RESEARCH ARTICLE
Critical care nurses’ communication
experiences with patients and families in an
intensive care unit: A qualitative study
Hye Jin Yoo 1 , Oak Bun Lim
1 , Jae Lan ShimID
2*
1 Department of Nursing, Asan Medical Center, Seoul, South Korea, 2 College of Medicine, Department of
Nursing, Dongguk University, Gyeongju, South Korea
Abstract
This study evaluated the communication experiences of critical care nurses while caring for
patients in an intensive care unit setting. We have collected qualitative data from 16 critical
care nurses working in the intensive care unit of a tertiary hospital in Seoul, Korea, through
two focus-group discussions and four in-depth individual interviews. All interviews were
recorded and transcribed verbatim, and data were analyzed using the Colaizzi’s method.
Three themes of nurses’ communication experiences were identified: facing unexpected
communication difficulties, learning through trial and error, and recognizing communication
experiences as being essential for care. Nurses recognized that communication is essential
for quality care. Our findings indicate that critical care nurses should continuously aim to
improve their existing skills regarding communication with patients and their care givers and
acquire new communication skills to aid patient care.
Introduction
Critical care nurses working in intensive care units (ICUs) care for critically-ill patients, and
their work scope can include communicating with patients’ loved ones and care givers [1]. In
such settings, nurses must make timely judgments based on their expertise, and this requires a
high level of communication competency to comprehensively evaluate the needs of patients
and their families [2,3]. The objective of nurses’ communication is to optimize the care pro-
vided to patients [4]. Therapeutic communication, a fundamental component of nursing,
involves the use of specific strategies to encourage patients to express feelings and ideas and to
convey acceptance and respect. In building an effective therapeutic relationship, a focus on the
patient and a genuine display of empathy is required [5]. Empathy is the ability to understand
and share another person’s emotions. To convey empathy towards a patient, one must accu-
rately perceive the patient’s situation, communicate that perception to the patient, and act on
the perception to help the patient [6]. Effective communication based on empathy not only
contributes greatly to the patient’s recovery [3,5–7], but also has a positive effect of improving
job satisfaction by nursing with confidence [8] In contrast, inefficient communication leads to
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OPEN ACCESS
Citation: Yoo HJ, Lim OB, Shim JL (2020) Critical
care nurses’ communication experiences with
patients and families in an intensive care unit: A
qualitative study. PLoS ONE 15(7): e0235694.
Editor: Liza Heslop, Victoria University,
AUSTRALIA
Received: January 21, 2020
Accepted: June 21, 2020
Published: July 9, 2020
Copyright: © 2020 Yoo et al. This is an open access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the manuscript.
Funding: This work was supported by the Dongguk
University Nursing Academy-Industry Cooperation
Research Fund of 2018.The funder had no role in
study design, data collectionand analysis, decision
to publish, or preparation of the manuscript
Competing interests: The authors have declared
that no competing interests exist.http://orcid.org/0000-0002-7795-0149https://doi.org/10.1371/journal.pone.0235694http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0235694&domain=pdf&date_stamp=2020-07-09http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0235694&domain=pdf&date_stamp=2020-07-09http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0235694&domain=pdf&date_stamp=2020-07-09http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0235694&domain=pdf&date_stamp=2020-07-09http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0235694&domain=pdf&date_stamp=2020-07-09http://crossmark.crossref.org/dialog/?doi=10.1371/journal.pone.0235694&domain=pdf&date_stamp=2020-07-09https://doi.org/10.1371/journal.pone.0235694http://creativecommons.org/licenses/by/4.0/
complaints and anxiety in patients and can also lead to other negative outcomes, such as
extended hospital stays, increased mortality, burnout, job stress, and turnover [9,10].
Therefore, communication experiences need investigation since effective communication is
an essential for critical care nurses. Nurses use curative communication skills to provide new
information, encourage understanding of patient’s responses to health troubles, explore
choices for care, help in decision making, and facilitate patient wellbeing [11]. Particularly,
patient- and family-centered communication contributes to promoting patient safety and
improving the quality of care [12,13]. However, communication skills are relatively poorly
developed among critical care nurses compared to nurses in wards and younger and less expe-
rienced nurses than in their older and more experienced counterparts [3,7,14–16]. This calls
for an examination of the overall communication experiences of critical care nurses.
