Critical Care Techniques

C OMMUNICATION BY
NURSES IN THE INTENSIVE
CARE UNIT:
QUALITATIVE ANALYSIS
OF DOMAINS OF
PATIENT-CENTERED CARE
By Christopher G. Slatore, MD, MS, Lissi Hansen, RN, PhD, Linda Ganzini, MD,
MPH, Nancy Press, PhD, Molly L. Osborne, MD, PhD, Mark S. Chesnutt, MD, and
Richard A. Mularski, MD, MSHS, MCR

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©2012 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2012124
410 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2012, Volume 21, No. 6
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Background High-quality communication is a key determinant
and facilitator of patient-centered care. Nurses engage in most
of the communication with patients and patients’ families in
the intensive care unit.
Objective To perform a qualitative analysis of nurses’ com-
munications.
Methods Ethnographic observations of 315 hours of
interac- tions and 53 semistructured interviews with 33
nurses were conducted in a 26-bed cardiac-medical
intensive care unit in an academic hospital and a 26-bed
general intensive care unit in a Veterans Affairs hospital in
Portland, Oregon. Communi- cation interactions were
categorized into 5 domains of patient- centered care.
Interviews were analyzed to identify major themes in nurses’
roles and preferences for communicating with patients and
patients’ families within the domains.
Results Most communication occurred in the domains of
biopsychosocial information exchange, patient as person,
and clinician as person. Nurses endorsed the importance of
the domains of shared power and responsibility and
therapeutic alliance but had relatively few communication
interactions in these areas. Communication behaviors were
strongly influenced by the nurses’ roles as translators of
information between physicians and patients and the
patients’ families and what the nurses were and were not
willing to communicate to patients and patients’ families.
Conclusions Critical care, including communication, is a col-
laborative effort. Understanding how nurses engage in patient-
centered communication in the intensive care unit can guide
future interventions to improve patient-centered care. (American
Journal of Critical Care. 2012;21:410-418)
www.ajcconline.org
T
he American College of Critical Care Medicine1 recommends patient-centered
care (PCC) to improve outcomes in the intensive care unit (ICU).
Communication is a critical component of PCC, and patients and their families
have identified good communication as a critical aspect of high-quality care in
the ICU.2,3 Indeed, com- munication is the primary mechanism that health care
providers, patients, and
patients’ families use to share information, elicit preferences, convey assessments and plans,
and make decisions.3-12 Nurses provide most bedside care and have the most opportunity to
interact with patients and patients’ families13; however, interventions to improve
communication have not always explicitly targeted nurses’ contributions.14 Research on
nurses’ communication in the ICU is sparse despite recommendations that nurses be
proficient in communication skills15 and the importance of nurses’ communication for
patients and patients’ families.2,16

PCC has several definitions but encompasses 5 nurses’ communication within this framework can
domains: the biopsychosocial perspective, with a facilitate better understanding of their contributions
focus on information exchange; the patient as person; to PCC. In addition, understanding the underpinnings
sharing power and responsibility; the therapeutic of nurses’ communication behaviors in specific PCC
alliance; and the clinician as person.17 The theoretical domains can guide the development of multidisci-
model of PCC in the Figure includes examples of plinary communication interventions that take
behaviors and interactions and how these behaviors advantage of nurses’ strengths.18
might contribute to specific outcomes. Analyzing Our objective in this study was to qualitatively
examine nurses’ communication behaviors within
the theoretical framework of PCC.19 We developed
About the Authors our ethnographic analysis on the basis of this
Christopher G. Slatore is an investigator, Health
Services Research and Development, a staff physician,
framework to help identify constructs to improve
Section of Pulmonary and Critical Care Medicine, the usefulness of the results.12,20 Through interviews,
Portland Veterans Affairs Medical Center, Portland, we also examined nurses’ communication roles to
Oregon, and an assistant professor, Division of better understand how and why
Pulmonary and Critical Care Medi-
cine, Department of Medicine, Oregon Health and Science
University, Portland. Lissi Hansen is an associate profes-
nurses engage in specific domains Patients and families
of patient-centered communication
sor, School of Nursing, Oregon Health and Science Uni-
versity. Linda Ganzini is a psychiatrist and director, Health with patients and families in the ICU. have identified
Services Research and Development, Portland Veterans
Affairs Medical Center. Nancy Press is a professor, School
Methods
good
of Nursing and Department of Public Health and Preven-
tive Medicine, School of Medicine, Oregon Health and communication as
Science University. Molly L. Osborne is a professor of Overview and Setting
medicine, integrated ethics program officer, Section of
The data for this analysis came
a critical aspect
Pulmonary and Critical Care Medicine, Portland Veterans
Affairs Medical Center, interim associate dean for edu-
cation, associate dean for student affairs, Division of
from a study of ICU patients with of high-quality
end-stage liver disease conducted
from 2007 to 2010. A prospective, care in intensive
care units.
