Communication in Pediatric Critical Care Units: A Review of the Literature

We searched the CINAHL Plus and MEDLINE databases with the search strings pathway OR algorithm OR care plan and neonatal OR pediatric OR cardiac OR technology AND ICU. We conducted an additional search with the terms communication and ICU and/or outcomes. These searches returned 172 articles. Inclusion criteria were articles published after 2007, peer reviewed, and available in English. We selected the year 2007 to ensure that communication and its interaction with evolving technology would be a primary focus in this review. Also, studies published after the introduction of HCAHPS (which was implemented in October 2006 and first reported in March 2008) were considered most appropriate for this review.³  We screened article titles for inclusion by selecting articles specifically related to caregiver decision-making (pediatric); communication with caregivers (adult or pediatric); communication with critically ill children (pediatric); outcomes for pediatric populations in critical care (pediatric); physicians’, nurse practitioners’, or registered nurse providers’ skills and communication with the health care team (pediatric); and tools developed to improve communication in critical care units. Communication with caregivers was the only category for which we included studies of adult as well as pediatric populations because the roles caregivers face in this situation are similar.

Title screening resulted in removal of 85 articles. We reviewed the abstracts of the remaining 87 articles for exclusion criteria. We excluded 32 articles about biological pathways, 12 about palliative care, and 11 about hospice care, leaving a total of 32 articles (see Figure). We were not able to locate 4 articles published outside the United States after consulting with the library services department and having no success with interlibrary loans. We conduced a full text review on the remaining 28 articles, reading them in their entirety for content and again for analysis.

We entered all articles into a matrix (Table 1) to facilitate understanding across the studies. We identified each study’s focus (provider, parent, patient, or tool) and synthesized findings across studies according to role and content. Studies that reported outcomes related to multiple stakeholders and tools were classified according to their main foci. We rated each study’s strength of evidence and quality according to the Johns Hopkins Nursing Evidence-Based Practice tool, which has a strength of evidence rating scale ranging from level I (experimental studies and meta-analysis) to level V (nonresearch evidence).³²  Article quality was ranked as high, good, or low.³² 

Of the 28 included articles, 2 were deemed to be low quality but were included because of lessons learned during their implementation.^30,31  Of the 26 remaining studies, 16 were deemed high quality^{1,2,6,7,8,10–12,14,18,22–28}  and 10 were considered good quality.^{9,13,15–17,19–21,26,29}  Eight studies reported significant results related to increased communication, satisfaction, and compliance.^{6,7,11,20,22–24,28}  In the examination of level of evidence, 16 articles were deemed to be level III, which includes nonexperimental studies, qualitative studies, and meta-synthesis.^{7,9,10,12,14–19,22–25,29,30}  One study, a systematic review, was deemed to be level IV, which includes expert consensus in systematic reviews and clinical practice guidelines.²⁶  The remaining 11 studies were level V and included quality improvement projects and descriptive reviews.^{1,2,6,8,11,13,20,21,27,28,31}  Of the included studies, 4 focused on provider communication, 8 focused on parent/caregiver communication, 6 focused on patient communication, and 10 focused on communication tools.

For the purposes of this review, providers are defined as physicians, nurses, and advanced practice providers. Provider communication includes intra- and interprofessional communication, provider-patient communication, and provider-parent/family communication. Patients with elevated acuity and multiple interventions and their families need increased opportunities for communication from their providers.^8,9  However, research has shown that a myriad of barriers to provider-family communication exists.

Physicians’ decisions often guide treatment of the patient, but several studies have indicated that effective communication from physicians is not common during hospitalization.^1,9–11  When physicians were evaluated during difficult conversations with parents, such as discussions about escalating care, physicians spoke 65% of the time, even when other providers were present, and 56% of that time was delivering biomedical information. Physicians posed questions to the family only 5% of the time.¹⁰  This pattern of communicating without adequately assessing how well the recipients comprehend the information may prevent the parents and care team from fully understanding the patient’s condition. Additionally, Riley et al¹  examined provider-provider communication and found that merely having an intensivist oversee care did not improve outcomes, especially if communication between the intensivist and the team was impaired. Communication and agreement issues also exist between providers. Justice and colleagues¹¹  showed that physician agreement on patient treatment decisions was only 62% at baseline. Several barriers, including time constraints, lack of communication training, different medical treatment styles, and personal experience, contribute to the lack of communication from physicians.^1,2,9,10  However, research also supports the use of tools like communication pathways¹¹  and processes like closed-loop communication, training in personal communication style, and a standard format for provider communication to reduce barriers to physician communication with all parties and ultimately improve patient outcomes.^1,7,11 