To date, most studies on the communication of critical care nurses have been quantitative
and have evaluated work performance, association with burnout, and factors that hinder com-
munication [2–4,7]. A qualitative study has examined communications with families of ICU
patients in Korea [17], while an international study has identified factors that promote or hin-
der communication between nurses and families of ICU patients [16,18]; however, few studies
have been conducted on participant-oriented communication (including patients and fami-
lies). Nurses’ communication with patients and their families in a clinical setting is complex
and cannot be understood solely on the basis of questionnaire surveys; therefore, these com-
munication experiences must be studied in depth.
This study explored critical care nurses’ communication experiences with patients and their
families using an in-depth qualitative research methodology. This study will help to enhance
communication skills of critical care nurses, thereby improving the quality of care in an ICU
setting.
Materials and methods
Design
This study employed a qualitative descriptive design using focus-group interviews (FGIs) and
in-depth individual interviews and was performed according to the consolidated criteria for
reporting qualitative research (COREQ) checklist [19]. An FGI is a research methodology in
which individuals engage in an intensive and in-depth discussion of a specific topic to explore
their experiences and identify common themes based on the interactions among group mem-
bers [20]. Individual in-depth interviews were also conducted to complement the content
identified in FGIs and further explore the deeper information developed based on experiences
at the individual level.
Participants
Sixteen critical care trained nurses providing direct care to patients in an ICU of a tertiary hos-
pital in Seoul were included in this study. The purpose of this study and the contents of the
questionnaire were explained to them, and they voluntarily agreed to participate and complete
the questionnaire. The exclusion criteria were as follows: 1) nurses with a hearing problem; 2)
nurses with less than 1 year of clinical experience; and 3) nurses diagnosed with psychiatric
disorders.
Snowball sampling—in which participants recruit other participants who can vividly share
their experiences regarding the topic under investigation—was used. Six participants for the
first FGI, six for the second FGI, and four for the individual in-depth interviews were
recruited. All participants were women (mean age = 29.0 years old; mean nursing experi-
ence = 4.5 years). Their characteristics are listed in Table 1.
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Data collection
Developing interview questions. The interview questions were structured according to
the guidelines developed for the focus-group methodology [21]: 1) introductory questions, 2)
transitional questions, 3) key questions, and 4) ending questions. The questions were reviewed
by a nursing professor with extensive experience in qualitative research and three critical care
nurses with more than 10 years of ICU experience (Table 2). These questions were also used
for individual face-to-face in-depth interviews.
Conducting FGIs and individual interviews. The two FGIs and four individual inter-
views were conducted between July 20, 2019 and September 30, 2019. The FGIs were moder-
ated by the principal female investigator and were conducted in a quiet conference room
where participants were gathered around a table to encourage them to talk freely. The FGIs
were audio-recorded with the participants’ consent, and the recordings were transcribed and
analyzed immediately after. Similar content was observed from the two rounds of FGIs, and
we continued the discussion until no new topics emerged.
To complement the FGIs and verify the results of the analysis, we also conducted individual
interviews of four participants. One assistant helped in facilitating the interviews and took
notes. The duration of each interview was about 60–90 minutes.
Ethical considerations and investigator training and preparation. This study was
approved by the institutional review board of the Asan Medical Center (approval no. 2019–
0859). Prior to data collection, participants provided written informed consent and were
informed in advance that the interviews would be audio-recorded, their participation would
remain confidential, the recordings and transcripts would only be used for research purposes,
the data would be securely stored under a double lock and would be accessed by the investiga-
tors only, and personal information would be deleted upon the completion of the study to
eliminate any possibility of a privacy breach. The collected data were coded and stored to be
accessed by the investigators only to prevent leakage of any personal information.
The authors of this study are nurses with more than 10 years of ICU experience and a deep
understanding of critical care. The principal investigator took a qualitative research course in
Table 1. Participant characteristics.
No. Sex Age (years old) Intensive care unit experience (months) Marital status Highest Educational Level
1 F 28 30 Single University
2 F 27 30 Single University
3 F 27 29 Single University
4 F 29 27 Single University
5 F 27 24 Single University
6 F 26 24 Single University
7 F 26 22 Single University
8 F 26 22 Single University
9 F 26 22 Single University
10 F 26 20 Single University
11 F 27 20 Single University
12 F 26 20 Single University
13 F 29 40 Single University
14 F 37 168 Married Master’s
15 F 38 180 Married Master’s
16 F 39 188 Married Master’s
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graduate school and has conducted multiple qualitative studies to enhance her qualitative
research experience.