Pulmonary and Critical Care Medicine, Department of SW US Veterans Hospital Rd, R&D 66, Portland, OR 97239 (e-mail:
Medicine, Oregon Health and Science University. Mark christopher.slatore@va.gov).
S. Chesnutt is a staff physician, Section of Pulmonary
and Critical Care Medicine, director, Critical Care,
Patient Care Services Division, Portland Veterans
Affairs Medical Center, and a clinical professor,
Division of Pulmonary and Critical Care Medicine,
Department of Medicine, Oregon Health and Science
University. Richard A. Mularski is an investigator and
senior staff physician, Center for Health Research,
Kaiser Permanente Northwest, Pulmonary and Critical
Care Medicine, Portland, Oregon, and an affiliate
associate professor of medicine, Division of Pul-
monary and Critical Care Medicine, Department of
Med- icine, Oregon Health and Science University.
Corresponding author: Christopher G. Slatore, MD, 3710
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multiple-case design,21,22 as ICU at the Portland Veterans Affairs Medical Center.
previously described,23 was used. Approval from the institutional review boards was
The study was conducted in 2 obtained at both institutions, and all patients
teaching hospitals in Portland, completed the informed consent process.
Oregon: a 26-bed cardiac- A total of 6 consecutive patients with end-stage
medical ICU at the Oregon liver disease and their families were enrolled. For
Health and Science Uni- versity the analysis described here, all nurses who provided
Hospital and a 26-bed general care for these patients and the patients’ families

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 Biopsychosocial perspective
• Information exchange
• Individualized risks
• Effective and accurate risk
communication
Patient outcomes
• Increased satisfaction
Patient as person • Decreased anxiety/pain
• Address worries and concerns • Improved decision making
• Questions encouraged
• Listen

Sharing power and responsibility

• Shared decision making High-quality
patient-centered
• Involvement of patient communication
• Agreement on plan

Therapeutic alliance
• Clinician knows patient’s desires
• Patient understands care plan Family outcomes
• Increased satisfaction
• Decreased anxiety and
posttraumatic stress
Provider as person
disorder
• Knows limitations of knowledge
• Improved decision making
• Appropriate involvement of other clinicians

Figure The 5 domains of patient-centered communication and the influence of such communication on important out-
comes for patients and their families.

were eligible. The patients’ median ICU length of stay
was 6 days (range, 4-20). The length of observation
consisted of a patient’s length of stay in the ICU,
beginning within 48 hours of admission and ending
when life-sustaining therapies were withheld or
withdrawn or the patient died or was transferred out
of the unit. Four patients received mechanical venti-
lation during at least part of their ICU stay, 4 received
renal replacement therapy, and 4 received vasopres-
sors. A total of 2 patients were listed on the liver
transplant waiting list before their ICU admission,
and 4 were considered potential candidates. Three
patients died in the ICU or shortly after discharge.
Data Collection and Analyses
Each “case” had a spatial and temporal
dimension, consisting of the patient and those
who interacted with him or her during the ICU
stay. Triangulation of data was provided by a com-
bination of interviews and direct observation in the
ICU, at family conferences, and during more infor-
mal conversations between patients’ family mem-
bers and health care providers. Trained observers
observed interactions and communication at the
bedside for approximately 10 hours daily, focusing
on times when major treatment decisions were
made.
The interviewers used a standardized format to record
field notes from 315 hours of ICU interactions and
communication during a total of 45 observed ICU-
patient days. The notes were transcribed at the end
of each observation shift.
