Cultural and systematic barriers to communication between nurses and family members in the ICU

Abstract

Background

Families need honest and clear information in order to make decisions about patient care. The study points to many cultural and systemic barriers to good nurse-family communication in intensive care units (ICUs). These barriers include time constraint, language barriers, culture differences, or emotional stress. As communication is key to patient/family outcomes, there is thus a need for more insight and understanding into why and how this occurs. The purpose of this study is to explore the cultural and systematic barriers that hinder effective communication between ICU nurses and family members in Jordanian healthcare settings.

Methods

An explorative qualitative approach was used to conduct the study, involving semi-structured interviews with 15 ICU nurses and 15 family members. Data were analyzed using thematic analysis framework.

Results

The findings revealed two main themes: cultural barriers to communication, with sub-themes including cultural expectations, family-centered care, and mistrust between family members and ICU nurses; and systematic barriers to communication in the ICU, with sub-themes including time pressure and heavy workloads, institutional policies and hierarchies, and inadequate medical explanations.

Conclusions

Nurse-family engagement can be strengthened through structured protocols to address cultural hierarchies and institutional constraints as a novel approach to enhancing patient-centeredness, though Jordanian healthcare families seek such approaches.

Introduction

The definition of care, as well as the understanding of proper care delivery, is heavily influenced by cultural beliefs and values. This, in turn, affects ICU nurses’ communication with family members during this critical stage of life [1]. Family-centered care is the act of inviting family members to be a part of the patient care, but cultural expectations often determine how much families will interact with providers about a patient [2]. Broader cultural traditions and religious views generate miscommunication that breaks down effective communication.

In Jordanian ICUs, families expect to be involved in decisions, but nurses often struggle to balance professional care with cultural expectations of deference to family hierarchy [3]. Communication with family members of critically ill patients is influenced by many barriers that hinder effective communication with family members. These barriers include work overload, language barriers, emotional stress or cultural aspects. This adds more challenges for nurses to communicate and transfer transparent information to families in the ICU [4].

It should be indicated that the role of nurses in family-centered care is different from one culture to another and between different regions. Nurses possess more roles in addition to providing health care services. Emotional and spiritual care are part of these roles [5, 6]. However, cultural barriers, such as role ambiguity, create uncertainty about the role of nurses in family interaction in Jordan [7]. Thus, the absence of structured communication training further increases the challenges faced by nurses in addressing cultural expectations effectively.

Family members act as advocates, decision-makers, and emotional caregivers for those in the ICU. However, what defines a family member varies widely across different cultures and healthcare systems. In Jordan, for example, extended family members frequently provide support, creating more complex communication dynamics [8]. Western models emphasize individual autonomy, whereas decisions in Middle Eastern cultures tend to be made collectively. While prior work focuses on individualistic cultures, Jordan’s collectivist norms necessitate distinct communication strategies. Surrogate decision-making in ICUs is often ambiguous and generates conflict among healthcare teams and families [9]. Because family roles are often overlapping, nurses sometimes find it difficult to discern who is the key decision-maker. These results imply that ICU nurses need structured protocols for identifying family hierarchies and to have defined communication paths open to the most appropriate kin. For nurses specifically, one important barrier to nurse-family communication in ICUs is mistrust [10, 11]. This may also be due to, among other things, insufficient health explanations, perceived neglect, and cultural clashes [12]. Using complicated language and depending on pure medical terms makes it more difficult for family members to understand the ICU nurses. This would result in several negative feelings, such as disappointment, frustration, and confusion among family members. All these challenges, in addition to high nursing workloads and systematic issues, might result in mistrust in Jordanian ICUs [13]. The demands of patient care mean that nurses do not have sufficient time to engage meaningfully with families. This leads families to perceive nurses as being too busy or uncaring. To overcome this barrier, researchers recommend the utilization of structural family meetings as well as better communication training for ICU nurses that allow them to connect with patients’ families [14].

Effective communication is a major challenge for ICU nurses and families due to workload and time constraints, which are the main variables that affect it. Most of the nurses don’t have a dozen deathbeds to hover around, so they have little time to sit with the family. Nurse workflow and patient acuity have a strong correlation with the quality of nurse-family interactions [15]. Nursing time is inadequate for the emotional support of families throughout critical periods. Shortages of staff and administrative burdens further complicate the workload of ICU staff in Jordan. Excessive documentation requirements reduce the time available to engage with families, so documentation has been claimed to sap time away from families [3]. This is exacerbated by the emotional challenges faced by nurses, which, depending on the extent of these, may contribute to burnout and reduced willingness to talk to anxious relatives for too long together.

