Nurses' Perspectives on a Communication Model Between Providers and Mechanically Ventilated Patients in the Intensive Care Unit

ABSTRACT

Background

Communication with mechanically ventilated patients in intensive care is complex. Decades of research demonstrate that communication barriers are commonly experienced and one of the most challenging experiences during an intensive care stay. Support for the health care providers in these situations could be a model for communication, guiding the interaction.

Aim

The aim of this study was to examine critical care nurses' (CCNs') perspectives of the clinical relevance and applicability of a communication model for mechanically ventilated patients.

Study Design

Qualitative, explorative design in accordance with Im & Meleis' phases of development of situation‐specific theories. We conducted six focus group interviews with CCNs from Denmark, Norway and the United States, two in each country, lasting between 58 and 90 min. The interviews were analysed by a content analytic approach with both inductive and deductive phases.

Findings

Twenty‐nine CCNs participated in the focus group interviews. The main category was identified during the analysis, which was: ‘Relationship‐building as a starting point for meaningful communication’. The main category was further described by three subcategories: (1) Patients' abilities and challenges in communication while being mechanically ventilated. (2) Nurses' competencies and strategies for effective communication with mechanically ventilated patients and (3) Tools and resources in practice.

Conclusions

The nurses' perspectives yielded a deeper understanding of how clinical practice both corresponds to and departs from a theoretical lens. Given that the interviews with nurses revealed the relational component as a critical starting point of communication, the model should highlight this specific element more explicitly. To understand the complexity occurring in the daily practice of an ICU, a situation‐specific theory will be useful for providing examples of good practice.

Relevance to Clinical Practice

Communication in an ICU setting requires the establishment of a relationship to find effective ways to communicate. Integrating clinical perspectives can refine and adapt the preliminary model to the real communication encounters and improve care.

Impact Statements

• The preliminary communication model evaluated in this study by the nurses helps bridge a critical gap between theoretical understanding and clinical practice in intensive care.

• The findings highlight the provider‐patient relationship as essential for the establishment of efficient communication between mechanically ventilated patients and nurses.

• Further development of a situation‐specific theory, has the potential to support healthcare providers in their communication practices in intensive care units.

1. Introduction

When critically ill patients in the intensive care unit (ICU) require intubation and mechanical ventilation, they lose their ability to vocalize due to the inflated cuff obstructing airflow through the vocal cords. Although this voicelessness may be temporary, it can evoke anxiety, frustration, and hinder patient engagement in care and treatment decisions [1, 2, 3, 4]. Various methods have been explored to facilitate and ease communication, yet there remains no consensus on the most effective approach within this context [5, 6, 7]. Studies have also investigated the effects of introducing systematic training programmes and/or communication aids for the ICU healthcare providers [8, 9, 10]. Implementing communication aids and new methods for interaction can be challenging in the ICU setting, dominated by a biomedical paradigm focused on life‐saving measures [11]. Consequently, communication with mechanically ventilated ICU patients remains a significant challenge for patients, their families, and healthcare providers alike after years of research and development within the field [12].

Communication with mechanically ventilated patients is complex. Although multidisciplinary expert panels have proposed definitions for effective communication for mechanically ventilated patients [13] and a core outcome set [14], there is not an organizing theoretical model to integrate and guide research and practice in this area of nursing practice. Communication theories focus mainly on dialogue between two (or more) vocal persons, whereas in the context of a mechanically ventilated patient, one of the communication partners lacks the ability to express themselves verbally [15, 16]. The research in the ICU setting has until now mainly focused on the patient, the nurse or the family member's experience of communicating and how to ‘solve’ the communication challenges by introducing augmentative and alternative communication (AAC) [2, 6, 7, 8, 17]. However, a more systematic, theory‐driven inquiry into this field is needed. Theory‐driven research moves analysis beyond descriptive accounts to explain underlying mechanisms, causal pathways and conditions under which effects manifest [18]. Therefore, we previously conducted a concept analysis of communication with mechanically ventilated patients [16]. During the process, 39 different phrases used to describe the patient were identified, and 60 relevant concepts describing the communication itself. A conceptual map outlined ‘communication and interaction’, ‘documentation and evaluation’ and ‘systematic assessment’ as important elements in a preliminary model (see Figure 1). The findings clearly demonstrated that communication in this context constitutes a distinct and multifaceted clinical practice that differs fundamentally from communication with a person able to communicate verbally.