Nighttime observations were not recorded, but
nurses who provided care for the patients during
the night were eligible for interviews. Because
these in-person, semistructured interviews were
conducted after major treatment decisions, a nurse
might be interviewed more than once. All nurses
who were approached for interviews agreed to
participate.
Interviews were audio recorded, transcribed, and
verified for accuracy. NVivo 7 (QRS
International) software was used for analysis of
data.
For the analysis described here, a single investi-
gator (C. S.) reviewed all the observational transcripts
and the interviews with nurses. From the observa-
tional data, elements of verbal and nonverbal com-
munication behaviors were categorized into each of
the 5 domains of PCC. Similarly, interviews were
analyzed to identify major themes of nurses’ roles
and preferences for communicating with patients
and patients’ families within the domains. In partic-
ular, interviews with the nurses were reviewed to
determine the stated rationales of how and why
412 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2012, Volume 21, No. 6
communication behaviors fit specific PCC
domains. Another investigator (L. H.) also
reviewed the obser- vational and interview
transcripts to corroborate the coding and thematic
schemes. Disagreements about the categorization
of communication into specific domains were
settled after discussion and then coming to
consensus. Comparisons were made between
observed dialogue and behaviors and the rationale
for these interactions as self-reported by
nurses. Italics are used to distinguish remarks made
by the nurses during interviews; plain text indicates
remarks from the observations.
Results
The Table gives the characteristics of the 54 nurses
who participated in the study (1 of the 55 who were
eligible declined to participate). Most were women
with a mean (SD) age of 41 (10) years and 14 (9)
years in practice. Of the 54 nurses, 33 were asked
for an interview (all assented) and completed a
total of 53 interviews.
PCC Domains
Biopsychosocial. The biopsychosocial domain
encompasses biomedical, psychological, and socio-
logical aspects of illness and disease for patients,
with a focus on information exchange. Direct
obser- vations indicated that most of the nurses’
commu- nication’ interactions with patients and
patients’ families were in this domain, most
commonly related
to acute biomedical problems. Topics often
discussed included review of vital signs, volume
status and interventions, medical history, technical
aspects of life-sustaining therapies, pain
management, and hygiene. Although these topics
were often related to life-sustaining therapies,
communication rarely focused on the implications
of why these interven- tions were required. In
several instances, nurses discussed a patient’s
blood pressure in relation to a vasopressor dose but
did not discuss that use of a
vasopressor indicated that a patient was critically
ill. For instance, when a patient required a
vasopressor to tolerate hemodialysis, the nurse told
the family, “[The patient] looks good, BP’s good.”
Patient as Person. The patient-as-person domain
encompasses attempts to understand a patient’s
unique personality outside the patient’s illness.24
Many communication behaviors fit in this domain.
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Table
Characteristics of the 54 nurses
in the ethnographic analysis
Characteristic Value
Female, No. (%) 42 (78)
Age, mean (SD), y 41 (10)
Race/ethnicity, No.
(%) White 45 (83)
Other 9 (17)
Years of practice, mean (SD) 14 (9)
instance, nurses referred to a patients and the
patient’s family members with colloquialisms such
as buddy, darling, honey, and sweetie. Patients,
patient’s families, and nurses often shared small
jokes and good-naturedly teased each other. Non-
verbal communication behaviors were frequent;
nurses often used touch and other personal interac-
tions, including offering and receiving hugs, hold-
ing hands, placing an arm around the person, and
silently praying for the patient.
Sharing Power and Responsibility. Sharing
power and responsibility includes actively involving a
patient or a member of the patient’s family in
treatment decision making and in forming an
agreement on the plan of care. Few communication
interactions between nurses and patients and
patients’ families fit in this domain. In interviews,
nurses acknowledged the overall importance of
shared decision making
but noted that the decisions they
made with patients usually focused
on routine aspects of biomedical
Nurses’ communi-
care that resulted from decisions cation with
previously made with physicians.
Therapeutic Alliance. Therapeutic
patients and
alliance incorporates a clinician’s patients’ fami- lies
knowledge of a patient’s desires
and is exemplified when the most commonly
clinician and patient work together related to acute
on the care plan. The ethnographic
obser- bio- medical
problems.