ICU hospital policies and hierarchical structures mediate communication dynamics. These constraints include institutional barriers such as limited visiting hours, restrictive communication protocols, and heavy bureaucratic processes [16]. Communication style also is dependent on organizational culture, and supportive environments create opportunities for better communication. In many cases, hierarchical structures within Jordanian hospitals mean that the physician is often at the center of decision-making, creating barriers to nurses having the autonomy to speak directly with families. Nurses have a tendency to seek to defer to physicians for medical updates, potentially delaying patients from receiving life-changing information [4]. The researchers suggest that nurse-led interventions should be implemented to structure communication pathways, which enables information to be exchanged while reducing the families’ stress [17, 18].

The most important communication barriers in ICUs are related to physicians providing clear and understandable medical explanations for patients’ families. Families need honest and clear information in order to make decisions about patient care [14]. In Jordanian ICUs, cultural sensitivity to frank discussions of prognosis and end-of-life care makes inadequate medical explanation even more pernicious [19]. Therefore, when healthcare workers don’t tell family members bad news directly, it creates confusion and distrust. Moreover, unrealistic perceptions about the health system and language barriers further complicate the challenges experienced by refugee families in Jordan [19]. To this end, structured communication training, such as standardized communication protocols, for ICU nurses has been suggested to improve outcomes. Another suggestion was having nurses trained to relay information using simple speech and visual aids [20]. Moreover, the ICU environment can be made less daunting for families by ensuring regular family meetings are held, appointing a liaison nurse, and facilitating communication.

Effective communication between family members and healthcare providers—including doctors, nurses, and specialists—is essential in intensive care units (ICUs), where patients are often critically ill and unable to speak for themselves. However, this communication is often hindered by various barriers such as medical jargon, limited time, cultural misunderstandings, and institutional policies. o explore these complex and context-specific issues, this study adopts a qualitative research design. Qualitative methods are particularly well-suited for examining interpersonal and cultural dynamics, as they allow for a deeper understanding of lived experiences, beliefs, and values that influence communication in critical care settings [21]. qualitative inquiry enables researchers to capture the emotional and relational dimensions of nurse-family interactions, especially in diverse cultural environments like Jordan.

Existing studies primarily focus on Western contexts, leaving a gap in the literature regarding Middle Eastern and Jordanian healthcare settings. The purpose of this study is to explore the cultural and systematic barriers that hinder effective communication between ICU nurses and family members in Jordanian healthcare settings. Specifically, the study seeks to examine how cultural expectations, institutional constraints, and language barriers impact family involvement, trust, and understanding of their loved one’s medical condition.

Methods

Design

An explorative qualitative approach is appropriate for studying complex unexplored phenomena, such as communication difficulties between ICU nurses and the families of patients in Jordan [21]. This enabled a detailed examination of participants’ experiences, with a focus on important patterns, themes, and contextual influences that shape nurse-family interactions in ICUs. Using qualitative explorative, the study captured subjective experiences systematically, allowing exploratory flexibility in data collection through a rigorous structure. This design allowed for an in-depth exploration of communication barriers and challenges facing healthy communication between family members and nurses in the ICU.

Settings

The Ministry of Health has authority over the public, private, and teaching hospitals that provide the Jordanian healthcare system. There are 118 hospitals, including secondary and tertiary care centers, in the country [22]. This was a multi-center study performed in two high-volume public hospitals, which are well-known for their heterogeneous population and advanced areas of the ICU. These facilities care for patients with life-threatening illnesses, such as post-cardiac arrest, acute respiratory failure, serious burns, diabetic ketoacidosis, acute kidney disease, and neurological trauma.

Participants in need of ICU wards have direct communication between the nurse, patient, and family and are located in close proximity to the other target population, which is hospital waiting areas of families spending longer hours interacting with hospital staff. All interviews with ICU nurses were conducted in private hospital rooms to maintain confidentiality, while family members were interviewed in waiting areas to encourage a familiar, accessible environment to enhance open discussions and unsanitized contacts. The area of the waiting room provided a degree of privacy and minimized disturbances. Only the participant and the interviewer were present during the sessions. This study blended the perspectives of both nurses and patient families to bring a contextualized depth of understanding to questions of ICU communication, with findings intended to enhance both patient-centered care and nurse-family engagement.

Sampling

Data were collected through semi-structured interviews from participants recruited using a purposive sampling strategy to ensure representation across various ICU types and nursing roles [21]. Participants were selected according to specific inclusion and exclusion criteria, which ensured both the richness and relevance of the data.

