Original article
ICU family communication and health care professionals: A qualitative analysis of perspectives

https://doi.org/10.1016/j.iccn.2015.02.003Get rights and content

Summary

Objectives

Although ineffective communication is known to influence patient and family satisfaction with care in intensive care unit [ICU] settings, there has been little systematic analysis of the features of the perceived problem from a communication theory perspective. This study was undertaken to understand perceptions of miscommunication and the circumstances in which they present.

Research methodology and design

Semi-structured interviews were conducted with 22 health care professionals [HCPs] in five adult ICUs at an academic medical centre in the United States.

Findings

From qualitative analysis of the transcribed interviews, four themes emerged, each containing multiple subthemes. Person factors are problems that originate within individuals, related to education, cultural background and emotion. Structural factors are associated with boundaries and coordination of institutional roles. Information management problems result from social and psychological processes by which HCPs and family members seek, distribute and understand information. Relationship management problems arise from difficulties in interpersonal interactions.

Conclusions

Ineffective communication is not a single problem, but rather several distinct problems that exist at different levels of abstraction and vary in over-time stability. These findings provide a framework for designing interventions to improve the well-being of patients and family members.

Introduction

When patients enter the intensive care unit [ICU], treatment decisions must be made quickly, often using limited or uncertain diagnostic information. In the United States, more than five million patients are admitted annually to ICUs (Society of Critical Care Medicine), and of these an estimated ninety-five percent (Wendler and Rid, 2011) cannot make independent decisions about their care (Luce, 2010). For this reason, a member of the immediate family is usually identified to serve as a surrogate decision maker and interact with the ICU health care professionals [HCPs] and with other members of the patient's family (Arnold and Kellum, 2003). The number of individuals involved in the patient's care increases the complexity of the decision process, as does the dynamic nature of the information and need for quick decisions on the part of the surrogate decision maker.

In trying to understand and improve the quality of care for patients in ICUs, interviews with family members have been collected and analysed by investigators in previous studies. Percentages of respondents indicating that communication was inadequate ranged from 12% to 50% (Azoulay et al., 2000, Azoulay et al., 2001, Heyland et al., 2003). When more closely analysed, the reasons for this dissatisfaction included inconsistent information, misunderstanding the role of decision making and substituted judgement, and inadequate understanding of the diagnosis, prognosis, or treatments by family members (Azoulay et al., 2001, Azoulay et al., 2009). In a literature review of communication and family-centred care in the ICU, Hunziker et al. noted that key determinants of family satisfaction were good communication, good decision making and respect and compassion shown to both the patient and family for both survivors and non-survivors (Hunziker et al., 2012). Likewise, in another family satisfaction study in the ICU, Schwarzkopf et al. (2013) found that the participants were highly satisfied and identified the need for consistent, clear and complete information as an area needing improvement (Schwarzkopf et al., 2013).

Communication experts have multiple views on how people make meaningful conversation. Craig (1999) draws on theories from sociopsychological and social cultural perspectives to theorise that problems with communication are situational and requires the manipulation of causes of behaviour to achieve certain outcomes (Craig, 1999). This study draws on theories of communication that include appraisal theories of emotion (Scherer et al., 2001), contingency theory of structure and performance (Ruekert et al., 1985), the motivated theory of information management (Afifi and Weiner, 2004) and relational framing theory (Dillard et al., 1999). In the ICU, the situational goals of care are a focus of communication between HCPs and patients’ families. HCPs must establish trust and rapport and deliver clinical information, often to guide and support critical decision-making. This communication fits a multiple goals perspective which assumes that people attempt to accomplish multiple objectives simultaneously in their interactions (Dillard et al., 1989). With multiple goals, communication actions that help achieve one goal may help or conflict with other relevant goals; thus, awareness of how goals affect message construction becomes important (Caughlin et al., 2009).

This current study was undertaken to better understand communication in the ICU, perceptions of miscommunication and the circumstances in which they present. Because bedside HCPs provide the majority of information to the families and patients, and have vast experience with a wide range of ICU communication issues, we chose to interview them initially to draw on their perspectives. Our study is unique in that we enlisted communication expertise to better understand the themes and categories that emerged in the context of a communication theory framework.

Section snippets

Method

HCPs were interviewed regarding communication issues in the ICU. Due to the exploratory nature of the inquiry, a basic qualitative analysis of semi-structured interviews was our preferred methodology. Participant selection was purposeful – defined as key informants who could provide rich case detail about the area of concern. Included were attending physicians, bedside nurses and physician assistants and nurse practitioners (registered nurses with additional qualifications to practice advanced

Themes

Using the constant comparative method, four major categories emerged and were categorised into themes (Table 2).

Evaluation of the typology of ICU communication

The goal of this project was to better understand the ICU communication problem through identification of its themes and their relationship to one another. To meet this objective we developed a typology of communication problems in intensive care delivery. Nine distinct subthemes were inductively derived from the data. Our findings provide evidence that inadequate communication in the ICU is not a single, homogeneous problem, but rather several distinct problems.

The nine subthemes were grouped

Conclusion

Communication is an important component of quality care for patients and their families. In this study we identified the themes representing communication concerns amongst the HCP professionals in a university hospital setting and related those concerns to what is known in the communication literature. Understanding that inadequate communication in the ICU is not a single problem, but rather several distinct problems, is important to guide effective interventions. Our typology offers clinicians

Funding

The authors have no sources of funding to declare.

Conflict of interest

The authors have no conflict of interest to declare.

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