Data analysis
We utilized Colaizzi’s [22] method of phenomenological analysis to understand and describe
the fundamentals and meaning of nurses’ communication experiences with patients and fami-
lies. Data analysis was conducted in seven steps: 1) Recording and transcription of the in-
depth interviews (all authors read the transcripts repeatedly to better understand the partici-
pants’ meaning); 2) Collection of meaningful statements from phrases and sentences contain-
ing phenomena relating to the communication experiences in the ICU. We extracted
statements overlapping with statements of similar meaning—taking representative ones of
similar statements—and omitted the rest; 3) Searching for other interpretations of participant
statements using various contexts; 4) Extraction of themes from relevant meanings and devel-
opment of a coding tree, with the meanings organized into themes; 5) Organization of similar
topics into a more general and abstract collection of themes; 6) Validation of the collection of
themes by cross-checking and comparing with the original data; 7) After integrating the ana-
lyzed content into one technique, the overall structure of the findings was described.
During data analysis, we received advice on the use of language or result of analyzing from
a nursing professor with extensive experience in qualitative research and had the data verified
by three participants to establish the universality and validity of the identified themes.
Establishing precision
The credibility, fittingness, auditability, and confirmability of the study were evaluated to ana-
lyze our findings [23]. To increase credibility, we conducted the interviews in a quiet place to
Table 2. List of interview questions.
Question
Type
Questions
Introductory What kind of care do you provide to your patients and their families as an ICU nurse?
Transitional As an ICU nurse, how is your communication with your family now?
Key What is your primary focus when communicating with patients and their families?
Do you have memorable experiences in your communication with your patients’ families?
a) If so, what were these experiences?
b) How do you feel about those experiences?
Do you have your own strengths in communicating with patients and their families?
a) If so, what are their advantages?
b) What role do your strengths play in communication?
c) What is the impact of communication on nursing?
Have you ever faced difficulties in communicating with patients’ families?
a) If so, please specify them.
b) What is the impact of these communication difficulties on your patients and their families?
c) How do these communication difficulties affect nursing?
Have you made any personal effort to communicate effectively with patients and their families?
a) If so, what have you done specifically?
b) How does the effort/s you have made affect your communication with patients and their
families?
Do you need hospital or external help to improve communication with your patients and their
families?
a) If so, what specific help do you need?
b) How do you feel about the changes in communication style with patients and families when
support and help are provided?
What does communication with the patients and their families mean to the nurse?
Ending Is there anything you would like to add?
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focus on participants’ statements and help participants feel comfortable during interviews; to
establish the universality and validity of the identified themes, data verification was performed
by three participants. To ensure uniformity in data, participants who could provide detailed
accounts of their experiences were selected, and the data were collected and analyzed until sat-
uration was achieved (i.e., no new content emerged). To ensure auditability, the raw data for
the identified themes were presented in the results, such that the readers could understand the
decision-making process. To ensure confirmability, our preconceptions or biases regarding
the participants’ statements were consistently reviewed to minimize the impact of bias and
maintain neutrality.
Results
After analyzing the communication experiences of 16 critical care nurses, three major themes
emerged: facing unexpected communication difficulties, learning through trial and error, and
recognizing communication experiences as being essential for care. The results are summa-
rized in Table 3.
The results of this study are schematized based on Travelbee’s Human-to-Human Relation-
ship Model [24,25] (Fig 1), which suggests that human-to-human interaction is at a develop-
mental stage. In this study, communication between patients and their families and
experienced nurses in ICUs promotes human-to-human connections, leading to a genuine
caring relationship through interaction, empathy, listening, sharing, and respect, which are all
therapeutic communication skills.
Theme 1: Facing unexpected communication difficulties
Nurses experienced more difficulties in communicating with patients and their families and
caregivers than in performing essential nursing activities (e.g., medication administration, suc-
tion, and various mechanical operations) The communication difficulties they experienced
were either nurse-, patient- and family-, or system-related. Distinct problems in an ICU are
related to urgency; for example, hemodynamically unstable patients or patients with respira-
tory failure or those suffering from a cardiac arrest may be prioritized.
Nurse-related factor: True intentions were not conveyed as wished. Although nurses
intend to treat patients and their families with empathy, they frequently lead one-way conver-
sations when pressed for time in the ICU. In addition, their usual way of talking, such as their
dialect and intonation, can sometimes be misunderstood and cause offense. Participants expe-
rienced difficulties communicating their sincerity to patients and their families.
