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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

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
©2012 American Association of Critical-Care Nurses future interventions to improve patient-centered care. (American
doi: http://dx.doi.org/10.4037/ajcc2012124 Journal of Critical Care. 2012;21:410-418)

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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 framework to help identify constructs to improve
Research and Development, a staff physician, Section of the usefulness of the results.12,20 Through interviews,
Pulmonary and Critical Care Medicine, Portland Veterans
Affairs Medical Center, Portland, Oregon, and an assistant we also examined nurses’ communication roles to
professor, Division of Pulmonary and Critical Care Medi- better understand how and why
cine, Department of Medicine, Oregon Health and Science
University, Portland. Lissi Hansen is an associate profes-
nurses engage in specific domains Patients and families
sor, School of Nursing, Oregon Health and Science Uni- of patient-centered communication
versity. Linda Ganzini is a psychiatrist and director, Health with patients and families in the ICU. have identified good
Services Research and Development, Portland Veterans
Affairs Medical Center. Nancy Press is a professor, School
Methods
communication as
of Nursing and Department of Public Health and Preven-
tive Medicine, School of Medicine, Oregon Health and Overview and Setting a critical aspect of
Science University. Molly L. Osborne is a professor of The data for this analysis came
medicine, integrated ethics program officer, Section of
from a study of ICU patients with high-quality care in
Pulmonary and Critical Care Medicine, Portland Veterans
Affairs Medical Center, interim associate dean for edu-
cation, associate dean for student affairs, Division of
end-stage liver disease conducted intensive care units.
from 2007 to 2010. A prospective,
Pulmonary and Critical Care Medicine, Department of
Medicine, Oregon Health and Science University. Mark multiple-case design,21,22 as previously described,23
S. Chesnutt is a staff physician, Section of Pulmonary was used. The study was conducted in 2 teaching
and Critical Care Medicine, director, Critical Care, Patient hospitals in Portland, Oregon: a 26-bed cardiac-
Care Services Division, Portland Veterans Affairs Medical
Center, and a clinical professor, Division of Pulmonary medical ICU at the Oregon Health and Science Uni-
and Critical Care Medicine, Department of Medicine, versity Hospital and a 26-bed general ICU at the
Oregon Health and Science University. Richard A. Mularski Portland Veterans Affairs Medical Center. Approval
is an investigator and senior staff physician, Center for
Health Research, Kaiser Permanente Northwest, Pulmonary from the institutional review boards was obtained
and Critical Care Medicine, Portland, Oregon, and an at both institutions, and all patients completed the
affiliate associate professor of medicine, Division of Pul- informed consent process.
monary and Critical Care Medicine, Department of Med-
icine, Oregon Health and Science University. A total of 6 consecutive patients with end-stage
liver disease and their families were enrolled. For
Corresponding author: Christopher G. Slatore, MD, 3710
SW US Veterans Hospital Rd, R&D 66, Portland, OR 97239 the analysis described here, all nurses who provided
(e-mail: christopher.slatore@va.gov). 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


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

Therapeutic alliance
• Clinician knows patient’s desires
Family outcomes
• Patient understands care plan
• Increased satisfaction
• Decreased anxiety and
posttraumatic stress disorder
Provider as person • Improved decision making
• Knows limitations of knowledge
• 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 The interviewers used a standardized format to record
was 6 days (range, 4-20). The length of observation field notes from 315 hours of ICU interactions and
consisted of a patient’s length of stay in the ICU, communication during a total of 45 observed ICU-
beginning within 48 hours of admission and ending patient days. The notes were transcribed at the end
when life-sustaining therapies were withheld or of each observation shift.
withdrawn or the patient died or was transferred out Nighttime observations were not recorded, but
of the unit. Four patients received mechanical venti- nurses who provided care for the patients during
lation during at least part of their ICU stay, 4 received the night were eligible for interviews. Because these
renal replacement therapy, and 4 received vasopres- in-person, semistructured interviews were conducted
sors. A total of 2 patients were listed on the liver after major treatment decisions, a nurse might be
transplant waiting list before their ICU admission, interviewed more than once. All nurses who were
and 4 were considered potential candidates. Three approached for interviews agreed to participate.
patients died in the ICU or shortly after discharge. Interviews were audio recorded, transcribed, and
verified for accuracy. NVivo 7 (QRS International)
Data Collection and Analyses software was used for analysis of data.
Each “case” had a spatial and temporal For the analysis described here, a single investi-
dimension, consisting of the patient and those gator (C. S.) reviewed all the observational transcripts
who interacted with him or her during the ICU and the interviews with nurses. From the observa-
stay. Triangulation of data was provided by a com- tional data, elements of verbal and nonverbal com-
bination of interviews and direct observation in the munication behaviors were categorized into each of
ICU, at family conferences, and during more infor- the 5 domains of PCC. Similarly, interviews were
mal conversations between patients’ family mem- analyzed to identify major themes of nurses’ roles
bers and health care providers. Trained observers and preferences for communicating with patients
observed interactions and communication at the and patients’ families within the domains. In partic-
bedside for approximately 10 hours daily, focusing ular, interviews with the nurses were reviewed to
on times when major treatment decisions were made. determine the stated rationales of how and why

