & CSD Groups x

14 1 CHAPTER 1 INTRODUCTION Communication may be one of the most important medical procedures that anyone involved in healthcare can do. The ability to communicate with health professionals during any encounter is critical to the patient s overall recovery. Understanding the patient provider communication process is key to empowering the patient to actively participate in treatment decisions. The research supports and highlights that adherence to treatment and increased patient satisfaction are directly tied to the patient s ability to actively participate in the treatment decision process (Hall, Roter, & Katz, 1988; Ley, 1988). Moreover, a patient s level of participation in the decision process has been examined from the standpoint of interpersonal, intrapersonal and contextual factors (Kaplan, Gandek, Greenfield, Rogers & Ware, 1996: Street, Gordon, Ward, Krupat, & Kravitz, 2005). According to Kaplan et al., (1996) patients confidence and communication patterns are among the most fundamental of the intrapersonal factors. The level of a patient s participation in their own care directly correlates to the communication style evidenced by the healthcare provider. Such a style encourages questions from the patient and elicits opinions or narratives related to the health problem being treated. One can postulate that successful joint communication between the patient and the healthcare provider must include a meaningful exchange of information from the onset of admission through discharge with equal responsibility on the part of the patient and the healthcare provider(s). In other words, the communication exchange must be a two-way process (expressive and receptive) to ensure that information conveyed by either party is discussed and understood (Romski & Sevcik, 1993). This suggests that effective communication occurs when information is provided by patients, and when patients understand accurate, timely, complete and unambiguous

15 2 messages provided by healthcare providers in a manner that allows them to participate responsibly in their care (Joint Commission, 2010a). Beukelman et al. (2007) have identified medical conditions that may preclude patients from communicating verbally with caregivers. Patients with severe communication impairment secondary to their underlying medical condition may experience difficulty talking and/or communicating with their loved ones and healthcare providers (Finke, et al, 2008). In general, severe communication impairment is considered to be a condition in which speech is temporarily or permanently inadequate to meet the individual s communication needs, and the inability to speak is not due to a hearing impairment (ASHA 1991). The Joint Commission (JC), the non-profit organization which accredits and certifies healthcare organizations and hospitals throughout the United States, is viewed as a symbol of excellence that upholds the commitment to meeting certain desirable performance standards. The JC recognizes the need to address patient-provider communication and has promulgated several standards related to improving patientprovider communication. Specifically, JC standard (IM.6.20; January 2006) stipulates the need to document all patients language/communication needs, promote early rehabilitation and increase nursing interactions. Perhaps the motivation for the JC to take a more active role in the need to enhance patient-provider turns has been by recent studies examining variables which contribute to an increase in adverse/sentinel medical events. When reviewing the literature related to sentinel events, communication barriers and/or breakdown are identified and noted as being contributory causal factors of sentinel events (JC Sentinel Events, 2011). The need to reduce sentinel events is critical to better medical care and patient satisfaction. Recently, the Department of Health and Human Services, Office of the Inspector General, reported on the incidence of adverse events in hospitals for Medicare beneficiaries (Levinson, 2010). The report, which examined patients discharged from

16 3 hospitals in 2008, revealed 13.5% of patients experienced adverse events. Alarmingly, 15% of those patients experienced an adverse event that contributed to death; this equates to 15,000 potentially avoidable deaths per month, a number that is unacceptable. A recent 2010 study reviewing trends in medical practice resulting in harm to patients identified two important findings: 1) the number of patients harmed by medical interventions accounted for 18% of all hospital admissions, 2) 63% of those injuries were deemed to be preventable (Landrigan, Parry, Bones, Hackbarth, Goldmann & Sharek, 2012). The authors identified poor patient-provider communication as a contributing factor to these preventable harms. In another earlier study, Bartlett et al. (2008) reported patients receiving care in intensive care units (ICU) who exhibited physical communication problem were 3 times more likely to experience an adverse medical event. This finding is supported by several studies examining patient provider communication and its impact on medical outcomes and patient satisfaction. (Hoffman et al., 2005; Balandin et al., 2007; Hemsley et al., 2007; Helmsley et al., 2011). These studies highlight the importance of the quality of the communication between the patient and the provider. Cohen et al. (2005) have noted that the occurrence of poor communication between patients and healthcare providers is not isolated to adult ICUs. Communication barriers experienced by pediatric patients also have an impact on the quality of care they received. The JC s commitment to eliminating communication barriers for patients is evidenced by the release of additional Patient-Centered Communication Standards for Hospitals (The Joint Commission New and Revised Standards and EPs for Patient- Centered Communication, Pre-publication Version, 2010b). These standards highlight the need for better patient provider communication and specifically require facilities to address the needs of patients with communication disabilities. These new standards amplified the earlier standards (IM.6.20; January 2006) and went into effect in July of

17 Recognizing that these standards may be a shift in paradigm, the JC has prepared a monograph entitled Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals (2010a). One primary goal of this monograph is to identify strategies that healthcare organizations in the United States should adopt to meet patients communication needs. In addition to outlining a wide range of strategies to meet the communication needs of patients, the monograph identifies Augmentative/Alternative Communication (AAC) as a viable treatment option for patients with Complex Communication Needs (CCN). The American Speech and Hearing Association defines the term of AAC in relation to corresponding attempts to study and, if necessary, compensate for temporary or permanent restrictions of speechlanguage production and/or comprehension, including spoken as well as written modes of communication (ASHA, 2004, pp. 1). Although AAC as a viable treatment option for acutely ill patients with CCN has been echoed by experts in speech-language pathology (Beukelman & Mirenda 2005), acutely ill patients with CCN continue to be undertreated by speech-language pathologists (SLP) despite advances in the area of AAC. Analyzing and understanding these issues and acquiring information on the use of AAC in acute care settings that enhances efficacy and minimizes negative feelings patients may experience are paramount for improving patient outcomes. At a minimum, the use of AAC in hospital settings can expand the patient s ability to express physical needs or vital information and support an increase in the quantity and quality of interactions between the patient and the nurse (Fried-Oken, Howard, Stewart, 1991). For example in pain management, the ability to effectively communicate the extent and locus of pain is critical to effective treatment. Effective control of pain can assist healing and reduce complications after surgery (Pear, 2008). Clearly, the field of speech-language pathology must play an integral role in enhancing patient-provider interactions, especially for patients with CCN.

18 5 The JC s view on AAC use with acutely ill patients is important. The JC recognized that, despite the field s increased focus on communication abilities of patients with chronic conditions who display CCN, many acutely ill patients with CCN continue to experience problems as a consequence of their inability to communicate effectively. When considering ways to improve patient-provider communication for such patients it is essential to start with nurses, as they are the frontline staff. It is the nurse who initially greets a patient upon arrival on a unit, has the most daily contact with the patient, and provides the majority of the direct hands-on care to the patient. This care includes: administering medication; subjectively and objectively monitoring a patient s condition; communicating directly with doctors regarding the physical status of the patient; educating the patient and family members with regard to the doctor s findings and/or orders. Each of these key care components requires effective patient-provider communication. Nurses are responsible for providing patients and their family members with the needed education to manage any medical conditions or disease related to the patient s admission and/or overall health. However, in addition to the physical care and education they provide, nurses also provide critical emotional support to the patient and family members. Thus, the ability of the nurses to be able to meet the needs of all of their patients, including those with CCN, will require them to have training in AAC strategy implementation. It is logical to assume that speech-language pathology as a field trained in the area of communication disorders is best suited to address the communication needs of acutely ill patients with CCN. In order to facilitate nurses patient-provider communication we must increase our working knowledge of the nurses understanding of the patient provider communication process. Specifically, we need to understand the following:

19 6 (1) Practice standards as they relate to patient-provider communication between nurses and acutely ill patients including the patients with CCN; (2) Practice standards as they relate to acutely ill hospitalized patients with CCN; (3) Practice standards as they relate to the nurse s working knowledge of AAC as it relates to acutely ill hospitalized patients. A Review of the Literature On Patient-Nurse Communication Practice standards for nursing include effective communication between the nurse and the patient. Nurses need to give clear information to the patients about their medical diagnosis and treatment status and to respond to the questions or concerns their patients may have (recall that the latter requires the patient to be able to express concerns and/or questions regarding either the diagnostic or the treatment regime). A lack of functional communication on the part of the patient may foster increased anxiety and frustration for the patient and have significant adverse effects on the patient s relationship with their caregivers and family members (Stovsky, Rudy, & Dragonette, 1988; Fowler, 1997). It is important to begin with a basic understanding of how nurses tend to interact with acutely ill patients. The literature unequivocally states that there is a significant relationship between the patient s perceived state of responsiveness and the degree of positive communication by the patient s nurse. Nurses tend to have more positive communication encounters with patients they perceive as being more responsive (Happ, 2001; Ashworth, 1980; Leathart, 1994). This was clearly outlined in Ashworth s study (1980) of communication difficulties between nurses and intubated patients. Ashworth observed the communication interactions between nurses and patients on five intensive care units in England. Her investigation analyzed the factors which influenced

20 7 communication between 39 intubated patients and 115 nurses. Her findings suggested that 71% of all communication was considered to be task-related and short in duration (less than a minute). She defined task-related encounters to involve commands and questions mostly associated with instances of physical care. Ashworth s findings were confirmed in similar studies conducted by Saylor and Stuart (1985) and Leathart (1994). The Saylor and Stuart study examined the nurses who were assigned permanently to intensive care units and enrolled patients who were intubated and conscious. Their findings suggested the more alert a patient was perceived by the nurse the greater the opportunity for interaction. Leathart (1994) designed an exploratory study to determine the state of communication between conscious, intubated and orientated patients, and intensive care nurses. Leathart was interested in analyzing whether nurses were able to identify the needs and problems of their patients. Leathart (1994) identified one significant problem with the state of the literature in this area. She suggested that Saylor and Stuart s (1985) findings must be interpreted cautiously since patients and nurses were aware of the nature of the study and that the results may have been the product of the Hawthorne Effect the subjects responses to questions or performance are biased by the knowledge that they are participants in a study (Treece & Treece 1977). Leathart s findings suggested that intensive care nurses understood the need to communicate with their patients as much as possible but recognized that by minimizing their communication with patients they could reduce their own anxiety. This is an interesting finding and one that references the importance of enhancing communication options for patients to reduce the patient s and nurse s levels of anxiety. Studies have suggested that the amount and quality of nurse-patient communication may be constrained by the nurse s level of experience in the intensive care units (Benner, 1984; Bergbom-Enberg & Haljamae, 1993). More experienced nurses, with more than 5 years of experience, are more familiar with the technical tasks

