Annotated Bibliography 12 Articles Please do Annotated Bibliography listed below and how is each article related to the topic:’ Management of Work-Life

Annotated Bibliography 12 Articles

Please do Annotated Bibliography listed below and how is each article related to the topic:’  

Management of Work-Life Balance and Nursing Staff’s Work-Related Problems in Critical Care: Strategies for the Nurse Manager


Critical care nurses’ communication

experiences with patients and families in an

intensive care unit: A qualitative study

Hye Jin Yoo
, Oak Bun Lim

, Jae Lan ShimID


1 Department of Nursing, Asan Medical Center, Seoul, South Korea, 2 College of Medicine, Department of

Nursing, Dongguk University, Gyeongju, South Korea



This study evaluated the communication experiences of critical care nurses while caring for

patients in an intensive care unit setting. We have collected qualitative data from 16 critical

care nurses working in the intensive care unit of a tertiary hospital in Seoul, Korea, through

two focus-group discussions and four in-depth individual interviews. All interviews were

recorded and transcribed verbatim, and data were analyzed using the Colaizzi’s method.

Three themes of nurses’ communication experiences were identified: facing unexpected

communication difficulties, learning through trial and error, and recognizing communication

experiences as being essential for care. Nurses recognized that communication is essential

for quality care. Our findings indicate that critical care nurses should continuously aim to

improve their existing skills regarding communication with patients and their care givers and

acquire new communication skills to aid patient care.


Critical care nurses working in intensive care units (ICUs) care for critically-ill patients, and

their work scope can include communicating with patients’ loved ones and care givers [1]. In

such settings, nurses must make timely judgments based on their expertise, and this requires a

high level of communication competency to comprehensively evaluate the needs of patients

and their families [2,3]. The objective of nurses’ communication is to optimize the care pro-

vided to patients [4]. Therapeutic communication, a fundamental component of nursing,

involves the use of specific strategies to encourage patients to express feelings and ideas and to

convey acceptance and respect. In building an effective therapeutic relationship, a focus on the

patient and a genuine display of empathy is required [5]. Empathy is the ability to understand

and share another person’s emotions. To convey empathy towards a patient, one must accu-

rately perceive the patient’s situation, communicate that perception to the patient, and act on

the perception to help the patient [6]. Effective communication based on empathy not only

contributes greatly to the patient’s recovery [3,5–7], but also has a positive effect of improving

job satisfaction by nursing with confidence [8] In contrast, inefficient communication leads to


PLOS ONE | July 9, 2020 1 / 15







Citation: Yoo HJ, Lim OB, Shim JL (2020) Critical

care nurses’ communication experiences with

patients and families in an intensive care unit: A

qualitative study. PLoS ONE 15(7): e0235694.

Editor: Liza Heslop, Victoria University,


Received: January 21, 2020

Accepted: June 21, 2020

Published: July 9, 2020

Copyright: © 2020 Yoo et al. This is an open
access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the manuscript.

Funding: This work was supported by the Dongguk

University Nursing Academy-Industry Cooperation

Research Fund of 2018.The funder had no role in

study design, data collectionand analysis, decision

to publish, or preparation of the manuscript

Competing interests: The authors have declared

that no competing interests exist.

complaints and anxiety in patients and can also lead to other negative outcomes, such as

extended hospital stays, increased mortality, burnout, job stress, and turnover [9,10].

Therefore, communication experiences need investigation since effective communication is

an essential for critical care nurses. Nurses use curative communication skills to provide new

information, encourage understanding of patient’s responses to health troubles, explore

choices for care, help in decision making, and facilitate patient wellbeing [11]. Particularly,

patient- and family-centered communication contributes to promoting patient safety and

improving the quality of care [12,13]. However, communication skills are relatively poorly

developed among critical care nurses compared to nurses in wards and younger and less expe-

rienced nurses than in their older and more experienced counterparts [3,7,14–16]. This calls

for an examination of the overall communication experiences of critical care nurses.

To date, most studies on the communication of critical care nurses have been quantitative

and have evaluated work performance, association with burnout, and factors that hinder com-

munication [2–4,7]. A qualitative study has examined communications with families of ICU

patients in Korea [17], while an international study has identified factors that promote or hin-

der communication between nurses and families of ICU patients [16,18]; however, few studies

have been conducted on participant-oriented communication (including patients and fami-

lies). Nurses’ communication with patients and their families in a clinical setting is complex

and cannot be understood solely on the basis of questionnaire surveys; therefore, these com-

munication experiences must be studied in depth.