ICU nurses were registered as critical care professionals, possessed a minimum of a bachelor’s degree in nursing, and had at least one year of ICU experience at the study site. This ensured participants were experts and familiar with the communication dynamics of the ICU [23]. Patient care had to be directly managed by the nurses, and they also required the ability to speak Arabic in order to ensure accurate participation. Nurses in administrative or non-clinical roles were not included because of their lack of direct communication with families. Likewise, nurses who possessed only diploma qualifications were excluded to maintain educational consistency, consistent with research indicating a positive association between higher levels of education and enhanced levels of clinical reasoning and patient outcomes.

Family members of first-degree relatives (parents, spouses, children, or siblings) of ICU patients who were hospitalized for more than three days. This criterion was intended to ensure familiarity with ICU dynamics beyond initial crisis reactions, and provide for enough exposure to ICU communication, resulting in more reflecting responses. Participants aged 18 years and older, able to read Arabic well enough to provide informed consent and insightful engagement. To maintain uniform data across patients, only one family member per patient was included. The study included 15 ICU nurses and 15 family members. Data were continuously collected through interviews until no new insights emerged. This ensured data saturation and a thorough exploration of communication challenges in ICUs [24]. For both family members and nurses, no new data were obtained after the interview number 13. Therefore, we conducted two interviews after interview 13. Data saturation was achieved after conducting 15 interviews with each group.

Data collection procedure

We employed a two-phase process involving (1) preparation and participant recruitment and (2) semi-structured in-depth interviews. An extensive literature review informed the development of a semi-structured interview guide, which was designed to systematically explore three key areas: communication barriers, factors influencing communication, and potential strategies for improvement. The questions (Table 1) were intentionally open-ended to elicit detailed perspectives while remaining guided by these research priorities. During data collection, the questions were iteratively refined to probe emergent themes more deeply (e.g., trust dynamics, institutional constraints) as they arose. Participants received an information sheet with study aims. This sheet showed that participants’ confidentiality was protected and ensured that voluntary participation is a basic right for each participant. Ethical approvals were obtained, as well as collaboration with hospital administration, nursing managers, and recruitment in ICU wards.

Table 1.

Interview questions

Interview questions (Open-Ended Questions)
• Can you describe your experience communicating with ICU nurses about your loved one’s condition? What were the biggest challenges you faced?
• How do cultural expectations about family involvement in medical decision-making influence your interactions with ICU staff?
• Have you ever felt that hospital policies or procedures limited your ability to receive clear and timely information? Can you share a specific example?
• For nurses: How do cultural norms and family expectations impact your ability to communicate with multiple family members?
• Have you experienced difficulties understanding medical information provided by ICU staff? What could be done to improve clarity in communication?
• For nurses: What challenges do you face when trying to provide updates to families while balancing patient care responsibilities?
• Have you ever felt that trust was an issue between ICU staff and family members? If so, what contributed to this feeling?
• In your opinion, what changes could be made to improve communication between ICU staff and family members while considering both cultural expectations and institutional limitations?

Interviews were conducted face-to-face in private hospital rooms (for nurses) and waiting areas (for family members). And each interview took 30 to 60 min, with open-ended questions to get rich narratives. Interviews were conducted with semi-structured open-ended questions, and probing techniques were applied to explain the answers; prior consent was taken for audio recording. Field notes recorded non-verbal cues and contextual details. The data collection process started on 15/09/2024 and finished on 25/12/2024.

Ethical considerations

The title of the Ethics research approval from the Institutional Review Board (IRB) of Applied Science Private University (code: 5/4/2017), Amman, Jordan, and additional permission from the Ministry of Health. Written informed consent was obtained from all subjects, and participants were informed they could withdraw from the study at any time without consequence. Confidentiality was guaranteed through the removal of personal identifiers from transcripts and secured storage of data. Research files were stored in password-protected electronic databases and locked filing cabinets for three years, then permanently deleted.

Data analysis

Data were analyzed according to Braun and Clarke’s [25] thematic analysis framework. This farmwork was chosen as it provides a systematic yet flexible method for analyzing qualitative data, making it suitable for diverse research questions and contexts. Additionally, it emphasizes generating rich and detailed descriptions of data, allowing researchers to capture complex patterns and themes that emerge from participants’ experiences. A qualitative data analysis software, NVivo 12 PLUS, helped in effective organization coding [26]. Interviews were both audio-recorded and transcribed verbatim, with anonymization. A field note writing was taken to distinguish the transcripts with non-verbal cues and contextual observations. The data were read several times to become familiar with them, systematic coding was used to identify key themes, and codes were grouped into higher-order themes reflecting communication barriers and facilitators. Arabic transcripts were back-translated to English to ensure the accuracy of translation used in the qualitative analysis. Any discrepancies were settled through discussion between translators and researchers. Internal consistency and coherence were assured through constant comparative analysis as themes were iteratively refined.