21 8 involved in patient care and can absorb more easily the gravity of the overall situation. In these situations, where the nurses are not overwhelmed by technical tasks, they can devote more time to establish a relationship with the patient (Bergbom-Enberg & Haljamae, 1993). Rotondi A, (2002) designed a prospective cohort study of 150 patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit at four East coast tertiary-care university based medical facilities. The patients included in this study received mechanical ventilation for 48 hours or more during their stay in the ICU. The investigators used a 32 item questionnaire that probed the patient s feelings and experiences while hospitalized on the ICU. While not all patients remembered any of the experiences outlined in the questionnaire, those that did recall events related to their hospitalization described them as being moderately to extremely bothersome. Patients recalled having experienced fear, anxiety, lack of sleep, nightmares, poor sleep patterns, feeling of tenseness, loneliness, spells of terror, and nervousness when left alone and an inability to speak/communication. The researchers argued that the data highlights the need for improved symptom management in order to reduce stressors associated with the ICU and improve patient outcomes. Fowler, (1997) interviewed 10 patients who experienced impaired verbal communication during short-term oral intubation on surgical critical care units. Her findings outlined the patients reported feelings of discomfort, fear and instances of frustration. Specifically, the patients interviewed reported a strong desire to communicate feelings of pain and discomfort, concerns and difficulties related breathing and suctioning, the desire to have more knowledge of the length of mechanical intervention, the need for restraint use, and questions regarding physical status and general family well-being. Fowler suggested her findings should be used to educate patients and families and to develop better patient driven communication tools.

22 9 Several research studies clearly outline the powerlessness that is experienced by the patient with impaired verbal communication due to oral intubation and suggest this feeling is shared by the patient s communication partner as well (Stovsky, Rudy, & Dragonette, 1988; Fowler, 1997). The need to empower the critically ill patients is vital and may be a factor in their rate of improvement (Pear, 2008). In summary, the literature suggested nurses have more contact with patients they perceived as being more alert. In addition, nurses recognized they could manage or reduce their own anxiety by reducing their communication attempts with patient who they perceived to be less alert. Nurses communication interactions with acutely ill patients tended to be isolated and limited to direct nursing care. Lastly, the literature suggests that the nurse s level of experience can impact the nurse s ability to manage the duties associated with general nursing care and the interactive quality of exchanges with the patient. From the patient s perspective, difficulties experienced during times of impaired verbal communication foster feelings of anxiety and frustration. Improving nurse-patient communication will reduce the feelings of frustration and anxiety for the patient and lead to increased patient satisfaction. These findings highlight the need for basic nurse training related to patient-provider interactions and have implications for practice-standard improvement and the development of communication tools for the nurse. A Review of Nurse-Patient Communication For Hospitalized Patients with CCN Imagine if you had been a patient described in Fowler s study and had a strong desire to communicate information regarding a basic but vital function, your breathing, but would have been unable to do so; how would you feel? How would you react when your actions or attempts to communicate were met with misinterpretation? Imagine your

23 10 inability to communicate limits your ability to convey your feelings to your family regarding how much you care for them during critical periods in your life, which may include end of life care. These common occurrences leave individuals receiving temporary ventilatory support who have intact language systems experiencing an inability to communicate effectively with their family members or medical providers. This often results in healthcare providers discussing pertinent issues about the patient s medical status with their families but typically not with the patient. Often this vital communication exchange occurs around the patient and without any consideration for inclusion of the patient (Hemsley, Sigafoos, Forbes, Taylor, Green, & Parmenter, 2001). The barriers precluding patients from communicating could contribute to a sense of hopelessness and depression. While there is clear agreement that effective communication enhances nursing practice, the literature regarding nurse-patient communication for patients with CCN is miniscule. In an attempt to expand our understanding of how nurses communicate with patients with CCN, Hemsley et al. (2001) interviewed 20 nurses who cared for patients with CCN. Data collected offered insight into both positive and negative experiences from the patient s viewpoint. Not surprising, findings suggested the nurse-patient communication is difficult when the CCNs are added to the equation of the patientprovider communication process. Hemsley et al. (2001) added the instances of communication breakdown experienced by the patient stemmed from a lack of readily interpretable communication systems that nurses could use during communication exchanges with their patients. The authors concluded that nurses need to collaborate with speech-language pathologists on the development of pre-admission information regarding communication status. They also highlighted the need for additional nurse training in the area of alternative modes of communication and specifically for implementing bedside strategies to communicate with hospitalized patients with CCN.

24 11 Finke, et al, (2008) conducted a systematic review of twelve studies of nurse communication with patients with CCN that focused on the use of AAC solutions. Specifically, their review identified: (1) the importance of the communication act; (2) perceived barriers to effective communication; and (3) recommendations for improving communication exchanges between nurses and patients with CNN. Nine of the studies reviewed highlighted the importance of communication between nurses and patients with CCN. Eleven of the studies acknowledged evidence of perceived barriers to effective communication between nurse and the patient with CCN; with barriers being perceived as directly related to the lack of AAC knowledge and training in seven of the studies. Attitudinal barriers were also noted in 6 of the studies specific to the nurse s belief that patients with CCN may have no real need to communicate, while some nurses felt it was not their job to provide the CCN patient with any tools or strategies to enhance their ability to communicate with the nurses. Finke et al (2008) noted that 8 of the 12 studies identified access to communication tools as barrier to effective communication. Finally, 4 of the 12 studies specifically identified offerings of improved nurse training in the area of AAC. Interestingly, this recommendation was cited by patients, the patients primary caregiver, as well as by nurses. Specifically, Finke, et al (2008) concluded that there was a need to train the nurse on how to communicate with patients regardless of the severity of patient s CCN. Hemsley, et al. (2007) reviewed nurses interactions with patients who presented with severe CCN secondary to the patients neuromotor condition. Their findings suggested that even when the patient with severe CCN reported attempting to be proactive to ensure that communication would be optimal prior to hospitalization, communication with nurses was rarely successful. This communication failure occurred despite their having provided the nurses with written instructions on how they communicated prior hospitalization (Hemsley, et al. 2007). Even more alarming was the

25 12 evidence to suggest that at a minimum, CCN patients perceptions were that basic cares often went unmet (Buzio et al. 2002). Certainly such findings could result in patient dissatisfaction and possibly a potential sentinel event. These findings are alarming for several reasons: 1) the perception on the part of the nurse that it is not nursing s responsibility to fix any instance of communication breakdown for patients with CCN 2) the intrinsic attitudes that the nurse may have toward individuals with disabilities that are unrelated to the medical event that has resulted in the patient s hospitalization 3) the lack of training the nurse may have received regarding communication enhancement for the CCN population. Barriers such as these need to be overcome. There is growing evidence that good or strong communication may assist patients recovery, whereas poor communication may affect the recovery process (Russell, 1999; Hemsley, et al, 2001; Finke et al, 2008). The evidence is clear that nurse-patient communication is essential and should be improved (Hemsley et al. 2001; Caress, 2003; Jones, 2003; Kettunen, Poskiparta, Karhila, 2003; Goode, 2004; Shattell, 2004; Fleischer, Berg, Zimmermann, Wuste, Behrens, 2009). It also suggests that there is a need for communication training for nurses who encounter hospitalized patients with CCN (Kruijver, Kerksta, Francke, Bensing, Harry, van de Wiel, 2000; Finke, Light, Kitko 2008). Nevertheless, significant barriers to effective communication between healthcare providers and patients with CCN exist (Bergbom-Engberg & Haljamae 1993, Leathart 1994, Hall 1996, Baker &Melby 1999, Happ 2000, Balandin et al. 2001, 2007,, Buzio et al. 2002) Hemsley et al. 2001; Robillard 1994). In order to better understand and identify barriers which exist for patients with CCN, a broader understanding of these barriers can be achieved by applying the participation model proposed by Beukelman & Miranda (1998).

26 13 Applying this model will address and identify opportunities and barriers that may preclude participation; noting that barriers to participation are not always physical and may be policies, practices, attitudes, knowledge, and skills that preclude successful use of an AAC system for a user. Additionally, the use of the participation model will help to identify the potential challenges to successful implementation. The participation model and the guidelines set forth by ASHA have been applied to the AAC population in the traditional environments of outpatient clinics, rehabilitation centers and school settings. Traditionally, these settings have been the only venue for AAC candidates to receive services. Implementation of the model in acute care settings is less common but is still applicable. Typically, barriers have been described as being access opportunity barriers and access access barriers with access access barriers being more physical barriers. An exemplar of an access opportunity barrier is the attitude that since the patient is not able to verbalize/vocalize he/she cannot or should not actively participate in the patientprovider communication exchange even when it includes decision making (Hemsley. et al., 2001). Another access opportunity barrier arises from some nurses attitude that it is not nursing s responsibility to implement communication strategies for patients with CCN. Additionally, a practice standard that appears to be pervasive in hospitals that allows the patient s perceived level of alertness to affect the quality of nurse-patient communication exchange would exemplify an access opportunity barrier as well. Lastly, the lack of knowledge and/or training regarding communication strategies to enhance the nurse-patient communication exchange should be viewed as an access opportunity barrier, too. Although some nursing communication pre-service training may exist, the focus of that training has been on more generic interactions and has not addressed training for nurses who deal with individuals with CCN (Raines 1993; Kruijver, Kerkstra, Francke, Bensing, Harry, van de Wiel 2000).