This study explored critical care nurses’ communication experiences with patients and their

families using an in-depth qualitative research methodology. This study will help to enhance

communication skills of critical care nurses, thereby improving the quality of care in an ICU


Materials and methods


This study employed a qualitative descriptive design using focus-group interviews (FGIs) and

in-depth individual interviews and was performed according to the consolidated criteria for

reporting qualitative research (COREQ) checklist [19]. An FGI is a research methodology in

which individuals engage in an intensive and in-depth discussion of a specific topic to explore

their experiences and identify common themes based on the interactions among group mem-

bers [20]. Individual in-depth interviews were also conducted to complement the content

identified in FGIs and further explore the deeper information developed based on experiences

at the individual level.


Sixteen critical care trained nurses providing direct care to patients in an ICU of a tertiary hos-

pital in Seoul were included in this study. The purpose of this study and the contents of the

questionnaire were explained to them, and they voluntarily agreed to participate and complete

the questionnaire. The exclusion criteria were as follows: 1) nurses with a hearing problem; 2)

nurses with less than 1 year of clinical experience; and 3) nurses diagnosed with psychiatric


Snowball sampling—in which participants recruit other participants who can vividly share

their experiences regarding the topic under investigation—was used. Six participants for the

first FGI, six for the second FGI, and four for the individual in-depth interviews were

recruited. All participants were women (mean age = 29.0 years old; mean nursing experi-

ence = 4.5 years). Their characteristics are listed in Table 1.

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Data collection

Developing interview questions. The interview questions were structured according to

the guidelines developed for the focus-group methodology [21]: 1) introductory questions, 2)

transitional questions, 3) key questions, and 4) ending questions. The questions were reviewed

by a nursing professor with extensive experience in qualitative research and three critical care

nurses with more than 10 years of ICU experience (Table 2). These questions were also used

for individual face-to-face in-depth interviews.

Conducting FGIs and individual interviews. The two FGIs and four individual inter-

views were conducted between July 20, 2019 and September 30, 2019. The FGIs were moder-

ated by the principal female investigator and were conducted in a quiet conference room

where participants were gathered around a table to encourage them to talk freely. The FGIs

were audio-recorded with the participants’ consent, and the recordings were transcribed and

analyzed immediately after. Similar content was observed from the two rounds of FGIs, and

we continued the discussion until no new topics emerged.

To complement the FGIs and verify the results of the analysis, we also conducted individual

interviews of four participants. One assistant helped in facilitating the interviews and took

notes. The duration of each interview was about 60–90 minutes.

Ethical considerations and investigator training and preparation. This study was

approved by the institutional review board of the Asan Medical Center (approval no. 2019–

0859). Prior to data collection, participants provided written informed consent and were

informed in advance that the interviews would be audio-recorded, their participation would

remain confidential, the recordings and transcripts would only be used for research purposes,

the data would be securely stored under a double lock and would be accessed by the investiga-

tors only, and personal information would be deleted upon the completion of the study to

eliminate any possibility of a privacy breach. The collected data were coded and stored to be

accessed by the investigators only to prevent leakage of any personal information.

The authors of this study are nurses with more than 10 years of ICU experience and a deep

understanding of critical care. The principal investigator took a qualitative research course in

Table 1. Participant characteristics.

No. Sex Age (years old) Intensive care unit experience (months) Marital status Highest Educational Level

1 F 28 30 Single University

2 F 27 30 Single University

3 F 27 29 Single University

4 F 29 27 Single University

5 F 27 24 Single University

6 F 26 24 Single University

7 F 26 22 Single University

8 F 26 22 Single University

9 F 26 22 Single University

10 F 26 20 Single University

11 F 27 20 Single University

12 F 26 20 Single University

13 F 29 40 Single University

14 F 37 168 Married Master’s

15 F 38 180 Married Master’s

16 F 39 188 Married Master’s

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graduate school and has conducted multiple qualitative studies to enhance her qualitative

research experience.

Data analysis

We utilized Colaizzi’s [22] method of phenomenological analysis to understand and describe

the fundamentals and meaning of nurses’ communication experiences with patients and fami-

lies. Data analysis was conducted in seven steps: 1) Recording and transcription of the in-

depth interviews (all authors read the transcripts repeatedly to better understand the partici-

pants’ meaning); 2) Collection of meaningful statements from phrases and sentences contain-

ing phenomena relating to the communication experiences in the ICU. We extracted

statements overlapping with statements of similar meaning—taking representative ones of

similar statements—and omitted the rest; 3) Searching for other interpretations of participant

statements using various contexts; 4) Extraction of themes from relevant meanings and devel-

opment of a coding tree, with the meanings organized into themes; 5) Organization of similar

topics into a more general and abstract collection of themes; 6) Validation of the collection of

themes by cross-checking and comparing with the original data; 7) After integrating the ana-

lyzed content into one technique, the overall structure of the findings was described.

