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Exp May 2, 2024

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Improving Family Communication in Critical Care

Melissa Jones, MN, RN

Abstract

Communication with family members in critical care is challenged by socioeconomic, environmental, and organizational factors. Ineffective communication between health care providers and family members results in psychological distress and anxiety among family members and can lead to misunderstanding of the patient’s condition and ineffective decision-making. This manuscript aims to explore barriers to effective communication, understand standardized communication tools, and support their implementation in critical care. An extensive search of various databases provided a variety of articles meeting the criteria of communication barriers in critical care, end-of-life, and strategies to overcome these barriers. Health literacy, diversity, and environmental factors are significant barriers to communication in critical care. The COVID-19 pandemic has further complicated communication, necessitating organizations to implement creative communication strategies. An effective strategy that is consistently identified for improving communication is the implementation of communication skills training. The READY framework, VALUE (Value, Acknowledge, Listen, Understand, and Elicit) guide, and Psychosocial Assessment and Communication Evaluation (PACE) tool are presented as frameworks to improve communication in critical care, and important elements of family meetings are identified. The collaborative efforts of the health care team and organization are essential in overcoming the specific challenges of communicating in critical care. Health care organizations and individuals are obligated to ensure that health care providers are appropriately trained, provided adequate resources, and are competent in communicating complex information with family members.

            Keywords: Family communication, critical care, communication training, communication framework, communication barrier

Implications for Nursing

  • Nurses are integral members of the health care team; their proximity to patients and family members provides an important opportunity for their participation in improving interdisciplinary communication and ensuring effective communication between the health care team and family members.
  • Nurses are strong advocates for patient and family member needs; ineffective communication witnessed by nursing staff can be identified and addressed by the health care team by implementing communication training and structured communication tools. 
  • Nurses are leaders in health care change; demonstrating the need for change is crucial to developing and implementing change practices across the interdisciplinary team.
  • Nurses can provide critical feedback on the effectiveness of new strategies to improve communication with family members.

Improving Family Communication in Critical Care

Critical care is a multidisciplinary and interdisciplinary approach to care designated to address acute life-threatening illnesses and injuries (Marshall et al., 2017). The life-sustaining technologies and invasive monitoring in intensive care units (ICUs) can be overwhelming for family members of patients requiring such care (Adams et al., 2017). Although families are often unprepared for these new roles, they are important critical care team members, acting as substitute decision-makers, informants for the health care team, and providers of support and comfort for patients (Lopez-Soto et al., 2021; Montauk & Kuhl, 2020). Effective communication between the health care team and families is critical in ensuring families have a clear understanding of the patient’s condition, reducing negative psychological distress and post-traumatic stress disorder (PTSD), and ensuring treatment plans are congruent with patient wishes (Newcomb et al., 2020; Seaman et al., 2017). Many communication barriers exist in critical care; therefore, it is important for organizations and health care professionals (HCPs) to make efforts to provide effective communication. Educating HCPs in using communication frameworks and tools supports the development of effective communication skills and overcoming barriers to communication. This manuscript aims to explore barriers to effective communication, analyze the literature on standardized communication tools, and support their implementation in critical care.

Background

Patients in the ICU often cannot communicate for themselves, placing an increased burden and emotional strain on family members (Bernild et al., 2021). The burden of uncertainty and the emotional toll of having a family member in the ICU place family members at risk of experiencing psychological distress, depression, and PTSD (Adams et al., 2017; Bernild et al., 2021; Newcomb et al., 2020). HCPs, including both doctors and nurses, are critical in supporting patients to reduce these risks by providing effective communication, emotional support, and education (Edward et al., 2020; Newcomb et al., 2020). Unfortunately, during a patient’s stay in critical care, the multidisciplinary team may be composed of numerous HCPs, resulting in variations of who, when, what, and how information is communicated (Bernild et al., 2021).