Several studies focused on the quality and experience of nursing providers (bedside registered nurses unless otherwise noted). Patients with complex medical conditions receiving critical care need effective communication from nurses who have completed robust orientation and have a strong knowledge base related to the specific care of these patients.^1,12,13  One study found that a nursing staff in which 20% or more of the nurses have 2 years or less of experience in a cardiac ICU increased the odds of patient mortality. However, the use of quality benchmarks, presence of nurses with bachelor of science in nursing degrees and CCRN certification, high-volume units, and a high percentage of nurses with 11 or more years of experience significantly improved outcomes and decreased mortality.¹²  These findings reveal the knowledge and skill nurses need to provide comprehensive care for pediatric patients receiving intensive care and illustrate that nurses face the same difficulties as physicians: lack of training, different communication styles, and personal experience.

Nurses’ communication also suffers from time and knowledge barriers. Although nurses’ responsibilities differ from those of physicians or nurse practitioners, nurses often have primary responsibility for 1 or 2 patients in an ICU. Nurses have additional patient-specific tasks and benchmarks required for evidence-based care, and sometimes these multiple tasks are barriers to communication.¹⁵  For example, record keeping related to quality bundles requires considerable time away from patients to comply with quality measures.^13,15  Additional tasks include providing high-quality bedside care and monitoring, coordinating care with the multiple services that intensive care patients require, providing education to family members, and documenting the education.^13,15  By reducing time spent in task-oriented decision-making, nurses could increase the time devoted to communication with families and providers. A lack of understanding of effective communication components may also be a barrier. For example, a study in a technology-dependent ICU showed that nurses have difficulty communicating well with families.¹⁶  Nurses who engaged in the communication behaviors of questioning, listening, explaining, and advocating received enhanced respect from parents, and parents believed they needed to engage in all communication behaviors to reach shared communication with nurses.¹⁶  A transfer nurse liaison has sometimes been used with success to fill the communication gap, but to engage fully in these behaviors nurses and physicians may need more time and training.¹⁷  We found very little research specifically addressing communication among advanced practice providers in pediatric ICUs.

Within the provider communication literature we identified consistent barriers related to time constraints, ineffective communication styles, and differences in experience, role, and specialization. Recommendations for mitigating barriers included team- or role-focused communication training, faculty and staff buy-in for interventions, and cultural foci of quality and safety through effective communication.

Parents and family caregivers are integral to the safety and security of pediatric critical care patients. Parents/ caregivers are the best patient advocates at the bedside and are also the resident experts in the social and cultural preferences of the child and family. Additionally, parents are often the child’s proxy and complete the hospital satisfaction survey after discharge. In a survey of over 6000 parents and 38 hospitals, ratings of the quality of hospital care were most closely correlated with communication and coordination of care.⁷  This finding is increasingly important as hospitals, especially ICUs, aim to improve their HCAHPS or satisfaction scores and thus their reimbursement.⁴  In the survey, most parents rated overall satisfaction with the unit or hospital as good. However, significant problems were reported in several dimensions of care, including information given to the parent, information given to the child, partnership, confidence and trust, coordination, continuity, and transition.⁷  Additionally, coordination of care was most problematic for academic health centers (those with teaching and/or fellowship programs), which also reported lower satisfaction on average than hospitals not associated with an academic medical center.⁷  Some academic health centers performed better than others, suggesting that institutional variations, such as process or culture changes, could improve scores.

Improving communication is a struggle for all involved because the ICU is a stressful environment for parents/ caregivers and is not conducive to learning and processing information.^8,10,19,20  Nevertheless, there are indications that parents/caregivers have a sophisticated holistic view of their child’s needs even in an inpatient setting.^8,19,21,22  Therefore, parents/caregivers could have strong, relevant contributions to care but may not be comfortable enough with providers or the setting to communicate effectively.