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Table
Characteristics of the 54 nurses
in the ethnographic analysis
communication behaviors fit specific PCC domains.
Another investigator (L. H.) also reviewed the obser- Characteristic Value
vational and interview transcripts to corroborate the
coding and thematic schemes. Disagreements about Female, No. (%) 42 (78)
the categorization of communication into specific Age, mean (SD), y 41 (10)
domains were settled after discussion and then Race/ethnicity, No. (%)
coming to consensus. Comparisons were made White 45 (83)
between observed dialogue and behaviors and the Other 9 (17)
rationale for these interactions as self-reported by Years of practice, mean (SD) 14 (9)
nurses. Italics are used to distinguish remarks made
by the nurses during interviews; plain text indicates
remarks from the observations. instance, nurses referred to a patients and the
patient’s family members with colloquialisms such
Results as buddy, darling, honey, and sweetie. Patients,
The Table gives the characteristics of the 54 nurses patient’s families, and nurses often shared small
who participated in the study (1 of the 55 who were jokes and good-naturedly teased each other. Non-
eligible declined to participate). Most were women verbal communication behaviors were frequent;
with a mean (SD) age of 41 (10) years and 14 (9) nurses often used touch and other personal interac-
years in practice. Of the 54 nurses, 33 were asked tions, including offering and receiving hugs, hold-
for an interview (all assented) and completed a total ing hands, placing an arm around the person, and
of 53 interviews. silently praying for the patient.
Sharing Power and Responsibility. Sharing power
PCC Domains and responsibility includes actively involving a patient
Biopsychosocial. The biopsychosocial domain or a member of the patient’s family in treatment
encompasses biomedical, psychological, and socio- decision making and in forming an agreement on
logical aspects of illness and disease for patients, the plan of care. Few communication interactions
with a focus on information exchange. Direct obser- between nurses and patients and patients’ families
vations indicated that most of the nurses’ commu- fit in this domain. In interviews, nurses acknowledged
nication’ interactions with patients and patients’ the overall importance of shared decision making
families were in this domain, most commonly related but noted that the decisions they
to acute biomedical problems. Topics often discussed made with patients usually focused
on routine aspects of biomedical
Nurses’ communi-
included review of vital signs, volume status and
interventions, medical history, technical aspects of care that resulted from decisions cation with patients
life-sustaining therapies, pain management, and previously made with physicians.
hygiene. Although these topics were often related Therapeutic Alliance. Therapeutic
and patients’ fami-
to life-sustaining therapies, communication rarely alliance incorporates a clinician’s lies most commonly
focused on the implications of why these interven- knowledge of a patient’s desires and
tions were required. In several instances, nurses is exemplified when the clinician related to acute bio-
discussed a patient’s blood pressure in relation to a and patient work together on the medical problems.
vasopressor dose but did not discuss that use of a care plan. The ethnographic obser-
vasopressor indicated that a patient was critically ill. vations revealed some communication between
For instance, when a patient required a vasopressor nurses, patients, and the patients’ families in this
to tolerate hemodialysis, the nurse told the family, regard, mostly focused on direct biomedical con-
“[The patient] looks good, BP’s good.” cerns. Nurses coordinated care for a patient by com-
Patient as Person. The patient-as-person domain municating with the patient’s family about topics
encompasses attempts to understand a patient’s such as the patient’s level of consciousness, response
unique personality outside the patient’s illness.24 to pain and sedative medications, and bodily func-
Many communication behaviors fit in this domain. tions. None of the observed interactions included
The interactions often involved discussions about a instances in which nurses ensured that patients and
patient’s children, religion or spirituality, and career, the patients’ families understood the care plan in
as well as everyday topics such as the weather, tele- terms of code status and liver transplantation.
vision, and books. In addition, nurses often shared Clinician as Person. The clinician-as-person
similar personal details about themselves. The con- domain includes appropriate involvement of other
versational style was often informal or familiar; for clinicians and self-recognition of the emotional

