Introduction: The patients with critical disease do not able to decision for care. Then, family and providers do it. One of the most important factors improve care is relationship between family member and staff members in Intensive Care Unit (ICU). Creating an effective communication with patients is an essential aspect of nursing care. This study aimed to explore communication process among team members with patients’ families in ICU. Methods: Based on the nature of the research question, qualitative study using grounded approach was used for collecting and analyzing data. A total of 22 participants (10 family members, 8 nurses, and 4 physicians) were selected based on purposive sampling. Sampling was terminated after saturation of emergent categories Data were collected through nonstructured individual interviews, observation. Subsequently; the data were analyzed according to the Strauss and Corbin constant comparative analysis method. Results: Data analysis has led to discover the main category that is called “superficial and ineffective individual relationship”as a main challenge for care team and hospitalized patients, families. They have used strategy is titled “effort” to solve this problem and strengthen the relationship. Extracted themes from this study include, unsuitable organizational conditions of social subclasses (social and cultural factors, inhibitory organizational atmosphere, job problems, indifference and disinterest of care team, and negative features of care team) also it needs strengthening the relationship, and mutual cooperation between care team and hospitalized patients, families in ICU. Conclusion: There are numerous problems and obstacles between care teams and hospitalized patients, families in ICU in communication process thus, to create effective and desirable communication, we must consider policies in educational, clinical and management plans of care and cure teams in universities and hospitals, also we must consider communication as the most important factor in this process.
Keywords: Communication barriers, family member, staff member
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Borhani F, Loghmani L, Abaszadeh A, Mahmoodi M. Communication barriers between staff member with family member intensive care unit: A grounded theory study. Ann Trop Med Public Health 2017;10:1552-7
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Borhani F, Loghmani L, Abaszadeh A, Mahmoodi M. Communication barriers between staff member with family member intensive care unit: A grounded theory study. Ann Trop Med Public Health [serial online] 2017 [cited 2021 Apr 14];10:1552-7. Available from: https://www.atmph.org/text.asp?2017/10/6/1552/222668
Man is a social creature who interchanges feelings, attitudes, and emotions through communication and whereby meets his physical and psychological needs; in other words, communication is a dynamic process between humans which is used to achieve effectiveness, to achieve mutual support, and to achieve what is necessary for health, growth, and survival, and life without it may be soundless, lethal, and deadly. Worsowics et al. writes if the communication is not done properly, the needs of the patients and their families won’t be met, their social processes will be disturbed, and their cooperations will be reduced which, by itself, can result in the increase of stress and tension in the care team. Critical disease is an incident which threatens the life and appears without previous warnings and gives the patients and their families a little time for getting adapted with it. Critical disease is a condition in which the patient needs residence in the Intensive Care Unit (ICU) and is known as an experience which has lots of stress-making stimuli. When a member of a family is hospitalized in the ICU, the whole family is influenced. Leske  emphasizes that there are numerous evidences which show that the pressure and stress caused by critical conditions of a family member exert a great effect on the whole family’s performance; in the meantime, the family’s behavioral pattern can, by itself, influence the disease-related results. As previously mentioned, the existence of stress and anxiety in the family and the care team is one of the main problems in the ICUs. Lack of communication can result in tension and stress in the individuals. Maxwell  reported that lack of a relationship between the family and the care team creates a huge amount of anxiety and tension for both parties, specifically when the family member dies that there are by the care team for achieving a more effective communication and relationship. The present research, with a comprehensive attitude toward experiences of families and care teams, has come over the important subject of communication barriers and eventually has provided solutions and approaches for more effective communication by presenting a theory for making a relationship.