FIGURE 1.

Preliminary model of communication between patients and providers in intensive care units. Note: From “Communication with mechanically ventilated patients in intensive care units: A concept analysis” by Karlsen, M.M.W., Holm, A., Kvande, M.E., Dreyer, P., Tate, J. A., Heyn, L.G., & Happ, M.B., 2023, page 574 https://doi.org/10.1111/jan.15501. CC‐BY‐NC‐ND.

Refining and developing the preliminary model and integrating it into a situation‐specific theory, it is important to examine how it aligns with ICU practice and whether it captures the complexities nurses encounter in day‐to‐day communication with mechanically ventilated patients. Understanding these perspectives is crucial to ensure that the model is both conceptually robust and clinically relevant.

1.1. Aim

The aim of this study was to examine critical care nurses' (CCNs') clinical perspectives on the relevance and applicability of a communication model for mechanically ventilated patients.

2. Methods

2.1. Design

Im and Meleis [18] argue for an integrative approach when developing situation‐specific theories. This includes four suggested phases: (1) checking assumptions for theory development, (2) exploring the phenomenon through multiple sources, (3) theorizing and (4) reporting, sharing and validating. The current study is considered part of Phase 2. However, during this process, the exploration, conceptualization and theorizing in the suggested phases all happen simultaneously as the process evolves into a useful description of nursing practice in a situation‐specific theory [18]. The aim of the present study was not to develop a situation‐specific theory but to explore critical care nurses' perspectives on the preliminary model as part of the broader theory development process.

Situation‐specific theories are not universal theories applicable at any time or in any context. Rather, they must be clinically specific, reflect the context and ‘include blueprints for action’ unique for nursing practice (Im & Meleis, 2021, 50). Clinical involvement is important and can contribute to a stronger link between theory and practice [18]. Based on these assumptions, focus group interviews with CCNs were chosen as an initial step in the clinical involvement [19]. We fully recognize that communication with mechanically ventilated patients is interdisciplinary, involving many healthcare professionals. However, nurses are the receiver of most messages from patients, providing interface and liaison between patients and other healthcare professionals. The reporting of the study followed the consolidated criteria for reporting qualitative research (COREQ) guidelines [20].

2.2. Study Setting, Participants and Recruitment

In Denmark and Norway, participants were recruited from ICUs across four hospitals. In the United States, participants were recruited through the Acute Care Nurse Practitioner and a PhD programme at Ohio State University, practising in a variety of ICUs across the country.

Participants were recruited aiming to ensure variation in age, experience and in‐depth knowledge of the topic. Inclusion criteria for CCNs were as follows: (1) a minimum of 1 year of ICU experience, (2) employment in ICUs in Denmark, Norway or the United States. Thus, the inclusion criteria were broad to ensure a wide range of experiences and perspectives and were partly guided by a pragmatic approach that sought to include all eligible nurses interested in participating. At the same time, recruitment was informed by purposive sampling principles, aiming to include participants with diverse characteristics and experiences who could provide rich and relevant perspectives on the aim of the study [21]. The participating ICUs differed with regard to the number of ICU beds, annual patient admissions, room layout (single‐, double‐ and triple‐occupancy rooms), nurse–patient ratios and availability of communication aids, ensuring representation from a variety of clinical settings across the participating countries.

2.3. Data Collection

Focus group interviews were chosen, allowing for discussions in which participants could share their experiences through dialogue [19]. We conducted six focus groups between September 2023 and January 2024, two in each country. The focus group interviews were moderated by members of the research team, either face‐to‐face or via Zoom with cameras enabled, depending on logistical feasibility. The interviewers were all experienced in qualitative research. Only one had reduced familiarity with moderating a focus group interview before.

Participants received preparatory information and the published concept analysis paper [16] before the focus group interviews. During the focus groups, participants were introduced to the study, and some ground rules were established (e.g., confidentiality, no wrong answers or perspectives and equal opportunity to speak). The interviews were guided by a semi‐structured interview guide developed by the research team, which would bring forth encouraging perspectives on the clinical relevance of the model. It was structured according to Krueger and Casey's phases of introductory questions, key questions and closing questions—including clinical relevance and design of the preliminary model. Open‐ended questions were mostly chosen to create dialogue between the participants. We also encouraged sharing their experiences in relation to all types of ICU patients on mechanical ventilation, as they may experience different communication challenges. Details about the preparatory questions and interview are provided in File S1.