The interactions often involved discussions about a patient’s children,
religion or spirituality, and career, as well as everyday topics such as
the weather, tele- vision, and books. In addition, nurses often shared
similar personal details about themselves. The con- versational style
was often informal or familiar; for
vations revealed some
communication between nurses,
patients, and the patients’
families in this regard, mostly
focused on direct biomedical
con- cerns. Nurses coordinated
care for a patient by com-
municating with the patient’s
family about topics such as the
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patient’s level of consciousness, response to pain
and sedative medications, and bodily func- tions.
None of the observed interactions included
instances in which nurses ensured that patients and
the patients’ families understood the care plan in
terms of code status and liver transplantation.
Clinician as Person. The clinician-as-person
domain includes appropriate involvement of other
clinicians and self-recognition of the emotional
AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2012, Volume 21, No. 6 413
responses to a patient and the situation. Nurses presence of a patient’s family members, the nurses
routinely communicated with other clinicians, usu- translated a physician’s medical jargon and
ally physicians, to inform the clinicians of the clarified the overall plan, including how various
nurses’ concerns. In addition, nurses reported and diagnoses and treatments were indicators of illness
demon- strated how a patient’s situation affected severity.
them. For example, a nurse described her reaction For example, a nurse noted, “I frequently jump
when, in a in and restate questions if I think the doctor
family meeting, the physicians hasn’t answered it or maybe didn’t get the
reported questions; or
that the I’d ask the person, could
Patie patient you restate that.”
nts, would not Nurses
survive the thought that
familie transplant working as a
s, and process, “Of translator was a
key component
course, I had
nurses tears in my of their role
within the team
fre- eyes.................................
think structure. A nurse
quently that did help reported as
the family follows:
shared understand I do
small that this was believe
tearing at us we do
jokes as well, and things as
and that we really
weren’t
a team. I
allow the
good- declining to physician
offer s to drive
nature treatment that the initial
dly would exist to direction
help [the of the
teased patient], that plan.................because
each just there was I am with
the
really no
other. hope.” At a patient
later observa- all the time, I
tion, this find myself
same nurse to be acting
had the as the eyes
follow- ing and ears, and
interaction so I see
with the everything . .
patient’s .
so my
contributio
ns are
primarily to
provide an
insight that
it’s over
the course
of a con-
family, wipes
“‘This is away
tearing me tears.”
up’ as she Finally,

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in many le sistent period you can
instances, nurses d of time rather reinforc
discussed their to than their e what
feelings and be insight, you
ha
challenges with which is know,
vi
other nurses and or much more remem
received s of a spot ber this
emotional support in check, they is what
in return. Of note, go in once or he said.
the nurses did not twice in a Nurses
discuss their 12-hour sometimes
concerns with period. thought that
patients or the Another nurse reported: their role was to
patients’ families I think it is be a 1-way
when the nurses’ always translator,
opinions differed important translating
from those of for the nurse information
physicians but to be in the from a patient or
often discussed room when the patient’s
these concerns physicians family to the
with other nurses. are talking physi- cian but
to the family not vice versa.
Nurses’ Roles so you can The nurses
in hear what seemed to think
Communication they say, that it was not
After the and you can their role to
communications reinforce it directly correct
were categorized later; ‘cause misun-
into the PCC the families derstandings of
domains, the do tend to patients and
data were have ques- patients’
evaluated to tions families about
better understand afterwards issues such as
why nurses when the code status and
communicated doctors liver
more or less in leave, and transplantation.
particular areas.
particular PCC domains
The results Nu the team and gave insight into
indicated 2
overlapping rses structure. why nurses seemed to
have few communication
themes that felt that interactions in the
guided nurses’
communi- cation workin domains of shared
decision making and
behaviors that
stemmed from
g as a therapeutic alliance.
the nurses’ roles trans- The first theme was
that nurses felt that one
in the ICU,
especially as the
lator of their key roles was
serving as a translator or
roles contrasted was a intermedi- ary between
with physicians’
roles. These key physicians and patients
and the patients’
themes provided
much of
compo families. The second
the nent of theme focused on topics
that nurses
rat
io their
nal
e
role
tha within
t
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For “It is not This is something a
example my role to physician needs to tell
, a nurse tell a the family.” This nurse
recogniz family recognized a family
ed that a member, member’s misunder-
patient ‘I am so standing of the process
was too sorry that of liver transplantation
ill to you are off but said, “And I never
receive the [liver stopped and said that is
a transplant incorrect.” In response
transpla waiting] to a question about the
nt but list’ meaning of this
did not because I misunderstanding and
inform didn’t make how it would be
the the clarified,
family: decision.