27 14 An identified access access barrier is the lack of equipment available to enhance the nurse-patient communication or the physical limitations of the patient and/or the environment itself, i.e., poor lighting and inaccessible nurse call buttons. While access access barriers can be more difficult to change, they need to be part of practice guideline standards and integrated at the earliest level of the nurse s pre-service training. Logically, it follows that the state of practice as it relates to nurse-patient communication for hospitalized patients with CCN must change. We should no longer ignore the patient s negative feelings and experiences associated with limited or no verbal communication during hospital stays. Basic cares should not continue to go unmet for this population and attitudinal, policy, equipment and knowledge barriers need to be overcome, as well. Nursing science must integrate its own theories of nursing care with theories of communication from other disciplines (Fleischer, Berg, Zimmermann, Wuste, & Behrens 2008). Speech-Language Pathology is uniquely positioned to assist in developing practice guidelines for enhancing nurse-patient communication for patients who experience physical, emotional and psychological barriers to successful communication during hospitalizations regardless of the underlying etiology, disease or treatment regime. The use of AAC strategies and solutions is critical for application to this population and to educate and offer implementation and support to nurses about AAC strategies and systems. A Review of the Literature On AAC Solutions for Patients with CCN Although there is extensive literature on the use of AAC with more traditional candidates, there are fewer studies addressing the use of AAC with patients with a temporary oral language impairment or who are acutely ill and often cannot communicate

28 15 and participate in their own care (Baker & Melby, 1996; Robillard, 1994). While the literature on the use of high-end AAC options is sparse, there are four medical centers that have pioneered the use of AAC in acute care settings. They include: Costello s (2000) work at Boston s Children s Hospital, Happ et al., (2005) research at the University of Pittsburgh Medical Center, Etchels et, al. (2003) at the Ninewells Hospital in Dundee and Hurtig and Downey (2005, 2006, 2009) on the implementation of highend speech generating devices at the University of Iowa Hospitals and Clinics (UIHC). The work at these four centers represents the genesis of implementation of AAC in acute care settings and will be reviewed more thoroughly below. Costello (2000) studied a model for preoperative AAC interventions for patients with planned admissions to critical care units due to anticipated surgical management needs. He reported on 43 patients ranging in age from 2.8 to 44 years of age who experienced temporary loss of speech secondary to intubation, tracheostomy, and/or mechanical ventilation. He outlined the details of preoperative and postoperative interventions as well as strategies for patient directed vocabulary selection and digital voice message banking, using a range of low to high-end AAC devices (e.g. Step by Step, single message unit, and DynaVox, a dynamic display SGD available from, Costello conducted discharge interviews with patients and family members suggesting that the Boston Children s Model successfully addressed the anticipated need to communicate via alternate means, as 100% of the participants denied feelings of frustration, or stress due to their inability to speak. Happ et al. (2005) investigated the use of voice output systems with patients following surgical procedures for head and neck cancer. She studied 10 patients with a mean age of 57 years who received electronic speech-generating devices, but retained functional writing abilities, following their surgical intervention. She offered patients a choice of two different voice output devices: (a) the Message Mate, a multi-level

29 16 communication aid that uses digital speech and offers the patient up to 32 messages per level previously available from Words+) and (b) the DynaMyte, a high-end communication device with unlimited vocabulary/message options, on-screen text to speech options and environmental control capabilities, as well as allowing patients the option of hand writing, Her findings suggested most patients preferred writing and gestures to a voice output device, but noted voice output devices may be more practical for patients who want to construct complex messages in the immediate postoperative period. It is important to note that there appeared to be two potential negatively influencing factors in this study. First, the Message Mate limits the user s vocabulary and does not provide the user with environmental control options, which can be critical in empowering the patient and lead to the patient s interest in using the designated communication system. Secondly, the use of the DynaMyte, while providing its users with an on-screen keyboard, is not as efficient as more standard text to speech devices such as the DynaWrite or LightWRITER ( if the patient is primarily using the text to speech option. The DynaWrite and LightWRITER devices provide users with a standard keyboard allowing them to use actual keyboarding skills, as compared to the one-handed hunting and pecking strategy that is typically displayed by most users of an on-screen keyboard. Thus, Happ s device selections may have been viewed by the users as either being too limiting or too slow. This led Happ to conclude that the barriers to successful implementation of high-end AAC systems may be addressed by design improvements, staff education, and individual assessment by a speech-language pathologist with expertise in AAC. The ICU-Talk project (Etchels et al. 2003) was collaboration among the Department of Applied Computing and the School of Nursing and Midwifery at Dundee University and the Department of Speech-Language Pathology and Intensive Care Units at Ninewells Hospital, Dundee, to examine the communication problems of their patients.

30 17 Their collaboration led to the initiation of prototype software termed ICU-Talk, which was designed specifically for their intubated patients who were alert and interested in communicating. They surveyed nurses who cared for 19 patients who were years of age and who used ICU-Talk. The patients involved in this study were unable to write. Their results included the following: 1. 68% of the nursing staff indicated they needed to cue the patient to use ICU-Talk; 2. 44% indicated that the patients also used ICU-Talk with someone other than the nurse; 3. 12% indicated that patients used ICU-Talk as the first means of communication; 4. 44% indicated that ICU-Talk helped with patient care; 5. 24% indicated that ICU-Talk did not interfere with their observation(s) or care of the patient; 6. 72% indicated that the patients stopped using ICU-Talk and preferred other forms of communication; and 7. 76% indicated that they did not find it difficult to understand the patient when they used ICU-Talk. Again, these findings highlight the need to examine the patient s needs and desire to communicate in acute care settings, as well as the nursing and medical staff s desire to provide the acutely ill patient with more effective and efficient communication options. Hurtig and Downey (2005, 2006, and 2009) have piloted the use of a range of high-tech communication systems in critical care and step-down units at the University of Iowa Hospitals and Clinics (UIHC) with patients who demonstrated CCN. They evaluated the use of a range of speech generating devices (DynaMyte 3100, DynaVox 3100, DynaVox DV-4, MT-4, V and Vmax, Vanguard Plus, wwwprc.com; Mercury and the Mini Mercury, and Tobii C12 and C15 with patients on ventilatory support in the Pediatric Intensive Care Unit

31 18 (PICU), the Surgical Intensive Care Unit (SICU), the Medical Intensive Care Unit (MICU), and the Respiratory Specialty Care Unit (RSCU). They have studied more than 100 patients ranging in age from toddlers to the elderly. They found the range of patients they studied were able to use the AAC devices and effectively communicate with their caregivers and family members. Hurtig and Downey focused on evaluating the benefit(s) of AAC, which included the use of switch activated systems, in recovery outcomes of patients who required the use of a mechanical ventilation system or who had compromised motor function due to trauma. The majority of their patients liked the enhanced communication the AAC systems provided and the ability to use the environmental control options that the systems provided (e.g. access to nurse call, control of the TV, lights and fans and access to the internet) during their hospital stay. Hurtig and Downey s work suggests that high-end assistive technology can be implemented with a variety of patients across the lifespan with various etiologies and prognoses. This contradicts earlier studies (Fried-Oken et al., 1991) which indicated that the use of highend speech generating devices was not the preference of most acutely ill patients. One reason for the change may be due to significant advances in AAC technology as well as the implementation strategy utilized by Hurtig and Downey that allowed for greater fidelity of implementation of high-end AAC systems with acutely ill patients. The implementation of AAC systems at UIHC has been broadly applied to a wide range of patients all who have required ventilatory support (i.e. trauma, cancer, neurodegenerative diseases, Guillian-Barre, organ failure and transplant patients). Given the wide range of etiologies, introduction of AAC systems varied such that some patients received the systems prior to intubation while others after they had been intubated. Hurtig and Downey found that across all of their patients providing an AAC system with an environmental control component (ECU) served as a critical motivator to engage use by patients of the ECU and use of the system for communication as well. Thus, introducing

32 19 an ECU is a starting point for the most challenging patients, or patients facing long-term disability. A patient who demonstrates the ability to communicate or control his/her environment will be viewed as being more responsive. Hurtig and Downey found that these systems with ECU also led to greater implementation by nurses and doctors. The AAC systems implemented at UIHC were customized to the needs of each patient and were designed based on screening of the patients sensory status, alertness level, motor abilities, cognitive-linguistic status, and reading abilities. Hurtig and Downey (2009) relied on nursing staff to alert them to patients who would benefit from high-end communication devices. They, as well as others, have recognized the importance of the role nurses play (Happ, 2001; Dowden, Beukelman, Lossing, 1986). Thus, the success of the implementation of these devices at UIHC needed the combined support of the nurses and nursing administration. Nursing Understanding of AAC Given that the work at UIHC identified nursing staff as a key component to successful implementation of high-end AAC systems in acute or critical care units, a needs assessment of the UIHC nursing staff s understanding of AAC was conducted in the summer of The needs assessment was aimed at obtaining information regarding the following: 1.) The working knowledge of inpatient nurses' knowledge of AAC options for acute care patients. 2.) The framework for future training needs of UIHC inpatient nurses as it pertains to AAC use with acute care patients. The needs assessment solicited responses to an on-line anonymous nursing survey of 12 questions to obtain quantitative descriptive data concerning use of AAC at UIHC (see Table 1.1). Data was obtained over a two week interval. An

