doi: 10.62486/agmu202476
REVIEW
Level of satisfaction with nurse-family communication of patients in intensive care: background on the topic
Nivel de satisfacción de la comunicación enfermero–familiar de pacientes en cuidados intensivos: precedentes del tema
Candy Angles Vargas1,
María Angela Paredes Aguirre de Beltrán1, Wilter C. Morales-García1 
1Unidad de post grado de Ciencias de la Salud, Universidad Peruana Unión. Lima, Perú.
Cite as: Angles Vargas C, Paredes Aguirre de Beltrán MA. Level of satisfaction with nurse-family communication of patients in intensive care: background on the topic. Multidisciplinar (Montevideo). 2024; 2:76. https://doi.org/10.62486/agmu202476
Submitted: 26-11-2023 Revised: 22-03-2024 Accepted: 30-08-2024 Published: 31-08-2024
Editor: Telmo
Raúl Aveiro-Róbalo 
ABSTRACT
Satisfaction is understood as the degree of congruence between the care expected and the care actually received. Nurses are the group that most influences user satisfaction in the hospital context. Patient satisfaction serves as an indicator of the quality of medical services, providing information on whether health personnel have successfully responded to patient values and expectations. Then, the level of satisfaction of patients and their families is used to evaluate the quality of care in health institutions. In order to update the state of the art of research on the level of satisfaction of nurse-family communication of patients in intensive care, the present bibliographic review was carried out. Effective communication in the care of patients in intensive care units is essential to improve the perception of care by family members. Empathy and a humanized approach are essential to address the emotions of family members, which can increase their satisfaction. However, many family members express dissatisfaction with aspects such as information, psychological support and education received, which highlights the need to implement improvements in these areas to offer more comprehensive and satisfactory care.
Keywords: Level of Satisfaction; Communication; ICU.
RESUMEN
La satisfacción se concibe como el grado de congruencia entre la atención esperada y la realmente recibida. Los enfermeros son el grupo que más influye en la satisfacción de los usuarios en el contexto hospitalario. La satisfacción del paciente sirve como un indicador de la calidad de los servicios médicos, proporcionando información sobre si el personal de salud ha respondido de manera exitosa a los valores y expectativas del paciente. Luego, el nivel de satisfacción de los pacientes y sus familiares se utiliza para evaluar la calidad de la atención en instituciones de salud. Con el objetivo de actualizar el estado del arte de las investigaciones sobre el nivel de satisfacción de la comunicación enfermero–familiar de pacientes en cuidados intensivos se realizó la presente revisión bibliográfica. La comunicación efectiva en el cuidado de pacientes en unidades de cuidados intensivos es fundamental para mejorar la percepción de atención por parte de los familiares. La empatía y un enfoque humanizado son esenciales para atender las emociones de los familiares, lo que puede incrementar su satisfacción. Sin embargo, muchos familiares expresan insatisfacción con aspectos como la información, el apoyo psicológico y la educación recibida, lo que resalta la necesidad de implementar mejoras en estos ámbitos para ofrecer una atención más integral y satisfactoria.
Palabras clave: Nivel de Satisfacción; Comunicación; UCI.
INTRODUCTION
According to Loureiro and Charepe,(1) satisfaction is conceived as the "degree of congruence between the expected care and the care actually received" being nurses the group that most influences user satisfaction in the hospital context. In addition, Haave et al.(2) point out that customer satisfaction serves as an indicator of the quality of medical services, providing information on whether health care personnel have successfully responded to customer values and expectations. Therefore, patient and family satisfaction is used to assess the quality of care in hospitals and intensive care units (ICUs).(3)
In this sense, Bravo and Gregor(4) emphasize in their research that "satisfaction depends on the perceptions and expectations that a user has with respect to a particular service" so that when comparing patient and family caregiver satisfaction in the ICU with service expectations, it is essential to link it to modifying factors such as communication between health professionals, patients and families; family support and shared decision making between family and patients as a model of care since addressing these variables allows taking into account the perceptions that influence the user's satisfactory or unsatisfactory impression of the health service provider.(5,6)
Accordingly, Garg(7) highlights the existence of an association between family satisfaction in the ICU and the domains of improved organizational culture and safety. Therefore, for a more comprehensive approach to family satisfaction, it is necessary to consider various characteristics, such as accurate information about the goal and treatment plan; adequate communication and updates about the patient's condition; expectations of family members; knowledge and information about critical illnesses; and dynamic medical interventions in continuous evolution according to the patient's conditions. This is because understanding the elements of satisfaction helps researchers, practitioners, and administrators focus their efforts on where nurses can really make a difference.(8)
In this context, information emerges as a primary need for the relatives of critically ill patients, often not adequately addressed by professionals. The latter is due to the centralization on the physiological needs of the critically ill patient, forgetting their role within a more complex family unit, as they indicate.(41)
Despite the fact that in the last decade, according to Fernández et al.(42) the participation of family members has been promoted, generating multiple benefits described by the literature in ICUs, they persist in acting as if they were closed units. Therefore, it is imperative to address nurse-family interaction as the key to providing comprehensive care, centered on the essential pillars of interaction, communication and information.(37)
With the aim of updating the state of the art of research on the level of satisfaction with nurse-family communication in intensive care patients, the present literature review was carried out.