The interviews were audio‐recorded and transcribed verbatim; relevant notes (e.g., non‐verbal communication) were included in the transcription process. The interview questions were not pilot tested. The interviewers knew some participants from previous interactions (mostly work‐related or educational). When this occurred, we sought to ensure that the moderator was someone who did not know the participants when that was possible.

2.4. Data Analysis

A qualitative content analysis guided by Elo and Kyngäs [22] was performed. The analysis included both inductive and deductive phases as we sought openness to data while also addressing specific questions related to the model being evaluated. The analytical steps were as follows: (1) making sense of the data as a whole, (2) developing an analysis matrix, (3) gathering data by content, (4) categorization and (5) abstraction (15). The first and second steps were inductive and conducted by the first and last authors, who read the six interviews to gain a deeper understanding of the participants' experiences and opinions, leading to the development of an unconstrained matrix. The matrix consisted of eight overall subjects and was transformed into a coding tree in NVivo 15 [23]. Step 3 was deductive, and two authors (AA and AAA) collated relevant data from the interviews. The meaning was condensed and categorized (Step 4) into an overarching category and three subcategories which encompassed the overall meaning of all the findings in relation to the preliminary developed model (Step 5). During coding, openness to emerging categories and subcategories was maintained through an ongoing discussion among all the authors. The final categorization and abstraction of the findings were discussed in the entire research team to reach consensus. The first author (A) performed the initial analysis, but three other authors (AA, AAA and AAAA) also manually coded and condensed meaning units during the process to familiarize with the data and ensure trustworthiness.

As the researchers had worked within this field for many years, ongoing dialogue was important to challenge potential preconceptions and assumptions to maintain openness to the data. Although some researchers were more involved in the data analysis, others maintained greater distance from the analytical process and provided critical feedback on the preliminary findings. An example of the process is presented in Table 1.

TABLE 1.

Analytic process and abstraction of findings.

Quotes from participants	Condensed meaning	Subcategory	Category
‘The patient can be completely lucid and then not lucid at all—seeing things on the ceiling and picking at things—so there's a big gap between when he opens his eyes, when he wakes up and when he's perhaps mentally clear’. Nurse 5. Focus Group 1, Norway	Variation in abilities and possibilities to achieve meaningful communication	Patients' abilities and challenges in the communication while being mechanically ventilated	Relationship‐building as a starting point for meaningful communication
‘I think for a day or two, even before, and I finally, you know, on day two or three, gave them a clipboard. And they wrote out how they had no idea what was going on and they were scared. And so it nudged me to approach my practices from the standpoint of like then we'll take time to understand my patient’ Nurse 4, Focus Group 1, USA	Experiencing the value of practical tools in everyday practice	Nurses' competency and strategies for effective communication with mechanically ventilated patients
‘In some way it's kind of a comfort to me that… there is a reason why it doesn't always work out… so many things that can distract me, and there are so many things that influence each other. So it's so complex that … It's really nice to get a picture of the fact that… there is a reason why it is difficult’ Nurse 2, Focus Group 1, Denmark	The complexity of the communication with the mechanically ventilated patients	Tools and resources in practice

2.5. Ethical Considerations

The study followed the standards of the International Committee of Medical Journal editors [24], alongside the specific ethical regulations for each country and institution. Participants were informed both in written form and verbally and signed a consent form. Participation was voluntary, and all data were anonymized during transcription. Data were stored securely according to each country's regulations.

In Denmark and Norway, ICU management at the participating hospitals granted permission to recruit nurses for the study. The date for the approval in the US is the 3rd of July 2023. In Denmark, interview studies do not require ethical approval; however, the project was registered with the Central Denmark Region (no.: 1‐16‐02‐207‐23), responsible for data protection. In Norway, we obtained a data protection advisory opinion from the Norwegian agency for shared services in education and research (Ref. number: 380417) and approval from the two hospitals' data protection officers (Ref. number: 3184 and 23/12787). In the United States, the study was approved by The Ohio State University Institutional Review Board as an exempt study (no.: 2023E0572).