33 20 solicitation was sent to 822 registered nurses and/or advanced nurse practitioners at the UIHC. All responses to the online survey were compiled and stored on a password protected computer at the Assistive Devices Laboratory in Wendell Johnson Speech and Hearing Center. The findings of this needs assessment were published in the article entitled Re-thinking AAC in Acute Care Settings (Downey, & Hurtig, 2006).The following provides a brief overview of the findings: During the two week interval 133 registered nurses and 2 advanced practitioner nurses responded to the survey. While only 16% of UIHC nurses responded, those that did respond represented all levels of years of nursing experience (See Table 1.2). Only 35% of the nurses at UIHC indicated that they were aware of the term augmentative/alternative communication. Thirty-five percent of the nurses surveyed indicated that that they were aware of an AAC Service at UIHC (even though no formal services existed). Of the nurses who responded 95% indicated that they have had patients who would have benefited from the use of AAC; 96% of those responding indicated that any form of AAC would most likely help their patients. Given these findings, it was determined 96% of these nurses desired an opportunity to learn more about AAC. The percentage of nurses responding varied across the inpatient units at UIHC. It was noted that the units where Hurtig and Downey had been most active in implementing some form of AAC had higher response rates (Table 1.3). The highest response rate (59%) came from the Surgical Intensive Care Unit. This is the unit in which the idea of the use of AAC in acute care was initiated by Dr. Hurtig in collaboration with the Department of Neurosurgery to develop a communication system for temporarily ventilated patients. The mean response rate across the various units was 16%. Other units with a response rate between 20-30% included: Medical Intensive Care Unit, Child

34 21 Med Psych, Psych, Hematology/Oncology, Pediatric Intensive Care Unit, Pediatric Cardiology, Bone Marrow unit, Oto/Eye/Oral surgery, GI Surgery/Transplant, Adult Psych, Intermediate Pulmonary Care Unit, and RCW-Medicine. The most striking result was that 100% of the nurses surveyed indicated that they have had a patient for whom communication was difficult. Additionally, 98% of the UIHC nurses indicated that they have worked with patients who could not successfully access a conventional nurse call system. Ninety-nine percent of the nurses indicated that they have used alternate forms of communication. The types of alternate communication most commonly used among those surveyed included: paper pencil 96% alphabet board 65% picture or symbol board 80% sign language 35% electronic voice output device 46% lip reading 70% other please specify 18% o o o o o interpreter service guessing assistive technology body gestures the use of stethoscope placing a stethoscope on the lamina of the thyroid to aid in hearing the patient s mouthing attempts a clearly (an impossible strategy). A breakdown of the types of AAC interventions used on the critical care units at UICH is listed in Table 1.4. It is important to note that several forms of AAC options are

35 22 being implemented on these units, thus confirming the nurses recognition of the need for multiple AAC strategies. Because the opportunity and need for nurses to interact and communicate with patients is high, it is important to address times during acute care when such interactions and typical communication patterns are altered. Atypical communication and altered interactions between nurses and patients occur at a high rate on critical care units (Happ, 2000; Etchels, 2003; Robillard, 1994). Clearly, there was compellingly evidence that all UIHC nurses encounter patients for whom communication and/or access to the nurse call is difficult. Additionally, the needs assessment highlights their strong desire to increase their ability to enhance communication opportunity for all patients. Although the units which were more vocal in this survey were those for whom AAC may have been more common (MICU, PICU, SICU, IPCU), these, also, are the units that are most likely to encounter more patients who are unable to communicate in a typical fashion. Additionally, while the needs assessment indicated that several forms of AAC were implemented in these units, it was clear that the higher-end forms of AAC (i.e., voice output devices) were being implemented in the critical care units at UIHC. The most common AAC interventions the nurses reported using were paper and pencil (96%) and picture boards (80%). Both require the patients to have intact upper extremity function. In addition, both require that the patient have immediate and continual access to these aids, something that may not consistently occur. Thus, these highly implemented techniques may not be accessible to a patient. And while 70% of the nurses reported that they used the technique of lip reading, the needs assessment did not address how successful the nurses were at understanding the messages via lip reading. Previous studies have documented that lip reading is often ineffective and may result in increased stress for the patient whose message is unheard (Etchels, et. al., 2003; Robillard, 1994).

36 23 An important finding that should be mentioned indicated that 34% of the nurses surveyed were aware that an AAC Service was available at UIHC, when in fact, no such service exists. Downey and Hurtig (2006) hypothesized that the nurses who responded positively to this question were confusing such a service with the research protocol entitled The Use of AAC in Acute Care Settings currently being implemented by Hurtig and Downey. Perhaps the most important finding of this needs assessment was the nurses willingness to learn more about AAC with 96% of the respondents indicating a desire for additional training. These findings highlight the recurring themes reviewed in literature of the importance of nursing in the implementation of AAC in acute care settings and the need for nurse training as it relates to AAC implementation. The need to assist the nurse in understanding how to communicate with a patient with CCN is paramount to the successful implementation of any AAC system. Limiting the breakdown in communication that may lead to sentinel events and increase the patient s level of anxiety and frustration is critical. Training nurses to participate and proceed in the implementation of a form of AAC within the acute care setting is a part of optimal care (Kruijver et. al., 2000). As stated earlier, Finke, Light, Kitko (2008) argued for more support and training of nurses on the strategies they should use to communicate more effectively with patients who demonstrate CCN. Given that nurses are not the only healthcare professionals who communicate with critically ill patients with CCN, any training on communication strategies should be designed to meet the needs of all healthcare professionals. When one considers how positively the JC values the implementation of AAC strategies for acutely ill patients with CCN, institutions will be obligated to insure that all staff are adequately trained in their use. Nursing and healthcare training should provide a framework to allow for successful implementation of all forms of AAC system (i.e., low- to high-end options).

37 24 Furthermore, the literature supports that the education of nursing staff include responding to patients perceived frustration and increased stress levels when low-end AAC options fail. The development of any healthcare or nursing in-service(s) or training protocol(s) must include the following: 1.) Screening protocols placing specific prominence on a hierarchy of assessment tasks permitting rapid decision making and minimal efforts by the acutely ill patient (Dowden, Honsinger, Beukelman, 1986). 2.) A thorough assessment of communication needs related to communication, partners, environment and desired messages, as critically ill patients are unable to participate in lengthy evaluations/trials (Dowden, Honsinger, Beukelman, 1986). 3.) A set of strategies to allow the healthcare staff to learn new communication techniques to allow for immediate enhancement of the patient s ability to communicate. 4.) Familiarity with the range of AAC systems for providing enhanced communication options for the patient with CCN. The aforementioned review of the literature makes clear the need for training and the elements of the training. What has not been addressed is how that training should be delivered. Should the tutorial be delivered live in a more traditional classroom or clinical setting or would there be value in e-learning using some form of an online medium? While there is a general trend towards on-line training/education, there is very little evidence to allow an informed choice of on-line over live training. The State of Online Training Online education, on-line training, e-learning, or computer based training are all rapidly becoming alternative methods of instruction and degree completion, as indicated by the multitude of course offerings available ranging from gardening to constitutional

38 25 law. While on-line instruction is no longer considered new and novel, the phenomenon of e-learning/ easy access has permeated in-service and on- the- job training, as well. Online training has become increasingly more common in the workplace. As an example, the majority of the JC mandated training for the University of Iowa Hospitals and Clinics professional staff (non-physicians) is delivered via a series of online tutorials. This includes issues related, but not limited to: fire training, mandatory reporting, biomedical hazards, and personal safety including blood borne pathogens, restraint use for patients, sexual harassment in the workplace, HIPPA violations and ethical practice. This shift in the delivery of training has emerged over the last decade. This type of training medium offers the hospital enhanced economical and flexible features allowing managers the means to deal with time constraints for their employees more effectively. Consider the cost effectiveness and time- saving features for the hospital: hiring a trainer, scheduling an area/classroom, and finding times to train are no longer needed. Additionally, employees who work offsite no longer need to travel to training sites nor do satellite training sessions need to be installed. Within a highly digitized world, the employee simply logs onto a computer and accesses the training at their leisure. Given today s economic climate, institutions are often managing the training needs of their workers using web- based training(s) due to cost effective measures and the ease of implementation that online training offers. While many studies have documented the benefits of online learning (Bartolic- Zlomislic & Bates, 1999; Clarke & Hermens, 2001; Evans & Haase, 2001) other researchers have doubted the effectiveness of online training for both the learner and/or the organization (Kilby, 2001). Jackson and Anagnostopoulou (2001) argued that there needs to be an evaluation to determine if online training is meeting the goals originally set during the initial planning process. They argue that without the evaluation of the

39 26 learning and performance of the learner, any business or organization may encounter an untrained, unprepared workforce. Finding the right course of action for training needs must ensure that there is motivation built in for the learner. Online training is more self-directed than traditional face- to- face learning situations. Research into the reasons why students drop out of online or distance learning courses revealed issues relating to boredom and the student s desire for a more engaging learning environment (Kyong-Jee & Bonk, 2006). Another factor associated with limitations of online learning centers on the delivery platform itself. Learners reported experiencing technical difficulties which either prohibited them from task completion (Kyong-Jee & Bonk, 2006) or caused them to lose confidence in the medium being used. The benefits of online training are attractive to the business and institution worlds. However, this type of training needs to include the learner in the process of meeting and learning the original goals of the training sessions. When considering the learning theories associated with e-learning, it is important to review Anderson s (2003) equivalency theory. Anderson suggested if the educational experience delivered online was viewed by the learner as equivalent to live or face- toface interaction; then the notion of equivalency exits. He added that one can then assume the outcomes associated with online learning should be equivalent, too (Anderson, 2003). It was Anderson s theory of equivalency that assisted this author in designing the training protocols outlined in this project. No items intended for use in a live or face- toface interaction were omitted in the online version of the training used in this study. The tutorials were designed to highlight the problem first, in an attempt to create a participatory response from the nurse and/or healthcare worker from the onset. Additionally, the factors which might lead to boredom were considered; consequently the training protocol was shortened from 60 minutes to 30 minutes with short and

40 27 specifically defined topics. This was done to avoid overwhelming the learner with too much information. Additionally, short video modeling clips were embedded throughout the tutorial as means of keeping the learner engaged and motivated. An option for review was built into the tutorial as well, as each learner is unique and may desire review or a structured question/answer phase. Lastly, to test the tutorial s effectiveness a comparison of live versus on-line modes of delivery were considered important to examine. Statement of the Problem The review of the literature suggests the need to develop training protocols for nursing staff for the effective implementation of AAC in acute care settings. And the needs assessment conducted in the Summer of 2006 indicated UIHC acute care nurses desire training in the area of AAC implementation for their patients with CCN (Downey & Hurtig, 2006: Hurtig and Downey, 2009). At the onset of the study, there is no generally used protocol for training acute care nurses in: a) Identification of patients who would benefit from AAC use; b) The implementation of AAC in acute care settings; or c.) d.) Methods for enhancing communication strategies for CCN patients; Nor is there evidence that any type of training protocol would effectively enhance clinical practice. Any tutorial must be constructed to allow the nurse and other general healthcare providers to assimilate the information from the tutorial into their practice, regardless of their level of education or job title( i.e., unit clerks, LPNs, pastoral care) This generality is necessary if we are to change the attitudinal, knowledge, and policy barriers currently pervasive throughout most hospitals.