Continuous data comparison and ground theory method were used for data analysis. The ground theory is a research method which is useful for studying the phenomena which are not well known such as communication with patient’s family or gaining a new vision about known phenomena. The ground theory is based on simultaneousness, data collection and comparison, and formation of the concepts. In the ground theory, the researcher does not begin his job with predetermined hypotheses but, instead, it is by appearance of the concepts that the research method and research questions are specified. Since the present research is aimed to investigate the communication between the nurses and patients hospitalized in the ICUs and due to the high capability of this method in elaborating the facts, the ground theory appears to be an appropriate approach for this study. In the present research, 10 patients’ families, 8 nurses, and 4 physicians were chosen from two training hospitals in Kerman city. The nurses had got MA and BA degrees; the families of the patients of 3–20 days hospitalization in ICU were all the next of kin relatives. Data collection was done through nonstructured interviews and observation. Interviews were done in the waiting rooms or the nurses’ resting rooms where, before interviewing, they were provided with some explanations about research goals, information confidentiality, and recording the interviews and then they, in case of intention to participate in the study, consciously filled in a letter of permit. The themes presented in this study are related to the finding obtained from the answers of the participants to the question “please express your experience about communication”. Time duration of the interviews was set according to the mental and psychological conditions of families and nurses free time. Time of interviews ranged from 25 to 90 min and the average time was 60 min. Another source for data collection included five observation sessions. Besides, the nonofficial (informal) interviews with five individuals from among nurses and families’ members at the end of the job were used as a proof of the researcher’s findings and observations. The data obtained from interviews, observations, and in-place notes was codified, by three steps of codification (open, pivotal, and selective codification) and analyzed alongside with using the continuous comparison methods and Corbin and Straus approach. Data collection was stopped when data repeatability occurred. To ensure that data interpretation indicates the understudy phenomenon, review by participants, review by individuals other than participants, and triangulation or time and place-incorporation were used. In addition, data sampling with maximum variation increases the confirmability.
Review by participants for data confirmation has been one of the most important actions of the researcher for perceiving the data credibility. Themes such as incompatible environmental conditions, interface conditions, communication strategies, and outcomes (consequences) express the communication experiences of the families and nurses.
Participants consisted of 10 patient-families, 8 nurses, and 4 physicians. The age of participants ranged from 18 to 50 years. The patients’ statuses were recognized suitable based on their consciousness score (completely conscious = suitable; Glasgow score between 9 and 12 = semi-critical; Glasgow score <9= critical). In the treatment team, two participants were nurses with MA degrees and other participants had got nursing BA degrees. The patients’ families included individuals whose literacy ranged from illiterate to BA and all were next of kin relatives. The most important theme of the present research included incompatible environmental.
Incompatible environmental conditions
The “incompatible environmental condition” is the same as “environmental inhibitory factors.”
Social and cultural (socio-cultural) factors – the sociocultural factors were of people’s social determinatives in the communication procedure which have acted as obstacles of communication. In most cases, the sociocultural factors and family prejudices prevented the effective communication between nurses and families. Some of the nurses expressed that to avoid connection with patients’ companions they preferred to work in the ICUs because these units are closed up and thus they have less connection with patients’ companions. The society’s negative attitude toward nursing and families’ prejudices were some of the outstanding problems mentioned by the nurses several times. They felt unhappy and distressed because the society still had a bad attitude toward nursing. They declared that those individuals who are in charge of such responsibilities have not done their duties perfectly and have understated this profession and have not considered it a valuable profession compared to other countries. Besides, in many cases, the nurses in the context of the society do not introduce themselves as nurses. Such a negative attitude have caused that they cannot effectively communicate with the families. Such an issue requires a cultural reconstruction which is mostly the responsibility of the governmental and organizational policies. One of the nurses said: “I am one of those nurses who prefer to not have contact with the patient’s companion and many of my colleagues are just the same; perhaps because the society lacks a good attitude toward this profession and assumes it as a good job. Most of the people believe that a person belonging to a noble family shouldn’t choose nursing as profession and also they think that a nurse’s job is only to provide first aids and primary care activities. They think that the nurses should be from the lower social levels and thus they should be able to bear any kind of desecration.” (Nurse-7) Cultural sensitivity – the cultural sensitivity is another sociocultural factor which results in misconception of the patient’s companion and can act as a communication obstacle. One of the married nurses who worked, together with her husband, in one of the units said: “most of the patient companions lack a veracious and correct judgment about nurse and if they enter the unit and see that two nurses are drinking tea during their rest time (break time) they will suppose the nurses as idles and will think that the nurses are always idle and never do anything for the patients. Sometimes it is the case that a nurse marries her colleague, who is a nurse too, and thus they are very intimate but the companions may think of such intimation as an immoral relationship.” (Nurse-6)