METHOD
A bibliographic search was carried out in the databases Redalyc, Elsevier Science Direct, PubMed/Medline, SciELO, as well as the Google Scholar search engine. To retrieve the information, search strategies were employed using the terms "level of satisfaction", "communication", "intensive care", etc., as well as their equivalents in English. From the resulting documents, those that provided theoretical and empirical information on the subject were selected.
DEVELOPMENT
The Nurse in the Intensive Care Unit and Information
According to Wang et al.(9) "the intensive care unit is a place for centralized monitoring and intensive treatment of critically ill patients". In congruence, Fajardo et al.(10) conceive the ICU as "a place with a high-pressure environment, where highly qualified care is performed". In view of this, the ICU nurse adopts a unique professional and behavioral profile, differentiating him/herself from other hospital departments due to the particular characteristics of the ICU. Therefore, when the relatives of hospitalized patients seek support to share their difficulties, worries and illnesses, as well as their moments of discouragement, the nursing professional should collaborate in the adaptation process of both patients and their relatives, contributing to the recovery process.
On the other hand, Guáqueta et al.(11) emphasize that several studies show the existence of various needs, the predominant one being the need for information. This need is related to the patient's situation, the treatment, and aspects of the ICU. In response, nurses are committed to implementing interventions aimed primarily at satisfying the need for information, providing support, assistance, and accompaniment to families during the difficult stage of having a loved one hospitalized in the ICU. These interventions take into account a series of elements such as the characteristics of the information, the assessment and identification of the need for information, the conditions for addressing this need, and family participation in the care, to contribute to improving the quality of care, reducing the anxiety and fears faced by the family.However, the intensive care unit (ICU), recognized for being a space for the centralized monitoring and intensive treatment of critical patients, imposes challenges on nurses, such as long working hours, high workload, frequent changes of service, and management of critical situations, which leads to a decrease in attention to users and a delay in results.(12)
Communication
Communication is defined by Arenas and Mirón(13) as "an active and bidirectional process of constant exchange of messages between both parties, so that communication cannot be considered as the handling of information in isolation". In congruence, the main ICU researchers indicate that communication is a crucial dimension; however, factors such as access, lighting, noise and activity restrictions can affect the communication process between the patient, his family and the nursing staff.(10)
Accordingly, Mendoza and Barría(14) highlight the evidence of the effects of communication on health outcomes, noting that the ways in which this process is established differentially impact various outcomes; for example, they reported a positive association between the quality of provider-patient communication and patient adherence. In contrast, the unequal presence of communication contributes to health disparities, manifesting a lack of effective tools amidst confusing information. This situation generates perceptions of insufficient information and confusion, which can exacerbate health disparities.
On the other hand, Duque et al.(15) show that communication is not a priority in Intensive Care Units. This situation generates discordance in the unit, since while some nurses consider that the family of the critically ill patient can provide great emotional support, generating benefits for the patient; other nurses perceive the family as a "burden" and believe that it worsens the situation of the family member. However, as Dees et al.(16) point out, "better communication between patients, their families, and nurses in the intensive care unit is essential to strengthen relationship-centered care."
Verbal and non-verbal communication
According to Diaz et al.(17) communication is classified into two types: verbal and nonverbal; of which, generally greater importance is given to verbal communication; however, studies have shown that more than 55 % of communication is carried out through nonverbal means. The latter form is based on the unspoken language of facial expressions, eye contact, and body language. In line with this, Holm and Dreyer(18) mention various factors such as blurred consciousness, delirium, cognitive impairment, physical weakness or paralysis, fatigue, and voicelessness due to intubation, which affect the patient's communication ability. Consequently, the caregiver must interpret the patient's verbal and nonverbal communication about their needs, wishes, and concerns.