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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 clarified
ally physicians, to inform the clinicians of the nurses’ the overall plan, including how various diagnoses
concerns. In addition, nurses reported and demon- and treatments were indicators of illness severity.
strated how a patient’s situation affected them. For For example, a nurse noted, “I frequently jump in
example, a nurse described her reaction when, in a and restate questions if I think the doctor hasn’t
family meeting, the physicians reported answered it or maybe didn’t get the questions; or
that the patient would not survive I’d ask the person, could you restate that.”
Patients, families, the transplant process, “Of course, I Nurses thought that working as a translator was
and nurses fre- had tears in my eyes. . . . So I think a key component of their role within the team
that did help the family understand structure. A nurse reported as follows:
quently shared that this was tearing at us as well, I do believe we do things as a team. I allow
and that we really weren’t declining the physicians to drive the initial direction
small jokes and to offer treatment that would exist to of the plan. . . . because I am with the patient
good-naturedly help [the patient], that just there was all the time, I find myself to be acting as the
really no hope.” At a later observa- eyes and ears, and so I see everything . . .
teased each other. tion, this same nurse had the follow- so my contributions are primarily to provide
ing interaction with the patient’s an insight that it’s over the course of a con-
family, “‘This is tearing me up’ as she wipes away sistent period of time rather than their insight,
tears.” Finally, in many instances, nurses discussed which is much more of a spot check, they
their feelings and challenges with other nurses and go in once or twice in a 12-hour period.
received emotional support in return. Of note, the Another nurse reported:
nurses did not discuss their concerns with patients I think it is always important for the nurse
or the patients’ families when the nurses’ opinions to be in the room when physicians are
differed from those of physicians but often discussed talking to the family so you can hear what
these concerns with other nurses. they say, and you can reinforce it later;
‘cause the families do tend to have ques-
Nurses’ Roles in Communication tions afterwards when the doctors leave,
After the communications were categorized and you can reinforce what you know,
into the PCC domains, the data were evaluated to remember this is what he said.
better understand why nurses communicated more Nurses sometimes thought that their role was
or less in particular areas. The results indicated 2 to be a 1-way translator, translating information
overlapping themes that guided nurses’ communi- from a patient or the patient’s family to the physi-
cation behaviors that stemmed from the nurses’ roles cian but not vice versa. The nurses seemed to think
in the ICU, especially as the roles contrasted with that it was not their role to directly correct misun-
physicians’ roles. These themes provided much of derstandings of patients and patients’ families about
the rationale that led to behaviors in issues such as code status and liver transplantation.
particular PCC domains and gave For example, a nurse recognized that a patient was
Nurses felt that insight into why nurses seemed to too ill to receive a transplant but did not inform the
have few communication interactions family: “It is not my role to tell a family member,
working as a trans- in the domains of shared decision ‘I am so sorry that you are off the [liver transplant
lator was a key making and therapeutic alliance. waiting] list’ because I didn’t make the decision. This
The first theme was that nurses is something a physician needs to tell the family.”
component of their felt that one of their key roles was This nurse recognized a family member’s misunder-
role within the serving as a translator or intermedi- standing of the process of liver transplantation but
ary between physicians and patients said, “And I never stopped and said that is incorrect.”
team structure. and the patients’ families. The second In response to a question about the meaning of this
theme focused on topics that nurses misunderstanding and how it would be clarified,
were and were not willing to discuss with patients the nurse replied, “. . . someone needs to tell the
and the patients’ families; these topics were classified patient and it is not us [nurses].”
as “said vs not said.” Nurses recognized problems and limits with
Translator. Nurses often described translating a translation from physicians to patients and patients’
physician’s communication to a patient and/or the families. Although the nurses understood the physi-
patient’s family members and vice versa. In the cians’ assessments and rationale for not discussing