Patient companions’ numerousness- since the ICUs are places where no visitation can occur and the families and relatives cannot have direct contact with the patients, the families have to bother the nurses and ask them about their patient’s status and thus the nurses get tired and disconcerted and fatigue due to consecutively giving repetitive information to the families. It may be a cultural characteristic in Kerman that when an incident occurs for a family member the sentimental relationships are increased and many of the far relatives increase the number of visitations in order to avoid discontent and vexation of the patient’s family. About this point, one of the nurses stated that: “another problem is that the nurses are encountered with more than one person. That is, the maternal cousin comes, the mother comes, the paternal cousin come, and all them want to know about the patient. But they should introduce a person as the first-degree companion, for example mother or father, in order to get all the information of the patient from the nurse and then he/she can transfer this information to other relatives” (Nurse-6). One of the nurses said: “in order to avoid bothering the nurses and other personnel of the unit, it is better that a member of the patient’s family gets the whole information about the patient from the nurse and then transfer it to the other relatives” (Nurse-8). Organizational inhibitory atmosphere – the organizational inhibitory atmosphere was another unfavorable ground of communication between the care team and families. A large number of the organizational factors prevented an effective communication. Solving such a problem requires fundamental changes in the organization; of course it is mostly related to the nurses rather than the families. Since the dominant health system in Iran is a physicianarchy system and the nursing profession when considered beside physicians’ profession fades, the nurses are understated, compared to the physicians, and thus they feel discontent of being considered as subordinates of the physicians. Nurses should always be responsible to the physicians, and they have not sufficient support. They do not receive a powerful and integrated support and may undergo interpellation and be blamed thus they do not attempt so much to communicate and give information to the families. A nurse said: “as nurses our problem in communication is that if we give information to the family then the doctor will reproach us. I think it is due to the fear from the doctors that the nurses don’t communicate with the families; because if we give information to the families they may retell that information to the physician and then the physician will blame the nurse thus the nurses try to avoid such a responsibility and give insufficient and incomplete information to the families” (Nurse-1).
Organization’s limited support for nurses – lack of organizational support for the nurses was another factor which reduced the nurses’ hopelessness, discouragement, and interest in communicating with families. This means that if the nurses encounter a problem with families there will be no powerful official who can support them and they do not receive sufficient respect and support. A nurse said: “nurses are not appreciated as much as the job they do and they don’t enjoy sufficient material and spiritual advantages. They only receive some null promises which are never realized. No official seriously supports them. Their social position is a low level one. They don’t receive any fringe benefit and advantage. They don’t have any special facilities which distinguish them from other professions and jobs” (Nurse-6). Unplanned communication – since communication in special units has not been defined properly, hospitals’ responsible and universities’ education responsible have not emphasized on this point, and treatment teams are not asked for explanation of not communicating with families and thus they do not consider it as one of their duties, thus the members of the treatment teams do what they want; this means that the team members will communicate with the patient only if he, himself, tends to do so otherwise such a communication will not be made, and nobody will ask and order them to do it. Those who are not interested in communicating with the patients’ families can provide many pretexts and reasons for justifying it while if there is a compiled and codified communication plan it will dissolve all of these justifications. As for the nursing noncompiled communication plan one of the nurses said: “I think that there should be compiled plan in ICU for communication. For example a 15to20-minute period is not a very long time period for nurses to give information to the families. The nurse, or even the physician, should undertake such a duty. A physician who is responsible to a patient actually has some duties for which he is earning money. Right now the communication between the nurse and the patient’s companion is a superficial and unconscious one” (Nurse-6). The only source from which the families can get information about their patients is the information given by the care team. It has been seen in many cases that the families are discontent and complain that the care team does not give them accurate and clear information. The information given to them is incomplete and they are not convinced and are informed weakly and improperly. Since the care team does not suppose giving information as its duty, its members do not communicate appropriately with the families and don’t give them sufficient information. Most of the participants were discontent of such conditions and of course both parties had their own reasons. The families had a sense of bewilderment and complained that the care team does not allocate enough time for them and do not provide them with perceivable and sufficient information and even evade their duty of giving information. One of the patients’ sisters stated: “physicians and some of the nurses don’t correctly answer our questions and we are not convinced by their answers and don’t understand them. They talk to us in such a way that we are not persuaded that they are allocating enough time for giving us sufficient information.” Economic approach – another problem preventing communication is the economic approach among the treatment team members. Today, the financial and economic issue is the main issue in the society. Most of the nurses need to work overtime and since working in the ICUs is too hard thus no time, and energy remains for them to communicate with the families because their principal priority is to meet their financial needs. A nurse said: “many of the nurses work in the special units only for gaining more income and work in extra shifts due to their financial problems; therefore, they get tired and spend their energy only for caring the patients thus no energy remains for them to communicate with patients and families” (Nurse-3).