41 28 The object of this study is to test the efficacy of a tutorial teaching the use of AAC strategies for use with patients with CCN in acute care settings, using both an online and live delivery mode. The study is designed to examine the effectiveness, measured in terms of test scores, of an AAC training module designed to increase UIHC acute care nurses and other potential healthcare providers knowledge about the needs of patients with CCN and AAC strategies.. Elements of the Study The Tutorial The tutorial includes five key elements and is approximately 30 minutes in length with an option for review. The five areas addressed include: 1) An outline of the problem associated with patients who have CCN and why it is important to provide the training for healthcare staff. This would include information regarding prevalence, a short literature review of pertinent issues specific to nurse interactions but applicable across the healthcare domain; 2) An outline of the importance of having a yes/no response for patients with CCN as well as how to develop a working yes/no response for a patient with CCN at the bedside; 3) A review of candidacy for implementation of AAC strategies for patients with CCN; 4) A review of low- to high-tech AAC systems and demonstration of their use with CCN patients; and 5) A review of troubleshooting strategies for the nurse to use with high-tech AAC options the speech-language pathologist may have deployed at the bedside for patients with CCN to use. The strategies should be easily implemented by the nurse or other healthcare professional.

42 29 This study is an attempt to develop meaningful training protocols for acute care nurses while being cognizant of the manner of delivery in terms of cost effectiveness and ease of access. The specific aims of this study are to: Develop a tutorial to provide nurses with an understanding of the importance of effective patient-provider communication and to provide nurses strategies for enhancing communication with their patients with CCN. 1) Develop a simple tool to assess nurses knowledge of patientprovider communication and techniques to enhance communication with patients with CCN. 2) Develop a set of scenarios to evaluate nurses ability to generalize knowledge of patient-provider communication strategies. 3) Evaluate the difference between self-directed access to an online tutorial to a proctored presentation of the tutorial content. While obtaining a measure on a change in actual clinical practice is desirable, it is beyond the scope of this study.

43 30 Table 1.1 UIHC AAC Nursing Needs Assessment Queries UIHC AAC Nursing Needs Assessment Queries 1. Description of nursing role? (i.e., LPN, RN, APN) 2. Years of experience? 3. Assigned unit? 4. Have you had a patient for whom communication was difficult? 5. Have you ever had a patient that could not successfully use a conventional nursed call? 6. Have you ever used an alternative form of communication with a patient? 7. Are you aware of the term Augmentative/Alternative Communication (AAC)? 8. Do you know if there is an AAC service at HIHC? 9. Do you think that there are patients you serve who might benefit from AAC? 10. Do you think that a form of AAC might help your patients?

44 31 Table 1.1 Continued 11. Would you like the opportunity to learn more about AAC for your patients? 12. If you answered Yes to Question 5 above, indicate the type(s) of alternative communication you have tried with your patients (Drop Down Box appeared with the following options: paper-pencil, alphabet board(s),picture or symbol board(s), sign language, electronic voice output devices [computer], lip reading and other please specify).

45 32 Table 1.2 Years of Nursing Experience Years of Nursing Experience Less than 1 year years years years years years 27

46 33 Table 1.3 UIHC Response Rate per Unit UIHC Nursing Units % of Response per Unit 1 JPE CHILD PSYC UNIT 27% 1 JPW ADULT PSYC UNIT 0 2 JPE GERIATRIC PSYCH UNIT 8% 2 JPW ADULT PSYCH UNIT 20% 4 SE MED PSYC 29% PICU 24% CWS SNU RN s 0 2 JCP PEDIATRICS CARDO 23% 3 JCP/7 RCE 2 PEDIATRIC HEMO 14% CVICU 5% IPCU 20% MICU 29% SICU/ALL BAYS 59%

47 34 Table 1.3 Continued 2 RCE NEUROLOGY 15% 4 RC SURGERY/MED (MSCU) 13% 4 JCW MED CARDO 6% 6 JCP NEUROSURGERY/NEUROLOGY 4% BURN CENTER 13% 3 RCW ORTHO/UROLOGY 10% 3 JPW OTO/EYE/ORAL SURGERY 22% 4 JPE H HEMATOLOGTY/ONCLOLGY 25% 4 JPW MED/SURG ONC 11% 6 RCE MEDICINE 20% 6 RCW 19% 7 JCE/2 RCW GI 21% 2RCW 0% 7 RCW BONE MARROW 23% CRU RN S 4%

48 35 Table 1.4 Breakdown of Critical Care Units use of Varying Forms of AAC Forms AAC of SICU PICU MICU RSCU Paper Pencil & 100% 92% 100% 100% Alphabet Board 100% 75% 92% 100% Picture Board 90% 92% 85% 100% Sign 40% 41% 2% 0% Language Electronic 50% 100% 50% 75% Device Lip 95% 83% 100% 25% Reading

49 36 CHAPTER 2 METHODS The elements specific to the research methods of this study include a description of the tutorial and its content, justification for use of video clip examples embedded in the tutorial, learning assessments and instrumentation used, a description of subject populations, and implementation of the tutorial with each subject group. The on-line tutorial was developed using Adobe Premier Software and developed in the Nursing Clinical Education Center at the University of Iowa. Video segments embedded into the tutorial were filmed in the Nursing Simulator suites in the Nursing Clinical Education Center at UIHC and were edited using Captivate Software. Description of Tutorial Content The focus of the tutorial can be summarized by paraphrasing a quote from Nelson Mandela, Communicating to a man in a language he can understand goes to his head but communicating in his language well, that goes to his heart. The underlying concept was to produce a tutorial that would allow nurses or other healthcare professionals to understand the content and use it when communicating with patients with CCN. The ultimate goal of the tutorial was to increase general knowledge of the nurse and/or other healthcare providers regarding effective communication strategies for CCN patients and foster a positive practice change in nurses and/or other healthcare providers daily encounters with these patients. In order to accomplish this, an organized and dynamic tutorial with embedded video clips was created using Adobe Premier Software. Because the goal was to foster change across the hospital setting, the generality of the tutorial was considered prior to its development. It was designed specifically to target nurses due to the frontline nature of their discipline. However, the tutorial does offer an appropriate self-learning experience for other healthcare providers, as well. The

50 37 generalization of the tutorial is key as system change must occur at every level of the hospital experience, if true access barriers such as knowledge, attitude, policy and equipment are to be overcome. The tutorial begins with rules regarding on-line navigation and then outlines these objectives of the tutorial: 1. To understand the communication associated with CCN patients 2. To increase communication between nurses and CCN patients 3. To understand the importance of establishing and using a functional yes/no response 4. To identify the range of communication options (low- to high-tech) available for use with patients with CCN The tutorial was designed and laid out with four main components: (1) The Problem: Provide general knowledge of the prevalence of patients who may experience CCN and the impact it can have on communication when no strategies or solutions are deployed; (2) Understanding the Parameters Associated with Patients with CNN: Review how the patient s limited ability to communicate affects them, how nurses perceive patients with CCN, and how nurses interact with these patients. (3) The Yes/No Response: Provide a review of the importance of a yes/no response, instructions on how to develop a yes/no response, and strategies for use of the yes/no response specific to pain management; (4) Low to High Tech AAC Options: Provide an introduction of low- to high-tech AAC systems and solutions appropriate for use with patients with CCN and options that can be deployed at the bedside by healthcare providers if technical difficulties ensue with high-end AAC systems.