were and were the nurse replied,
not willing to “. . . someone
discuss with needs to tell the
patients and the patient and it is
patients’ families; not us [nurses].”
these topics were Nurses recognized
classified as “said problems and limits with
vs not said.” translation from physicians
Translator. to patients and patients’
Nurses often families. Although the
described nurses understood the
translating a physi- cians’ assessments
physician’s and rationale for not
communication discussing
to a patient
and/or the
patient’s family
members and
vice versa. In
the

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these thoughts with a patient and the patient’s fam-
ily, the nurses felt constrained and frustrated in the
ability to translate this information. For example, a
nurse reported as follows:
I have a personal belief, and I have been
in the ICU for 20 years, and most of the
time families don’t have enough
information.
They don’t have the information they need
to make a choice. We [nurses] talk amongst
ourselves, or it is in the chart . . . and all
those people [physicians] talk amongst
themselves. They [physicians] have a kind
of consensus of what they perceive, what
they think is happening, but they are afraid
to tell the family because they don’t want
to destroy hope. But, I think sometimes
patients and families suffer because of that,
[the physicians’] inability to come clean.
Said vs Not Said. Several different aspects of the
theme of said vs not said were evident in observa-
tions and were described in interviews. First, as
alluded to in the previous quotation, nurses often
felt limited or constrained in their ability to com-
municate with patients and patients’ families. For
example, in several observations, nurses’ opinions
differed from those of physicians, but the nurses
did not disclose these differences. For instance,
dur- ing an interview, a nurse reported feeling
strongly that the timing and pace of therapeutic
interventions were delayed and slow. However,
when talking to the patient’s family about this
issue, this nurse told the family, “[The patient] is
doing a lot better today. I think we did a good job
of catching it early.”
At other times, nurses seemed to want corrobo-
ration of their interpretation of events before talk-
ing with patients and the patients’ families. When a
patient’s condition deteriorated unexpectedly,
before sharing their concern with the patient’s
family or the patient, nurses conferred among
themselves or with physicians. For instance, when a
patient’s blood pressure decreased precipitously
during dialysis, the patient’s nurse conferred with
the dialysis nurse quietly while the patient’s family
members in the room continued to talk among
themselves.
In several instances, nurses did not
communicate with patients and the patients’
families because the nurses did not think such
communication was part
of a nurse’s role. For example, nurses often seemed
to think that reporting bad news was the responsi-
bility of a patient’s physician. The nurses
understood the seriousness of critical events for
individual patients but did not directly discuss these
first providers to learn the devastating results of an
imaging study and clearly understood that the find-
ings indicated the patient would not survive a liver
transplant. However, the nurse deferred to physicians
to tell the patient’s family. The nurse said, “I just
talked to the doctors. They’re down there looking at
some stuff. They’ll be up by 3 to talk to you about
the results.” But to a physician on
the care team who asked if the fam-
ily had any “clue,” the nurse
Nurses often felt
replied, “They don’t have a clue. I limited or con-
don’t think I have the emotional
stability to give one more piece of strained in their
bad news.” ability to communi-
Similarly, nurses rarely
discussed code status, major issues cate with patients
about liver transplantation, or
implications of hypotension,
and families.
vasopressors, and renal replacement
therapy directly with
patients or patients’ family members. When nurses
recognized that a patient or the patient’s family had
misunderstandings about life-sustaining therapies,
the nurses seldom tried to directly address the
prob- lem. This aspect of communication was
illustrated in a previous quotation about nurses
functioning as 1-way translators. In another
example, patients and their families often did not
understand the contraindi- cations to liver
transplantation. A nurse providing care for a
severely acidemic patient who was receiv- ing
renal replacement therapy and 2 vasopressors
recognized that the patient’s family did not under-
stand that these interventions indicated that the
patient was too critically ill to safely
receive a transplant. This nurse
reflected, “They really thought Nurses
the patient was going to get a recognized misun-
liver transplant, like it was just
going to happen. I don’t think derstandings of
they under- stand that process life-sustaining
either.....................................and I
kind of just blew it off.” therapies and
Finally, nurses did not often
have communication interactions
shared this
with patients and patients’ families information with
in the domain of sharing power and
responsibility or the domain of physicians.
