I’d like to leave you with a final message that is a reflection on what I believe is the key to providing the best care for our critically ill and injured patients: communication. Effective communication is at the heart of everything we do in the intensive care unit (ICU). From the communication needed within the healthcare team to create a nurturing, safe and efficient culture to the open and caring communication required to build a relationship of trust among ICU caregivers, patients and their loved ones, communication informs our diagnostic abilities and enhances our ability to build clear, therapeutic, collaborative plans.

In several areas of critical care medicine, the need for careful communication has been established. Families whose loved ones die in the ICU often report conflicts in communication with physicians as a common factor in their dissatisfaction with the care provided.(1) Effective protocols are dependent on communication across disciplines and professions for their development as well as during creation of requisite educational materials needed to facilitate implementation.(2) Any intervention targeting a change in clinical practice must incorporate multiprofessional communication into the resources required to implement behavior change.

Most important, and most interesting, are data suggesting that the factor that identifies high-performing ICUs is not simply the presence of a full-time intensivist, but the distinctive characteristics of the unit’s culture. Rather than being dependent on the skills of a single individual, high-quality care arises through the environment in which that care is delivered. And key to that culture’s definition is good communication around those attributes so embedded in the functions of a high-performing ICU: conflict resolution, collaboration among team members, application of protocols and ease of interdisciplinary and multiprofessional communication.(3)

Arguably, nowhere in medicine is communication as valued as in the ICU. We must, then, be expert in our communication roles. Not only must we understand our position as a source of information for our team members as well as for fragile patients and their families, we must carefully craft the messages we deliver, whether they are medication orders or words that may change someone’s life. We must consider how and when we deliver messages so that they are understood precisely, and we must consider the abilities of those to whom we are speaking to understand our messages.

What can we do to enhance our communication skills? Ironically, the element that may be most important in the delivery of high-quality care is that for which ICU caregivers may have the least training. For some, communication skills come naturally, but many of us are not so fortunate. It seems to me that one of the most important steps we can take to enhance our communication skills is learning how to listen. It is patently obvious how important listening is in the ICU. Listening to our patients, their loved ones, our colleagues, our subordinates, the myriad alarms and the unspoken words in between will provide the building blocks of good critical care. Listening to our patients and colleagues in a genuine and open manner can transform our ability to communicate and engender a nurturing ICU environment.

How do we listen? What skills are key in the listening process? As is true for our end-of-life skills, the answer lies in being simple, not complicated. That is, we should listen (or not, as the case may be) to our patients and their loved ones in the same way we would listen to the concerns of our own families. Of course, many elements create the foundation for effective listening: three that I consider vital are discipline, patience and presence. In terms of listening, discipline is simply a process of remembering to try. Listening, as I said, does not come naturally to all of us, especially in the midst of the chaos we call the ICU. The first step is acknowledging the importance of listening. That is discipline.

The second is patience, which should be self-evident. Maintaining equanimity and not being distracted during the process of communicating with patients and their loved ones requires patience. In this case, it means holding firm the belief that our time could not be better spent any way other than just talking with this particular patient and family at this moment. Patience is the process of making an investment in caring.

Third is presence. What does presence mean? Even busy, distracted ICU caregivers can stop focusing on what we need, if only for a moment, and instead focus on the needs of our patients. We all possess the ability to look out and see patients and families – vulnerable and in need of our full attention. This full attention, which is often perceived as simple genuineness by our patients and their loved ones, should be the goal of communication: simple, uncomplicated and without pretense. A moment of shared concern between a patient and his or her caregiver is what defines good communication.

In my presidential address at the beginning of this year, I invited all of us to work together to remember to care and make a difference. Despite the chaos and distractions that are ever-present in the ICU, it is imperative that, as caregivers, we develop good listening skills so we can create the culture and environment out of which a demand for quality and excellence will arise automatically. That is what allows us to provide the high-quality care our patients deserve and allows us to make the difference we seek.

References:

1.  Heyland DK, et al. Family satisfaction with care in the intensive care unit: Results of a multiple center study. Crit Care Med. 2002;30:1413-1418.

2.  Pronovost P, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732.