Background: A purpose-built outcome measure for assessing communication effectiveness in patients with an artificial airway is needed.

Shape The ratio of the Australian Flag is 1:2 with the Union Flag occupying the upper quarter on the staff side. The external diameter of the Commonwealth star is 3/10 while that of the Southern Cross is 1/7, excluding Epsilon’s which is 1/12 of the flag’s width. The inner diameter of each star is 4/9 of the external diameter.

Other flags used include the Anti-transportation league flag that looked almost like the present national flag except for the lack of the Commonwealth star. The flag was designed in 1849 and was used from 1851 by the league. It is the oldest to feature the Southern Cross as Reverend John West, the designer, arranged the stars as they appear in the sky. It also had a blue background and a Union flag at the canton. The yellow stars symbolized members of the colony. The flag ceased usage after the British stopped transportation in 1853. This flag is similar in design to later flags including that of Victoria, New Zealand and Australia too. Another was the Eureka Flag that had stars representing the Southern Cross. This was used during the 1854 Eureka rebellion started by the gold miners who revolted against the British. The battle was fought between the colonial forces and the miners in a battle referred to as the Battle of the Eureka Stockade. This flag was the first to feature the southern cross without the union flag. From the 1850s, the Murray river flag became popular. Boats traversing the main Australian waterway still use it today. However, they replaced the quadrants, (excluding the canton one) with four blue and white stripes that alternate and represent the four major rivers running into river Murray.

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Results: Fifteen patients with a mean age of 53 years (standard deviation [SD]: 19.26) were included. The clinician-reported scale was administered on 50 attempts (100%) with a mean completion time of 4.5 (SD: 0.77) minutes. The patient-reported scale was administered on 46 out of 49 attempts (94%) and took a mean of 1.5 (SD: 0.39) minutes to complete. The CAT was feasible for use in the Intensive Care Unit, with patients with either an endotracheal or tracheostomy tube, whilst receiving invasive mechanical ventilation or not, and while using either verbal or nonverbal modes of communication. Preliminary establishment of responsiveness, validity, and reliability was made. The tool was acceptable to participants and their family members.

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On June 2, 1904, a resolution to replace the Union Jack with an Australian flag passed.  The decision received opposition from the department of defence, but from 1911, the Australian Ensign became the saluting flag. Until the 1920s, the public and some official events used the Federation flag. In 1924, the Union flag took precedence over the National flag. Local and state governments could use the blue ensign. Schools could purchase the blue ensign flags by 1940 and the following year, Australians could use either ensign so long as they did so respectfully. In 1951, the Blue Ensign was recognized as the National flag by King George VI and the status formalized on February 14th, 1954. South Australia continued using the Union flag until 1956 when they allowed schools to use either the Australian or Union flag. Most Australians still regarded the Union flag as the National flag, and this led Arthur Smout to start a campaign urging them to give the Australian flag precedence. The Governor-General, Sir William Deane proclaimed an annual celebration of the Australian national flag in 1996. It takes place on  September 3rd and these celebrations occur in major centers and schools. This day, however, is not a public holiday.

The design selected had a star added to the Victorian flag. The New South Wales government and the Federal government wanted the Australian federation flag because they thought the winning one was too Victorian. Prime Minister Barton took it up with the admiralty and submitted this flag along with other entries the judges had chosen for final approval. They adopted the Blue Ensign for government ships and red for private vessels. However, the Barton government considered these two colonial maritime flags. They did, however, eventually agree to use the flag on naval ships. Later on, as the years progressed, the governments, including that of Chris Warton and Andrew Fisher, did not like the design and wanted distinctive flags that indicated Australian Unity.