Trustworthiness

This study utilized Lincoln and Guba’s criteria for credibility, transferability, dependability, and confirmability [27]. Prolonged engagement, triangulation by multiple sources of data, member checking, and peer debriefing with qualitative research experts established credibility. We deliberately recruited the sample based on well-defined inclusion and exclusion criteria to ensure a representative and appropriate participant group for the study. After identifying potential participants, we obtained their informed consent, ensuring ethical standards and voluntary participation. This rigorous approach helps guarantee that all participants share key characteristics relevant to the study, thereby strengthening the credibility, validity, and reliability of the findings.

Transferability was supported through rich descriptions of ICU settings, participant characteristics, and distinctive communication obstacles, enabling readers to determine relevance to comparable settings. Additionally, a pilot study was conducted to assess the relevance and clarity of the interview questions. Participants involved in the pilot testing were excluded from the main sample to prevent any potential bias, ensuring the validity and reliability of the study findings. A complete audit trail provided a record of all research decisions taken, coding applied, and themes developed, ensuring dependability. The code-recode strategy was undertaken to ensure consistency. Confirmability is aided by reflexivity, in which, as a researcher, I kept a journal that noted biases and details of methodological decision-making. The audit was an external one to ensure objectivity and neutrality. The study, therefore, embeds validity, reliability, and transparency by utilizing these rigorous strategies, enabling it to produce credible and transferable findings regarding ICU communication in Jordan.

Findings

Demographic characteristics of ICU nurses and family members

ICU nurses’ specialization and workload

The study included 15 ICU nurses purposively selected to represent diverse clinical backgrounds, including variations in work experience, educational qualifications, and positions (e.g., staff nurses, charge nurses, and clinical educators). Participants were recruited from four ICU settings (general, pediatric, neonatal, and surgical) to capture a range of perspectives influenced by unit-specific demands (see Table 2). The participants’ ages ranged from 26 to 41 years (mean: 33.6 years). The majority held a bachelor’s degree in nursing (11 nurses), while 4 nurses held a Diploma in Nursing. The nurses had between 3 and 15 years of total clinical experience, with 1 to 10 years of ICU-specific experience.

Table 2.

ICU nurses’ specialization and workload

ICU type	No. of nurses	Avg. patients/Shift	Typical roles	Average of ICU experience
General ICU	7	3 − 4	Staff Nurses (5), Charge nurse (1), Clinical educator (1)	5.2
Pediatric ICU	3	2	Staff nurses (3)	4.3
Neonatal ICU	3	3	Staff nurses (2), Charge nurse (1)	5.7
Surgical ICU	1	4	Staff nurse (1)	3.0

In terms of positions and ICU specialties, 9 nurses worked in general ICUs, 3 in pediatric ICUs, 3 in neonatal ICUs, and 1 in a surgical ICU. The average number of patients cared for per shift ranged from 2 to 4. Most nurses spoke Arabic, with 5 also proficient in English. Furthermore, 9 nurses had received formal training relevant to their ICU role, while the remaining 6 had not (See Table 2).

Family members’ relationships and communication comfort

The following table explores the relationship of family members to ICU patients and their comfort level when communicating with ICU staff. Most family members were male relatives, specifically fathers and brothers. Many sisters and wives feel comfortable interacting with ICU staff, while brothers and some fathers do not. This indicates, at minimum, the need for enhanced communication strategies for family members who find ICU communication challenging (See Table 3).

Table 3.

Family members’ relationships and communication comfort

Relationship	No. of participants	Communication comfort level
Fathers	5	Varies
Brothers	3	Mostly Uncomfortable
Mothers	2	Mixed Responses
Sisters	2	More Comfortable
Wives	2	Comfortable with ICU staff
Husband/Son	1 each	Mixed Responses

Major themes and subthemes

Ultimately, as human beings, we all have our struggles, and in these human elements of health care, effective communication between nurses and family members of patients in the ICU is an essential component of holistic and patient-centered care. However, different cultural and systematic barriers hinder this communication process, resulting in frustration, misunderstanding, and emotional distress for both families and healthcare delivery system providers. The results of this study highlight two main themes – cultural barriers (with sub-themes including cultural expectations, family-centered care, and mistrust between family members and ICU nurses) and systematic barriers to ICU communication (with sub-themes including time pressure and heavy workloads, institutional policies and hierarchies, and inadequate medical explanations (See Table 4).

Table 4.