Parent/caregiver communication needs are dynamic within inpatient settings, varying across times and situations. Because of these variations, repeated communication best helps family members understand and process information in pediatric critical care.^8,10,20  For example, during discussions about escalation of care in a neonatal ICU, parents/caregivers asked questions only 5% of the time, making it difficult for physicians to truly assess family members’ understanding of the condition and treatment options.¹⁰  Parents often feel overwhelmed during crisis times and are unsure how to make the right decisions.^8,10  Melnyk and colleagues²²  reported that during noncrisis times in the pediatric ICU, high parental confidence was protective against parental stress, anxiety, and depression. They also found that cognitive beliefs can be influenced by an educational-behavioral intervention. A note of caution: parental knowledge must be assessed because beliefs and confidence were not always correlated.²² 

The stress for parents/caregivers does not end when the patient leaves the ICU. In one survey, 85% of respondents reported that during changes such as transitions to a lower level of care, a transfer nurse liaison helped reduce transitional stress by explaining plans and processes and being available to family members as they assumed more of their child’s care.¹⁷  Furthermore, in the neonatal ICU, parents may not fully understand their child’s diagnosis after discharge from the hospital. At follow-up appointments, 62% of parents could not report the corrected age of their child or anticipate developmental patterns.²³  Without a working understanding of their child’s diagnosis before leaving the hospital, parents may seek health care information from less reliable sources and have heightened anxiety. Additionally, parental concerns did not often align with the diagnosis, suggesting a lack of knowledge related to the hospital admission.²³ 

Parents of patients in the technology-dependent ICU often provide most of the care for their children. Parents are often very confident in their ability to care for their children in this area. In one study, parents felt they had to question, listen, explain, and advocate for their children while they stayed in the technology-dependent ICU.¹⁶  When parents and nurses engaged in effective communication behaviors, both groups reported having higher satisfaction and feeling more respected.¹⁶ 

Parent/caregiver barriers to communication are certainly case and/or unit specific, but in the literature we found commonalities related to low parental confidence, stressors in the environment, poor emotional health (eg, anxiety and depression), and lack of knowledge. Recommendations for practice improvements included varied and repeated forms of communication, roles focused on care coordination, and educational-behavioral interventions.

Regarding patients specifically, the literature review revealed several findings relevant to communication about mortality and morbidity, anxiety, quality of life, development, and pain and sedation. An increased risk of death following discharge was associated with low socioeconomic status, nonwhite race, comorbidities, age (depending on type of surgical procedure), and postoperative arrhythmias. This increased mortality risk may be related to poor understanding of patients’ conditions and required care.^2,18 

For adolescent patients, an increased understanding of their disease and a sense of coherence in their life reduced anxiety and increased the ability to communicate.^24,25  Health status was not related to quality of life, but parental support and the adolescent’s perception of the disease correlated with improved quality of life, indicating that communication to encourage parental support and patient understanding is important.²⁵  Children younger than 6 months have consistent cognitive and motor delays after surgery and may need additional therapy to combat those delays while in the hospital, a need that may be addressed with appropriate parent communication and education.²⁶ 

Physical symptoms such as pain, agitation, and sedation, which are common in children receiving critical care, also limit communication. Winch and colleagues²⁷  found that patients on an early extubation track must be carefully monitored for pain and sedation requirements; in 10 of 22 patients requiring reintubation, the need for reintubation was directly related to agitation and increased pain. Decreasing the frequency of venipuncture for laboratory tests may also reduce patients’ pain.²⁸  Expert symptom management is required not only for patient comfort but also for improved communication. For patients of all ages and conditions, consistent and effective communication is indicated in order to include patients in treatment planning when appropriate, to improve quality of life, and to increase patients’ understanding of their condition and treatment. Communication should continue into adulthood. Adults with congenital heart disease indicated that they needed more communication and contact, especially if they had poor function and increased use of the health care system.¹⁴ 

In summary, patient-related barriers to communication are related to age, knowledge, and physical comfort and/or status (eg, pain, agitation, and discomfort). Age-appropriate education and expert symptom management have been recommended for practice improvement.