3. Findings

The focus groups lasted between 58 and 95 min, with a median of 82 min. In total, 29 CCNs participated in the interviews, including four men and 25 women aged 30–63 years, with 2–32 years of ICU experience. Table 2 shows additional demographic data. As the education in critical care nursing varies across the countries from hospital‐based education without a formal degree to a master's degree in critical care nursing, we specify this further in the explanation of the abbreviations in the table. We have also reported the highest number of education (PhD). The CCNs worked in both medical, surgical or general ICUs across the countries, ensuring a variety of experience with different types of ICU patients.

TABLE 2.

Demographic data.

Gender number	Age median (range)	Years of nurse experience median (range)	Years of ICU experience median (range)	Education(s) type and number	Current role in the ICU type and number	Communication course a ? number
DENMARK
Focus Group 1. Recruitment: A university hospital. Participation: face‐to‐face. Duration: 90 min
F: 7	42 (30–53)	18 (6–30)	15 (2–30)	RN: 1 CCRN: 6 MScN: 4	Clinical nurse: 3 Clinical and professional development nurse: 2 PhD student: 2	Yes: 6 No: 1
Focus Group 2: Recruitment: A regional hospital. Participation: face‐to‐face. Duration 80 min
F: 4	50 (50–52)	25.5 (25–28)	22.5 (15–25)	CCRN: 4 MScN: 3 PhD: 1	Clinical and professional development nurse: 1 Nurse leader: 1 Nurse coordinator: 1 Researcher: 1	Yes: 1 No: 3
NORWAY
Focus Group 1. Recruitment: A university hospital. Participation: face‐to‐face. Duration 84 min
F: 6 M: 1	56 (30–63)	32 (8–39)	23 (3–32)	CCRN: 3 MScN (ICU): 4	Clinical nurse: 6 Clinical and professional development nurse: 1	Yes: 1 No: 6
Focus Group 2. Recruitment: A university hospital. Participation: face‐to‐face. Duration 58 min
F: 3 M: 1	41.5 (32–49)	8.5 (8–17)	8.8 (3–16)	RN: 1 CCRN: 1 MScN (ICU): 2	Clinical nurse: 2 Clinical and professional development nurse: 1 PhD student and clinical nurse: 1	Yes: 0 No: 4
USA
Focus Group 1. Recruitment: An acute care nurse practitioner programme and a PhD programme at a university. Participation: Zoom. Duration: 95 min
F: 2 M: 1	35 (27–58)	13 (5–25)	7 (4–9)	CCRN: 2 Other: 1	Clinical Nurse: 3	No: 3
Focus Group 2. Recruitment: An acute care nurse practitioner programme and a PhD programme at a university. Participation: Zoom. Duration: 60 min
F: 3 M: 1	33 (27–40)	7.5 (5–8)	5 (5–7)	CCRN: 3 MScN: 3	Clinical nurse: 2 ACNP: 2	No: 4

Abbreviations: ACNP, Acute Care Nurse Practitioner (120 ECTS credits); CCRN, Critical Care Registered Nurse with postgraduate specialist education in critical care nursing; MScN (ICU), Master of Science in Critical Care Nursing (120 ECTS credits); MScN, Master of Science in Nursing (120 ECTS credits); PhD, Doctor of Philosophy; RN, Registered Nurse (highest degree reported; all CCRNs, MScNs and PhDs are also registered nurses).

^a Participated in a course concerning communication with mechanically ventilated patients.

Nurses shared perspectives on the model, and the main category identified was ‘Relationship‐building as a starting point for meaningful communication’. This was supported by three subcategories: (1) Patients' abilities and challenges in communication while being mechanically ventilated, (2) Nurses' competencies and strategies for effective communication with mechanically ventilated patients, and (3) Tools and resources in practice.

These findings are illustrated in Figure 2. The identified categories are asymmetrical in nature: the main category, shown in green, highlights relationship‐building as the starting point for meaningful communication. The two subcategories representing the communication partners (nurses and patients) are shown in blue, while the final subcategory, ‘tools and resources in practice’, described as enhancing and bridging interaction between the partners, is represented in peach.

FIGURE 2.

Figure representing the CCNs' perspectives on the preliminary model. *The model has an overarching theme in one green bubble: Relationship‐building as a starting point for meaningful communication. The three bubbles underneath, in the colour blue and peach, represent the sub‐themes.