Therefore, during human care, communication acts as the gateway to satisfy the patient's basic needs, demonstrating closeness, attention, understanding, and immediate predisposition to establish a good personal relationship, which translates into a more favorable prognosis.(19) This aspect acquires crucial importance, since a lack of disposition in the team or errors in communication can lead patients to perceive that they are not heard or noticed. As a consequence, patients may experience a feeling of helplessness and defenselessness. Given the above, Jöbges20 concludes that communication with patients in the ICU is a challenge. In this sense, the healthcare team should reflect on the imbalance in the communicative influences between patients and the team to help patients survive and cope with the critical period.
Content of the communication
In the ICU, communication is predominantly characterized by being instrumental, regulatory, and informative, because the care personnel are dedicated to commenting on the techniques and procedures to be performed; the supplies to be used, and the patients are concerned about their health. Therefore, communication content is mainly linked to physical needs, pain, and moments of agitation. Given this, improving the patient's general condition and well-being involves involving them in discussions about their care and facilitating communication.(21)
Consequently, the implementation of communication strategies in the ICU provides the patient with the opportunity to be considered and to express themselves effectively. This allows them to exercise control over their environment, engage in more satisfying communicative exchanges, and contribute to the creation of a favorable environment for the well-being of all.(21)
Form of communication
Ferreira et al.(22) emphasize the importance of paying attention to the way in which each person constructs his discourse to identify his priorities, what is really relevant to him, as well as his preferences on how to receive information.
Likewise, in recent times, there has been much talk of humanization in healthcare and effective communication as part of this goal. Still, little time is devoted to improving communication with patients to improve healthcare quality. Given this, various forms of communication can enhance the quality of care as long as eye contact and an expectant expression on the part of the interlocutor are maintained. Therefore, communication training for the group of nurses, as found by Giraldo,(21) facilitates the use of communication cards and gesticulation to interact with patients.
In this context, Ull et al.(23) state that "communication with nonverbal ICU patients can be improved by augmentative and alternative communication (AAC)". Grouping into the categories non-technology AAC (e.g., emotions, gestures, blinking, lip reading), low-technology AAC (e.g., pencil and paper, alphabet (whiteboards, charts, writing boards) and high-technology AAC (e.g., software, tablets, apps, eye tracking). In this way, it enables voiceless ICU patients to use various types of communication tools or devices to alleviate communication difficulties between patients and healthcare providers in the ICU setting.
Ramirez and Soto(24) base their approach on the ideas of Peplau, who states that nursing practice is guided as much by academic training and procedural skills as by the attitude and personality of the nurse. In addition, she highlights the interpersonal relationship, conceiving it as the gateway to nursing care, composed of two key elements: the exchange of knowledge and the exchange of feelings/emotions.
In congruence, Parada et al.(25) emphasize in their book the importance of the nurse-patient relationship, calling it "a meaningful, therapeutic, interpersonal process". They emphasize that the nurse should be aware of all the verbal and nonverbal messages transmitted by the patient, considering it as an "empathic bond", which implies the ability to feel in oneself the emotions experienced by the other person.
In addition, Martinez(26) describes the nurse-patient relationship as a meaningful and therapeutic process. On this last point, Machado et al.(27) explain that by going through the process of nurse-client interaction, they guide the patient and family towards the psychodynamic perspective, orienting them towards a creative, constructive, productive, personal and independent life.
In addition, through Hildegard Peplau's theory, understanding human behavior is facilitated to help others by identifying perceived difficulties and applying the principles of interpersonal relationships to identified problems at all levels of experience. Thus, according to Peplau, the success of nursing care is directly related to what is provided to the patient as well as what is provided to the patient and what the patient provides to the caregiver.(26)
In Ecuador, Sanchez Vega(28) conducted a study entitled "Therapeutic communication between the nurse and the patient's family in critical care: a humanized care approach". Based on Jean Watson's theory of humanized care, the author set out to determine the therapeutic communication between the nurse and the patient's family in critical care. In terms of methodology, a mixed, cross-sectional, exploratory study was carried out. The population is composed of 13 nurses working in the intensive care unit (ICU) and 15 family members of critical care patients. The study leaves evidence that the nursing professionals have a good predisposition to provide humanized care to the family. However, the quality of communication and emotional support with the family still needs to be improved. The study concludes that therapeutic communication is fundamental in human relations, where the nursing professional provides emotional support to the family and takes integral care of ICU patients.
Edward et al.(29) conducted a study in entitled "Improving communication with family members in the intensive care unit: a mixed methods study" in the United States, the objective was to examine changes in family members' satisfaction with intensive care unit nurses' communication after nurses received a communication education program for intensive care unit nurses. The methodology used was a mixed methods design with a sample of 17 nurses and 81 family members. The results showed that staff members were very confident in communicating with family members of critically ill patients. This finding was probably related to the staff members' experience in the position: 88 % of the nurses had more than 11 years of experience. Family members were happy with the care, but dissatisfied with the environment. In conclusion, environmental factors may negatively affect communication with family members in the intensive care unit.
