Similar to part 1 of this article, there is not much in the way of published evidence-based practice in this article. The reference material I use is, instead, based on 2 independent interviews I conducted with critical care nurses (acknowledged at the bottom of this article), 2 editorials published in intensive care medicine journals (Brown, Azoulay, et al., 2018; Brown, Talmor, & Howell, 2018) that were both written more than a year after the interviews (referenced below), and more than 20 years of experiences on both sides of the endotracheal tube.
In the first article I asked SLPs to self-reflect, “Am I right for the ICU?” That is, I addressed the broad topic of personal style for those SLPs who want to work or are working in the ICU. This part 2 (of 2) of the article departs from the discussion of introspective, personal style and moves toward interpersonal relationship qualities common among personnel working in the ICU that create the culture that is ICU. At its core, the focus here is broadly on the concept of respect. Within the framework of respect, this article specifically addresses the 5 central qualities of trust, knowledge, communication, teamwork, and flexibility in ICUs and what SLPs should consider as they care for patients who are critically ill and interact with the clinicians who care for them.
We can all agree that patients in critical care span the gamut from those who have recently entered a world where facing mortality and the issues/questions/decisions just became very real to those in their last minutes of life…to those who survived critical illness and are on their way to lower levels of care as they continue to recover. It is a setting filled with critical decisions within and among critical conversations, frequently in a critical window of time. Patients seek clinicians to “get better” and clinicians see patients to help them toward recovery. Implicit in this relationship between patients and clinicians is trust. But what about between clinicians and other personnel? For SLPs in the ICU, maybe trust begins with nurses? It did for me…and it continues to be validated daily.
So how is trust earned in the ICU (and medical care broadly)? In many cases, it’s a combination of the best parts of knowledge, communication, and action.
Physicians have to complete residency (and fellowship) in critical care. Nurses are oriented and precepted by more seasoned nurses. Therapists, in general, are no different. Nope… Having your CCC-SLP (or PT or OT) after your name isn’t enough in the setting of the ICU. During the period of time you will acclimate to the ICU, you will get to know the staff and the medical teams. You will communicate your knowledge within the discussions pertaining to each patient and, more broadly, within your scope of practice as an SLP. People (patients, family members and friends, nurses, physicians, therapists) will engage you in conversation…and just know that everything is “on the record.” And the walls may have ears—many of them. Although you may not be given a pat on the back for the knowledge/wisdom you just shared, you will be called on the carpet if you’re incorrect or what may be perceived as “blowin’ smoke.” Better to say “I don’t know” and follow up with that person—always! This is a good portion of the “action” part of earning trust, perhaps equally (or close) with your clinical skills. In general, this is a solid recommendation to earn trust. In the ICU, it’s, well…critical.
You’ve probably heard the cliché, “Knowledge is power.” In the therapy business (healthcare, more broadly), we thrive on evidence-based knowledge within the domains of both subjective and objective data, both in and out of the therapy room. The referral/order, medical record, and the patient’s status (i.e., the why you’re consulted, what led to why you’re consulted, and what you can do for the patient while you’re consulted) are the starting points and provide the basis of knowledge for any patient. In the ICU, however, knowing the patient from the previous day, or even 2 hours ago, doesn’t mean that you know the patient on this day or even at this time. Patient status and goals of care may change quickly in the ICU and documentation may lag behind you seeing the patient. Regardless, you need to start with a strong understanding of what has happened with the patient (i.e., getting caught up on what has happened with patient) and the medical chart is the primary source. After you have updated yourself, consider walking past the patient’s room to notice whether the patient is in the room and if so, who is also in the room, a quick vital signs check from the monitors and simple observations of the patient (e.g., awake, sleeping, restless), who the nurse is, and informational placards (e.g., contact precautions)—things that will augment any conversation you’ll have with the rest of the medical team. Completed consistently, this combination of these bits of information are invaluable in saving time and a terrific springboard into conversation with all of the patient’s providers, caregivers, and the patient.
Explict. Concise. Direct. Stated with confidence and with respect, often in hushed tones as part of the implicitly (and ubiquitously) understood method. These are among the adjectives used to describe communication qualities in the ICU. Spend 20 minutes on morning rounds with the medical team and you’ll recognize these qualities immediately as the medical team is discussing each patient.
But how do you get the attention of the nurse, nurse practitioner, physician assistant, and physician? Before entering the patient’s room, it is strongly encouraged that you speak with the nurse to inform him/her of your plan once you gather the patient’s current information. Be clear, concise, and direct. If you know you are going to need the nurse’s help, make a plan with the nurse…and plan ahead as best you can. If the patient is off the floor, get some information about when the patient might return and whether the patient will be appropriate for you to see him/her. If applicable, let the nurse know that you’re not signed off for suctioning patients; they may help you toward that goal, even assist with training you. Regardless, “straight talk” is a critical (yep, there it is again) first step to the trust needed for teamwork in the ICU.