51 38 Component 1: The Problem The goal of this component is to provide the nurse or healthcare professional with the buy in to the tutorial. In order to foster a practice change, it is important for healthcare professionals to understand the prevalence of ventilated patients on their caseloads. More than one million patients experience permanent or temporary ventilation during a hospital stay. The literature review highlighted studies detailing patients with CCN reporting feelings of anxiety and frustration. Moreover, this research outlined the negative effect this had on the patient s ability to interact with his or her caregivers and family members (Stovsky, Rudy, & Dragonette, 1988; Fowler, 1997). Specifically, the tutorial was designed to educate the healthcare professional on how complex and fundamental the episodes of an inability to communicate may be. The ability to communicate is crucial during episodes of critical care and end of life care. Therefore, the introduction of AAC and its potential is to provide the nurse or healthcare worker with AAC solutions for communication enhancement for their patients to reduce instances of anxiety and frustration. The final portion of The Problem reviews the literature on the common problems patients with CCN typically experience. It underscores the patients feelings of powerlessness and emphasizes how an inability to communicate may negatively impact the recovery phase (Pear, 2008). The contents of Component 1: The Problem is covered in six slides of the tutorial. Component 2: The Communication Parameters Associated with CCN Patients Component 2 begins with a review of the literature specific to nurses current state of practice specific to acutely ill patients and patients with CCN. This portion of the tutorial highlights the literature that suggests the quality of nurse-patient communication may be constrained by the nurse s level of experience (Benner, 1984; Bergbom-Enberg & Haljamae, 1993) and suggests that nurses may minimize their communication with

52 39 patients who may exhibit CCN as a way to reduce their own anxiety (Leathart, 1994). In addition, the tutorial highlights Ashworth s 1980 important study suggesting nurses tend to interact more with patients they perceive as being more alert. The tutorial then outlines commonly used strategies by and/or with patients with CCN, that are known to be ineffective, such as mouthing, gestures, head nods (Etchels, et. al., 2003; Robillard, 1994). That is followed by a review of Downey and Hurtig s 2006 nursing survey, which identified a number of ineffective strategies. The tutorial then provides an introduction of the JC standards on communication for patients with CCN. Finally, the role of the speech-language pathologist (SLP) as a resource is introduced along with the concept and definition of AAC. The Tutorial then provides a summary to reinforce the need to deploy AAC solutions for patients with CCN. Two key elements for candidacy for AAC are reviewed. They include the patient s need to demonstrate: (1) a functional yes/no response; and (2) the ability of the patient to demonstrate some form of volitional movement. The tutorial outlines that this movement may involve any part of the patient s body and can be miniscule in nature. Examples of tongue into cheek movement, an eye blink/wink and/or minimal movement of fingers, hand, arm shoulder toes, foot, leg or head are reviewed. The contents of Component 2 are covered in 9 slides. Component 3: The Yes/No Response Component 3 begins with a review of the most typical motor responses used by patients with CCN. Examples given include: squeezing of the hand, using eye gaze, thumbs up or down, and head gestures. This is followed by the importance of establishing a reliable yes/no response. This was added to demonstrate to the nurse how easily this strategy can be implemented with patients with CCN. Specifically, it illustrates the implementation of a communication strategy at the bedside without the need of any equipment. The tutorial then introduces the importance of having all

53 40 communication partners use the same type of yes/no response and suggests that the yes/no response can empower the patient with all listeners across all environments. The tutorial addresses the importance of developing a reliable yes/no response to facilitate assessing a patient s attending and orientation behaviors. In addition exemplars are provided to illustrate attempts to obtain two successful completions of two or more tasks involving attending and orientation behaviors. The tutorial also reviews eliciting a correct motor response to a single step command. Examples outlined in the tutorial include: squeeze my hand, blink, stick out your tongue, or shrug your shoulder. The rationale for asking such questions is reviewed. The nurse and/or healthcare provider are cautioned that asking such questions is not to identify a strong motor response but to assess the patient s ability to follow a single step command. Any patient unable to complete at least two of these tasks must be rescreened. Additionally, the tutorial stresses the importance of rescreening patients with CCN on a regular basis in order to check routinely on the patient s AAC candidacy. The tutorial then presents a video vignette highlighting the strategies outlined for developing a reliable yes/no response. That is followed by a description of how to deploy the use of a yes/no successfully. Specifically, the tutorial instructs healthcare provider to only ask yes/no questions, avoid open-ended questions, and to cue the patient to use the identified yes/no response. This is followed by a second video vignette designed to highlight how a yes/no response can be used for pain identification and management. The content of Component 3 is presented in eleven slides, 2 of which include video examples. Component 4: Low-tech to High-tech Options Component 4 is the longest section of the tutorial. It consists of 16 slides all accompanied with images describing the use of low- to high-tech AAC solutions. It begins with an introduction of the various options the healthcare worker might implement

54 41 at the bedside. These include high-tech speech generating devices (SGD) and various switches that may be used as a means of access for some of the more motorically compromised patients. The tutorial introduces the healthcare practitioner to the three main AAC strategies of low-, mid- and high-tech solutions. Low-tech communication options are discussed first: In the tutorial, low-tech strategies are described as solutions consisting of customized picture/word and/or alphabet boards and the use of pen and paper. The tutorial highlights that all of these items are available on the unit for immediate deployment with this population. Customization is emphasized as a key strategy for meeting the individual patient s communication needs. The tutorial then, provides a video clip of a patient with CCN using an alphabet board with some customized messages. Additionally, there is an example of the speechpathologist providing the patient with a brief explanation of how to use the board most effectively. The next AAC strategy outlined is an example of mid-tech solutions. This consisted of SGDs with limited vocabulary options, digitized speech output and a static display utilizing a paper overlay. Additionally, the use of mid-level systems for bilingual patients is introduced as a solution to enhance bedside communication. The tutorial describes how a mid-tech SGD can be used by both the patient and the healthcare provider. The exemplar provides instructions on how to use a static display with 2 rows and recorded/digitized speech for patients with limited English proficiency. In the example, the top row (color coded in a particular color, i.e., blue) contains messages that the patient would want to communicate to the nurse. The labels used on this row are written in the patient s language but the corresponding messages are recorded in English. The bottom row (color coded in a different color, i.e., pink) contains the messages that the healthcare provider wants to communicate to the patient. Labels on this row are

55 42 written in English with the messages recorded in the patient s own language. This example serves to illustrate providing one system that both communication partners can use to communicate key issues vital to the recovery of the patient (i.e., pain management). The tutorial does not suggest that this should replace interpreters for discharge planning, obtaining consent other important making communication exchanges. The tutorial then introduces high-tech options. The high-tech SGDs addressed in the tutorial are described as being micro-computer based devices, offering synthesized and digitized speech options. The tutorial emphasizes that high-tech solutions can be easily implemented at the bedside with acutely ill patients due to the systems programming flexibility and range of access options. The access or selection options, typically used with high-end SGDs include: touch, mouse emulation, and scanning with a switch interface. Although eye gaze as an access modality is now available, this tutorial did not provide a discussion of this mode of access since this method of direct access is too sophisticated to be deployed without the assistance of a SPL trained in the use of such a system. The tutorial then provides another vignette featuring a simulation of an acutely ill patient using a high-end SGD in scanning mode with access via a switch. This vignette highlights the importance of ensuring that a patient can actually see the system and suggests the importance of the need to reinforce the patient s use of the device with verbal praise. The vignette demonstrates how the system can control devices in the patient s environment (i.e., fan controls and nurse calls) through the use of infrared remote control options available with most high-end SGDs. The tutorial then summarizes Key Things to Remember that are critical and when these are overlooked can render a system useless despite its appropriateness. These include:

56 43 Checking the vision and hearing status of the patient Verifying that the patient can see the communication system Ensuring the patient has access to the communication system Encouraging the use of the identified yes/no response and/or low- to high-tech system The next slides in this part of the tutorial provide explanations and video- clip examples of direct and indirect access methods and images of various SGDs typically used with patients with CCN. These exemplars are offered to enhance the awareness and recognition of the various pieces of equipment that the healthcare providers may encounter at the bedside. Direct access is described as the patient s ability to access the device by using his/her hand, a hand-held mouse and/or stylus. Images of how this is accomplished are presented, followed by a video vignette modeling direct access with a patient using her hand, a stylus (yankauer), and a hand-held mouse. This portion of the tutorial also provides instruction on how a pointer/stylus can be fabricated using items found at the patient s bedside. An example is provided on how to use a yankauer;(the plastic tubing connected to the end of a hand-held suction unit) and washcloth. The washcloth is wrapped at the base of the yankauer and taped at the base creating a makeshift handle to allow the patient to hold the stylus easily. Use of a more technologically advanced system (i.e., a hand-held mouse) is also demonstrated. These exemplars are provided to illustrate meeting the needs of a patient who has limited mobility of his or her hand/arm secondary to trauma and/or during restraint. The tutorial then defines indirect access and scanning as an access method to be used when a patient is unable to choose an item/message directly from a selection set due to poor or limited motor control. The use of switch interfaces and scanning methods are outlined. The tutorial reviews mounting platform options for the switches that can be

57 44 used as well. These include; pinning the switch to the patient s pillow or attaching the switch to a towel roll and placing it at the designated access site on the patient s body. These various mounting options can be easily implemented with materials that are readily available on the unit and at the bedside. A video vignette demonstrates how to implement indirect access via a switch interface with switches pinned to a pillow and towel roll. Specifically, the vignette offers exemplars of indirect access via switch use with exemplars that model the use of minimal movements of the shoulder, hand or head that can accomplish switch activation. Furthermore it demonstrates a range of options for individuals with a range of motor limitations. Next, there is a summary of the items that might be available on the unit to assist in adapting AAC systems: washcloths, pillows, yankauers, safety pins and tape. The tutorial reiterates the importance of using readily available items/systems to meet the communication needs of patients with CCN and facilitate the daily bedside cares. The last element in Component 4 includes troubleshooting of high-end systems. The tutorial provides an image of a troubleshooting card outlining solutions for minor malfunctions of the systems. The tutorial identifies the location of the card, hanging atop the IV pole on which the AAC system is mounted. The tutorial reviews the troubleshooting strategies outlined on the card. These solutions include instructions to: Check all battery connections Check the power strip on the IV pole Check directions for resetting the device To page the SLP to obtain assistance, if needed The next slide in the tutorial provides the viewer with an option to move directly to the post-test quiz or to review pertinent information prior to starting the post-test quiz. However, this opportunity for review was only available on the online version of the tutorial. Elements offered for review included:

58 45 Review of general AAC information o o o o o o Prevalence What is AAC Criteria for AAC Items used for AAC adaptation Troubleshooting Contact Information Review of issues associated with nurse-patient interactions o Understanding the factors that can influence the ability of patients with CCN to communicate. o Communication strategies commonly used by nurses Review of AAC Technology Options o o o Low-Tech Options Mid-Tech Options High-Tech Options Yes/No Responses. The review options linked the viewer back to the slides presented in the tutorial describing the topic selected for review. No new content material was created for the review of the tutorial. Unlike the main portion of the tutorial in which the learner could move forward and backward through all the material, in the review navigation was restricted to the particular topic selected for review. However, the navigation buttons on the side of the slide available in Adobe Premier do allow for navigation back and forth from a particular slide (see Figure 2.1). The learner could navigate only to another item targeted under the review category or advance to the next main topic for review. The learner could review each slide in the review process multiple times. Each of the four

