Patients (adults and children) with a tracheal cannula, tube or a respiratory mask aren’t able to talk. This makes the communication more difficult: the current tools for communicating (lip-reading, writing, yes-nodding, no-shaking or the use of a letter board  or keyboard/laptop can’t replace the voice that is missing. At the ICU of the Radboudumc Nijmegen 2399 patients were using artificial respiration in 2011, with an average of 3 artificial respiration days. So the communication problems concern a huge patient group. Communication with and by the IC patients is of a big importance, for both the patient as for his/her surroundings. A few years ago all IC patients were kept to sleep constantly. It was better for the artificial respiration patient to know nothing about the IC recordings – this was the way of thinking – and the artificial respiration machines were only able to ventilate the patient if the patient didn’t have any own breathing stimulations. For them, the patients had to be brought in a deep sleeping condition. However, scientific research discovered that the shorter the period the patient is asleep the faster the healing process (Jacobi J, 2002). Also, the artificial respiration machines are, because of the current technological development, able to ventilate the patients if they have a breathing stimulant. In this case the artificial respiration machine supports the patients instead of taking over the breathing completely. So it is possible for ICU patients to be awake during the ICU admission; this can be better for their healing process. However, this causes their need for more communication.  ICU patients are strongly relying on the workers of the ICU; the employees need to communicate with the ICU patient about the treatment, care, interventions, actions and of course the workers are needed for the mental and emotional well-being of the patients. Reassuring, explaining and taking away insecurities are the daily tasks for the workers of the ICU. The awake ICU/MC patient would love to communicate verbally, but because of the ventilator/tube/cannula speaking is not possible. This makes communication difficult. There can be other communication hindering symptoms that are related to the stay at the ICU and being really sick (Hurting & Dowey, 2009);

  • Concentration problems
  • Visual perception disorder
  • Confusion/ disorientation
  • Disorders in the (fine) motorics
  • Adynamia

Not being able to reach each other or to understand each other almost every day results in certain emotions like:

  • Anger
  • Powerlessness
  • Frustration
  • Despair
  • Feeling of failure
  • Feeling of losing control

Communication tools A scientific research that was held in 2011 in ICU departments in the United States, looked at how ICU nurses communicate with ICU patients and what results came out of these interactions. It showed that the communication was successful in 70% of all the interactions, but with certain subjects, like pain, often successful communication was not found. Patients indicated that 40% of all the interactions of communication with the ICU nurses was classified as ‘difficult’ up to ‘extremely difficult’ (Mary Beth Happ, 2012). What was noticeable in the research was that few communication tools were used. The use of these tools could improve communication; this was the outcome of a pilot research that took place in 2004 in the United States. Through the use of an electrical communication tool that was able to give a voice to artificial respiration ICU patients, the communication improved. Especially the communication between the ICU patient and the family really improved. (Happ, 2004). Communication tools can improve the communication, but the current ‘standard’ communication tools – like a keyboard or letter board or a pen and paper – are not always good to use because of the patient problems at the ICU (Hurting & Dowey, 2009). Worldwide there are different apps that work with patients, but they can’t speak: often the search  & controlling function are more complex than the communication-app voICe. The communication app voICe works through the use of an iPad;  the structure, interior and control require only a small amount of muscle power and locomotion; the app works intuitive, is simple and understandable for everyone. The app ‘ learns’ the choices of the patients and adapts itself to him/her. The app is also easy to adjust and to update. The ICU of the Radboudumc Nijmegen hopes with this app to improve the communication for artificial respiration patients and awake patients.