Communication tools developed and used within ICU settings include rounds and visual and written tools. Written patient goals, a visual display of goals on whiteboards, and a structured discussion about the plan of care during provider team rounds improved provider agreement on the treatment plan from 62% to 87.6% and increased parent/caregiver satisfaction from 19% to 75%.¹¹  Including parents in rounds and writing down information increased understanding and satisfaction with patient treatment goals for both parents and providers.^11,20  Daily checklists have been found to increase positive patient outcomes.²⁸  Tarrago and colleagues²⁸  originally used written daily goals but eventually converted to goals entered in the electronic medical record to increase provider buy-in. However, this provider-centric focus may have left parents and patients unable to contribute as fully as possible. The varied forms of communication used (rounds, visual and written displays, and electronic medical record checklists) substantiate findings that parents prefer multiple forms of communication to better understand their children’s conditions.^{8,10,11,19,28} 

Bundles or care pathways are other communication tools used to facilitate care, but support for them is ambiguous. Quality care bundles are often used to promote evidence-based care at the bedside, and critical care patients generally are assigned the most bundles.¹⁵  Compliance with evidence-based treatment of pediatric burns increased after a care pathway was implemented.²⁹  In contrast, a family-centered care pathway resulted in minimal increase in parent/caregiver satisfaction but also had poor physician buy-in and did not specifically define rounds or family conference interventions.³⁰  Nurses are often aware of treatment pathways but may not always employ them because they are confusing and have multiple iterations.¹⁵  Whelchel and colleagues¹⁵  found that most nurses were aware of care bundles but that significantly fewer nurses reported completing the assigned bundles. These findings are consistent with barriers related to time constraints and communication struggles. Studies suggest that building on the strengths of nurses as communicators and using a single pathway for specific patient types may improve quality of care.¹⁴ 

An intervention with the potential to improve communication and coordination of care is creation of a nurse liaison role. Nurse liaisons are nurses who visit patients and answer questions about patient care and the unit when the primary nurse is unavailable. Caffin and colleagues¹⁷  found that 98.5% of floor nurses deemed nurse liaisons an important and vital part of the care team. Additionally, nurse liaisons could be used to communicate with staff members and parents, highlighting the fact that nurses may need more time to communicate with patients, families, and the interprofessional team to provide the highest quality care.^16,17 

For communication tools to be effective, all members of the treatment team must use them consistently and collaboratively, and the tools must be integrated into the normal workflow. The effectiveness of communication tools has been demonstrated for episodic communication, such as handoffs and time-outs, but not for day-to-day communication.^33–35 

Because of the need for effective communication, the use of communication tools is an essential part of the evolving model of pediatric critical care delivery.¹  Two studies found that improving the quality of communication may have the biggest impact on quality care ratings.^6,7  It is paramount that team members communicate well to provide the best care and reduce misunderstanding. Process flow for the use and integration of tools needs to be evaluated regularly to increase buy-in and use. Some examples of proposed key processes and tools are daily rounds, daily written goal sheets, bundles for high-risk interventions, care pathways, and condition-specific protocols.¹  Improving processes and using communication tools within pediatric ICUs has the potential to overcome communication barriers, especially in busy units with changing staff, and to increase satisfaction with all involved.^1,6,7,11,28 

In one study, investigators found that communication efforts were related to cost savings. By using a checklist to reduce unnecessary costs, pain, and tests, one hospital saved a mean of $565 per patient day.²⁸  To be effective, tools must address barriers to communication and consider providers’, parents’, and patients’ needs. An effective and efficient communication tool in pediatric critical care should address all parties equally, demonstrate multiple and varied forms of communication, and be user-friendly and time conscious.

We reviewed the available body of evidence surrounding communication in pediatric critical care settings by investigating the needs of providers, patients, and families and by evaluating tools that have been developed. Our findings, which are consistent with those of other research reports, indicate that communication is highly important and predictive of other quality benchmarks, such as reduced patient costs, improved patient outcomes, and reduced hospital-acquired infections.^6,7  However, little has been done to verify that the suggested communication tools improve communication or are used properly, especially in pediatric critical care. Our findings indicate a notable lack of rigorous research to support the use of tools to improve communication in pediatric critical care settings.