As family members face many challenges and fears as they make decisions on behalf of their loved ones (Adams et al., 2017; Cussen et al., 2020), collaboration between the health care team and their families in decision-making can ensure there are considerations for the patient’s values and beliefs alongside evidence-based recommendations (Cussen et al., 2020). This shared decision-making process is important to ensure that the health care team and family members have a common understanding of the issues in order to facilitate decision-making and treatment planning (Cussen et al., 2020; Edward et al., 2020). Unfortunately, misunderstanding of treatments, diagnoses, and prognoses is a common problem, occurring in 71% of families of ICU patients (Mathew et al., 2015).

Methods

            An extensive search of multiple databases through the Athabasca Library was accessed to gather the most current and relevant literature, including CINAHL, PubMed, MEDLINE, and Science Direct. Search terms included: family communication, critical care, intensive care, communication framework, communication policy, barriers, and communication education. Due to the nature of critical care, the search was extended to include articles discussing communication in the context of end-of-life care. A health systems librarian verified the search for scholarly articles, and a selection of current articles was chosen for this discussion. Included articles were chosen based on their relevance to communication in ICUs, communication tools or frameworks, and strategies for improving communication. Screening reference lists of the selected articles identified further articles relevant to this discussion.

Findings

Multiple influences affect the health of individuals and populations, including income, social status, literacy and education, physical environments, access to health services, gender, culture, and race (Government of Canada, 2022). Several of these health determinants are recognized as significant barriers to effective communication, including health literacy (Halm, 2021); cultural diversity (Brooks et al., 2019); and environmental factors (Edward et al., 2020). The COVID-19 pandemic has further complicated communication in critical care. In this section, communication barriers are further described, along with recommended strategies for communicating with families.

Barriers to Communication

Health Literacy

            Health literacy can be defined as an individual’s ability to make health decisions that promote well-being and demonstrate their ability to seek, understand, and apply health information (Fields et al., 2018; Halm, 2021; Sentell et al., 2020). Health literacy encompasses one’s ability to use health information, their confidence in navigating the health care system, and their ability to comprehend health information (Fields et al., 2018). Being in stressful and unfamiliar environments, such as the ICU, can affect a person’s ability to understand health information (Halm, 2021). Family members with limited health literacy are two and a half times more likely to have difficulty communicating and navigating within the health care system (Fields et al., 2018). When communication strategies are targeted to the individual, their burdens are reduced, they are more self-efficient, and have an improved quality of life (Fields et al., 2018).

Interventions at both the system and individual levels can be applied to improve communication impaired due to health literacy. Fields et al. (2018) suggest that family members with low health literacy may benefit from being active participants in the patient’s admission, allowing them to better integrate and understand the information they receive, ask questions directly, and receive immediate feedback from the health care team. At a systems level, organizations should consider training HCPs to support the development of communication skills, the application of communication tools, and the understanding of health literacy (Fields et al., 2018; Halm, 2021). Halm (2021) also recommends developing resources available in simple and clear language that HCPs can access and provide to families to enhance communication.

Diversity

            Canada is a nation of diverse populations with whom HCPs must strive to ensure equitable care provision; unfortunately, health inequities continue to exist concerning social determinants of health (Government of Canada, 2022). Language, religion, culture, race, socioeconomic status, and sexual orientation are some characteristics that socially isolate individuals, requiring special care considerations from HCPs and organizations (Zurca et al., 2020). Culturally sensitive communication is the “effective verbal, nonverbal, and written interactions among individuals or groups, with a mutual understanding and respect for other’s values, beliefs, preferences, and culture, to promote equity in health care” (Brooks et al., 2019, p. 516). Lack of culturally sensitive communication results in patients and families feeling unheard (Zurca et al., 2020), impacts decision-making, and leads to distress in patients, families, and HCPs (Brooks et al., 2019). Many HCPs feel unprepared to provide culturally sensitive care, especially in end-of-life discussions (Brooks et al., 2019), emphasizing the need for communication training that supports cultural sensitivity (Brooks et al., 2019; McKivett et al., 2019). Various studies further support communication training to encourage shared decision-making and improve patient satisfaction (Cussen et al., 2020; Edward et al., 2020; Newcomb et al., 2020).