Everywhere in patient care requires teamwork, whether it’s the bloodwork that is collected by the nurse and then handed off to the lab, or it’s the complex surgical team associated with a transplant surgery. The setting of the ICU is no different. It can’t be every person for him/herself because every person wears a different hat. Daily, the nurse holds steadfast to the patient’s care, with a 1 nurse to 2-3 patient ratio, with many people in and out of the patient’s room. Physicians have been dubbed gatekeepers to patient care. I like to think of ICU nurses as the gateway to the patient’s care. In some sense, the price of admission for therapists (and other referral services) is a conversation with the nurse—and well worth the time spent. Teamwork by therapists begins here.
Your conversation need not be lengthy. In fact, a lengthy conversation is discouraged. Anyone entering the patient’s room (and the activities that go on in that room) effectively are the responsibility of the nurse (and the rest of the medical team, more broadly). Simply introducing yourself (if you don’t know each other), stating what service you’re with, and why you’re interested in seeing the patient is a great start. Be prepared for questions such as whether the patient will need repositioning (even raising the head of the bed), how long the session will be (or more likely, when you’ll be done), and whether you will need the nurse’s help. Be confident in your knowledge and answers, no matter the question. If you’re uncertain, again, a definitive “I don’t know” is a very good answer…about anything. No “fake it ‘til you make it” in ICU. If you have questions about the patient or about the patient’s care, even if you need an extra set of hands for feeding or suctioning the patient, problem solve with the nurse…but make sure you do it as best you can before you enter the room. SLPs love planning…and so do nurses! Foresight and planning are key in the ICU, but when the plan fails (and it will frequently), flexibility must ensue!
Time management, problem solving, and prioritizing are the keys to being flexible. Whether the issue at hand is a patient who is being transported for a procedure 10 minutes into your session, a patient who suddenly becomes somnolent or restless, or the seemingly calm patient who “decides” the endotracheal tube is not necessary any longer and attempts to self-extubate, you’ll need to adapt to the situation…and pretty quickly. Experience will be the best teacher in these cases, but it never hurts to think on your feet. In fact, experience and quick thinking, combined with your clinical skills, will set up the best chance for success.
Everyone working in the ICU has experience (even you newbies out there) and everyone’s experiences matter. As SLPs, we gravitate naturally toward problem solving. Nurses are very similar. The one thing nurses will have more than the SLPs—in many circumstances—is experience with this particular patient. As you work through addressing the situation and circumstances, with or without the patient’s nurse, you’ll need to keep a level head, remain cool, and immediately problem solve. Things may be said during the situation (by anyone) that might be taken in ways other than that which was intended. Maybe it was the patient who said something you didn’t take well. Perhaps his/her spouse or family member? Or maybe it was a very clear and direct instruction provided by the nurse that you took personally? First, don’t. Hardly anything in this professional environment is personal. Instructions, for example, are not personal—they’re said with reason. Take them at face value and with the perspective that you now have an opportunity to learn (i.e., gain even more experience). Second, many conversations are indeed intended, immediate, and intense. They have to be. It will be your ability to respond flexibly to the content of these communications that will pave the way to your success.
Although the common understanding of the acronym ICU is “intensive care unit,” I often refer to it as the “intense communications unit.” And these 5 central qualities of trust, knowledge, communication, teamwork, and flexibility are the reasons why. These qualities are not unique to the ICU setting; perhaps only the intensity and frequency of the medical teams’ interactions. Nonetheless, before darting off to see your next patient, take a few moments to observe the professional interactions in the setting in which you work. There’s a lot to learn…and not just about the therapy.
Acknowledgements: Many thanks to Rebecca Coeyman, RN and Lauren Chasan, RN. Your time and thoughts will serve to help many SLPs on their journey to critical care.
Brown, S. M., Azoulay, E., Benoit, D., Butler, T. P., Folcarelli, P., Geller, G., Howell, M. D. (2018). The practice of respect in the ICU. American Journal of Respiratory and Critical Care Medicine, 197(11), 1389-1395. doi:10.1164/rccm.201708-1676CP
Brown, S. M., Talmor, D., & Howell, M. D. (2018). Building communities of respect in the intensive care unit. Intensive Care Medicine, 44(8), 1339-1341. doi:10.1007/s00134-018-5259-9