“Oftentimes, I only say what I have to say instead of what the caregivers really want to know
when I’m pressed for time to convey my thoughts and go on to the next patient to explain
things to the other patient.” (Participant 2)
“I usually speak loudly, and I speak in dialect; so, things I say are not delivered gently. . .I
try to be careful because my dialect can seem more aggressive than the Seoul dialect; but it’s
not easy to fix what I have used for all my life at once.” (Participant 3)
Nurse-related factor: Hesitant to provide physical comfort. Participants were not famil-
iar with using non-verbal communication. The participants realized the importance of both
verbal communication and physical contact in providing care, but the application of both
these communication styles was not easy in clinical practice.
“I want to console the caregivers of patients who pass away; but I just can’t because I get
shy. I feel like I’m overstepping, and when I’m contemplating whether I can really speak to
their emotions, the caregiver has already left the ICU in many cases.” (Participant 6)
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Table 3. Critical care nurses’ communication experience with patients and their families.
Sub-category Category Theme
Theme 1: Facing unexpected communication
difficulties
In critical care, communication with patients and their
family is burdensome
1.1. True intentions not conveyed as wished Nurse-related
Misunderstanding because of the linguistic characteristics
of a nurse (e.g., dialect, voice tone, etc.)
Impatience/lack of care for patients and caregivers
ICU nurses need both verbal and nonverbal
communication skills
1.2. Hesitant to provide physical comfort
Nonverbal communication is unfamiliar
Not sure how to effectively provide nonverbal
communication
Patient in ventilator feels frustrated because he or she
cannot speak
1.3. Mechanical ventilation hindering communication
with the patient
Patient- and family-related
Difficulty understanding because the patient is on a
ventilator and thus cannot speak
Ventilator interferes with the communication between
nurse and patient
ICU patient’s caregiver is sensitive 1.4. Caregivers’ negative responses to nurses
Normal communication is impossible owing to caregivers’
aggressive attitude
As an ICU nurse, I have no choice but to respond to the
conversation
I have not learned properly about communication in the
clinic
1.5. Lack of experience and a mismatch between
theory and practice
System-related
Communication is the most difficult task for less
experienced, young nurses
The scheduled visit time in the intensive care unit is when
most communication occurs
1.6. Intense visiting hours in limited time
One-way conversation with the caregiver in a short period
Life-dependent care is a priority in the intensive care unit 1.7. Urgent workplace that deprioritizes
communication
Insufficient time to talk with patients and caregivers owing
to heavy workload
Nurses are hurt by distrustful patients and caregivers 2.1. Fundamental doubts about the nursing profession Theme 2: Learning through trial and error
Difficulty in nursing because of trauma from patients and
caregivers
Follow senior nurses and learn practical communication 2.2. Finding out which communication style is better
suited for patients and their families
Explains the patient’s daily life in detail
Communication is indispensable to nursing 2.3. Knowhow learned through persistent effort
Studying the lack of communication by searching books
and videos
Understand the anxiety and difficulties experienced by the
critically ill and their caregivers
3.1. Empathy garnered through various clinical
experiences
Theme 3: Recognizing communication
experiences as being essential for care
Nurse’s words have the power to make the patients and
their families cry or laugh
Listening as an intensive care nurse is more important than
talking
3.2. The power of active listening
Nurse empathy strengthens patients and caregivers and
enhances their feelings of control
Patients and caregivers are easy to reach 3.3. Mediator between physicians, patients, and
caregivers
(Continued)
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“I’m really bad at physical contact even with my close friends; but I’m even worse when it
comes to patients and caregivers. Because of my tendency, there are times when I hesitate to
touch patients while providing care.” (Participant 7)
Patient- and family-related factor: Mechanical ventilation hindering communication
with the patient. Mechanical ventilators were the greatest obstruction to communication in
ICU. Although it is normal for patients on a mechanical ventilator to lose the ability to speak,
patients and their families did not understand how mechanical ventilators work and were frus-
trated that they could not communicate freely with the patient. Participants expressed diffi-
culty in communicating with patients in ways other than verbal communication as well.
“Patients who are on mechanical ventilation can’t talk as they want and do not have enough
strength in their hands to write correctly; so, even if I try to listen to them, I just can’t
Table 3. (Continued )
Sub-category Category Theme
Nurses use words that are easy to understand
Nurses convey sincerity to others with respect and
understanding
3.4. Expressing warmth and respect
Nurses’ heartfelt expressions promote trust
Fig 1. Summary of communication experiences encountered by intensive care unit nurses.