Major themes and subthemes with quote examples

Theme	Subthemes	Quotes examples
Communication Challenges influenced by cultural factors	Cultural Expectations	They don’t understand that we’re not just visitors; we’re here as a family to protect and support. In Jordan, you don’t just hand over your loved one and walk away (Family 9, M).
	Family-Centered Care	Jordan is different from the Western countries. Here, we have big and extended families. Sometimes, we have more than ten family members come at different times and they all want to know what is going on with their patient. Honestly, we want to help, but we cannot answer all of them (Nurse 14, F).
	Mistrust between family members and ICU nurses	They keep telling us that they did everything they can do and telling us brief information. Sometimes, they just tell us that the patient’s condition is stable while we see something different. This leads to a lack of trust between relatives and nurses (Family 2, M).
Systematic Barriers to Communication in ICU	Time Pressures and Heavy Workloads	“The family wants to know everything, but with the workload, I can’t keep up. They expect so much more than we can tell them we’re doing our best” (Nurse 14, F).
	Institutional Policies and Hierarchies	I know that they have special policies and guidelines to limit visiting in the ICU. It is for the benefit of patients. However, giving us information about our patients is essential to maintain a healthy relationship between families and nurses. (Family 8, M)
	Inadequate Medical Explanations	“Whenever I inquire about my mother’s treatment, they say something alien to my ears. I feel like I require a translator just to understand what’s happening” (Family 10, F).

Theme 1: Cultural barriers to ICU communication

Cultural expectations and Family-Centered care

Cultural expectations play a pivotal role in shaping communication needs within the ICU, particularly in Jordanian society, where family involvement in patient care is deeply embedded in social norms. Family members expressed a strong desire for regular, compassionate updates and direct access to caregivers, viewing involvement in medical decisions as a fundamental cultural responsibility rather than an optional privilege. One father articulated this expectation clearly, stating:

“In our culture, family is everything. We need to be included in every decision and update; leaving us out feels like disrespect to the whole family” (Family 4, M).

Another father reinforced this sentiment, explaining,

“They don’t understand that we’re not just visitors; we’re here as a family to protect and support. In Jordan, you don’t just hand over your loved one and walk away” (Family 9, M).

However, ICU nurses often struggle to balance these culturally ingrained expectations with the demands of their clinical responsibilities. Many nurses acknowledged the importance of family-centered communication but found it challenging to meet these expectations due to high workloads and institutional constraints. One nurse shared her frustration, saying:

“I know how important it is here to keep the family updated, but we’re constantly under pressure with so many patients. We can’t give each family the time they deserve” (Nurse 6, F).

Another nurse described the difficulty of navigating cultural expectations while managing multiple patients, noting,

“Families expect us to talk to them as if we’re part of the family. But I’m juggling care for multiple patients; it’s impossible to meet that cultural expectation all the time” (Nurse 3, M).

Family members often interpreted these limitations as intentional distancing or a lack of respect for their cultural values, leading to tension and dissatisfaction with the care process. One brother expressed his frustration, saying,

“They act like we’re meddling, but it’s our duty to stay informed. We’re Jordanians—family support isn’t optional; it’s a responsibility” (Family 12, M).

Another father highlighted how the ICU system clashes with traditional Jordanian customs, stating,

“In Jordan, you’re expected to stand by your loved ones. Here, it feels like they want us to stand back and keep quiet. That’s not who we are” (Family 7, M).

A mother voiced her distress, emphasizing,

“All I ask is to be kept in the loop. This is a part of our culture—to be close and involved, but here it’s like we’re treated as outsiders” (Family 8, F).

Family-centered care

Most of the nurses in this study appreciated the importance of communicating with family members in the ICU. They admitted the difficulty of the situation of having critically ill patients in the ICU. Many of them expressed their readiness to deal with and communicate with family members. However, they raised an important point about the authorized persons to communicate about the condition of ICU patients. They explained that critically ill patients usually have many visitors, and they all introduce themselves as family members. These family members visit their patients at different times of the day and night. They all keep asking and looking for detailed information about the patient’s condition. One of the nurses commented:

Jordan is different from the Western countries. Here, we have big and extended families. Sometimes, we have more than ten family members come at different times and they all want to know what is going on with their patient. Honestly, we want to help, but we cannot answer all of them. (Nurse 14, M).

Some of the nurses further raised a sensitive point about the ethics and legal issues of disclosing information to all these family members. They explained that they do not know the wishes and desires of their patients.

We studied in the university something about the term “next of kin”. This means that the patient assigns their relatives as authorized persons to obtain information about their conditions, and this next of kin is able to make decisions in case the patient’s condition deteriorates. (Nurse 8, F).

Interestingly, around five family members agreed with the nurses about these points. These family members showed the complexity of nurses’ jobs in the ICU. Communication with family members was viewed as an extra effort by nurses. One of the family members stated:

During my presence in the ICU, I noticed the hard job of nurses. Communicating with family members would be exhausting for them. There should be a solution to delegate this task to somebody else in the hospital. (Family 3, M).