Environmental Factors and COVID-19

            Communication practices prior to the pandemic were challenging; however, the COVID-19 pandemic further complicated communication efforts when hospitals were required to restrict visitors to reduce virus transmission (Bernild et al., 2021; Montauk & Kuhl, 2020; Rose et al., 2021). Unfortunately, these limitations left many patients alone at the end of life in the ICU (Montauk & Kuhl, 2020) or facing challenging recoveries and uncertain outcomes alone (Rose et al., 2021). These restrictions have negatively impacted patients, families, and HCPs. Problems identified with ineffective communication, such as psychological distress, poor understanding of patient wishes and medical history, and moral distress among HCPs, have been exacerbated by implementing these restrictive measures (Rose et al., 2021). HCPs and organizations needed to creatively and quickly develop measures to allow communication with families. Unique measures, such as family liaison teams (FLT; Lopez-Soto et al., 2021) and virtual visits (Montauk & Kuhl, 2020; Rose et al., 2021; Savino & Crispino, 2020), were implemented to enhance communication.

An FLT implemented in a health organization in the United Kingdom designated a team to provide daily communication and updates for families and friends of patients in the ICU (Lopez-Soto et al., 2021). The study demonstrated the importance of communication and its impact on family satisfaction. Challenges identified in the study included: designated members of the FLT were not ICU trained or trained in communication skills; FLT members only met with the health team twice a day to share and gather information; and end-of-life discussions required more support than the FLT could provide (Lopez-Soto et al., 2021). These issues emphasize that communication goes beyond providing objective information; communication skills and close contact with the patient and health care team are invaluable tools.

A recent study identified certain aspects of communication that families value when communicating with HCPs. Bernild et al. (2021) identified that families value receiving valid and accurate objective information; the information provided in the proper context, with the right people, and in an appropriate manner; and finally, that HCPs show honesty regarding what is known and not known about the patient’s condition. Some examples of this approach include having designated times for families to communicate with the health care team, having HCPs proactively initiate communication in a consistent pattern, and using video to communicate with the HCP (Bernild et al., 2021). The impact of the COVID-19 pandemic has emphasized the challenges of providing effective communication in critical care, demonstrating the need for strategies to overcome the specific communication challenges faced in critical care.

Discussion

            Implementing structured communication tools, such as communication frameworks and family meetings (Gruenewald et al., 2017; Nelson et al., 2009; Piscitello et al., 2019), offers many benefits to improve communication with family members, such as enhancing comprehension, reducing family distress, and increasing satisfaction (Halm, 2020; Sviri et al., 2019). Ensuring HCPs are trained in communication tools is important in improving communication.

Communication Frameworks

            Communication tools are commonly used to improve communication (Shannon et al., 2011). Three frameworks developed to support communication between HCPs and family members in critical care include the READY framework (Mackie et al., 2021), the VALUE (Value, Acknowledge, Listen, Understand, and Elicit) guide (Rhoads & Amass, 2019), and the Psychosocial Assessment and Communication Evaluation (PACE) tool (Higginson et al., 2013). These tools are recommended to allow HCPs and organizations to choose which tool best fits the needs of their population and HCPs (see a comparison of these frameworks in Appendix A).

            The READY (Right language, Environment, Assessment of families’ readiness to communicate, Do your preparation, and You have the opportunity to deliver different news) mnemonic aims to prepare HCPs to communicate with family members in challenging situations (Mackie et al., 2021). The framework was developed during the COVID-19 pandemic to support communication with family members with limited access at the bedside and ensures HCPs consider the barriers created by health literacy, the environment, and communication preferences. The framework comprises a training workshop and a visual tool (see Appendix B). The framework can improve confidence and skills and reduce the effects of ineffective communication (Mackie et al., 2021).

            The VALUE guide supports HCPs in communicating with families during challenging end-of-life discussions (Rhoads & Amass, 2019). This guide (see Appendix C) has been shown to reduce PTSD, anxiety, and depression scores among family members and helps HCPs respond appropriately and empathetically to family members’ concerns (Davidson et al., 2017; Rhoads & Amass, 2019).