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these thoughts with a patient and the patient’s fam- first providers to learn the devastating results of an
ily, the nurses felt constrained and frustrated in the imaging study and clearly understood that the find-
ability to translate this information. For example, a ings indicated the patient would not survive a liver
nurse reported as follows: transplant. However, the nurse deferred to physicians
I have a personal belief, and I have been in to tell the patient’s family. The nurse said, “I just
the ICU for 20 years, and most of the time talked to the doctors. They’re down there looking at
families don’t have enough information. some stuff. They’ll be up by 3 to talk to you about
They don’t have the information they need the results.” But to a physician on
to make a choice. We [nurses] talk amongst the care team who asked if the fam-
ourselves, or it is in the chart . . . and all ily had any “clue,” the nurse
Nurses often felt
those people [physicians] talk amongst replied, “They don’t have a clue. I limited or con-
themselves. They [physicians] have a kind don’t think I have the emotional
of consensus of what they perceive, what stability to give one more piece of strained in their
they think is happening, but they are afraid bad news.” ability to communi-
to tell the family because they don’t want Similarly, nurses rarely discussed
to destroy hope. But, I think sometimes code status, major issues about liver cate with patients
patients and families suffer because of that, transplantation, or implications of
[the physicians’] inability to come clean. hypotension, vasopressors, and renal
and families.
Said vs Not Said. Several different aspects of the replacement therapy directly with
theme of said vs not said were evident in observa- patients or patients’ family members. When nurses
tions and were described in interviews. First, as recognized that a patient or the patient’s family had
alluded to in the previous quotation, nurses often misunderstandings about life-sustaining therapies,
felt limited or constrained in their ability to com- the nurses seldom tried to directly address the prob-
municate with patients and patients’ families. For lem. This aspect of communication was illustrated
example, in several observations, nurses’ opinions in a previous quotation about nurses functioning as
differed from those of physicians, but the nurses 1-way translators. In another example, patients and
did not disclose these differences. For instance, dur- their families often did not understand the contraindi-
ing an interview, a nurse reported feeling strongly cations to liver transplantation. A nurse providing
that the timing and pace of therapeutic interventions care for a severely acidemic patient who was receiv-
were delayed and slow. However, when talking to ing renal replacement therapy and 2 vasopressors
the patient’s family about this issue, this nurse told recognized that the patient’s family did not under-
the family, “[The patient] is doing a lot better today. stand that these interventions indicated that the
I think we did a good job of catching it early.” patient was too critically ill to safely
At other times, nurses seemed to want corrobo- receive a transplant. This nurse
ration of their interpretation of events before talk- reflected, “They really thought the Nurses
ing with patients and the patients’ families. When a patient was going to get a liver recognized misun-
patient’s condition deteriorated unexpectedly, before transplant, like it was just going to
sharing their concern with the patient’s family or happen. I don’t think they under- derstandings of
the patient, nurses conferred among themselves or stand that process either. . . . and I life-sustaining
with physicians. For instance, when a patient’s blood kind of just blew it off.”
pressure decreased precipitously during dialysis, the Finally, nurses did not often therapies and
patient’s nurse conferred with the dialysis nurse have communication interactions
quietly while the patient’s family members in the with patients and patients’ families
shared this
room continued to talk among themselves. in the domain of sharing power and information with
In several instances, nurses did not communicate responsibility or the domain of
with patients and the patients’ families because the therapeutic alliances. Nurses thought physicians.
nurses did not think such communication was part that behaviors associated with these
of a nurse’s role. For example, nurses often seemed domains usually occurred directly between patients
to think that reporting bad news was the responsi- and the patients’ families with the physicians. Nurses
bility of a patient’s physician. The nurses understood often explicitly referred to physicians as the primary
the seriousness of critical events for individual patients decision makers and thought that nurses’ role was
but did not directly discuss these issues with the to carry out the consequences of these decisions.
patients or the patients’ family, deferring instead to Nurses reported that their decisions, such as vaso-
the physicians. For example, a nurse was one of the pressor dosing, titration of supplemental oxygen,

