A systematic review and meta-synthesis examining the relationship between virtual communication and mental health outcomes of family members of intensive care unit patients

Abstract

Introduction

Effective communication between family members, intensive care unit (ICU) patients, and healthcare providers is essential for easing family member's distress. We sought to understand how virtual communication patterns between family members, ICU patients, and healthcare providers are related to the mental health outcomes of family members.

Methods

We systematically searched CINAHL and PubMed for peer-reviewed studies published between January 2015 and August 2024 that documented virtual communication with the family member of an adult ICU patient (e.g., phone calls, video calls) and used the family member's mental health as an outcome. Guided by the adapted Source, Channel, Message, Receiver, Outcome Model of Communication, quantitative mental health outcomes were categorized as “improved, neutral, or negative,” and qualitative study findings were synthesized into themes.

Results

Among 2,573 articles initially identified, 21 were selected for review. Phone and video calls were the most common communication modalities, and text messages were uncommon. Measured mental health outcomes included anxiety, depression, post-traumatic stress disorder, and stress or distress. Virtual communication was associated with either improved or no difference in measured mental health outcomes. However, meta-synthesis revealed two themes that suggest ways virtual communication can negatively influence emotions: (1) anxiety with variations in communication source, message, and frequency and (2) reassurance versus distress with communication modality.

Discussion

Promoting communication through virtual communication strategies may improve mental health outcomes or emotions experienced among family members of ICU patients. ICU healthcare providers should consider tailoring virtual communication modality and frequency to family members’ preferences.

Plain language summary

When a person is in the intensive care unit (ICU), it can be very stressful for family members—especially when they cannot visit or talk to the patient, doctors, or nurses in person. This study looked at how virtual communication, like phone calls, video calls, and text messages between families, patients, and ICU doctors and nurses, is related to the mental health of family members.

We reviewed 21 studies published between 2015 and 2024. These studies measured how virtual communication is related to family members’ mental health and emotional well-being. Most studies focused on anxiety, depression, post-traumatic stress disorder, or stress. For the studies that directly measured mental health, we found that virtual communication usually helped family members feel better or made no difference—none of the studies showed that virtual communication made mental health worse. However, some studies that interviewed family members showed that video calls could either reassure families or make them have negative emotions, such as feeling worried.

It is important for ICU doctors and nurses to ask families about their communication preferences. This way, they can adjust the type and frequency of virtual communication to support the mental health of family members of ICU patients.

Keywords

Surrogate decision maker family communication adult critical care mental health virtual care telehealth systematic review meta-synthesis

Introduction

Being the family member of a person hospitalized in the intensive care unit (ICU) is associated with adverse mental health outcomes including increased rates of anxiety, depression, and post-traumatic stress disorder (PTSD).^1–3 Effective communication between family members and ICU healthcare providers is known to ease family members’ stress, anxiety, and comfort with decisions.^4–6 Traditionally, most communication between ICU healthcare providers and family members occurs in-person, but can also occur via phone calls. A 2017 study of 14 Canadian ICUs found that 71.3% of families communicated with healthcare providers in-person, 15.4% of families communicated by phone, and 13.3% of families did not receive communication on the day the survey was administered.⁷

Virtual communication (VC) is any information exchange that occurs between two parties using communication technology, including but not limited to audio communication (e.g., phone calls), video communication (e.g., video calls), and text-based communication (e.g., text messages, emails, messages via healthcare portals). Family members may rely on VC when they are unable to visit the patient's bedside due to geographic distance, limited time off from work, other family duties, or limited transportation access.⁸ Limited ICU visiting hours were compounded during the COVID-19 pandemic by extensive visitor restrictions in hospitals,^9,10 broadly shifting in-person communication patterns to VC between in-hospital healthcare providers and out-of-hospital family members.^10,11

Three recent scoping reviews^12–14 and one integrative review¹⁵ examined altered family communication practices in the ICU during the COVID-19 pandemic. Common findings among these reviews were that phone calls and video calls were used to communicate with out-of-hospital family members.^12–15 All reviews noted that the mental health of family members was impacted by restricted visitation and altered communication practices^12–15; however, these reviews did not examine how specific aspects of VC, such as modality or frequency, impacted mental health outcomes of family members of ICU patients.

Given the body of evidence supporting communication as key in mitigating poor mental health outcomes among family members of ICU patients, and the continued reliance on VC modalities in the post-COVID-19 pandemic world, this review examines how aspects of VC between family members, ICU patients, and healthcare providers relate to family member' mental health outcomes.

Methods

Search strategy

The search strategy was developed in consultation with a library informaticist. We searched CINAHL and PubMed databases without restrictions to population or level of evidence. We limited to studies published between January 2015 and August 2024 to account for contemporary VC practices occurring 5 years before, during, and 1 year after the COVID-19 pandemic, which was declared over by the World Health Organization in May 2023. Our comprehensive search strategy used a combination of MeSH keywords and synonyms for ICU, family members, and VC (Table 1).

Table 1.

Search terms used.