3.1. Relationship‐Building as a Starting Point for Meaningful Communication

Although the model included a section on communication and interaction with a brief reference to the patient–provider relationship, nurses felt it did not adequately capture what they considered the starting point of meaningful communication. Relationship‐building based on empathy, acknowledgment and knowledge about the patient was described as essential for effective interactions and should occupy a far more central position in the model. The communication needed to be tailored to each patient's individual situation while fostering engagement and involvement. These findings indicated that the relational dimension was more fundamental than the model currently reflected.

To bridge communication barriers and enable meaningful interaction, attention, patience and the ability to establish a two‐way communication pattern were critical:

The relational aspect of it and the patience in figuring out how we create this, there's such a strong awareness that when we stand here, it truly requires something very special… But I think two important factors are patience and the relational aspect. (Nurse 3, Focus Group 1, Denmark)

The ICU environment is described in the model as challenging the nurses' possibilities to provide relational, humanistic care. Equipment, fast‐paced workflows and multiple personnel were described in the interviews as contributing to a sense of distance from patient and to an extent confirmed the preliminary model's description of the environment. Despite this, nurses emphasized recognizing patients' experiences and acknowledging their presence:

Knowing that patients hear you even though they're not responding to you… I remember a young gentleman who woke up or was extubated, and he remembered conversations. He felt like nobody was addressing him. They were just working around him… (Nurse 4, Focus Group 1, US)

Based on nurses' perspectives, useful refinements to the model would be to highlight the foundational role of trust, presence, continuity in the nurse–patient communication process and emphasize individualization. One‐size‐fits‐all approaches were not sufficient as strategies were needed to interact effectively with the patients.

3.2. Patients' Abilities and Challenges in Communication While Being Mechanically Ventilated

One element in the model was related to the systematic assessment of the patient's abilities to communicate. Assessing mechanically ventilated patients' communication abilities was described in the focus groups as a complex task, including evaluations of the level of sedation/consciousness, cognitive and motor abilities, sensory impairments, collaboration, emotional expressions, the ability to use communication aids and comfort:

I find it very challenging to effectively communicate with ventilated patients who have a cognitive disability, especially when they're on sedation. When they wake up, they're delirious or confused and have no idea what's going on. You almost have to start at zero each time. (Nurse 4, Focus Group 1, US)

The interviews illuminated the fact that ICU patients are not all similar patients with the same struggles. For example, patients admitted for longer periods were easier to communicate with, allowing nurses and patients to develop shared communication patterns. Nurses expressed compassion for the patient experience and emphasized the emotional consequences when patients were not understood:

Doing everything possible to ensure the patient has their needs met… the inability to be understood breaks them down instead of building them up. (Nurse 2, Focus Group 1, Norway)

Although the model emphasizes systematic assessment, the participants recognized the complexity and a need to tailor communication approaches to daily fluctuations in patient condition and particularly challenging situations, for example delirium. These findings indicate that communication ability is not a stable patient characteristic but a fluctuating clinical state requiring continuous assessment. Individuality therefore remained central, allowing for flexibility and variation in the approach towards the patients. These perspectives underscore that the model required clearer operational guidance to enhance its clinical applicability.

3.3. Nurses' Competencies and Strategies for Effective Communication With Mechanically Ventilated Patients

Effective communication required competence, confidence, collaboration and adequate tools. The nurses emphasized the need for training, mentorship and interdisciplinary support to achieve meaningful interaction and involve patients in their own care. Tailoring communication to each patient's condition and daily variations demanded clinical judgment, patience and emotional presence.

The persistence to remain engaged, even when communication was difficult, was essential to maintaining patient trust and safety. Nurses therefore drew on both technical skills and human sensitivity to achieve understanding with mechanically ventilated patients. The interviews revealed that the model did not provide an exhaustive list of different communication methods, strategies and techniques used in practice.

Verbal strategies mentioned included short sentences, closed questions, reality orientation or facilitating communication through blinking. Non‐verbal approaches, such as lip reading, interpreting gestures, adjusting tone, maintaining eye contact and providing reassurance, were considered equally important:

Sometimes I also ask, ‘Do you understand what I'm saying?’ or ‘Do you know where you are?’ And if I get a clear nod, I kind of feel like I've gotten through… Then I follow up with questions to check if they've understood. That's when I think I've achieved something concrete. (Nurse 1, Focus Group 1, Norway)

Experience, informal mentoring and team support were crucial for building the nurses' competence:

We all know who's really good at communicating with patients… I've learned to go to those people and ask, ‘Have you had this before? What worked for you?’ (Nurse 3, Focus Group 2, USA).