Eltaybani and Ahmed(30) in Egypt developed an investigation entitled "Family satisfaction in adult intensive care units in Egypt: a mixed methods study " to examine family members' satisfaction in adult intensive care units. The methodology used is a mixed methods research, in which family members of critically ill patients initially responded to a structured questionnaire and then were interviewed through semi-structured interviews. Quantitative and qualitative data were analyzed separately and integrated during the discussion. For this purpose, six adult intensive care units in university hospitals in Egypt were available. Regarding the results, it was found that the mean total satisfaction score was 12,8 ± 3,5, and comfort had the lowest mean subscale score: 2,07 ± 0,96. Multivariate regression analysis showed that family members' satisfaction was positively associated with their ability to communicate with patients (B [95 % confidence interval]: 2,1 [1,19 to 3,02]) and negatively related to daily purchase of medications and supplies (-2,41 [-3,23] to -1,59]), low economic status (-1,57 [-2,47 to -0,67]), and perception that the patient's condition is deteriorating (-0,99 [-1,93 to -0,04]). Concluding that in adult intensive care units in Egypt, regular family meetings, flexible visiting hours, shared decision making, and increased staff-to-patient ratios are promising strategies for improving family satisfaction.
Ponnapa et al.(31) Conducted a study in Australia entitled "Family satisfaction with intensive care unit communication during the COVID-19 pandemic: an Australian multicenter prospective Family Satisfaction - COVID ICU study", which aimed to assess overall family satisfaction with intensive care unit (FS-ICU) care involving virtual communication strategies during the period of the COVID-19 pandemic. Within the methodology, essential predictors that influenced family satisfaction were identified through quantitative and qualitative analyses. Also, this prospective multicenter study involved three metropolitan hospitals in Melbourne, Australia, asking the next of kin of all eligible ICU patients between July 1, 2020, and October 31, 2020, to complete an adapted version of the FS-ICU 24 questionnaire. Group comparisons were analyzed and calculated for family satisfaction scores: ICU/care (satisfaction with care), FS-ICU/dm (satisfaction with information/decision making), and FS-ICU/total (overall satisfaction with the ICU). The sample consisted of 73 of the 227 NOK patients who initially agreed to complete the FS-ICU questionnaire (response rate 32,2 %). As a result, the mean FS-ICU/total was 63,9 (standard deviation [SD], 30,8). While the mean satisfaction score with FS-ICU/dm was lower than FS-ICU/care (62,1 [SD= 30,3] vs. 65,4 [SD= 31,4]; p<0,001). Concluding that there was low overall family satisfaction with ICU care and virtual communication strategies adopted during the COVID-19 pandemic.
Llacctas and Navarro(32) In Andahuaylas, the research entitled "Assertive communication of the health professional and the psychoemotional problems of the relatives of adult patients admitted to intensive care at the sub-regional hospital of Andahuaylas during 2022" was presented. The authors set out to determine the relationship between assertive communication and the psychoemotional problems of family members of adult patients admitted to intensive care at the Sub-Regional Hospital of Andahuaylas in 2022. It was a cross-sectional study of 30 relatives of patients admitted to intensive care. The results show that about non-assertive communication, 53,33 % of family members perceive the non-verbal communication of health professionals as good, 26,67 % of participants think that the non-verbal communication of health professionals is bad, and 20 % consider it as regular. It is concluded that there will be no psychosocial problems if there is good assertive communication from health professionals.
Montoya(33) The research entitled "Communication strategies and perceived acceptability of care by relatives of COVID intensive care patients in a Lima hospital" was presented in Lima. The study focuses on finding the relationship between communication strategies and the perceived acceptability of care as perceived by relatives of COVID intensive care patients in a hospital in Lima. According to the methodology, this is basic, non-experimental, correlational, cross-sectional research. A survey was used for data collection, and the instrument was a questionnaire. The family members responsible for the hospitalized patients were the study population. The results show that 96 % of the sample recognizes the importance of communication strategies in their three dimensions: digital, written, and nonverbal, which are carried out by the nursing professional. Only 2 % do not know or do not agree with these communicative tactics. It is concluded that there is a significant relationship between the communication strategies have a meaningful relationship (φ= 0,700 and p< 0,001) with the acceptability of care perceived by relatives of COVID intensive care patients in a hospital in Lima.