therapeutic alliances. Nurses
thought that behaviors associated
with these
issues with the patients or the patients’ family, deferring instead to
the physicians. For example, a nurse was one of the
 domains usually occurred directly between patients and thought that nurses’ role was to carry out the
and the patients’ families with consequences of these decisions.
the physicians. Nurses often Nurses reported that their decisions, such as vaso-
explicitly referred to physicians pressor dosing, titration of supplemental oxygen,
as the primary decision makers
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2012, Volume 21, No. 6
administration of medications, and routine nursing
care, did not lend themselves to shared decision mak-
ing because patients do not have much choice in these
types of decisions. As a nurse reported,
“In most cases, it is not really an
Nurses want issue because it is really if they
to maintain hope– [patients] don’t go with the
treatments they are going to die, and
one reason for not they are aware of that.”
fully informing
Discussion
families PCC is important, and nurses’
of communications have a large impact
on ICU quality.16 We found that nurses
important mostly communicate with patients
and patients’ families in the
aspects of biopsy-
care.
chosocial, patient-as-person, and clinician-as-
person domains of PCC. Nurses had fewer
communication interactions in the domains of
therapeutic alliance and shared power because the
nurses thought these types of communications
were not part of a nurse’s role. The nurses
expressed support for including patients and
patient’s families in these 2 domains but thought
the primary responsibility for providing these
aspects of PCC rested with physicians.
Our analysis revealed 2 major themes to
explain much of the communication behaviors
between nurses and patients and patients’ families.
Previous investigators16,25 have reported on the role
of ICU nurses as translators between physicians and
patients and patients’ families, and this approach is
recom- mended.26 In terms of the theme of said vs
not said, Bach et al25 found that one reason nurses
did not fully inform patients’ families of important
aspects of care was the nurses’ desire for the
families to maintain hope. Reinke et al27 discovered
that nurses outside the ICU expressed discomfort
with directly
discussing prognosis among patients
Nurses involved decisions reported that
in end-of-life care they felt con- strained
415
Our results indicate that nurses have many
interactions with patients and families in the
patient-as-person domain, and several studies25,30-32
have emphasized the importance of this role.
Patients’ families appreciate nurses who treat patients
and the patients’ family members as persons in
addition to sharing personal details.16 Patients have
reported that nurses are more friendly and less
controlling than physicians are,32 emphasizing the
enhanced role nurses play in the patient-as-person
domain of PCC.
Nurses and physicians have different roles in
decision making. Physicians usually conduct formal
discussions and form decisions, whereas nurses
expound, translate, and review plans with patients
and the patients’ families.28,33-35 For example, in one
study36 a total of 99.5% of nurses thought that physi-
cians should participate in do-not-resuscitate
orders; 81% thought nurses should be involved;
and although the nurses rarely initiated
conversations with patients’ families about such
orders, 45% initi- ated these discussions with
physicians. Nurses may experience distress
because of physician-made deci- sions that the
nurses do not agree with.28 This finding was echoed
in our study by the nurse who was frus- trated with
physicians’ inability to “come clean.” However,
we did not observe explicit communica- tion
interactions between nurses and patients and
patients’ families that circumvented these
decisions. Indeed, as in the theme of said vs not
said, nurses discussed these dilemmas among
themselves but not with patients or patients’
families.
Many of the communication interventions to
improve quality of care in the ICU have centered
on physicians.14,37-39 Interdisciplinary
communication between physicians and nurses is
often poor,18,40-42 and improving outcomes through
communication
by not being able to act on their
beliefs.
with life-limiting illnesses informal rules against speaking interventions has been difficult.43-45 Furthermore, an
but acted as a translator directly with patients and patients’ intervention to include patients’ families on daily
when the nurses thought families about physician rounds, which usually focus on informa-
patients and physicians did tion exchange in the biopsychosocial domain, did
not understand each other. not lead to improvements in overall satisfaction,46
Nurses involved in end-of- suggesting that increasing the frequency of
life care decisions for physicians’ communication with patients’ families
patients in the hospital and may not be sufficient to improve perceived quality
ICU have reported that they of care.