During data analysis, we received advice on the use of language or result of analyzing from

a nursing professor with extensive experience in qualitative research and had the data verified

by three participants to establish the universality and validity of the identified themes.

Establishing precision

The credibility, fittingness, auditability, and confirmability of the study were evaluated to ana-

lyze our findings [23]. To increase credibility, we conducted the interviews in a quiet place to

Table 2. List of interview questions.




Introductory What kind of care do you provide to your patients and their families as an ICU nurse?

Transitional As an ICU nurse, how is your communication with your family now?

Key What is your primary focus when communicating with patients and their families?

Do you have memorable experiences in your communication with your patients’ families?

a) If so, what were these experiences?

b) How do you feel about those experiences?

Do you have your own strengths in communicating with patients and their families?

a) If so, what are their advantages?

b) What role do your strengths play in communication?

c) What is the impact of communication on nursing?

Have you ever faced difficulties in communicating with patients’ families?

a) If so, please specify them.

b) What is the impact of these communication difficulties on your patients and their families?

c) How do these communication difficulties affect nursing?

Have you made any personal effort to communicate effectively with patients and their families?

a) If so, what have you done specifically?

b) How does the effort/s you have made affect your communication with patients and their


Do you need hospital or external help to improve communication with your patients and their


a) If so, what specific help do you need?

b) How do you feel about the changes in communication style with patients and families when

support and help are provided?

What does communication with the patients and their families mean to the nurse?

Ending Is there anything you would like to add?

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focus on participants’ statements and help participants feel comfortable during interviews; to

establish the universality and validity of the identified themes, data verification was performed

by three participants. To ensure uniformity in data, participants who could provide detailed

accounts of their experiences were selected, and the data were collected and analyzed until sat-

uration was achieved (i.e., no new content emerged). To ensure auditability, the raw data for

the identified themes were presented in the results, such that the readers could understand the

decision-making process. To ensure confirmability, our preconceptions or biases regarding

the participants’ statements were consistently reviewed to minimize the impact of bias and

maintain neutrality.


After analyzing the communication experiences of 16 critical care nurses, three major themes

emerged: facing unexpected communication difficulties, learning through trial and error, and

recognizing communication experiences as being essential for care. The results are summa-

rized in Table 3.

The results of this study are schematized based on Travelbee’s Human-to-Human Relation-

ship Model [24,25] (Fig 1), which suggests that human-to-human interaction is at a develop-

mental stage. In this study, communication between patients and their families and

experienced nurses in ICUs promotes human-to-human connections, leading to a genuine

caring relationship through interaction, empathy, listening, sharing, and respect, which are all

therapeutic communication skills.

Theme 1: Facing unexpected communication difficulties

Nurses experienced more difficulties in communicating with patients and their families and

caregivers than in performing essential nursing activities (e.g., medication administration, suc-

tion, and various mechanical operations) The communication difficulties they experienced

were either nurse-, patient- and family-, or system-related. Distinct problems in an ICU are

related to urgency; for example, hemodynamically unstable patients or patients with respira-

tory failure or those suffering from a cardiac arrest may be prioritized.

Nurse-related factor: True intentions were not conveyed as wished. Although nurses

intend to treat patients and their families with empathy, they frequently lead one-way conver-

sations when pressed for time in the ICU. In addition, their usual way of talking, such as their

dialect and intonation, can sometimes be misunderstood and cause offense. Participants expe-

rienced difficulties communicating their sincerity to patients and their families.

“Oftentimes, I only say what I have to say instead of what the caregivers really want to know

when I’m pressed for time to convey my thoughts and go on to the next patient to explain

things to the other patient.” (Participant 2)

“I usually speak loudly, and I speak in dialect; so, things I say are not delivered gently. . .I

try to be careful because my dialect can seem more aggressive than the Seoul dialect; but it’s

not easy to fix what I have used for all my life at once.” (Participant 3)

Nurse-related factor: Hesitant to provide physical comfort. Participants were not famil-

iar with using non-verbal communication. The participants realized the importance of both

verbal communication and physical contact in providing care, but the application of both

these communication styles was not easy in clinical practice.

“I want to console the caregivers of patients who pass away; but I just can’t because I get

shy. I feel like I’m overstepping, and when I’m contemplating whether I can really speak to

their emotions, the caregiver has already left the ICU in many cases.” (Participant 6)

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Table 3. Critical care nurses’ communication experience with patients and their families.

Sub-category Category Theme

Theme 1: Facing unexpected communication


In critical care, communication with patients and their

family is burdensome

1.1. True intentions not conveyed as wished Nurse-related

Misunderstanding because of the linguistic characteristics

of a nurse (e.g., dialect, voice tone, etc.)