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understand what they are saying. You know in that game where people wear headphones play-
ing loud music and try to communicate with one another—words completely deviant from the
original word are conveyed. It just feels like that.” (Participant 9)
“Patients on mechanical ventilation and who thus cannot communicate are the most diffi-
cult. The patient keeps talking; so, it hinders respiration—the ventilator alarm keeps going off,
the stomach becomes gassy, and the patient has to take the tube off and vomit later. No matter
how much I explain, there are patients or caregivers who tell me that the tube in the throat is
making [it] hard [for them] to breathe or [they] ask me to take it off just once and put it back
on, and these patients are really difficult. There is no way to communicate if they cannot accept
mechanical ventilators even if I explain.” (Participant 8)
Patient- and family-related factor: Caregivers’ negative responses to nurses. It was also
burdensome for nurses to communicate with extremely stressed caregivers and loved ones,
especially when patients were in a critical state. Despite the role of nurses in helping patients
during health recovery, caregivers’ negative responses to nurses, such as blaming them and
speaking and behaving aggressively, intimidated the participants and ultimately discouraged
conversations.
“I can manage the patients’ poor vital signs by working hard but communicating with sensi-
tive caregivers who project their anxiety about the patient’s state onto nurses doesn’t go as I
wish, so, it’s really difficult and burdensome.” (Participant 6)
“When the patient is in a bad state, caregivers sometimes want to not accept it and project
their feelings onto the nurses, and in such cases, there are no words that can console them.
Even approaching the caregivers is a burden, and I get kind of intimidated.” (Participant 5)
System-related factor: Lack of experience and a mismatch between theory and prac-
tice. Participants have learned the importance of communication during training; however,
they had trouble appropriately applying the learned concepts in their workplace. Participants
in this study were in their 20s and 30s, with limited life and social experiences, and felt the gap
between theory and practice in communicating with patients and families in ICU.
“Talking to the patient or caregiver was the most challenging thing when I was new. . .it is
impossible for nurses with not much life experience to communicate skillfully.” (Participant
10)
“It would be nice if the real-world conversation proceeds in the way shown in our textbook;
but it doesn’t in most cases. So, it is more practical to observe and learn from what other nurses
do in the actual field.” (Participant 2)
System-related factor: Intense visiting hours in limited time. The 30-minute ICU visit-
ing period is the only time when patients and families can talk to one another. Although nurses
are well trained to care for the patients to the best of their ability, caregivers distrust the nurses’
ability to care for patients since caregivers only have a limited amount of visiting time, thus
hindering effective communication. Some participants even experienced mental trauma fol-
lowing short but unforgettable interactions with caregivers.
“. . .the caregiver browbeat me and intimidated me for doing so. This gave me a mental
trauma for visiting hours. . .I didn’t know how to start a conversation and the visiting hours
were really stressful for me.” (Participant 3)
“The caregivers don’t stay in the ICU for 24 hours; so, once they begin to doubt our nursing
practice, we cannot continue our conversation with them. . .” (Participant 11)
System-related factor: Urgent workplace that deprioritizes communication. The ICU
is a unit for treating critically-ill patients; therefore, ICU nurses were more focused on tasks
directly linked to maintaining patients’ health, such as stabilizing vital signs, than on commu-
nication. Participants frequently encountered emergency situations, in which they could not
idly stay around to communicate with one patient because another required immediate
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assistance, i.e., they faced a reality in which they had to prioritize another patients’ health over
communication with one.
“. . .I’m really pressed for time when the patient keeps writing things I can’t understand
with their weak hands. . .I don’t have time to spare even if I want to listen to them.” (Partici-
pant 12)
“Vital signs are the utmost priority in [the] ICU. I’m on my feet the entire shift and don’t
even have time to go to the restroom. . .During early ICU treatment, there are a lot of emer-
gency situations; so, communication is way down in the priority list.” (Participant 5)
Theme 2: Learning through trial and error
The negative experiences arising from communicating with various individuals sometimes
forced nurses to think twice about their vocation; however, due to a sense of responsibility,
they tried to engage in therapeutic communication and to overcome difficulties.
Fundamental doubts about the nursing profession. Experiencing unfriendly and con-
frontational conversations with patients and caregivers was intolerable for participants. These
experiences were shocking enough to make them fundamentally question their decision to
choose and stay in the nursing profession.