The app voICe; the launch & development.
The development of voICe has started in November 2012. In April 2013 the basic version was finished and has passed his test round. The test took place at IC patients (adults + children and their neighbors, respectively parents), ex-IC patients and their closest, IC nurses, IC doctors, speech therapists, pedagogic co-worker, physiotherapists, MC patients and MC nurses. In total 50 – 60 people have shared their opinion about the voICe app. During the tests of the app the users looked at several different aspects such as: the user friendliness, clearness, simplicity, the accuracy of having the right themes and questions, missing parts, development- and execution faults en improvement suggestions. Thanks to the test several errors have been taken away and the readability and accent colors have been improved in the app. There were also suggestions for a larger keyboard,  more applications and expansions of the current pictograms. Also, someone also asked a different controlling possibility for the app, for patients with a paresis/paralyzes of the hands or polyneuro(myo)pathy; now this other controlling system has been made, see above. The remaining suggestions are kept in mind and maybe useful for future updates. In 2016, an English speaking version of the voICe app  is developed.  Since May 2013 the app is used in reality at the IC and MC of the Radboudumc Nijmegen. Every unit has an iPad, at which the app is installed. Every caregiver is introduced about the existence and the use of the communication app. They can help the patients at the IC and MC and their neighbors with this new equipment to communicate. Since May/June 2013  the app voICe is also offered to different places in the Netherlands and Belgium and is used in many ICU-organisations in these countries.  Publication took place in specialist journals and at congresses, stock exchanges and symposiums. The app is available in the App Store, tags are: ‘voice intensive care’ , ‘intensive care voice’ and ‘intensive care’.

Colofon. © voICeRadboudumc Nijmegen 2013 / English version february 2016
A financial support of the Stichting Patiëntenfonds Radboud umc Nijmegen, Netherlands, enabled the development of the app voICe .

Principals. Prof. dr. J.G. van der Hoeven, Department Intensive Care Radboud umc: Mrs. A.M.M. Broods, MHA, Department Intensive Care Radboud umc:

Co-workers/ contribute to the app voICe Designbureau LaVerbe: Mariena Steensma: Technique app and website: Dots&Digits: Voice of the man: DJ Menno Barreveld. Voice of the woman: Lise-Lott Kok. Voice of the girl: Sterre. Voice of the boy: Niek. Recording studio voices Niek en Sterre: Thijs de Nijs Producties Recording studio voices Lise-Lot: Multimedia Studiecentrum Radboud Universiteit. J. Oostveen, Department Speech therapy Radboud umc. Department Ergotherapy Radboud umc Th. Tollenaar, Department Intensive Care Radboud umc

Thanks to all the patients, ex-patients and their neighbors for their share at the extensive tests of the app voICe. A special thanks to Siebe, an extraordinary boy that brought us this idea.


Happ, M. R. (2004). Electronic voice-output communication aids for temporarily nonspeaking patients in a medical intensive care unit: a feasibility study. Heart & Lung: The Journal of Acute and Critical Care, 92-101.
Hurting, R. R., & Dowey, D. A. (2009). Augmentative and alternative communication in acute and critical care settings. San Diego: Plural Publishing.
Jacobi J, F. G. (2002). Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Critical Care Medical, 119-141.
Mary Beth Happ, R. P.-S. (2012). Nurse-Patiënt Communicatie Interacties in de Intensive Care Unit. American Journal of Critical Care, 28-40.
Roudijk, W. (2012). Interviews met IC patiënten & naasten of nabestaanden. Nijmegen, Radboudumc Nijmegen.

Use and demo
Below you can watch a short movie about voICe. With thanks to Thijs Tollenaar Radboud umc Nijmegen.

Film ontbreekt !

User’s manual voICe. (Download here the information and guide of voICe)

Before introducing the app to the patient and the family, you need to screen the patient first if he/she is able to use the app, thus avoiding  frustration for everyone. Is the patient using a tool (glasses/hearing-aid)? Make sure these are applied.

  • Does the patient speak or understand Dutch or English?
  • Is the patient at the moment alert and suitable?
  • Can he give answers to simple questions with ‘yes’ or ‘no’ signals?
  • Can the patient point at something at request (for example the toes/nose) ?