Impatience/lack of care for patients and caregivers

ICU nurses need both verbal and nonverbal

communication skills

1.2. Hesitant to provide physical comfort

Nonverbal communication is unfamiliar

Not sure how to effectively provide nonverbal


Patient in ventilator feels frustrated because he or she

cannot speak

1.3. Mechanical ventilation hindering communication

with the patient

Patient- and family-related

Difficulty understanding because the patient is on a

ventilator and thus cannot speak

Ventilator interferes with the communication between

nurse and patient

ICU patient’s caregiver is sensitive 1.4. Caregivers’ negative responses to nurses

Normal communication is impossible owing to caregivers’

aggressive attitude

As an ICU nurse, I have no choice but to respond to the


I have not learned properly about communication in the


1.5. Lack of experience and a mismatch between

theory and practice


Communication is the most difficult task for less

experienced, young nurses

The scheduled visit time in the intensive care unit is when

most communication occurs

1.6. Intense visiting hours in limited time

One-way conversation with the caregiver in a short period

Life-dependent care is a priority in the intensive care unit 1.7. Urgent workplace that deprioritizes


Insufficient time to talk with patients and caregivers owing

to heavy workload

Nurses are hurt by distrustful patients and caregivers 2.1. Fundamental doubts about the nursing profession Theme 2: Learning through trial and error

Difficulty in nursing because of trauma from patients and


Follow senior nurses and learn practical communication 2.2. Finding out which communication style is better

suited for patients and their families

Explains the patient’s daily life in detail

Communication is indispensable to nursing 2.3. Knowhow learned through persistent effort

Studying the lack of communication by searching books

and videos

Understand the anxiety and difficulties experienced by the

critically ill and their caregivers

3.1. Empathy garnered through various clinical


Theme 3: Recognizing communication

experiences as being essential for care

Nurse’s words have the power to make the patients and

their families cry or laugh

Listening as an intensive care nurse is more important than


3.2. The power of active listening

Nurse empathy strengthens patients and caregivers and

enhances their feelings of control

Patients and caregivers are easy to reach 3.3. Mediator between physicians, patients, and



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“I’m really bad at physical contact even with my close friends; but I’m even worse when it

comes to patients and caregivers. Because of my tendency, there are times when I hesitate to

touch patients while providing care.” (Participant 7)

Patient- and family-related factor: Mechanical ventilation hindering communication

with the patient. Mechanical ventilators were the greatest obstruction to communication in

ICU. Although it is normal for patients on a mechanical ventilator to lose the ability to speak,

patients and their families did not understand how mechanical ventilators work and were frus-

trated that they could not communicate freely with the patient. Participants expressed diffi-

culty in communicating with patients in ways other than verbal communication as well.

“Patients who are on mechanical ventilation can’t talk as they want and do not have enough

strength in their hands to write correctly; so, even if I try to listen to them, I just can’t

Table 3. (Continued )

Sub-category Category Theme

Nurses use words that are easy to understand

Nurses convey sincerity to others with respect and


3.4. Expressing warmth and respect

Nurses’ heartfelt expressions promote trust

Fig 1. Summary of communication experiences encountered by intensive care unit nurses.

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understand what they are saying. You know in that game where people wear headphones play-

ing loud music and try to communicate with one another—words completely deviant from the

original word are conveyed. It just feels like that.” (Participant 9)

“Patients on mechanical ventilation and who thus cannot communicate are the most diffi-

cult. The patient keeps talking; so, it hinders respiration—the ventilator alarm keeps going off,

the stomach becomes gassy, and the patient has to take the tube off and vomit later. No matter

how much I explain, there are patients or caregivers who tell me that the tube in the throat is

making [it] hard [for them] to breathe or [they] ask me to take it off just once and put it back

on, and these patients are really difficult. There is no way to communicate if they cannot accept

mechanical ventilators even if I explain.” (Participant 8)

Patient- and family-related factor: Caregivers’ negative responses to nurses. It was also

burdensome for nurses to communicate with extremely stressed caregivers and loved ones,

especially when patients were in a critical state. Despite the role of nurses in helping patients

during health recovery, caregivers’ negative responses to nurses, such as blaming them and

speaking and behaving aggressively, intimidated the participants and ultimately discouraged


“I can manage the patients’ poor vital signs by working hard but communicating with sensi-

tive caregivers who project their anxiety about the patient’s state onto nurses doesn’t go as I

wish, so, it’s really difficult and burdensome.” (Participant 6)

“When the patient is in a bad state, caregivers sometimes want to not acc

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