“I felt so disappointed and frustrated when patients or caregivers bombard[ed] rude com-
ments at me with complete disregard of what I have done over a long period. . .I can’t sleep
well at night and my values as [a] nurse are shaken from their root.” (Participant 14)
“It becomes so difficult the moment communication fails and mutual trust is lost. Maybe I
could survive if this is just with one patient or caregiver; but the afterimage lingers with me persis-
tently while I’m working. . .I came to think whether I could continue nursing.” (Participant 7)
Finding out which communication style is better suited for patients and their fami-
lies. Nurses learned how to resolve communication-related difficulties that they encountered
from their seniors and mentors and tried to communicate better from their position at the
nursing station.
“A senior nurse of mine was talking to a caregiver who was really concerned, and she was
using affirmations like ‘Oh, really’ and ‘I see’ with a relaxed facial expression, and the caregiver
would spill her heart out to her. That’s when I thought that empathy is to express responses to
what the other person is saying.” (Participant 10)
“I can feel that I am able to bond with patients’ families when I tell them about the patient’s
daily living, such as how much the patient had slept, eaten, and whether the patient was not in
pain, during visiting hours.” (Participant 13)
Knowhow learned through persistent effort. Nursing activities, such as taking vital signs
and performing aspiration and intravenous injection, are learned over time; however, it is
impossible to acquire therapeutic communication skills without personal effort and interactive
experiences in the field.
“I’m reading a book about conversation and am learning about how to express empathy and
understand other people. . .Nursing skills are developed and improved over time; but it’s not easy
to enhance communication without personal effort or change in perception.” (Participant 16)
“Communication is an indispensable part of nursing. If you want to provide high-quality
care, you need to enhance your communication skills first.” (Participant 15)
Theme 3: Recognizing communication experiences as being essential for
care
Nursing and communication are inseparable. Although communication is a challenge while
caring for ICU patients, therapeutic communication is important for the patients’ and their
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families’ overall wellbeing. In an ICU, communication based on empathy and experience is a
significant component that helps patients perceive their illnesses more positively.
Empathy garnered through various clinical experiences. Since participants met many
patients and their families in the ICU, they were able to communicate. Participants understood
patients’ discomfort and learn why it was difficult for them to communicate and to comfort
and assure unease families who could not observe the patient’s condition. However, it was a
necessary communication method in the ICU. Participants realized the value and importance
of their words.
“. . .his endotracheal tube was touching his throat and was so uncomfortable: his mouth
was dry, he couldn’t talk, and his arms were tied; so, he thought the only way to communicate
was to use his legs and that’s why he was kicking. I felt really sorry. . .” (Participant 7)
“I gave a little detailed explanation to the caregiver during visiting hours and she thanked
me overwhelmingly. I feel that, because this is the ICU, patients and caregivers can be encour-
aged and discouraged by the words of the medical professionals.” (Participant 9)
The power of active listening. Although the ability to handle tasks promptly is important,
listening to patients amid the hectic work schedule in the ICU is also an important nursing
skill. Critical care nurses realized that listening to patients and caregivers without saying any-
thing is also meaningful and therapeutic.
“I was listening to the caregiver the entire duration of the visiting hour. . .She said that she
just had to open up to someone to talk about her frustrations, and that my listening to her was
a huge consolation for her.” (Participant 12)
“While listening to the caregiver and showing empathy every day at the same time, I was
able to witness that the caregiver who had been aggressive and edgy changed in a way to trust
in and depend on the nurse more.” (Participant 16)
Mediator between physicians, patients, and caregivers. Participants were at the center
of communication, serving as the bridge connecting physicians to patients and patients to
caregivers. They served as mediators, explaining the doctors’ comments to the caregivers, and
providing details regarding the patients’ state to families. Participants helped maintain a close
and balanced relationship between the doctor, the patients, and their families by conveying
messages not effectively communicated by the doctor or patients.
“Caregivers would not ask any questions to the doctor in the ICU and would ask me instead
once the doctor is gone. They would ask, ‘what did the doctor say?’ and ask me for an explana-
tion.” (Participant 4)
“The patients can’t say everything they want; so, as nurses, we are the mediators between
patients and caregivers. . .Tell[ing] the family about things that happened when they were not
around the patient is meaningful.” (Participant 14)
Expressing warmth and respect. Participants have experienced sharing emotions with
the patient’s family as well as with the patient during disease improvement and exacerbation.
In particular, sincere actions, such as staying with the families of patients who died or those
whose condition was deteriorating, led to more genuine relationships, as respect for human
life was expressed.