Mistrust between family members and ICU nurses

Both family members and nurses showed the importance of trust in building effective communication in the ICU. Several family members explained that they wanted to stay at the bedside of their loved ones to be sure that everything was done perfectly by the nurses. Moreover, family members were not satisfied with the brief information they received from the ICU nurses. This led many of the family members to keep asking for updates about the condition of their loved ones.

They keep telling us that they did everything they can do, and telling us brief information. Sometimes, they just tell us that the patient’s condition is stable while we see something different. This leads to a lack of trust between relatives and nurses. (Family 2, M).

Several nurses stressed the above issue that was raised by the family members. These nurses showed that many of the family members do not trust them. They indicated the difficulty of communicating with people they do not trust. This negatively influenced the relationship between nurses and family members in the ICU. Two of the nurses showed that they decreased communication with family members, as they thought it was not useful. They give priority to patients more than communicating with family members.

I keep moving between patients. We are always busy and do not have enough time to communicate with families. Our job is to provide care for our patients. (Family 7, M).

Several nurses showed that they do the best for their patients and that they know what is good for them. They respected the role of family members. However, they supposed that they know what is best for patients more than family members. This caused many of the nurses to ignore communicating with family members.

Patients are critically ill, and they need us more than their families at this stage. We know what is best for our patients. We have this right more than anybody. (Nurse 5, M).

The above paternalistic approach was clear in one of the family members’ statements, as he explained that many ICU nurses push family members outside the department inappropriately. It was explained to him that this was for the sake of his patient.

Once, I was beside my father in the ICU. When a nurse came to take a blood sample from my father, he shouted at me to leave the ICU. The nurse pushed me out against my wish to stay in. (Nurse 6, F).

Theme 2: Systematic barriers to icu communication

Time pressures and heavy workloads

Communication challenges in ICU settings are further compounded by systematic barriers, as well as cultural mismatches. Significant barriers to meaningful interactions between families and nurses included time pressure and workload. Nurses routinely said they felt overwhelmed by the number of patients they were responsible for, with little time to give families regular updates. One nurse explained:

“The family wants to know everything, but with the workload, I can’t keep up. They expect so much more than we can tell them we’re doing our best” (Nurse 14, F).

Another nurse spoke of the emotional burden of being unable to fulfill families’ expectations, saying:

“When families view us as cold, it stings because we do care. But having so many tasks and responsibilities, it’s difficult to demonstrate it” (Nurse 14, F).

Family members, in response, interpreted this lack of communication as neglect or simply a refusal to communicate with them, thus amplifying even more their own pain. “It’s frustrating,” one father said, adding:

“Family members are never left alone in Jordan, especially in times of sickness, but here it seems they want us to stay out of the way. It’s disrespectful” (Family 13, M).

Another relative talked about how the hospital’s institutional procedures seemed exclusionary, adding:

“We challenge because it’s our responsibility. They need to realize this isn’t being nosy. This is being family. How can they not see that?” (Family 11, M).

Most nurses often demonstrate high stress levels, compassion fatigue, and burnout, which may impact their ability to communicate effectively. Avoidance of communication may be caused by pressure to provide bad news or discuss complicated treatment options. The emotional strains can reduce the quality of communication, distance families further, and affect their understanding of the condition of their loved ones.

Institutional policies and hierarchies

Many of the institutional policies in place prevent the nurses from speaking openly with the families. Numerous nurses said they work under hospital protocols that prioritize patient care over family communication, to the point where they can’t provide family members the level of communication they want. One nurse explained:

“We’re trained to look at the patient, not the family, and we’re not given the support to give them the level of attention that they want” (Nurse 5, M).

Another nurse described how the system fails to accommodate communicating with family members:

“We don’t have the time, and we don’t have the bandwidth to be able to meet their expectations. This doesn’t mean we don’t want to. The system just isn’t built for this kind of support” (Nurse 4, M).

In an ICU context, institutional policies are a key determinant in the configuration of communication practices in nurse-family communication. Such protocols greatly affect the degree to which families have access to information about their loved ones’ conditions and treatment plans. The restrictive policies were viewed by many family members as limiting family participation and, consequently, hindering effective communication. For example, visit restrictions often come from the need to maintain a sterile environment or to ensure that proper care is provided to critical patients. However, these family members showed that such policies could inadvertently isolate families in the decision-making process, exacerbating their emotional anguish.