The preliminary model was framed within a patient‐centred approach in which persistence, patience, individual adaptation and attentiveness are essential skills. A reflective practice where experiences are shared and competency development occurs through learning from colleagues was also addressed in the interviews; however, this was not illustrated in the model.

Despite these strategies, nurses reported frustration and helplessness when communication broke down and highlighted the lack of formal training or structured guidance:

Just to outline the general principles of communication, not just the tools, but the communication itself… I think a lot of us could really benefit from that. (Nurse 7, Focus Group 1, Denmark).

Together, these findings indicate that effective communication relies not only on individual nurse competence but also on structured training, shared team knowledge and access to organizational resources that support communication in practice, which are not yet sufficiently articulated in the model.

3.4. Tools and Resources in Practice

The nurses described the need for both tools and resources to be able to communicate effectively with patients, which the preliminary model acknowledges but does not yet sufficiently align with available practical and accessible communication aids. Although communication aids were available in some of the ICUs, they were not used unless they were easily accessible and simple to employ:

It has to be very simple… only in the last few years have people used the communication board every day. (Nurse 4, Focus Group 1, Denmark).

Documentation and evaluation, essential elements in the model, were acknowledged as critical for continuity and for reducing patient frustration but were inconsistently applied:

I don't think I've ever documented how a patient communicates other than if I'm using a language interpreter. I'm shocked. I've never even considered that. (Nurse 4, Focus Group 2, USA).

The model was perceived as reflecting key aspects of communication with mechanically ventilated patients, but it was not immediately intuitive. Translating the model into daily ICU practice could therefore be challenging, with some noticing that it did not fully capture the complexity and interconnections inherent in real‐world communication, and was therefore more conceptual:

I actually believe it captures the phenomenon, but it perhaps doesn't show how complex and intertwined things really are, especially with communication. (Nurse 5, Focus Group 1, Denmark).

The visual elements of the model prompted reflection on the gap between ideal and actual practice experienced by nurses:

I asked, is this the ideal or the actual? The model reflects how communication should take place, but a typical ICU day might only have bits and pieces of this. (Nurse 4, Focus Group 1, USA).

Nurses recognized the model's potential as a reflective and educational tool, particularly for onboarding new staff, but emphasized that its practical application depended on additional support: clearer guidance, structured instructions and integration with practical methods (assessment algorithms, case examples and teaching). They highlighted the importance of linking the model to documentation practices, care planning and interdisciplinary collaboration (e.g., speech therapists) to ensure it could be operationalized in everyday ICU work. As one nurse noted

The interaction between staff and patient, the role of staff in creating good communication, I think that's missing here… We need ideas for what to do when communication breaks down, not just what to document. (Nurse 1, Focus Group 2, Denmark).

Overall, nurses valued the preliminary model's intent and relevance but emphasized the need for greater practical integration and operational guidance to support its use in everyday ICU practice.

4. Discussion

This is the first study, to our knowledge, to conduct cross‐national focus groups examining nurses' perspectives on a model of communication with mechanically ventilated patients, positioning the work as an important step in the iterative development of a situation‐specific theory [18]. By linking nurses' clinical perspectives with ongoing theory development, the study contributes both empirically grounded insights and conceptual direction for future model development and implementation.

4.1. The Model's Relevance and Clinical Applicability

By exploring a very specific phenomenon in depth, we have identified what the nurses find relevant in communication with mechanically ventilated patients and their perspectives on the preliminary communication model. Nurses generally perceived the model as clinically relevant and feasible, emphasizing that it addressed a recognized gap in patient–provider communication in critical care. The model was seen as a potentially valuable framework for supporting individualized communication strategies and for promoting reflection on nurses' own practices. This aligns with previous studies demonstrating that structured communication tools can strengthen nurses' confidence and competence in interacting with non‐verbal or mechanically ventilated patients [9, 25, 26].

The findings suggest that clinical applicability depends on contextual factors, such as organizational support, access to communication resources, opportunities for training and collaborative learning within the clinical team. Our findings, together with previous research [9, 10, 27], suggest that sustained improvements in communication may depend on systemic and educational initiatives in addition to individual motivation. Thus, although the preliminary model holds potential for enhancing communication quality, its adoption into practice is likely to require careful attention to institutional and contextual barriers. Taken together, these findings indicate that the preliminary model is conceptually relevant but not yet fully operationalized for routine use in clinical practice. The findings therefore highlight the importance of addressing organizational and educational factors when further developing and implementing the model.