“When patients whom we have spent a long time [with] are about to pass away, we cry for
them and we stay beside them in their final moments. . .Showing respect for a person’s final
moments of life and expressing our hearts is meaningful, and it is something critical care
nurses must do.” (Participant 16)
“When the patient’s state worsened and. . .his daughter was sobbing next to him. . .I softly
touched her shoulder, and she really thanked me. As I saw the patient’s family grieve, I just
expressed how I felt, and, fortunately, my intention was well conveyed” (Participant 4)
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Discussion
This study evaluated critical care nurses’ communication skills and experiences with patients
and their caregivers. Based on the two FGIs and four individual in-depth interviews, three
themes have been identified: 1) facing unexpected communication difficulties; 2) learning
through trial and error; and 3) recognizing communication experiences as being essential for
care
For theme 1, we examined nurse-, patient-, family-, and system-related (i.e., pertaining to
hospital resources and education) factors. Theme 1 can be considered as the communication
involving human-to-human interaction, as mentioned in Travelbee [24,25], that takes place at
an incomplete stage. First, critical care nurses struggled with balancing their heavy workload
and communicating with patients and their families. In Korea, an ICU nurse, on an average,
cares for two to four patients, which is higher than in some other countries, wherein an ICU
nurse cares for one or two patients at the most; thus, the Korean work environment for ICU
nurses is more stressful [26]. This limits the amount of time nurses may have to communicate
and interact with their patients and caregivers. Misunderstandings are also common owing to
the patients’ inability to speak while intubated and to use of regional dialects. Patients and
caregivers want to hear specific and comprehensible information from health professionals
regarding the treatment procedures in the ICU [17,27]. However, previous studies [4,28] have
reported that critical care nurses experience communication difficulties due to high mental
pressure due to work, time constraints, and the inability to use their own language; these are
consistent with our findings. As nurses are required to interact with patients having various
needs, they need to learn how to communicate verbally and nonverbally in a sophisticated
manner [27], and hospital managers should implement practical communication programs in
the ICU.
Communication between nurses and their patients in the ICU is also often adversely
affected by the therapeutic environment, such as patient emergencies and the use of mechani-
cal ventilation [27,28]. Mechanical ventilators are one of the greatest obstacles to communica-
tion. Although they are essential for critically-ill patients who are incapable of spontaneous
breathing, they affect their ability to speak [29]; therefore, these patients need to employ other
strategies for communication, such as using facial expressions and lip movements, which
make communication extremely difficult [27,30]. Our participants strived to understand the
needs of critically-ill patients through verbal and nonverbal communication, such as writing
and body language. However, when the intentions were not conveyed properly, some patients
responded aggressively, hindering respiratory treatment and ultimately prolonging treatment.
This is in line with many previous findings [29,31,32] indicating that patients’ failure to effec-
tively express their needs to nurses or their family members triggers negative emotions. In
addition, participants had trouble interacting with caregivers who were extremely tense and
sensitive. According to Lee and Yi [17], families of critically-ill patients experience fear and
anxiety regarding the patients’ health state and strive to save the patient. Thus, nurses must
consider this when addressing vulnerable patients and their families and must actively identify
and resolve causes of discomfort in patients on mechanical ventilation (i.e., by using appropri-
ate analgesics/sedatives and removing the ventilator). Further, considering a systematic review
revealing that electronic communication devices enable efficient communication with criti-
cally-ill patients through touch or eye blinks [33], Korea should also keep abreast with techno-
logical advances in communication technology.
Concerning theme 2, as participants experienced emotional exhaustion from being misun-
derstood or unfairly criticized by patients and their families, they contemplated and doubted
the occupational values of nursing. Park and Lee [7] found that higher job satisfaction for ICU
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nurses is associated with better communication. This is consistent with our participants’ doubt
for choosing the nursing profession. However, instead of giving up on this profession, they
closely observed the effective communication skills of more experienced nurses, actively
learned about therapeutic communication through books and videos, and applied their learn-
ings during practice. Similar results were reported by Park and Oh [3] that patient-centered
communication competency among critical care nurses was the highest when a biopsychoso-
cial perspective, focused on delivery of factual information, was followed and the lowest in the
therapeutic alliance domain, which is required for performing cooperative care with patients.
