Table 1.

Summary of the development of the communication bundle, based on Bleijenberg et al. (2018).

	Strategy	Education of nurses	Communication tools
Problem identification and definition	No national or international guidelines exist on the subject and the nurses have no guidance.	Nurses find communication with MV patients difficult. Implementation of AAC in ICUs is challenging.	Communication tools have to be tailored to the local context in relation to contents and language.
Identification of evidence	An algorithm may support nurses’ assessment of patient communication, choice of communication strategies and documentation. Providing structure and building the relationship are two cornerstones in communication theory, also in the ICU.	Communication training may improve nurses’ communication skills. Evidence detailing the contents and duration of nurse education programmes in ICUs is sparse.	Communication tools can increase patient satisfaction and reduce communication difficulties.
Identification of theory	Augmentative and alternative communication (AAC) and the Calgary Cambridge Guide.
Needs determination	Nurses need support tools to help them assess patient communication and guide them in a systematic and structured approach.	Nurses need more knowledge about communicating with mechanically ventilated patients.	There is a need for updated, evidence-based communication tools in clinical practice.
Examination of current practice and context	Nurses describe communication as a ‘guessing game’, illustrating that communication can be random and unstructured. There is a lack of systematic communication assessment and documentation of patient communication and the methods applied.	72% of nurses in our ICU report received teaching on communication with mechanically ventilated patients, but their contents and duration are unknown.	Communication tools in clinical practice are very different in design and contents; some departments have many different tools to choose from, while others have none.
Modelling process	The algorithm: –Developed with inspiration from ten Hoorn et al. (2016) –Targeted nurses –Focused on ‘fundamental communication principles’ as the basis of all communication The framework: –Developed with inspiration from the Calgary Cambridge Guide –Overview of the most important aspects of communication	Teaching session:- Introduction of how to use the bundleE-learning: –Curriculum containing basic knowledge about communicating with voiceless ICU patients and introduction to methods to enhance communication Workshops: –Detailed description of the bundle and instructions of how to use it	A simple communication toolbox was chosen to make it easy for nurses to choose the right tool. –Pen and paper (already used) –Low-tech communication book (developed for the project) –High-tech communication app (already existed)
People involved in the process	–Speech-language pathologists –Clinical nurses –Graphic designer	–Centre for E-learning (including graphic designer) –Expert nurses responsible for education of ICU nurses –Clinical nurses	–Software company (including graphic designer) –Hygiene nurse –Speech-language pathologists –Clinical nurses –IT experts