Accompanying verbal communication with written information that can be repeatedly reviewed may fulfill the need for multiple forms of communication and may increase communication between all interested parties.²³  Parents prefer varied, repeated forms of communication to allow them to process information at their own pace, and written forms of communication have been shown to increase satisfaction.^6,14,32  For example, using written goals on a whiteboard and focused discussions about the treatment plan at the bedside increased physician agreement on the treatment plan and increased parental satisfaction, demonstrating effective use of varied forms of communication to meet the needs of providers and parents.¹¹  To increase compliance with a treatment plan, other researchers also used a written form of communication in a pathway that addressed providers’ lack of time and guided decision-making.^21,29  In one study, researchers found that written daily checklists successfully increased positive outcomes such as safety and costs for patients by simply asking if the endotracheal tube was in place or if the patient was ready for oral medications, but when the written records were converted to electronic medical records, the communication loop between parents and providers was possibly impaired.²⁰  Without proper buy-in, a communication tool can be ineffective.²⁰  Extensive work should be done to encourage and educate provider teams to use communication tools when implemented.²⁶ 

As patient care in pediatric critical care becomes increasingly complex, all parties involved must have a strong understanding of the care plan. To facilitate consensus, pediatric ICU nurses should employ varied, repeated forms of communication; clear, consistent messages about the plan of care; communication integration into the workflow pattern; communication training for the interdisciplinary team; staff buy-in for planned interventions; a culture of safety and communication; and vigilant assessment and interventions related to patient and family/caregiver information needs, emotional status, and well-being. Table 2 presents examples of common barriers and suggested solutions based on this review. We gathered the information in this review from current literature related to pediatric, cardiac, and neonatal ICU settings, and each of these settings may benefit from the information presented.

Results from several studies showed that communication was tied to improved scores and ratings.^1,6,7,11,28  Without proper buy-in, the tools become just another task that does not facilitate proper flow of information.^30,31  Follow-up with a new tool, redevelopment of the tool, and audits of the tool’s use may be required to fully benefit from tool implementation.

Tools will not always work in every situation. Providers using communication tools need to ensure that all parties are reaching mutual understanding through additional forms of verification such as verbal discussion and teach-back methods.^8,10,11  Further rigorous research is needed to develop and test communication tools and their outcomes to establish best practices for pediatric critical care environments, providers, and patients.

This literature review was limited to English-language publications and did not include a review of gray literature. Therefore, some important evidence may not have been captured. Additionally, unintentional bias may be present because a single researcher conducted the search, reviewed and classified the articles, and analyzed the findings. Bias, however, was minimized by multiple readings of the articles, continuous comparison of findings, and peer review. The included studies represent similar populations, have predominantly good to high evidence ratings, and have level III to level V quality ratings, supporting the findings.

Communication is clearly one of the most important things we can do to protect our patients and our revenues. Many pediatric ICUs have the same problems, such as time limitations, lack of communication training, heavy acuity, and the need to develop varied and effective communication styles. The language of health care is often foreign to patients and family members. Although formal provider education may foster better communication, the educational benefit is constrained by staffing realities including constant changes in staff and decreasing staff numbers. An interdisciplinary approach that remains consistent for each patient every day may facilitate understanding among providers, ICU patients, and family members.

A communication tool that places safety at the fore-front, standardizes the summary of rounds and plans, creates a written record for review throughout the day, and is adapted to the workflow of each individual ICU will likely result in a reduction in patient cost, an increase in satisfaction, and an increase in reimbursement based on eventual C-HCAHPS scores. An interdisciplinary intervention of this nature will need point people who care strongly about communication and will need buy-in from the team to be successful. During rounds, identification of roles, including that of the leader, is vital to team cooperation. Providers are at substantial risk for being oversaturated with data during rounds and may miss vital information. Nurses have functioned as communicators, translators, and care coordinators within hospital settings and are also at patients’ bedsides around the clock every day. Although this review shows that no one-size-fits-all communication tool exists, future research should identify whether nurse-led rounds in which data are presented in a concise and consistent manner, perhaps using a well-developed tool that contains cognitive prompts for safety and quality, can transform the care provided at the bedside.