As our work on the development of a situation‐specific theory began, other research has contributed to our current understanding of communication with mechanically ventilated patients. Zaga et al. [13, 28] have identified seven key elements of effective communication with critically ill patients through a consensus panel methodology: quantity, comprehension, rate, effort, duration, independence and satisfaction, and developed a measure of effective communication for intubated, nonvocal ICU patients [29]. In addition, Freeman‐Sanderson et al. [14] proposed a core intervention outcome data set for research. The preliminary model does not explicitly cover all these elements, nor did nurses specifically identify their absence. Practising nurses have broad experience in critical care nursing; however, they are not necessarily experts in best practice within the communication field. Nonetheless, mapping and incorporating these consensus outcomes to our findings suggests that ease or effort of communication, satisfaction and treatment involvement should be made more explicit within the preliminary model to strengthen its clinical utility.

4.2. Relationship‐Building as a Starting Point for Meaningful Communication

The main category, Relationship‐building, emphasizes that meaningful communication with mechanically ventilated patients begins with establishing trust, presence and mutual understanding. The nurses in this study described how relational aspects form the starting point for any subsequent communication, whether verbal, non‐verbal or aided by tools. This finding resonates with person‐centred care frameworks, where relational continuity and empathy are prerequisites for understanding patient needs and preferences [30], on which the preliminary model was also founded (Figure 1). Trust is fundamental to human relationships and is also defined as meaning ‘giving yourself to another’—relying on that person to care for you [31, 32]. The nurses emphasized that patients' trust in their healthcare providers also created a sense of responsibility.

In work beginning in the American Academy of Nursing's expert panel on acute and critical care, Curley et al.'s Blueprint for Change in Acute and Critical Care Nursing lists relationship‐building as one of the nine domains of acute‐critical care nursing practice [33]. Other domains relevant to the care of communication‐impaired patients include creating a healing environment, symptom identification and management. The expert work group calls for better outcome measures of nursing practice in these domains. The preliminary model, as it currently stands, is a holistic representation of how communication can be planned and individualized to each patient in the ICU, without going into depth regarding specific topics, such as symptom management. Our findings suggest that clinically challenging scenarios must be addressed for the preliminary model to guide communication in real‐world complexity. Incorporation of specifically challenging communication encounters in greater depth in a situation‐specific theory would therefore enhance the clinical applicability.

The nurses identified professional competence, clinical experience and to some extent creativity, as central to effective communication. They highlighted the need for ongoing training in communication techniques adapting to individual patients' abilities. These findings correspond with previous studies emphasizing that nurses' competence in augmentative and alternative communication (AAC) methods is critical for promoting patient participation and emotional safety [8]. We did not observe the nurse's communication practice. Inability to accurately identify patients' needs represents a potential threat to the patient's safety. Even getting the provider's attention can be a challenge for ICU patients [15], let alone trying to communicate their needs effectively [1, 15, 34]. A situation‐specific theory can provide practical examples of use and serve as a guide when planning pedagogical activities to increase the providers' competence in all types of communication aids as well as strengthen effective communication techniques.

Nurses acknowledged that patients' cognitive status, sedation level, fatigue and emotional distress often limited communication attempts, requiring patience and clinical sensitivity to recognize and adapt to fluctuating capacities. This awareness reflects a relational understanding of communication as a dynamic, co‐constructed process rather than a one‐way transfer of information, supported by prior research showing that communication abilities are heavily influenced by physical and emotional factors and that supportive nurse behaviours can mitigate frustration and isolation [2, 3]. As illustrated in Figure 2, the findings depict a dynamic nurse–patient process and the bridging role of tools and resources in increasing the likelihood of effective communication. Healthcare providers also carry a responsibility to use available tools and actively reduce patients' isolation associated with mechanical ventilation [1, 34]. Together these points support the need for a model that integrates relational, contextual and technical components into a coherent theoretical framework.

Finally, nurses underscored the importance of accessible and user‐friendly communication tools, such as picture boards, digital tablets and speech‐generating devices. Yet, they acknowledged that tools alone were insufficient without training and institutional facilitation. The integration of such resources into daily care routines is essential for consistency and effectiveness. This echoes previous findings that successful AAC implementation relies on both the availability of technology and the cultivation of a supportive communication culture within the ICU [2, 9, 12].