Barreto and Sandiga(34) Conducted a study in Tumbes entitled "Perception of the family member regarding the therapeutic communication of the nurse in the adult intensive care unit, Regional Hospital II-2, Tumbes 2019"; to discover the perception of the family member regarding the therapeutic communication of the nursing professional in the Adult Intensive Care Unit of the Regional Hospital II-2. It is qualitative research with a case study approach. The sample was determined by speech saturation, leaving 13 research subjects who met the inclusion and exclusion criteria; participant observation was used for data collection. The results obtained. The results show that empathy, receptive listening, and attending to emotions with a humanized touch are necessary in therapeutic communication.
Saravia(35) Carried out his research entitled "Satisfaction of the family member on the nursing care of the critical patient of the Adult Emergency Department at the Edgardo Rebagliati Martins Hospital - 2019", conducted in Lima, to determine the satisfaction of the family member on the nursing care of the patient in the Critical Care Unit of the Adult Emergency Department of the Edgardo Rebagliati Martins National Hospital in the first semester of 2019. It is a study with a quantitative, descriptive, cross-sectional, and non-experimental design approach. One hundred thirty relatives of patients in the Critical Care Unit constituted the sample. The results show that 45,4 % of the overall satisfaction were considered dissatisfied; 40,7 % were moderately satisfied in the information dimension; 52,3 % were moderately confident in the information dimension; 40,7 % were moderately confident in the information dimension. Regarding the dimension of psychological support, 52,3 % are moderately satisfied and 30 % are dissatisfied. In the education dimension, 38,5 % were moderately satisfied and 37,7 % were dissatisfied. The conclusion is that the relatives of patients in the Critical Care Unit show dissatisfaction with nursing care.
Cruz and Acurio(36) state that the Intensive Care Unit represents a crucial space for the recovery of patients, facing a high demand, especially in recent times. In this unique scenario, the nursing staff is exposed to complex, urgent and rapidly changing situations with high levels of stress and workload, as Comezaquira et al. point out. However, this problem does not only affect nursing staff, since, according to Duque and Arias(15) the relatives of ICU patients also experience distress due to the severity of their loved ones' condition. This suffering is exacerbated by the characteristics of the ICU, such as rigidity in terms of visiting hours to observe and receive information on the condition of their relatives, which leads to the family not being taken into account in the care plans and the consequence is that they are deprived of having the nurse-family relationship.
Likewise, there are physical, regulatory, organizational and human barriers that hinder interaction and communication between the nurse and the family, turning it into an asymmetrical, protocol and mechanical process, limiting interaction to minimal contact, according to Duque and Arias.37 In this context, the exposure of family members to this environment is unknown and frightening, and can generate feelings of anguish, anxiety and worry due to the state of insecurity caused by lack of information and communication. In addition, it causes to feel frustrated, with remorse, loss of confidence and even guilt; generating in many cases: anxiety, depression and multiple sleep disorders.(38) It is in this framework that Duque and Arias15 propose the implementation of "patient and family centered care" in order to give greater relevance to the family in health services.
On the other hand, Arenas and Mirón(13) refer that in the nursing context there has always been a process of social interaction and communication; however, the lack of participation of nursing professionals in the flow of information is also observed. Regarding this last issue in particular, Heredia and Pinzón(39) report that it is common that such informative work is discouraged because it is an exclusive competence of the medical staff or because of institutional restrictions that limit the delivery of adequate information to family members and companions, often providing deficient information to the family members and/or companions.(40)
CONCLUSIONS
Effective communication in the care of patients in intensive care units is essential to improving family members' perceptions of care. Empathy and a humanized approach are necessary to attend to family members' emotions, which can increase their satisfaction. However, many relatives express dissatisfaction with the information, psychological support, and education they receive. This highlights the need to improve these areas to provide more comprehensive and satisfactory care.
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FINANCING
The authors did not receive funding for the development of this research.
CONFLICT OF INTEREST
The authors declare that there is no conflict of interest.
AUTHORSHIP CONTRIBUTION
Conceptualization: Candy Angles Vargas, María Angela Paredes Aguirre de Beltrán, Wilter C. Morales-García.
Data curation: Candy Angles Vargas, María Angela Paredes Aguirre de Beltrán, Wilter C. Morales-García.
Formal analysis: Candy Angles Vargas, María Angela Paredes Aguirre de Beltrán, Wilter C. Morales-García.
Research: Candy Angles Vargas, María Angela Paredes Aguirre de Beltrán, Wilter C. Morales-García.
Editor - original draft: Candy Angles Vargas, María Angela Paredes Aguirre de Beltrán, Wilter C. Morales-García.
Writing - proofreading and editing: Candy Angles Vargas, María Angela Paredes Aguirre de Beltrán, Wilter C. Morales-García.