If these questions all have been answered with ‘Yes’:

  • Try the easy version first; 4 pictograms (settings)
  • If this is OK, try the basic version.
  • If the patient understands how the app works, explain him/her the whole version and make an username and a password for the patient
  • A stylus and/or a supporting pillow can be used if beneficial.

For care professionals; the next crieria must be fulfilled to be able to work with the app voICe;
1. The patiënt must be able to react to an assignment or execute the assignment
2. The ICU nurse describes the patient as awake or alert (may be fearful or in other aroused mood)
3. The patiënt scores 6 in the M-score of the Glasgow Coma Scale (GCS)
4. The patient scores 4 or better in the Riker Sedation Agitation Scale
5. The patient scores 1-3 in the Modified Ramsey Sedation Scale
6. The patient reacts adequately when given verbal communication by the ICU nurse (words, gestures, handsigns, other non-verbal methods etc.)
The patients must be able tot show this conduct during a 12-hour nursing shift, being supported by a ventilator.

The app starts normally in ‘main menu’ with the male voice. However, the voices can be changed at  ‘settings’ . Here, the patient can also turn off the speaking of the main menu and certain themes. This can be very pleasant for someone who knows the app quite good.

In the main menu there are 6 pictograms:

  1. Themes: with the 6 themes: feelings; body; treatment; basic words; relaxation; care. These are obvious. At the pictogram ‘pain’ the person can open a menu so he/she can indicate the location of the pain, the intensity of the pain and the kind of the pain. At the pictograms ‘freshen up’ and ‘aid’ in the theme ‘my personal care’ the app shows a new screen with 6 choices.
  2. Drawing and text paper: Here you can draw or type something. With the ‘trashcan’ you can erase what you’ve drawn or typed. With the ‘gum’ you can erase a part of what you’ve made. You can choose between different keyboards (QWERTY; ABC and numerical) at the bottom left button.
  3. Preferences: If you are logged in, the 6 most used pictograms can be found here. Your 6 most used pictograms can also be set in here.
  4. Settings: the user can change the voice and pronunciation of the menu titles to on or off.

An easier version or the basic version can be chosen. The location where the app is going to be used can also be recorded here.

  1. Date and time: The app will tell you the time at the same time. If you touch the date, the voice will tell you the day and date. The location works the same way.
  2. Messages: If you’re logged in you can record here your video messages. (pictogram ‘television’). What you can do as well is leaving a typed message. (pictogram ‘keyboard’). Saving is possible with the pictogram ‘computer’. With the ‘thrash can’ you can erase these files.
  3. Log in: by touching this button you’ll visit a page where you can make a new user (‘add user’) or, you can log in as an user that already exists. Once logged in, you can record a (video) message for the patient (pictogram ‘messages’) and use the pictogram ‘preferences’. Under this pictogram are the 6 most used pictograms in order.

The app asks for an account to change the name of the place and to be able to erase different accounts. For making an account, take contact with We are going to make this function easier in the next version.

Anyone can make a new user. When you work with more patients, it would be useful to make a fixed appointment within your unit. For example: Username first letter of his/her first name and surname of the patient. For a password you can use a room number or patient number. This way the nurse can easily log in for the patient. However, the nurse should be aware of changing users when changing a patient.

Touching the pictogram ‘home’ brings you back to the main menu. The arrows left and right are there for a page back or the next page. You can use also a ‘swipe’ function for this. That means that if you make a sweep  move on the touch screen it has the same effect as the use of the arrows.



voICe de communicatie-app voor de Intensive Care.



The Radboud UMC uses  an iPad case with matte screen protector around the iPad. These can be cleaned with an alcohol cloth.

Single button control
The pictograms of the app voICe can also be controlled by a one-button-switch, through the use of an adapter called the Pererro. This adapter is developed for the iPad and can, because of its technical way of construction, control  the voICe app. This means that patients with less or no hand locomotion can still be able to control the app through the use of a low-pressure switch, a lip switch, a blow switch or other one button techniques. For more information, visit  the website of the Pererro-builder, RSL Steeper;