I know that they have special policies and guidelines to limit visiting in the ICU. It is for the benefit of patients. However, giving us information about our patients is essential to maintain a healthy relationship between families and nurses. (Family 8, M)

Inadequate medical explanations

There are language barriers between medical providers and families. Languages used in the ICU may differ from patients’ or family members’ native language in communicating war contexts with complexity, like explaining medical conditions and procedures. While most families speak primarily Arabic at home, or at best, some gibberish English, many medical terms, as used through clinical conversation, are conveyed in technical English or Latin-derived medical terminology. Esoteric terms that mangle their pronunciation make them even more alienating to the family, who ends up feeling like a bystander of their loved one’s medical care. One frustrated father said:

“They tell me ‘He’s critical’ or ‘He’s stable,’ but what does that even mean? “Should I feel relieved or scared?” (Family 7, M).

A family member echoed this concern, stating:

“Whenever I inquire about my mother’s treatment, they say something alien to my ears. I feel like I require a translator just to understand what’s happening” (Family 10, F).

Linguistic differences and using complex medical terms were viewed by many family members and nurses as a reason for critical misunderstandings, potentially compromising patient safety. Several family members viewed this phenomenon as a barrier that not only complicates care but can also create distress in patients and families who feel marginalized and unable to defend their loved ones. Nurses often use specific language for procedural and clinical contexts that can even more alienate patients and their families. For example, terms such as “emergency intubation” or “multisystem organ failure” can be overwhelming for laypeople. It is not uncommon that families do not feel prepared to participate actively in discussions on care decisions when they do not fully understand the terms involved.

“Many families said they felt lost in the translation, struggling to impart the enormity of the condition of their loved one”. (Participant 1, Female, Family)

The findings highlight the role of cultural expectations, systematic limitations, and language barriers in ICU communication. Addressing these challenges requires culturally competent training, institutional support, and improved language accessibility to bridge the gap between families’ expectations and ICU communication practices.

Discussion

The findings from this study shed light on the communication barriers nurses face with family members in Jordanian healthcare settings. These problems arise from cultural norms, systemic inefficiencies, and language barriers that strangle communication between the nurses and the family. Previous studies have identified nurse-family communication as an important aspect of family-centered care and have demonstrated that both staff and families perceive communication as a way to reduce emotional stress and promote trust between families and healthcare staff [2, 14]. This discussion situates the findings within the greater literature and offers applied recommendations on how to address identified patterns and practices of communication barriers.

The cultural expectation of patients’ families to participate in their care is highlighted in the study results in Jordan. Families see participation in decision-making as a cultural imperative and a moral duty and, therefore, expect to have unfettered access to information and regular updates. But such expectations are hard to reconcile with their professional duties, and that has left both sides frustrated. The literature backs these findings, showing how cultural values significantly affect perceptions of care and communication in ICUs [3, 7]. Unlike Western models, Jordanian families expect collective decision-making, complicating nurse-family dynamics [8]. Therefore, ICU nurses need structured communication protocols to manage expectations yet communicate ethically and efficiently.

Known as the primary family decision-maker, one of the biggest struggles ICU nurses face is finding out this information. Particularly in Jordanian society, extended families have a mutual role in taking care of patients, which explains the fact that you may find several family members looking for updates at different times. It creates confusion and additional work for nurses, who have to field questions from all of these individuals. These results are consistent with Scheunemann et al. (2019) [9], who detail the nuance around surrogate decision-making in the ICU. The idea of “next of kin” can be vague, and hospitals need to craft clearer policies about who should be consulted in decision-making. To face misunderstanding and make information dynamic, structured protocols in which an official family spokesperson is identified could be adopted [16].

Nurse-family interactions are mainly characterized by mistrust, the study shows, highlighting transparency issues and informational inconsistencies.

In a climate of uncertainty, family members who provide brief or vague updates are often seen as trying to withhold important information, which increases anxiety and leads to confrontations with healthcare workers. This observation aligns with previous research indicating that poor communication fosters feelings of neglect and undermines trust [12]. In addition, subjective differences between families and health professionals, both parties involved have different backgrounds and cultural practices, and understanding who they are all leads to strained communication between families and health professionals [20]. In establishing trust, we need to train ICU nurses on clear, empathetic communications and implement structured family meetings to ensure consistent information-sharing [14].

The study’s findings indicate that ICU nurses find less time to discuss patients’ concerns in detail with family members due to the substantial time constraints placed on them with high patient loads. This results in frustration for families who expect communication to be more direct and frequent. The challenge is well documented in the literature. Price et al. (2023) [15]  highlight that excessive workloads prevent nurses from spending adequate time with family members. Another study by Maharmeh et al. (2023) [3] conducted in Jordanian ICUs points out the extra burden imposed by administrative tasks. To tackle this issue, institutions should consider hiring more nurses and integrating communication needs into structured work practices. Nurses frequently face restrictions on communicating with families due to hospital policies and hierarchical structures. They often relay medical updates to physicians, which can result in delays and inconsistent communication.