            The PACE tool was designed to facilitate the assessment of patients and families and communication throughout their ICU admission (Higginson et al., 2013). The PACE tool addresses barriers that arise from low health literacy and communicating with culturally diverse patient populations. The program comprises a training program for HCPs, additional learning resources, and a PACE record to ensure accountability and documentation. This program was designed for ICU environments and gathers information regarding the patient’s family, relationships, social details, patient preferences, communication preferences, and any concerns (see Appendix D for the adapted PACE tool). The tool can be integrated into electronic health record systems and has shown positive outcomes on family satisfaction, symptom control, and support for patient and family members’ needs (Higginson et al., 2013). These structured frameworks are a starting point for training HCPs to communicate skillfully; however, communication in formal situations, such as family meetings, should be considered.  

Family meetings are a valuable tool for communicating with families in the ICU; unfortunately, family meetings are typically held with the goal of negotiating the withdrawal of life support instead of supporting the patient and family (Piscitello et al., 2019). Further, family meetings require a wide range of communication skills, for which many HCPs do not receive formal training (Singer et al., 2016). When used appropriately and offered in a timely, reliable manner, family meetings can reduce conflict of care goals and hospital length of stay (Nelson et al., 2009). The shared decision-making process between family members and the multidisciplinary team supports therapeutic relationships and enhances communication (Powazki et al., 2018). Family meetings should be planned, structured events led by HCPs trained in leading family meetings and should include members from more than one involved discipline (Gruenewald et al., 2017; Nelson et al., 2009; Powazki et al., 2018). Family meetings are inherently stressful for family members and HCPs. Ensuring appropriate measures are in place is not a light recommendation; an unplanned family meeting can result in negative outcomes or cause potential harm (Powazki et al., 2018).

Implications for Practice

Critical care imposes unique challenges on communication that are difficult to overlook. Challenges such as patients’ inability to represent their values and wishes, the uncertainty and unpredictability of outcomes, and the common need for end-of-life discussions illustrate the need for structured and consistent communication strategies. Overcoming these challenges is a collaborative effort between all health team members, including nurses, physicians, and family members. Organizations also play an important role in providing adequate support and resources, training, and supporting quality improvement initiatives. Communication is an essential component of care that demands consistent and effective strategies implemented by HCPs. As a basic competency, HCPs should be held accountable for ensuring they have adequate knowledge and skills to communicate effectively with family members. Health care organizations should be responsible for adequately providing resources and support to HCPs as they endeavour to improve communication skills and implement communication strategies. The described frameworks and tools can guide HCPs and organizations in improving communication and incorporating best-practice communication processes. 

Conclusion

            Effective communication with family members in ICUs can be challenging and complicated by socioeconomic factors, environmental factors, and organizational processes. Due to the stressful environment and uncertainty in the ICU, it is critical that family members are encouraged to participate as health care team members and supported throughout the process to mitigate the negative consequences of ineffective communication. HCPs and organizations should consider taking steps to overcome communication barriers by improving communication skills through the implementation of communication frameworks, communication skills training, and best practice communication processes. Although frameworks and communication strategies exist, there remains a significant gap between research and actual strategy used in practice; further research in implementation strategies and the challenges of implementing such strategies in the current work climate would help bridge this gap.

Author Notes

Melissa Jones, MScN, RN, The University of Ottawa Heart Institute

Address for correspondence:  Melissa Jones, MN, RN

Email:  Melissa.ejones18@gmail.com

Funding and Conflict of Interest

The authors received no funding and have no conflict of interest to declare.

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Appendix A

Communication Framework Table

FrameworkPurposeHow it Works
READY Framework    To prepare health care providers to better communicate with family members regarding challenging situations. (Mackie et al., 2021)A five-part mnemonic and training intervention.Contextualized for use in critical care.A half-day training workshop for health care professionals lead by a research team and a patient’s family representative, consisting of real-life stories and case studies. A feasible training intervention that improves the confidence and skills of health care providers in delivering challenging news, managing emotions, and reducing negative impacts.Includes a simple visual representation. (Mackie et al., 2021)  
VALUE Guide  Provides guidance to health care providers in discussions with family members of critically ill patients and at the end of life (Rhoads & Amass, 2019).Demonstrates reduced rates of PTSD, anxiety, and depression among family members (Rhoads & Amass, 2019).Helps address concerns appropriately and with empathy (Rhoads & Amass, 2019).A five-part mnemonic implemented through a two-hour didactic training session for ICU staff (Pagnamenta et al., 2016)A simple pocket card was provided to staff with the mnemonic (Pagnamenta et al., 2016).
PACE ToolAn interventional tool was developed to improve communication and palliative care in critical care (Higginson et al., 2013).A two-part program that consists of a PACE training program and a PACE record. Training lasts one week prior to implementation.Posters and information leaflets were made available on the unit.A representative from the palliative care team and researchers remain present for 3- to 4- hours each day to help staff adjust. A brief 2-page record is to be completed within 24 hours and used to log further communications. (Higginson et al., 2013)


