Understanding equitable and affirming communication moments and relationship milestones during the intensive care unit journey: findings from stage 1 of a design thinking project

Patient and family-centred care, communication, and relationships in the intensive care unit

Patient and family-centred care (PFCC) is a paradigm that recognizes the benefits of a mutual partnership between patients, their loved ones, and health care providers.1 In the PFCC paradigm, the patient and their loved ones are empowered and supported to make decisions and define successful outcomes based on what is important to them.2 In the intensive care unit (ICU), best practices for PFCC include family presence and participation in bedside care; routine communication to engender trust and reduce conflict; and the use of active listening, expressions of empathy, and statements of support during communication with families.3,4

Although effective communication underpins much of PFCC, ICU-specific factors make communication particularly challenging in the critical care setting. The complexity of care, number of health care providers involved, nature and pace of the decisions, and the emotional and physical toll of having a loved one in critical condition are barriers to effective communication in the ICU.5 Intensive care unit clinicians must attempt to overcome these barriers and create space for empathetic, respectful, and collaborative communication with patients and their loved ones, in a manner that facilitates trust.6 Ineffective communication in the ICU may hinder relationship development by creating bias, distrust, and social distance.5 Clinicians have skills in both communication and in therapeutic relationship building, which has the potential to improve the experience of patients and positively affect outcomes.7 Essential conditions for therapeutic relationship building, such as a present, genuine, receptive, collaborative, and committed health care provider, can provide a foundation for engaging patients and their loved ones in PFCC.7,8,9

Equity, Diversity, Decolonization, and Inclusion

Diversity is inherent in the presence of individual differences that shape lived experiences (e.g., race, gender, ethnicity, place of origin, disability, sexual orientation, age).10Intersectionality refers to the overlapping nature of an individual’s multiple identities that interact to shape distinct lived experiences of social oppression, privilege, and positional power (e.g., race and gender interact so women of colour experience higher levels of oppression perpetuated by systems of power than either men of colour or White women do).11,12Inclusion is an ongoing process of building welcoming, respectful, and affirming spaces to support equity or parity in policy, process, power, access, opportunity, and outcomes.10Decolonization is a process of deconstructing systems that prioritize settler ideologies, thoughts, and approaches over those of Indigenous culture, traditional ways of knowing, empowerment, and self-determination across all systems, including health care.13,14,15 The acronym EDDI refers to the interconnectedness of process and pursuit of Equity, Diversity, Decolonization, and Inclusion.

Persons representing diverse intersectional identities bring practical, contextual, and historical experiences and realities that can have implications for communication and trust building. For example, Indigenous, Black and people of colour (IBPOC) populations may have experienced systemic racism and oppression, intergenerational trauma, the long-term effects of colonization, and inequitable access to housing, sustainable food, and health care.16,17,18 For patients and loved ones whose primary language is not English, communication can impact their experience and mental wellbeing during their ICU stay.19,20,21,22,23,24,25,26,27,28 Diversity in culture, language, and spiritual or religious beliefs can influence expectations of critical care patients and their loved ones.19,20,21,23,24 These factors with which diverse patients and loved ones come into health care systems may require specific consideration to create a safe and affirming space for communication and trust building.5,29

Health care systems have been developed on a foundation of colonial white supremacy and subsequently, systemic racism, which often negatively impacts IBPOC populations’ access to appropriate or even adequate health care. Individuals who are negatively impacted by health disparities and inequity have more complex health needs and often delay seeking medical attention due to racism, discrimination, stigma, sexism, and bias.30,31,32 Indigenous populations in Canada continue to be disproportionately affected by colonial health care structures.32

Focus of the current investigation

The focus of this investigation was to understand communication, connection, and relationship building in the ICU through a lens of EDDI. By understanding the intersection between PFCC and diverse identities, the ICU can become a more equitable and culturally safe space where patients and their loved ones are empowered to actively participate in shared decision-making, engage the health care team, and feel valued and affirmed.

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