Nurses are often restricted from talking with families due to hospital policies and hierarchical structures. Nurses often inform physicians of medical updates, leading to delays and disparate communication. In much of Jordanian hospitals, strict visitation policies only make it more difficult for families to get information. Othman et al. (2021) [4] point out that these kinds of rigid institutional hierarchies prevent effective communication in the ICU, supporting the necessity of nurse-led communication interventions. Studies show that giving nurses the freedom to provide medical updates can enhance the efficiency and clarity of information flow [16]. Structured nurse-family liaison roles may address deficiencies in communication and relieve nurses of some workload.

The study finds this is a lack of understanding, not always due to poor communication of medical updates through medical jargon. Many families of patients feel that they are outside the decision-making process because they don’t have the specialized knowledge to understand medical information correctly. Previous studies emphasize the necessity of using plain medical language to facilitate understanding for families [14]. Alarjeh et al., (2023) [19] pointed out that refugee families in Jordan confront even more difficulties due to language barriers and unfamiliarity with medical procedures. Utilizing visual aids, bilingual medical interpreters, and templated communication where feasible can improve understanding [20].

Strengths and limitations of the study

Highlighting the use of the Jordanian ICU context, an area lacking in the literature, is one of the major strengths of the study. The study adds important qualitative detail, including data from both nurses and family members, to what is known about barriers to effective communication. These insights are valuable for shaping culturally relevant interventions aimed at enhancing communication practices in CA-ICU settings. However, the study has its limitations. It was conducted in only a few hospitals, which may restrict the applicability of the findings to other health sectors in Jordan. Additionally, it was conducted in a single-country focus, Jordan, which might limit the study’s generalizability. In addition, the sample was recruited purposively, and the research depended on self-reported experiences, which could be subject to recall bias. Further studies should investigate communication difficulties in a more diverse range of healthcare facilities and employ mixed-methods strategies to verify findings.

Implications and recommendations

Several recommendations can be issued based on the study findings to improve communication between ICU nurses and family members in Jordan. Implement biweekly structured family meetings led by designated liaison nurses not only facilitate standardized communication approaches but also serve to update family members regularly, helping to alleviate confusion, reducing family distress and enhancing care adherence. Educating nurses about cultural competency and empathetic communication will strengthen the interaction between nurses and families. Fatigue and workload challenges are common barriers to the authentic engagement of nurses with families; support for nurses can include increasing institutional support (e.g., allocating sufficient staff and delegating tasks) that allows for meaningful interpersonal connections between families and nurses. Moreover, as an intervention that can be examined, using simple and clear language to replace medical terms by training the nurses, using visual media, and having interpreters are important approaches that can be done to improve family understanding. Finally, giving nurses a greater role in conveying medical updates would not only increase the efficiency of the sharing of information but would also strengthen the relationship between the nurse and the family by showing that the nurse has decision-making power.

Conclusion

There are cultural, systemic, and linguistic barriers that hinder effective communication in Jordanian ICUs. Overcoming such challenges cannot be achieved through a single solution. Instead, it should be through a combination of institutional reforms, communication training, and culturally sensitive practices. Nurse-family engagement can be strengthened through structured communication protocols as a novel approach to enhancing patient-centeredness, though Jordanian healthcare families seek such approaches.

Abbreviation

ICUs

Intensive care units

Author contributions

ARS: Conceptualization, Methodology, Formal analysis, Writing - original draft, Writing - review & editing, Project administration.ET: Formal analysis, Writing - original draft, Writing - review & editing, Project administration.HR: Formal analysis, Writing - original draft, Writing - review & editing, Project administration.HA: Formal analysis, Writing - original draft, Writing - review & editing, Project administration.GA: Formal analysis, Writing - original draft, Writing - review & editing, Project administration.WA: Formal analysis, Writing - original draft, Writing - review & editing, Project administration.RE: Formal analysis, Writing - original draft, Writing - review & editing, Project administration.ZA: Formal analysis, Writing - original draft, Writing - review & editing, Project administration.NA: Formal analysis, Writing - original draft, Writing - review & editing, Project administration.FRA: Formal analysis, Writing - original draft, Writing - review & editing, Project administration.

Funding

This research received no fund.

Data availability

Derived data supporting the findings of this study are available from the corresponding author on request.

Declarations

Ethics approval and consent to participate

This study has been contacted according to Declaration of Helsinki 1964. The title of the Ethics research approval from the Institutional Review Board (IRB) of Applied Science Private University (code: 5/4/2017), Amman, Jordan, and additional permission from the Ministry of Health.

Consent to participate

Each participant signed an informed consent before the participation in this study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.