Critically ill patients are a highly complex and heterogenous group. A commonality within this group is that many need mechanical ventilation (Wunsch et al., 2010, Zilberberg et al., 2020, Cheung and Napolitano, 2014, Casamento et al., 2018). Communication, including both verbal and non-verbal modalities is often impaired or impossible due to many factors, including the nature of the patient’s illness, weakness, cognitive impairment, fatigue, and sedation (Vincent, 1997). Mechanical ventilation necessitates placement of a tube within the airway (orally, nasally or via a tracheostomy). The presence of the tube obstructs normal airflow through the upper airway, larynx and vocal folds and prevents vocalization (Kazandijian and Dikeman, 2022). This creates a communication impairment attributable to the presence of an artificial airway. In addition, some patients present with a communication impairment(s) secondary to a co-occurring medical condition such as stroke, with concomitant dysarthria or dyspraxia (motor speech disorders), aphasia (disordered language), the presence of delirium and/or because of intubation trauma to laryngeal structures and function (Wallace and McGrath, 2021), a surgical complication resulting in dysphonia (disordered voice). Thus, an artificial airway combined with these disease specific conditions creates barriers to communicating effectively. Other factors which can negative impact a patient’s capability to engage in communication include impaired vision and hearing (Cruice et al., 2009), and cultural and linguistic diversity (Li et al., 2017, Yu et al., 2020). In the case of an unplanned Intensive Care Unit (ICU) admission, it is not uncommon for glasses or hearing aids to be left at home.

The communication difficulty of a patient with an artificial airway is unique compared with that of patients with an acquired, progressive degenerative, congenital communication or cognitive-linguistic impairment. Importantly, the clinical environment of the ICU (Backes et al., 2015) is known to significantly impact wellbeing, experience, and recovery (Halvorsen et al., 2022, Wenham and Pittard, 2009, Tronstad et al., 2021, Topcu et al., 2017). The experience of critically ill patients in the ICU highlights the negative relationship between mechanical ventilation and significant distress, frustration, helplessness and anxiety due to their inability to communicate (Ashkenazy et al., 2021, Guttormson et al., 2015, Khalaila et al., 2011, Carroll, 2007) which mirrors their nurses’ report of frustration and stress which arises from difficulty communicating with their patients (Yoo et al., 2020, Magnus, 2006, Bergbom-Engberg and Haljamae, 1993). This patient group can be described as “communication vulnerable” (Blackstone et al., 2015).

There are a range of alternative and augmentative communication (AAC) or non-verbal interventions and verbal communication interventions which have been examined in the ICU setting (Carruthers et al., 2017, Ten Hoorn et al., 2016, Zaga et al., 2019). Non-verbal interventions or AAC such as a communication board (Hosseini et al., 2018, El-Soussi et al., 2015), electrolarynx (Tuinman et al., 2015, Rose et al., 2018, Sato et al., 2016), speech-generating device (Happ et al., 2005, Happ et al., 2004, Koszalinski et al., 2015, Rodriguez et al., 2016) or eye-gaze or eye-blink technology (Garry et al., 2016, Miglietta et al., 2004, Maringelli et al., 2013)can be utilised by patients with either an endotracheal or tracheostomy tube dependent on their level and duration of alertness, cognitive status and the degree of ICU acquired weakness. Verbal communication interventions with a tracheostomy tube include above cuff vocalization (McGrath et al., 2019, McGrath et al., 2016, Mills et al., 2021) talking tracheostomy tubes (Pandian et al., 2014), ventilator-adjusted leak speech (Hoit et al., 2003, Hoit and Banzett, 1997, Garguilo et al., 2013) and one-way speaking valve in-line with the ventilator (Prigent et al., 2010, Sutt et al., 2015, Freeman-Sanderson et al., 2016). Interventions targeting communication in the critically ill have demonstrated feasibility, utility and safety (Zaga et al., 2019). While these findings are positive, without a patient-specific definition of the outcome, clinicians are unable to determine which interventions and therapies are most beneficial to improve communication (Zaga et al., 2020).

Effective communication most often refers to the effectiveness of communication between healthcare professionals’ or between staff and patients or their significant others (Bramhall, 2014, Ratna, 2019, Grover, 2005). Effective communication is fundamental to humanizing care and enabling patients to participate in their healthcare (Blackstone et al., 2015, Nin Vaeza et al., 2020).

While general definitions of communication and functional communication exist (Blackstone et al., 2015, Beukelman and Light, 2020, Doedens and Meteyard, 2022), there is no internationally agreed upon definition of effective communication that pertains specifically to critically ill patients with an artificial airway, nor consensus on the key elements that determine the effectiveness of communication for this patient population. As such, a population-specific definition of effective communication is needed to standardise the evaluation of these patients’ communication abilities, enabling appropriate therapeutic recommendations. Furthermore, such a definition may promote outcome measurement consistency in future research. The aim of this study was to define elements of effective communication specific to critically ill patients with an artificial airway, to underpin the future development of quantitative outcome measurement tools.