Therapeutic communication provided by nurses to patients and their families in the ICU effec-
tively diminished their psychological burden and fostered positive responses from families
[34]. Currently, ICUs implement a systematic education system for nurses that focuses ontherapeutic techniques, such as hemodynamic monitoring, mechanical ventilation care, aspi-
ration, and extracorporeal membrane oxygenation; however, they lack a program targeting
effective therapeutic communication with patients and caregivers. The communication diffi-
culties experienced by nurses will persist without this additional program; thus, its implemen-
tation is critical to improve patient satisfaction and nursing quality of care. Further, instead of
coercing unilateral effort from critical care nurses, nurse managers should pay attention to
nurses’ emotional wellbeing and promptly develop systems to offset potential burnout, such as
voluntary counseling systems or measures to “refresh” nurses.
Concerning theme 3, participants learned that communication is a challenging but essential
aspect of critical care. The concept of communication resonates through Travelbee’s model
[24,25]. Getting to know another human being is as important as performing procedures. Anurse must establish a rapport with the patient and the patient’s caregivers, otherwise he or she
will not know the patient’s needs. As a place where life-and-death decisions are made, the ICU
induces anxiety in critically-ill patients and their caregivers. Hence, nurses should fully empa-
thize with patients and their caregivers [4,5,17].
Travelbee [24,25] emphasized the relationship between the nurse and the patient by estab-
lishing the Human-to-Human relationship model, which gives meaning to disease and suffer-
ing based on empathy, compassion, and rapport building. In addition, it presents concepts,
such as disease, hope, human-to-human relations, communication, interaction, patient’s
needs, perception, pain, finding meaning, therapeutic use of communication, and self-actuali-
zation. The participants cultivated empathy and active listening skills when speaking with
patients and their families, and, as they spend more time doing so, their quality of care and
nonverbal communication skills (such as eye contact, soft touch, and tears) improve and
became more genuine. Our findings are consistent with the meaning of human-centered care
suggested by Jang and Kim [35], which involves paying close attention to and protecting
patients’ lives, deeply empathizing with patients from a humanistic perspective, and being sin-
cere. The experience of nursing, including active interaction, has a positive impact on estab-
lishing the roles and caring attitudes of professional nurses [36], which is significant for critical
care nurses. Patient-family-centered care, which has been confirmed to positively promote
critically-ill patients’ recovery worldwide [1], is possible when nurses engage in therapeutic
communication with patients and their families through dynamic interactions [34,37]. There-
fore, critical care nurses and nurse managers should pay attention to communication and
develop an effective communication course that can be applied in clinical practice. To do this,
first, it is necessary to hire appropriate nursing personnel for active therapeutic communica-
tion with the patients and their families in an ICU. Second, continuous, and diverse educa-
tional opportunities should be provided to critical care nurses, along with policy strategies. For
example, at the organizational level, it is necessary to develop manuals on how to deal with dif-
ficult situations by gathering challenging communication cases from actual clinical practice.
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Simulation education for communication is an important component of the nursing
curriculum.
Limitations
First, this study included a small number of participants; however, we ensured that the maxi-
mum data was collected from these participants. Second, specific information was collected
from only those nurses who provided direct care in the ICU of a general hospital in a large city
in Korea. The homogeneity and dynamics of the focus groups may have resulted in congruent
opinions. Third, because the experiences of nurses from only one hospital were analyzed, cau-
tion should be exercised in generalizing our results and applying them to other hospitals in
Korea. Therefore, follow-up studies with larger sample sizes and more representative partici-
pants are warranted.
Conclusion
This qualitative study explored critical care nurses’ communication skills and experiences with
patients and caregivers from various perspectives. Although these nurses felt discouraged by
the unexpected communication difficulties with patients and their families, they recognized
that they could address these difficulties by improving their communication skills over time
through experience and learning. They realized that empathy, active listening, and physical
interaction with patients and their families enabled meaningful communication and have
gradually learned that effective communication is an indispensable tool in providing nursing
care to critically-ill patients.
Supporting information
S1 File. COREQ checklist and coding tree.
(DOCX)
Acknowledgments
The authors would like to thank all the participants for their time and contribution in this
study.
Author Contributions
Conceptualization: Hye Jin Yoo, Jae Lan Shim.
Data curation: Hye Jin Yoo, Jae Lan Shim.
Formal analysis: Oak Bun Lim, Jae Lan Shim.
Funding acquisition: Jae Lan Shim.
Investigation: Hye Jin Yoo, Oak Bun Lim.
Methodology: Hye Jin Yoo, Jae Lan Shim.
Resources: Oak Bun Lim.
Supervision: Jae Lan Shim.
Validation: Hye Jin Yoo, Oak Bun Lim, Jae Lan Shim.
Writing – original draft: Hye Jin Yoo.
Writing – review & editing: Jae Lan Shim.
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