Job problems or professional problems are other factors preventing the communication. The care team members are discontent of various problems in their profession, and this cause them to not have enough tendency to communicate with the patients’ families. Problems such as hardness of working in ICU, human force shortage, units’ crowdedness, and time shortage of the nurses and physicians were some of the obstacles of communication with families. Many of the professional problems of the nurses are problems which must be resolved by the organizational system.
Nurses express that the treatment team, including nurses and physicians, cannot spent their time for communicating with families due to various reasons such as time shortage, human force shortage, and increase of their work, because if they do so, then their patient-related tasks will not be performed perfectly. One of the physicians said: “we are very busy and the number of patients and units is too high and thus we don’t have enough time to communicate with the patients’ families in order to provide them with explanations and information about their patients” (Physician-2). Human force shortage – the shortage of human forces is one of the main obstacles of communication with families. As for this point, one of the nurses said: “there should be sufficient forces since shortage of forces is one of the factors preventing the communication with the patient’s family. When we are faced with shortage of human force, how can we both do the unit’s tasks and communicate with the patient’s companion; thus, evidently, a part of the unit tasks is left undone. Sometimes the unit tasks get very difficult and thus no time remains for us to communicate with the patient’s companion. As you know doing the unit’s tasks is a very difficult job but if there is enough force in the unit then we can both do the task perfectly and communicate with the patients’ families” (Nurse-3). Speech-behavior paradox – one of the communication preventives is the paradox and conflict between speech and behavior of the treatment team. It is due to the paradox in speech of the nurses and physicians or other treatment team members that the families and patients can’t trust on them. “The physician says something but the nurse says something else and the neurologist says something different, thus we can’t find out which one is right. There is paradox and conflict between what they say. They can at least coordinate their speech. We are bewildered” (Family-1). Lack of motivation and interest in nursing profession – another problem is that the nurses are not interested in nursing and they don’t love their profession and are not encouraged. Some of the nurses haven’t chosen this job based on their interest. A nurse said: “I think that this problem must be solved basically. The nurses who are employed should be chosen from among those ones who love and are interested in this job. This job is perhaps the only job which requires great interest and enthusiasm because its salary is not too much and in the meantime it is a very hard job” (Nurse-2). Negative individual characteristics of the care team – the negative individual characteristics of the care team members are other obstacles of communication. Some of these characteristics include pride, obstinacy, violence, aggression, impatience, and fatigue. Any individual communicates with other people based on his own temperament thus there are some individuals who don’t have any tendency to communicate. Obstinacy was a negative characteristic which reduced team members’ tendency to communicate. They had an obstinate behavior toward the families and even toward their colleagues. Most of the participants have mentioned this point. Among the families, one of the participants said: “once due to suggestion of one of my friends I entered the unit, the nurses were annoyed and told me in a bad manner ‘when you know the fact so what is the reason of your insistence?’ We really get angry. The nurses behaved obstinately and didn’t regard their colleagues at all” (Nurse-2). The nurses’ aggressiveness was another negative characteristic which caused the families’ discontent and complaint. Of course the nurses, too, proved this fact and thought that it was resulted by the nurses’ fatigue and the unit’s hard work thus they give the right to the families to be discontent. One of the families expressed: “it depends on the nurse’s temperament. A nurse is calm while another one may be obstinate and prevent the patient’s companion from entering the unit” (Family-6). Environmental and physical conditions of ICU – the environmental and physical conditions of ICU and shortage of equipment and facilities of the unit and hospital are of other important ground factors which are mentioned by families and nurses as the obstacles of communication. In the ICUs, due to special and sensitive condition, the families cannot easily visit their patients and