59 46 parameters targeted for review is linked to the slides outlined in the bulleted items listed above. The learner had the option to advance to selected items for review or simply advance to the next target topic. The learner could exit the review portion of the tutorial without actually accessing any items for review. The learner had, however, to advance through the four topics of review in order to arrive at the slide that provided the link to the post-test quiz. In summary, the tutorial consists of 47 primary content slides outlining the four primary areas: the problem, understanding the parameters associated with CCN patients, the yes/no response and low- to high-tech AAC options. Each of the four components is announced to the learner in a topic only slide delineating the specific topic. There were 2 slides that followed the last of the 47 content slides of the tutorial. The first of these offered the learner the option for review or la direct link to the post-test quiz. The second slide provided the list of the topics available for review and instructs the learner how to navigate through the review of the content. In total the tutorial included a total of 66 slides. This included the 47 content slides, 2 instructional navigation slides, 4 topic header slides for selecting review content and 13 duplicated content slides. Six key video vignettes are embedded in the tutorial. The average time to go through the tutorial from start to finish was estimated at approximately 30 to 40 minutes (depending on an individual learner s navigation rate). The Use of Videos as Means Of Learning Enhancement The purpose of the tutorial was to advance the healthcare provider s knowledge and foster a practice change. In order to assist the healthcare provider in this process, vignettes of key demonstrations were embedded into the tutorial. Video demonstrations were used to enhance self-managed learning, as there is evidence to suggest positive

60 47 implications for educators and employers who use short video tutorials to foster more effective and efficient outcomes (Luke & Hogarth, 2011). Each vignette incorporated into the tutorial was selected specifically to provide motivation for healthcare staff and ultimately foster a practice change in the following areas: 1.) In the development and use of an effective yes/no response for CCN patients 2.) In the use of low- to high-tech AAC solutions 3.) In the introduction of novel learning conditions which are not common to the healthcare practitioner, i.e., direct and indirect access for patients with CCN. Learning Assessment and Instruments In order to measure the subject s level of learning several testing measures were constructed. A pre-test measure was designed to obtain the subject s baseline level of knowledge of patients with CCN and AAC solutions. Additionally, a post-test measure was constructed to document the change in established learning after exposure to the tutorial. Finally, Scenarios were developed to assist in determining the subject s level of transfer of learning into clinical practice. Basic testing theory and writing principles were applied to the test construction designed to provide the subject with an opportunity to demonstrate prior knowledge and/or the knowledge gained from instruction. From Jacobs, Cheser, Clinton, and Chase s study (1992), these basic principles of test writing were used in the construction of all testing measures. Specifically, test items were written to: Avoid ambiguous language Use language that was familiar to the subject; Use simple syntax structure

61 48 Avoid providing clues to the answer The same principles were applied to the development of the multiple choice questions: Avoid using direct phrases from the tutorial Write all answers prior to the foil Write foils similar in syntax use and parallel in length to the correct answer Additionally, all questions constructed for the pre- and post-test measures were aimed to probe the participant s understanding of general nurse knowledge and practice relating to patients with CCN and general AAC knowledge, AAC practice and AAC candidacy relating to patients with CCN. Pre-and Post-Test Measures Pre-test Question Probes The pre-test measure was designed to obtain a baseline level of all the subjects prior knowledge of the issues and best practice strategies used with patients with CCN. The pre-test consisted of 5 true-false questions and 5 multiple choice questions probing for a prior understanding of 8 critical areas specific to patients with CCN. The areas probed during the pre-test measure related to the subject s prior knowledge of: 1.) The use of non-vocal behaviors as an ineffective strategy for communication with CN patients 2.) The prevalence of patients with CCN they may encounter 3.) The term AAC 4.) Effective AAC strategies 5.) Candidacy criteria for AAC solution; 6.) Communication strategies causing increased frustration for patients with CCN 7.) Nurses interactions with patients with CCN

62 49 8.) The importance of the yes/no response and its use with this population. The rational for selecting the above targeted area as appropriate test probes was based on the review of the literature, the principle investigator s personal experience working with patients with CCN, and with the UIHC nursing staff providing daily care for such patients. The Rational for Pre-test Question Probes Probe 1: The learners prior understanding of the use of non-vocal behaviors as an ineffective strategy for communication with CCN patients. This area probe was selected as the literature clearly documents the use of non-vocal behaviors as being ineffective for patients with CCN (Etchels, et. al., 2003; Robillard, 1994). Additionally, a review of the Downey and Hurtig (2006) nursing survey suggested that nurses at UIHC reported using these ineffective strategies. Probe 2: The learners level of prior knowledge of the prevalence of patients with CCN they may encounter. The issue of prevalence is significant as the probability of encountering a patient with CCN is likely for most healthcare providers. Nurses need to understand that a significant number of the patients they are caring for may have CCN. Probe 3: The learners level of prior understanding of the term AAC. The probe was included to determine the extent to which the term AAC or Augmentative/Alternative Communication is understood by nurses and/or other healthcare professionals. Probe 4: The subject s prior knowledge base regarding effective use of AAC strategies. Since the tutorial targeted AAC strategies and solutions in greater detail than any other topic, it was imperative to probe for the subject s prior knowledge of AAC. Specially, their familiarity with low- mid- and high-tech solutions for patients with CCN needed to be assessed.

63 50 Probe 5: The subject s prior understanding of candidacy criteria for AAC solutions. This area was probed as one of the tutorial goals was having the learners recognize communication solutions for patients with CCN and be able to identify potential candidates for implementation of these solutions. Probe 6: The subject s prior knowledge regarding communication strategies which cause increased frustration for patients with CCN. This area was probed as the tutorial addressed minimizing the use of ineffective communication solutions that can cause increased anxiety and frustration for the patient. Probe 7: The subject s prior knowledge of how nurses tend to interact with patients who present with an inability to communicate through speech patterns. This topic area was probed to gather a more complete understanding of the nurse s prior knowledge of the research in this area. If nurses are aware and demonstrate a high degree of prior knowledge, this could provide guidance for further tutorial development. Scientific evidence and information from the tutorial could be eliminated if the subject s knowledge base of the area is strong Probe 8: The subject s prior understanding of the yes/no response use with patients with CCN: This content was targeted to determine the extent of understanding of the use of an effective non-technical AAC strategy without the benefit of equipment. In summary, probing for the subject s prior knowledge in the above areas provides the base from which to determine the extent of learning following exposure to the tutorial. The specific pre-test items used are provided below (See: Table 2.1, Pretest Questionnaire). Completion of the pre-test measure took approximately 5 minutes contingent on the knowledge base of the participants. Post-Test Measure The post-test questionnaire contained 20 questions, 10 true/ false questions and 10 multiple-choice questions. Purposely, 10 of the questions contained in the post-test

64 51 overlapped the content of the questions in the pre-test, but the delivery format of the questions was altered. Thus any true-false question used on the pre-test was written as a multiple-choice question on the post-test. Likewise, any multiple- choice question used on the pre-test measure was written as a true-false question on the post-test. Ten additional questions were added to the post-test measure, 5 in the format of a true-false question and an additional 5 in multiple- choice format. The 10 additional questions were constructed to assess the participant s understanding of the following issues that were targeted in the tutorial: 1. The JC standard regarding communication 2. The importance of functional communication for patients with CCN and the totality of its impact 3. The development and implementation of the yes/no response 4. Patient candidacy for AAC use 5. The implementation of low-tech solutions 6. The value of the SLP as a resource for the healthcare practitioner 7. Items to consider when implementing a low-, mid- or high-tech AAC solutions 8. Troubleshooting techniques for mid- to high-end solutions These items were selected to cover the content covered in the tutorial that were the aimed at fostering a practice change. The post-test questionnaire is outlined in Table 2.2. Completing the post-test quiz took between 5-10 minutes, depending on the participant s overall competence level. In summary, the pre- and post-test questionnaires were designed to assess the participant s prior knowledge and to assess the impact of the tutorial.

65 52 Scenario Assessment The goal of the tutorial was to foster significant practice changes. Therefore, it was necessary to distinguish a participant s ability to understanding of the principles from their ability to apply those principles to practice. The literature suggests that enabling a sense of self-efficacy is an effective outcome that accompanies mastery experiences (Bandura, 1997). The scenarios assess whether acquire knowledge could be applied clinically an instrument was designed (Scenario-measures) to allow us to estimate a participant s ability to implement knowledge obtained in simulated clinical cases. The use of scenarios offers the benefits of standardization and repetition of content without risk to an actual patient. It also provides the means of assessing learners in goal-oriented clinical experiences/scenarios. The use of competency testing is common for medical personnel. Typically, competency testing requires the use of full-scale, high-fidelity patient simulation giving rise to more proficient clinical practice in a forgiving setting (Wayne, et al., 2005). Competency testing using simulation scenarios is common practice in the education of nurses (Lee, Pardo, Gaba, et al., 2003). Because the focus of this study was on communication between nurses and their patients, the use of simulator testing did not appear appropriate given current simulator technology. Due to the time demands of simulator testing and the lack of nurses availability for testing, a modified online assessment tool was developed. Nine case scenarios were developed to assess the participants proficiency in the implementation of effective communication strategies with patients demonstrating CCN. The scenarios were based on case studies the author and other practicing professionals most commonly encountered during actual care of patients with CCN in the acute care setting (Hurtig & Downey, 2009).