felt con- strained by not Whether or not multifaceted strategies that do not
being able to act on their explicitly include changes in the communication of
beliefs.28 In a study29 of ICU bedside nurses with patients and patients’ families
cul- ture, nurses reported yield improvements in care is not clear.47-49 Thus,
end-of-life care decisions. These data corroborate communication interventions to improve overall
our observations that nurses act as translators PCC may need a more interdisciplinary focus and
between patients and patients’ families with explicit inclusion of nurses’ communications.9
physi- cians but not necessarily vice versa, Our study has several strengths. First, we used
leaving unsaid many aspects of physicians’ rigorous qualitative methodologic techniques, and
assessments.

416 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2012, Volume 21, No. 6 www.ajcconline.org
our analysis was based on a theoretical model to
ensure a comprehensive organized analysis and to
relay results in a way that can better guide future
research and interventions. Second, although the
observations centered on only 6 patients, we
observed 315 hours of ICU interactions and
completed 53 interviews with nurses to provide an
in-depth analy- sis. We had 98% participation by
nurses, so the risk of response bias is minimal.
Finally, communication may be of lower quality
for patients who die in the ICU,50 and because most
patients survive their ICU stay,51 inclusion of both
survivors and nonsurvivors is important.
Despite these strengths, our study has several
limitations. The study was conducted in 2 teaching
hospitals among patients with end-stage liver dis-
ease, so our findings may not be applicable to other
settings and other populations of patients. Commu-
nication among day-shift and night-shift nurses might
have differed, because we interviewed the night-
shift nurses but did not directly observe their
interactions with patients and patients’ families. We
have attempted to present our findings clearly, and
although the categorization of communication into
5 domains was based on a widely used theoretical
model, our categorization of nurses’ communication
interactions was subjective. Finally, we did not
evaluate the thoughts and feelings of physicians or
patients and patients’ families about nurses’
communication and cannot measure the effect of
nurses’ communica- tion on outcomes.
Patient-centered critical care requires a
collabo- rative approach that takes advantage of all
the skills and expertise provided by the members
of the ICU team. Expecting an individual provider
to provide all aspects of patient-centered
communication with each individual patient and
family is unrealistic.
Nurses provide most of the bedside care to patients
and patients’ families and accordingly have the
most opportunities to communicate with them. We
found that nurses often engaged in the
biopsychosocial, patient-as-person, and clinician-
as-person PCC care domains. The nurses were
supportive of the domains of shared decision
making and therapeutic alliance, although, in
general, they considered these domains best
provided by physicians. These results should guide
the development of interventions to take advantage
of nurses’ strengths and roles to improve PCC in
the ICU.
ACKNOWLEDGMENTS
Dr Slatore is a Veterans Affairs Health Services Research
and Development Career Development Awardee. This
study is the result of work supported by resources from
the Portland Veterans Affairs Medical Center. Neither
the National Institutes of Health nor the Department of
Veterans Affairs had a role in the conduct of the study;
in the collection, management, analysis, or
interpretation of data; or in the preparation of the
manuscript. The views expressed in this article are
those of the authors and do not necessarily represent
the views of the Department of Veterans Affairs or the
US government.
FINANCIAL DISCLOSURES
The study was funded by grant R21 NR009845 to Dr
Hansen from the National Institute of Nursing
Research.
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SEE ALSO
For more about nurse communication, visit the Critical
Care Nurse Web site, www.ccnonline.org, and read the
article by Grossbach et al, “Promoting Effective Com-
munication for Patients Receiving Mechanical Ventila-
tion” (June 2011).
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418 AJCC AMERICAN JOURNAL OF CRITICAL CARE, November 2012, Volume 21, No. 6 www.ajcconline.org
Communication by Nurses in the Intensive Care Unit: Qualitative Analysis
of Domains of Patient-Centered Care
Christopher G. Slatore, Lissi Hansen, Linda Ganzini, Nancy Press, Molly L. Osborne, Mark S.
Chesnutt and Richard A. Mularski
Am J Crit Care 2012;21:410-418 doi: 10.4037/ajcc2012124
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