stay with them or directly observe the care activities; thus, the nurse or care team is an important interface and the most important information source, and they are the only ones who can inform the families and remove their worries. A nurse expressed: “strictly forbidding visitation in the unit is not a good option. They should regard the rules and wear covers but they don’t regard the rules. They only put the gown on their shoulder and enter the unit. They should wear hat and gown thoroughly. They should the single-use dresses only once while, here in this unit, the dresses are so dirty that the patient’s companion doesn’t like to wear them (Nurse with MA degree). Shortage of facilities and equipments is one of the reasons for preventing the families from entering the unit because entering the unit requires wearing single-use shoes and dresses while the ICUs lack sufficient equipments. The families don’t like to wear these dresses since they believe that their own dresses are cleaner than them.” “The hospital must have sufficient equipments and clean single-use gowns and dresses but here they give us very dirty gowns to wear while these dresses have revolting odor. Are these dresses really hygienic? They, themselves, enter the unit wearing their own casual dresses and shoes but meanwhile insist that the families must wear the dirty dresses. I have seen with my own eyes that some of the physicians enter the unit with their own shoes.” (A patient’s sister)
The present research studied the barriers of communication between the care team and the families of patients hospitalized in the ICUs. On the whole, four categories, namely, incompatible environmental conditions, professional and individual values, communication strategies, and communication consequences were recognized and then the relationships of these four categories with each other and with the central variable and also with each category’s subcategories were explained. The results of the present research revealed a remarkable part of various factors influencing the process of communication between families and care team. It is quite evident that many of these factors have indirect effects on the communication process. Some of these factors are sociocultural factors which greatly influence the communication between families and care team and can prevent this communication from being created. The organizational inhibitory atmosphere was another one of the incompatible environmental conditions which prevented the communication between the families and the treatment team in this research. Factors such as nurse’s professional role, care team’s job problems, physical and environmental problems, physicianarchy, nurses’ economic approach and financial conditions, care team’s lack of motivation, and care team’s negative characteristics were some of the incompatible ground conditions in the present research’s findings. By performing a comparison between opinions of the nurses and the patients about the nurse-related communicative obstacles, Aghabarari demonstrates that factors such as shortage of enough nurses, high workload of a nurse in a workday, and nurses’ discouragement and lack of interest in their job are of the most important nurse-related communicative obstacles which are expressed by both nurses and patients as factors which can cause the nurses’ inability to use their communicative skills in their interaction with the patients. Results obtained in Park Song’s study, too, showed that high workload is one of the most important nurse-related communicative obstacles which influence the quantity and quality of the relationship between nurse, patient, and patient’s family. It is evident that an effective communication is achieved when the nurses apply their skills practically not by merely having the knowledge of communication because, based on Heaven et al., many nurses are acquainted with the communicative skills but they cannot apply these skills practically.
The present research’s results demonstrate that incompatible environmental conditions such as sociocultural factors, organizational inhibitory atmosphere, physical and environmental conditions, negative individual characteristics, and job (professional) problems are obstacles preventing the communication, which require organizational, cultural, and social infrastructures to be resolved. As a result, this communication barriers leads to a series of consequences and outcomes which comprise a spectrum of negative consequences. Some of these consequences include dissatisfaction, discrimination, distrust, anxiety/stress, and companionship.
At the end, we would like to sincerely thank and acknowledge those who have helped us in performing this research.
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Conflicts of interest
There are no conflicts of interest.
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Source of Support: None, Conflict of Interest: None