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administration of medications, and routine nursing Our results indicate that nurses have many
care, did not lend themselves to shared decision mak- interactions with patients and families in the
ing because patients do not have much choice in these patient-as-person domain, and several studies25,30-32
types of decisions. As a nurse reported, have emphasized the importance of this role.
“In most cases, it is not really an issue Patients’ families appreciate nurses who treat patients
Nurses want to because it is really if they [patients] and the patients’ family members as persons in
don’t go with the treatments they are addition to sharing personal details.16 Patients have
maintain hope–one going to die, and they are aware of that.” reported that nurses are more friendly and less
reason for not fully controlling than physicians are,32 emphasizing the
Discussion enhanced role nurses play in the patient-as-person
informing families PCC is important, and nurses’ domain of PCC.
of important communications have a large impact Nurses and physicians have different roles in
on ICU quality.16 We found that nurses decision making. Physicians usually conduct formal
aspects of care. mostly communicate with patients discussions and form decisions, whereas nurses
and patients’ families in the biopsy- expound, translate, and review plans with patients
chosocial, patient-as-person, and clinician-as-person and the patients’ families.28,33-35 For example, in one
domains of PCC. Nurses had fewer communication study36 a total of 99.5% of nurses thought that physi-
interactions in the domains of therapeutic alliance cians should participate in do-not-resuscitate orders;
and shared power because the nurses thought these 81% thought nurses should be involved; and
types of communications were not part of a nurse’s although the nurses rarely initiated conversations
role. The nurses expressed support for including with patients’ families about such orders, 45% initi-
patients and patient’s families in these 2 domains ated these discussions with physicians. Nurses may
but thought the primary responsibility for providing experience distress because of physician-made deci-
these aspects of PCC rested with physicians. sions that the nurses do not agree with.28 This finding
Our analysis revealed 2 major themes to explain was echoed in our study by the nurse who was frus-
much of the communication behaviors between trated with physicians’ inability to “come clean.”
nurses and patients and patients’ families. Previous However, we did not observe explicit communica-
investigators16,25 have reported on the role of ICU tion interactions between nurses and patients and
nurses as translators between physicians and patients patients’ families that circumvented these decisions.
and patients’ families, and this approach is recom- Indeed, as in the theme of said vs not said, nurses
mended.26 In terms of the theme of said vs not said, discussed these dilemmas among themselves but
Bach et al25 found that one reason nurses did not not with patients or patients’ families.
fully inform patients’ families of important aspects Many of the communication interventions to
of care was the nurses’ desire for the families to improve quality of care in the ICU have centered on
maintain hope. Reinke et al27 discovered that nurses physicians.14,37-39 Interdisciplinary communication
outside the ICU expressed discomfort with directly between physicians and nurses is often poor,18,40-42
discussing prognosis among patients and improving outcomes through communication
with life-limiting illnesses but acted interventions has been difficult.43-45 Furthermore, an
Nurses involved in as a translator when the nurses intervention to include patients’ families on daily
end-of-life care thought patients and physicians did physician rounds, which usually focus on informa-
not understand each other. Nurses tion exchange in the biopsychosocial domain, did
decisions reported involved in end-of-life care decisions not lead to improvements in overall satisfaction,46
that they felt con- for patients in the hospital and ICU
have reported that they felt con-
suggesting that increasing the frequency of physicians’
communication with patients’ families may not be
strained by not strained by not being able to act on sufficient to improve perceived quality of care.
their beliefs.28 In a study29 of ICU cul- Whether or not multifaceted strategies that do not
being able to act ture, nurses reported informal rules explicitly include changes in the communication of
on their beliefs. against speaking directly with bedside nurses with patients and patients’ families
patients and patients’ families about 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 physi- explicit inclusion of nurses’ communications.9
cians but not necessarily vice versa, leaving unsaid Our study has several strengths. First, we used
many aspects of physicians’ assessments. rigorous qualitative methodologic techniques, and

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our analysis was based on a theoretical model to the National Institutes of Health nor the Department of
Veterans Affairs had a role in the conduct of the study;
ensure a comprehensive organized analysis and to
in the collection, management, analysis, or interpretation
relay results in a way that can better guide future of data; or in the preparation of the manuscript. The
research and interventions. Second, although the views expressed in this article are those of the authors
and do not necessarily represent the views of the
observations centered on only 6 patients, we observed
Department of Veterans Affairs or the US government.
315 hours of ICU interactions and completed 53
interviews with nurses to provide an in-depth analy- FINANCIAL DISCLOSURES
The study was funded by grant R21 NR009845 to Dr
sis. We had 98% participation by nurses, so the risk
Hansen from the National Institute of Nursing Research.
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 eLetters
Now that you’ve read the article, create or contribute to an
stay,51 inclusion of both survivors and nonsurvivors online discussion on this topic. Visit www.ajcconline.org
is important. and click “Submit a response” in either the full-text or
PDF view of the article.
Despite these strengths, our study has several
limitations. The study was conducted in 2 teaching
hospitals among patients with end-stage liver dis- SEE ALSO
ease, so our findings may not be applicable to other For more about nurse communication, visit the Critical
settings and other populations of patients. Commu- Care Nurse Web site, www.ccnonline.org, and read the
article by Grossbach et al, “Promoting Effective Com-
nication among day-shift and night-shift nurses might munication for Patients Receiving Mechanical Ventila-
have differed, because we interviewed the night-shift tion” (June 2011).
nurses but did not directly observe their interactions
with patients and patients’ families. We have attempted
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ACKNOWLEDGMENTS communication heal? Pathways linking clinician-patient
Dr Slatore is a Veterans Affairs Health Services Research communication to health outcomes. Patient Educ Couns.
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distress in patients’ family members during critical care Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax,
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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 10.4037/ajcc2012124
©2012 American Association of Critical-Care Nurses
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