66 53 Typically, the development of scenarios is accomplished using scenario software designed for use in high-fidelity patient simulators at the University of Iowa Nursing Clinical Education Center. Although this study did not use the patient simulator facility, the scenarios used in this study were designed to include all the necessary elements used in medical scenario development. The scenarios were developed with the assistance of Mark Miksch, Instructional Services Specialist in the Department of Nursing Administration at the University of Iowa Hospitals and Clinics. A primary responsibility of Mr. Miksch s duties is the fabrication of on-line training used by nurses in the Nursing Educational Center at the University of Iowa. With Mr. Miksch s assistance, the investigator designed nine separate scenarios. This included outlining for the respondent the necessary medical profile and conditions to simulate the desired patient problem. Using these scenarios allowed the nurses to apply practical knowledge independently without commentary or direct instruction. The scenarios targeted three topics: 1. Patients with CCN and sensory issues 2. Patients with CCN and the yes/no responses 3. Patient with CCN and candidacy issues 4. Repositioning of switches Four different scenarios were designed for each of the three categories. The format used to generate the scenarios consisted of the following key elements: 1. An outline of the scene for the subject in the form of a narrative that included parameters associated with: a. Diagnosis and medical problem list b. Rational for CCN, c. Motor status d. Current communication status

67 54 e. Possible social and emotional factors of the patient f. Shift change update 2. An outline of the problem for the subject in the form of a narrative that included descriptions of the elements in the patient s room associated with: a. Communication equipment for the patient b. Sensory aids for the patient c. Psychological status of the patient 3.) The clinical question: What would you do to help this patient communicate? Preceding the scenarios the participants were presented with instructions on the response modality that should be used in response to the question of what they should do in the particular scenario. (i.e., free choice/open- ended responses versus forced multiple choices). The scenarios probed for a demonstration of applied learning as it related to: 1.) Strategies to establish yes/no responses with a non-oral patient who does not have a working communication system 2.) Strategies for implementation of a low-tech communication system left at the patient s bedside 3.) Strategies for implementation of a high-tech communication system left at the patient s bedside 4.) Verification of patient access to the nurse call button 5.) Awareness of the sensory needs of the patient and the potential impact on a patient s ability to use any form of AAC effectively 6.) Assessment of candidacy for particular AAC strategies/solutions

68 55 While the verification of patient access to the nurse call button was not included in the tutorial, it seemed logical to probe the subject for knowledge of the importance of the call button as a means of communication. The initial goal of the assessment with scenarios was to measure each participant s applied knowledge in each of the targeted areas using one scenario from each category with an open- response answer format. It was estimated that responding to each scenario would take 10 to 15 minutes to complete. The nine scenarios used with the pilot LEND group can be found in Appendix A. However, while piloting the scenario instrument, it became clear that utilizing the open- response format online did not lead to consistent completion of the scenarios. Reconstruction of the Scenarios Assessment Tool The pilot study with the LEND students was conducted to measure the feasibility of the study s methodology and guide the investigator on improving the overall research design (Mason and Zuercher, 1995; Muoio, Wolcott and Seigel, H, 1995). During the piloting of the scenarios, several problems arose which required the reevaluation of the time involved in responding to each scenario. Upon review of the successfully completed scenarios, it was evident most answers were approximately 5 sentences or less and many of the respondents did not complete all 3 of the scenarios they were asked to respond to the Nursing Research Committee recommended that the investigator reconsider the time demands on the nurses and that the scenario questionnaires be simplified prior to providing approval of this project,. Consequently, the scenarios were re-written to include a forced- choice response format in place of the open- response format used in the piloting. During re-construction of the scenario response modality, two parameters were considered: (1) the time element involved for the respondent; and (2) the need to motivate the participant to respond and complete the scenarios. Format changes focused on needs

69 56 to reduce the time element for completion and to continue encouraging more thoughtful responses from the respondent. The questions that were used in the pre- and post-test did not directly address generalization and mastery of learning. By contrast, an analysis of omission and commission errors in a multiple choice format could address issues of mastery of learning. The revised response format allowed the nurse to identify clinically desirable acts and to avoid the use of less clinically desirable acts. Thus, the revised scenarios allowed the investigator to assess whether the tutorial enhanced the nurse s ability to increase positive communication attempts with patients with CCN and avoid less effective strategies common to practice. Omission errors would indicate the nurse s lack of understanding of the actions she should perform to allow for effective clinical practice (like failing to give medication). Commission errors would highlight less desirable actions performed by the nurse contributing to poorer clinical performance (like giving too much medication). The response options for the 9 scenarios were revised so that the participants were presented 10 to 12 plausible strategies and asked to identify each strategy as a strategy they would use or a strategy they would not use in their clinical practice. The estimated time for completion of each scenario was reduced from 10 to 15 minutes to 5 to 7 minutes. The initial design of the 9 scenarios was predicated on constructing a larger set to avoid discussion of the scenarios among subjects and to repeat assessments for mastery of the tutorial content over time. The final 3 scenarios selected for use in the study are presented in Appendix B.

70 57 Institutional Review Board Approval All methods of subject recruitment, procedures, as well as data collection and analysis methods were approved by the University of Iowa Institutional Review Board (IRB) in January, Approval from the Nursing Research Committee was obtained in February of 2010 and again in November of At UIHC the Nursing Research Committee, along with IRB, must approve all forms of research involving the Department of Nursing and/or procedures occurring outside of the realm of typical patient care or the development and research of any type of instrument or procedure. Delivery Medium for the Tutorial Online The medium for delivery of this tutorial was an on-line posting of the tutorial on the Iowa Course On-line Network (ICON) which, at the time of this study, was the primary delivery mode for staff training at UIHC. This delivery system was selected given its familiarity to the nurses and other healthcare staff and ease of access. ICON was available on most in-house computers or via access through the POINT, an on-line resource for house staff at UIHC. Additionally, it allowed for the capability of providing the subjects with all testing measures; and, immediate feedback regarding their performance (i.e., test score) following completion of all test measures. Live For a subset of the participants (graduate students in Department of CSD),the tutorial was presented in a classroom setting with the content, identical to that of the online version, projected onto a large screen. The investigator was present to navigate through the tutorial as the participants watched the ICON presentation. No new information was presented or offered. The investigator did not answer any questions posed by participants. All assessment measures in this condition were presented in paper format

71 58 and completed prior to leaving the classroom setting. Each participant was assigned a random ID that was used to identify the participant s corresponding assessment forms. Pilot Participants Participants Iowa s Leadership Education in Neurodevelopment and Related Disabilities (LEND) students were targeted for subject recruitment. LEND Programs are interdisciplinary leadership training programs federally funded through Health Resources and Services Administration s (HRSA) Maternal Child Health Bureau. LEND is an interdisciplinary leadership training program for graduate students with a commitment to providing family-centered, coordinated systems of health care and related services for children with special health care needs and their families (ILEND, 2010). Training opportunities are provided in an interdisciplinary clinical environment, the classroom and the community. A special emphasis is placed on understanding and recognizing the dynamics of family life when caring for a child with a disability. The 24 LEND students targeted to participate in the pilot study were graduate students in the areas of: audiology (2), dentistry (4), hospital administration (1), medicine (2), nursing (1), nutrition (1), occupational therapy (1), physical therapy (3), psychology (4), public health (1), speech pathology (2) and social work (1). UIHC Nurses Three hundred and two nurses or advance practice nurses from the following targeted units at UIHC were invited to participate: burn, pediatric intensive care (PICU), medical intensive care (MICU), neurology, adult general medicine (2 RC) respiratory specialty care (RSCU), surgical intensive care (SICU), and the step-down unit for adult neurology and neurosurgery patients. These units were targeted as they typically serve individuals who experience temporary ventilation resulting in limited patient communication. The participating nurses level of experience could not be obtained given

72 59 the constraints of the IRB approved protocol. (General demographic data on UIHC nurses suggested that experience ranges from 1 to +20 years of experience). Communication Science and Disorders Students A total of 51 second-year graduate students in the Clinical Doctorate in Audiology Program and the Masters in Speech-Language Pathology Program from the Department of Communication Science and Disorders at the University of Iowa were invited to participate. Fifty students participated. Procedure Basic Procedure Outline for All Participant Groups The research design included examination of two study components. The first examined the amount of knowledge and learning demonstrated by the participants following exposure to the tutorial. The second examined the transfer of the knowledge gained from exposure to the tutorial to clinical practice. The procedures deployed during each component of the study are outlined in more detail below. Component 1 1. Participants received an inviting them to participate in the study. 2. Participants were randomized into two groups a control group (Group A) and a test group (Group B). Note that the CSD graduate students were all assigned to the test group. 3. A baseline measure of the participant s prior knowledge was obtained by administering a pre-test measure. The pre-test was made available via Iowa Communication On-line Network (ICON) allowing for on-line submission; the CSD student group utilized a paper form of the pre-test. 4. Only the test groups were exposed to the tutorial (see description above).the CSD student test groups were provided with a quasi-live presentation of the on-line tutorial materials in a classroom.

73 60 5. Following completion of the pre-test measure, the control group completed a post-test assessment; the test group completed this measure following exposure to the tutorial. Component 2: Approximately 7 days later, and not more than 28 days, the participants who successfully completed both the pre- and post-test measures in Component 1 of the study were sent a second script inviting them to log back onto ICON and complete 3 scenarios. For the CSD student groups, the presentation of the scenarios occurred immediately following the administration of the post- test of component 1 of the study. Table 2.3 lays out the protocol for each of the subject groups in this study. Lastly, the CSD students completed a short tutorial evaluation form asking them to rate the effectiveness of the tutorial as it related to the following: 1) educational relevance, 2) ability to increase the students knowledge base, 3) ability to foster the implementation of newly acquired communication strategies, 4) foster a real practice change; and 5) novelty of information from the student s perspective. This evaluation was added to gain a better understanding of the value that these participants placed on the tutorial itself. It was only possible to obtain this evaluation from the CSD cohort. A copy of the AAC Tutorial Evaluation can be found in Table 2.4. Statistical Analysis The Student T tests will be used to determine if the data sets are significantly different. It was selected as the t-test assesses whether the means of two groups are statistically different from each other

74 61 Figure 2.1 Tutorial Navigation Slide Example