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The Australians wanted a federal flag, and the Melbourne Herald held a design competition in 1900. The winner would walk away with 25 Australian pounds. The participants had to include the Union flag and Southern Cross in their designs. The results would be flags with the British Ensign. The Review of Reviews for Australia, who conducted the competition later agreed that the restrictions were unwise even though designs without the emblems would not succeed. However, the designers were asked to incorporate the two elements. However, the Federation, a process where the British colonies of Queensland, Victoria, South Australia, New South Wales, Tasmania, and Western Australia, united under the Commonwealth of Australia took place on January 1st, 1901. At the time, the British government also requested for a new flag design and the Commonwealth government held a new federal flag competition. They got 32,823 entries in total including those received earlier by the Review of Reviews.  Competitors submitted two coloured sketches. One was the blue ensign for official and naval use; and a red ensign for public and merchant use. Judging of the designs depended on whether the flags depicted the federation history, loyalty to the empire, utility, distinctiveness, heraldry, and cost of manufacture. The entries varied and included some with the two emblems and those with indigenous animals playing cricket. The entries were displayed in Melbourne at the Royal Exhibition Building and judging took six days. The winning designs were from five identical entries. The designers shared the prize money which had totalled to £200 after an addition from the Commonwealth government and a donation of £50 from the Havelock Tobacco Company.

The first Australian Flag flew on September 3rd, 1901 from the Royal Exhibition Building in Melbourne. The date eventually became the Australian National Flag Day. The British Colonial Secretary received the winning designs in 1902. On February 11, 1903, an announcement on the Commonwealth Gazette by Prime Minister Edmund Barton, confirmed the approval of the flag by King Edward VII. The published flag had seven-pointed stars in the Southern Cross, except the smallest. This design resembles that of the current design but excluded the six-pointed Commonwealth Star. After the federation, private citizens used the red ensign flag due to restrictions by the Commonwealth government and flag suppliers on selling the blue ensign to the public. During the first and second World War, the armed forces used both the blue and red versions. The public was encouraged to use the blue ensign by the government in the 1940s, but there was still confusion between the two flags. In 1953, the Flags Act made a declaration for the Red Ensign for the Australian Mercantile Marine Flag while the Blue became the national flag. They still use the Red Ensign on Anzac Day to recognize its history and it is flown on land together with the Australian National Flag on 3rd September. In 1904, the Union Jack was replaced by the Blue Ensign during the Olympic games held at St. Louis. The same year saw the Blue Ensign receive the same status as the Union Flag after lobbying by Richard Crouch. The House of Representatives proclaimed usage of the Blue Ensign on all vessels, forts, public buildings and saluting places on all official occasions. It also flew on special flag days but its usage was limited to when a national flag wasn’t available.

Lieutenant James Cook was the first to bring the Union Flag onto Australian soil at Botany Bay on April 29, 1770. At the time, the Union Flag did not have Saint Patrick’s Saltire. The Europeans settled in the country on January 26, 1788. After 1801, the Saint Patrick’s Saltire was included after the Acts of Union, and this is the version depicted on the Australian flag. At the time, the British had separated Australia into six separate colonies. Each colony had a flag based on the Union Flag, but which represented them collectively. A national consciousness began to emerge in Australia, and the people formed different flag movements. New unofficial flags came into usage and the 19th century saw two attempts at designing a national flag. Captains John Bingle and John Nicholson designed the National Colonial Flag from 1823-1824. The flag was a red background with a red cross. Each of the four limbs of the cross had an eight-point star with a Union Flag on the canton. Nicholson also designed a popular national flag in 1831 known as the Federation Flag. The flag was like the National Colonial Flag, but the cross was blue. The flag became popular late into the century when the Australian people started demanding a federation.

Objectives: The objective of this study was to develop the Communication with an Artificial airway Tool (CAT) and to test the feasibility and to preliminary evaluate the clinical metrics of the tool.

Conclusion: The clinician-reported and patient-reported components of the study were feasible for use. The CAT has the potential to enable quantifiable comparison of communication interventions for patients with an artificial airway. Future research is required to determine external validity and reliability.

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The flag of Australia features three components: The Southern Cross, the Commonwealth Star, and the Union Flag. King Edward VII approved this design after a competition for the flag design in 1903. The Australian flag was gazetted in 1934 and got its official status as the national flag in 1953.

Methods: Eligible patients with an artificial airway in the Intensive Care Unit were enrolled in the pilot study (Crit-CAT). The CAT was administered at least twice before and after the communication intervention. Item correlation analysis was performed. Participant and family member acceptability ratings and feedback were solicited. A qualitative thematic analysis was undertaken.