Appendix B

READY Framework

(Mackie et al., 2021, p. 298; Reprinted with Permission)

Appendix C

VALUE Reference Card

    V.A.L.U.E. A 5-step mnemonic to improve ICU clinician communication with families   V = Value comments made by the family A = Acknowledge family emotions L = Listen U = Understand the patient as a person E = Elicit family questions      

“VALUE” was developed by the University of Washington End-of-Life Care Research Program at Harborview Medical Center (End-of-Life Care Research Program, n.d.; Reprinted with Permission)

Appendix D

PACE Tool

This tool was adapted from the author’s (Higginson et al., 2013, electronic supplementary material) online version, publicly available for use at https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-11-213#Sec22.

Any member of the healthcare team to commence within 24 hours of admission and continue use until discharge.

Patient name: ­­­­­________________________    DOB: _____________ 

Hospital Number: ___________________

Date / time of admission:  ___________/____________     

Date / time form completed:   __________/_________              

Staff member completing form (sign & print): _______________________________

Family member completing form:    _________________________

Key family contact: __________________

1. Family details including key relationships:

If yes to any of the following, detail action taken below:

Children under 18?                                                  o Yes        o No       If yes, contact palliative care social

Guardianship issues of any children?                  o Yes        o No       worker to discuss supported visits

Vulnerable adults?                                                 o Yes        o No       

Action taken:

2. Social details (incl. employment; religious, spiritual & cultural needs; perceptions of hospital/ ICU):

Financial concerns?                                   o Yes        o No   

Religious / spiritual needs?                      o Yes        o No   

Language / cultural needs?                       o Yes        o No   

Transport / parking needs?                        o Yes        o No   

Other supportive needs?                            o Yes        o No   

Action taken:

3. Patient Preferences

Has the patient previously expressed views about any treatment / care wishes:          

o Yes        o No

Specify: _____________________________________________________________________

Has the patient expressed a preference for place of care?                                         

o Yes        o No   

Specify: ____________________________________________________________________

Does the patient have an advance directive / statement?                               

o Yes        o No 

Details and action taken: ______________________________________________________________________

Does the patient have a will?                                          

o Yes        o No     o Not appropriate to discuss currently (must give reason)   

______________________________________________________________________

______________________________________________________________________

(NB staff cannot witness signing of wills – for advice contact Consultant or palliative care team social worker)

4. Communication and information:

Is the patient aware of the current situation and likely outcome? 

o Yes        o No, alert  o No, conscious level    

Is the NOK aware of the current situation and likely outcome?      o Yes        o No    

Details and action taken: ______________________________________________________________________

______________________________________________________________________

Names of people information about patient to be given to: _____________________________________________                              

Has the ITU been explained to the patient, OK?

  1. Visiting hours                                                                     o Yes        o No
    1. Who to ask for information                                              o Yes        o No
    1. Who the different staff members are                              o Yes        o No
    1. Has the relative information leaflet been given?          o Yes        o No

5. Any other concerns / issues

Action taken:

6. Communication Update – please complete each time the patient/ NOK/other is updated

DateUpdate given byUpdate given toCommunication documented?
NameDesignationYes/NoMedical notesNursing evaluation
         
         
         
         
         
         
         

Useful Contact Numbers

Palliative Care Team

Palliative Care Social Worker

Hospital social work team

Social work team for elderly                                                          

Counselling service            

Chaplaincy Services                      

PALS                                     

Local Out of hours Emergency Social Services

Information and Support Centre

Return to Winter 2023 Journal

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