Table 3.

Identification of Multilevel Barriers to Communication

Level of Barrier to Communication	Manifestation	Nurse	Nurse Practitioner	Physician	Psycho-Social
Individual: Clinician Characteristics Factors related to clinicians	Lack of comfort with difficult topics
	Lack of competence or experience
	Numb or blunted response to family’s experience
	Personal beliefs or biases
	Need for boundaries
Individual: Family Characteristics Factors related to patients or families	Ability to understand and interpret information
	Expectations, desires, and demands
	Misperceptions of beliefs
	Disagreement within family
	Strong emotional responses
	Intimidation or embarrassment
	Lack of parental self-care
Individual: Clinician-Family Interactions Factors related to the clinician-family interaction or relationship	Cultural differences
	Personality mismatch
	Misunderstanding the other’s intentions
	Differing priorities
Team Inter-team or intra-team dynamics	Lack of shared team mental model
	Inconsistent information given to family
	Unclear roles and authority
	Complexity of teams in academic medicine
Organization Structures, norms, or processes governed by the hospital	Time pressure
	Problematic model of care
	Insufficient structural resources or personnel
Collaborating Hospital Structures, norms, or processes arising from a collaborating institution	Different standards of care
	Limited responsiveness
Community Characteristics of the social communities of families and patients	Alternative sources of information
	Perceptions of hospital in community
	Limited availability of cultural representatives
Policy Characteristics of the medico-legal system governing medical care	Insurance issues
	Medicolegal issues
	Excessive logistical requirements

Dark squares indicate providers who identified specified barrier