4.3. Strengths and Limitations

The interviews elicited rich descriptions from a significant number of participants working in various ICUs. We have sought to derive tentative propositions to improve the preliminary model and continue the development of a situation‐specific theory based on these findings. Despite the contextual differences between countries, shared experiences related to the care of mechanically ventilated patients were identified, thereby enhancing the transferability of the findings [19]. We also believe a strength of the study is the richness in the data regarding descriptions of various communication encounters from the nurses. This has further exemplified the complexity of the communication with a mechanically ventilated patient.

The two authors primarily responsible for the analytic phase were not present at all interviews, but the moderators documented and shared their reflections with the entire research group. Although all groups demonstrated active participation, it remains uncertain whether the dynamics of face‐to‐face interactions differed from those observed in the Zoom interviews [35].

The interviews were conducted in the participants' native languages, using a structured interview guide designed to ensure coverage of key topics. Nonetheless, variations in interview dynamics may have arisen due to differences in the moderators' skills. Cultural nuances, subtle distinctions in discussions and implicit codes of communication may have been particularly challenging to fully detect and capture in the analysis. Focus groups enable participants to discuss and reflect [19], and this sometimes resulted in deviations from the interview guide. However, this was interpreted as a sign of positive engagement from the participants and proved useful in the analytic phase.

Lastly, the research group members' preconceptions have been thoroughly discussed and reflected upon. Throughout the analytical process, findings and interpretations were discussed within the research group to challenge assumptions and explore alternative understandings of the data. We believe this reflective process has strengthened the trustworthiness of the findings. As experienced ICU nurses with knowledge about this topic, we might, however, have missed what seemed familiar or not gone into details about specific parts of the phenomena which could have been important [19].

4.4. Recommendations for Practice and Future Research

Concepts, models and theories can guide practice, ensure a unified standard of care, and establish measurable variables for testing interventions. Although every ICU patient has unique experiences, some core phenomena appear to be common across countries and centre on communication during mechanical ventilation. The same applies to nurses caring for these patients, sharing common experiences across countries. The findings suggest a need for initiatives that promote communication training, ensure availability of communication resources and integrate communication practice into ICU care standards.

This study combines knowledge embedded in clinical practice and theoretical perspectives on the phenomena communication with mechanically ventilated patients. The findings highlight the provider–patient relationship as essential for the establishment of effective communication and indicate that this dimension warrants further exploration. Further research should therefore focus on integrating the findings into a situation‐specific theory to refine important concepts and to test propositions and relationships in clinical contexts.

5. Conclusion

The nurses' perspectives provided a deeper understanding of how clinical practice both aligns with and diverges from the preliminary model. To better understand the ‘real‐world encounters’ in the ICU between mechanically ventilated patients and healthcare providers, a preliminary model can illuminate what constitutes good practice and which competencies are required for meaningful and effective communication. The findings further highlighted the importance of relationship‐building, training, organizational support and access to communication resources for the model's clinical applicability. The knowledge generated by this study may contribute to the ongoing refinement and operationalization of the preliminary model and inform the further development of a situation‐specific theory within this complex field.

Author Contributions

M.M.W.K., A.H., M.E.K., L.G.H., J.A.T., P.D. and M.B.H. made substantial contributions to conception and design or acquisition of data, or analysis and interpretation of data, involved in drafting the manuscript or revising it critically for important intellectual content, gave final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding

The authors have nothing to report.

Ethics Statement

The data utilized in the manuscript have been lawfully acquired in accordance with the Declaration of Helsinki and permissions to perform interviews were obtained in all three countries following the national regulations and participation was voluntary. In Denmark, the project was registered with the Central Denmark Region (no. 1‐16‐02‐207‐23). In Norway, we obtained a data protection advisory opinion from the Norwegian agency for shared services in education and research (Ref. number: 380417), as well as the two hospitals' data protection officers (Ref. numbers: 3184 and 23/12787) recommendation. In the United States, the study was approved by The Ohio State University Institutional Review Board as an exempt study (no.: 2023E0572).

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

File S1: Interview guide and question table for focus group interviews with critical care nurses on communication with mechanically ventilated patients and the preliminary communication model.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.