Invisible Care: Breaking the Silence at the Intensive Care Units

Section: Editorial

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Perelló Campaner C. Cuidados invisibilizados: rompiendo silencios en las unidades de cuidados intensivos. Metas Enferm jun 2021; 24(5):3-6. Doi:


Dra. Catalina Perelló Campaner


Centro de Innovación y Desarrollo en Enfermería y Fisioterapia de las Illes Balears(SATSE-CIDEFIB).

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There is a type of nursing care which is very subtle, translucent, sometimes even invisible. And although this happens in any other clinical practice setting, the invisibility of certain nursing interventions is even more highlighted in the Critical Care setting, traditionally characterized by a model of care focused on the patient’s body and organs. The person is treated like an object of care, rather than like a subject with capability to decide on their treatment (1). There are some nursing interventions which are not associated with something tangible, such as a urinary catheter, a pillow, or a hemofiltration machine, and therefore these are hardly prioritized in daily practice. To identify and give priority to these invisible care actions requires high sensitivity from the nurse to detect their need and, most of all, high skills to cover them. In order to do this, the nurse must be able to bypass all barriers against the prioritization of these actions, which could be described as invisibilized rather than invisible. And they are made invisible due to the conditions in the Critical Care Unit setting, such as heavy workload and lack of time, but also by the beliefs of professionals or lack of training in some settings.

The current situation of global pandemic has contributed even more to reveal the deficiency in those areas of non-biotechnological care, showing the more dehumanizing face of critical care. Inadequate nurse/patient ratios, the fast incorporation of new professionals in Critical Care areas, and the high workload experienced by nurses in these Units, have not contributed at all to an advance in the humanization of care for Critical Care patients.

Communicative Care in the intubated critical patient is, undoubtedly, one of those invisible care actions. When a person is admitted to the ICU with an artificial airway (an orotracheal tube or tracheostomy), but is awake and therefore maintains his/her ability to interact with their environment, they are suddenly faced with the unknown challenge of communicating efficiently with others (professionals and/or relatives / close people). Even though the communicative problems in intubated critical patients who are awake appeared with the initial use of invasive mechanical ventilation, back in the 60s, the evolution in the way Nursing professionals have addressed it has been very low until today.

A recent qualitative research within the Balearic setting reached the conclusion that the communicative process of intubated patients who are awake was perceived by professionals as a situation inherent to intubation, that could not be really modified, and difficult to tackle. (2).

The communication failure in these patients generates a set of emotional consequences which range from stress and impotence to passivity and resignation, which settle progressively, mostly when their communication attempts are not understood. The relatives and close people of these persons, as well as professionals, also report reactions of stress, uselessness, and impotence. In the study mentioned, this type of emotional consequences were easily detected by Critical Care nurses; however, this was not the case with other negative effects which were hardly perceived by the professional group, such as consequences on clinical and safety variables, or in the ability of intubated patients to exercise their right to make decisions about their own treatment and care (2).

There are multiple and interdependent factors determining an efficient communication in intubated and awake critical patients (2,3). These can be classified into those associated: with the patient (e.g. lack of physical strength or cognitive alteration), with relatives (e.g. behaviors inhibiting the communication attempts by their relative in order to avoid the stress derived), with the ICU setting (e.g. the availability and characteristics of communication aids, workloads, or the physical configuration of the unit), or those associated with nurses (2).

Regarding the latter group of determining factors, said qualitative research highlighted the major impact that the skills, attitudes and beliefs of Nursing professionals seem to have on maintaining the communication failure. It seems that the care approach implemented in our daily practice, and which ranges from the most biotechnological to the most holistic, will have an impact on the way in which we communicate with our intubated patients who are awake (2).
There is no easy solution to the communication problem, and even though the training of the professionals involved in care for these patients does not seem to be the only way, it represents a necessary and essential step. This training must be orientated towards boosting the professional skills targeted to optimizing the communicative efficacy of these users, and at the same time reducing the adverse effects associated with the communication failure, in the way suggested by the Synergy Model for Patient Care (4). With this objective, training for Critical Care professionals on communication strategies with intubated patients should include various lines of action, beyond the traditional training actions (2):
–    To encourage higher sensitivity towards the communication problem, insisting on the emotional, behavioural, ethical and clinical consequences generated. A recent study (5) research-action as the methodology to create awareness among nurses regarding the communication problem in intubated patients who are awake. There was a demonstrated increase in the levels of patient satisfaction regarding communication with nurses, as well as an increase in nurse awareness regarding the communication attempts by patients.
–    The development of competences for an adequate evaluation of the communication ability of intubated persons, which would allow nurses and other professionals to understand the factors determining communication, and to identify those strategies and devices available that will be more adequate in each case.
–    Deep awareness about the professional factors determining the communication process: how our own attitudes, beliefs or care approaches will limit or facilitate the communication of intubated patients.

There might be some who continue thinking that the priorities at the ICU must be those associated with physical and biotechnological care. I would suggest them to reconsider what it means for persons in critical condition and awake at an ICU not being able to express that they are afraid or lonely. What it means not being able to say goodbye to your loved ones, to tell them that you love them, or that you intend to do your best in order to return home. What it means not being able to ask someone to hold your hand because you need it, or that they leave the light on at night to avoid falling again into depths of delirium.

Let’s consider this as a starting point, a trigger for change to make visible the communicative care for critical, intubated and awake patients. A hope for the design of innovative training interventions targeted to Critical Care professionals, which will lead to a measurable impact on care for these persons. An inspiration to design studies which will generate significant and lasting changes in the cultures of care implemented in these Units. Let’s turn up the volume of these voices which have been silenced and made invisible so far. They should not keep quiet because they cannot be heard, but in any case, because this is their wish .


  1. Piperberg M, Malagón S. La UCI, ¿tecnificación versus humanización? Bioética del cuidar, ¿que significa humanizar la asistencia? Madrid: Tecnos; 2015.
  2. Perelló-Campaner C. Rompiendo silencios en la unidad de cuidados intensivos. Fenomenología de la comunicación con personas intubadas, perspectivas de los usuarios, familiares y profesionales de enfermería [internet]. Palma: Universitat de les Illes Balears; 2019. Disponible en:
  3. Istanboulian L, Rose L, Gorospe F, Yunusova Y, Dale CM. Barriers to and facilitators for the use of augmentative and alternative communication and voice restorative strategies for adults with an advanced airway in the intensive care unit: A scoping review. J Crit Care. 2020; 57:168-76.
  4. Hardin SR, Kaplow R. Synergy for clinical excellence: the AACN synergy model for patient care. 2th ed. Burlington, MA: Jones & Bartlett Learning; 2017.
  5.  Noguchi A, Inoue T, Yokota I. Promoting a nursing team’s ability to notice intent to communicate in lightly sedated mechanically ventilated patients in an intensive care unit: An action research study. Intensive Crit Care Nurs. 2019; 51:64-72.