Date of search	Search engine	Search terms	Retrieved citations
8/14/2024	PubMed	(“intensive care units"[MeSH Terms] OR “critical care"[MeSH Terms] OR “intensive care"[Title/Abstract:∼3] OR “critical care"[Title/Abstract:∼3] OR “ICU"[Title/Abstract]) AND (“Communication"[MeSH Terms] OR “Cell Phone Use"[MeSH Terms] OR “Cell Phone"[MeSH Terms] OR “Telemedicine"[MeSH Terms] OR “family meeting"[Title/Abstract:∼3] OR “family meetings"[Title/Abstract:∼3] OR “family conference"[Title/Abstract:∼3] OR “family conferences"[Title/Abstract:∼3] OR “virtual discussion"[Title/Abstract:∼3] OR “virtual discussions"[Title/Abstract:∼3] OR “virtual conversation"[Title/Abstract:∼3] OR “virtual conversations"[Title/Abstract:∼3] OR “video communication"[Title/Abstract:∼3] OR “video communications"[Title/Abstract:∼3] OR “video discussion"[Title/Abstract:∼3] OR “video discussions"[All Fields] OR “video conversation"[Title/Abstract:∼3] OR “video conversations"[All Fields] OR “phone communication"[Title/Abstract:∼3] OR “phone communications"[Title/Abstract:∼3] OR “phone discussion"[Title/Abstract:∼3] OR “phone discussions"[Title/Abstract:∼3] OR “phone conversation"[Title/Abstract:∼3] OR “phone conversations"[Title/Abstract:∼3] OR “Cell Phone"[Title/Abstract:∼3] OR “cellphone"[Title/Abstract] OR “cell phones"[Title/Abstract:∼3] OR “phone call"[Title/Abstract:∼3] OR “phone calls"[Title/Abstract:∼3] OR “audio call"[Title/Abstract:∼3] OR “audio calls"[Title/Abstract:∼3] OR “video call"[Title/Abstract:∼3] OR “video calls"[Title/Abstract:∼3] OR “zoom"[Title/Abstract] OR “facetime"[Title/Abstract] OR “skype"[Title/Abstract] OR “Telemedicine"[Title/Abstract]) AND (“Family"[MeSH Terms] OR “proxy"[MeSH Terms] OR “Family"[Title/Abstract] OR “decision maker"[Title/Abstract:∼3] OR “decision makers"[Title/Abstract:∼3] OR “healthcare proxY"[Title/Abstract:∼3] OR “healthcare proxies"[Title/Abstract:∼3] OR “health care proxy"[Title/Abstract:∼3] OR “health care proxies"[Title/Abstract:∼3] OR “prox"[Title/Abstract] OR “surrogate*"[Title/Abstract] OR “healthcare power of attorney"[Title/Abstract:∼3] OR “Health care power of attorney"[Title/Abstract:∼3]) AND 2015/01/01:2024/12/31[Date - Publication]	1206
8/14/2024	CINAHL	TI ((family N3 meeting) OR ((virtual OR video OR phone) N3 (conversation OR discussion* OR communicat))) AB ((family N3 meeting) OR ((virtual OR video OR phone) N3 (conversation* OR discussion* OR communicat*))) AND PUBYEAR > 2015	1367

Inclusion and exclusion criteria

Peer-reviewed quantitative, qualitative, and mixed methods studies were included if they (1) included adult family members of adult ICU patients, (2) reported at least one occurrence of VC with the family member (e.g., phone or video call, text-based messaging including email or patient portal messages), and (3) used family member's mental health as an outcome (e.g., anxiety, depression, PTSD, stress, distress).

Exclusion criteria included (1) non-English languages due to resource limitations, (2) non-peer-reviewed literature, and (3) simulated family-communication scenarios used to train healthcare providers. The main focus of this systematic review is VC; however, studies that included some in-person visitation (e.g., in-person updates, family meetings, or rounds) were not excluded if VC modalities were the primary communication strategy reported.

Article extraction and synthesis

All titles, abstracts, and full-text papers were reviewed independently by two reviewers (CMP, EP, MF, SK); disagreements were resolved by consensus among the reviewers.¹⁶ Results are reported according to the Preferred-Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram.¹⁷

The adapted Source, Message, Channel, Receiver, Outcome (SMCRO) Model of Communication (Figure 2) guided extraction. In the context of this review, the “source” is a communication partner in the ICU (e.g., healthcare provider or patient). The “message” is the words or information shared (e.g., updates on patient clinical status, test results). The “channel” includes communication frequency, duration, and modality (e.g., phone call, video call, text-based messaging, or in-person communication). The “receiver” is the family member of the critically ill patient (e.g., surrogate decision maker or other family member). Our adaptation adds a communication “outcome,” which is the family member's mental health. Communication broadly affects the emotions and mental well-being of a person,^4–6 meaning it is important to consider as a key outcome to study.

We extracted descriptive study data and summarized study findings¹⁸ relating to the Source, Message, Channel, and Outcome components of the SMCRO Model of Communication, as outlined above. For quantitative studies, we coded mental health outcomes resulting from communication as positive (indicating improved or positive association in mental health outcome), neutral (indicating no difference or change in mental health outcome), or negative (indicating worsened or negative association in mental health outcome). We used meta-synthesis¹⁹ of qualitative studies to identify themes related to family members’ mental health and emotional responses to using VC technologies in the ICU, and subsequently integrated these themes with each component of the SMCRO Model of Communication.

Results

The initial search resulted in 2,573 articles; 21 were extracted for this review (Figure 1).

Figure 1.

Prisma flow diagram.

Figure 2.

Modified SMCRO model of communication.

Study characteristics

Table 2 reports overall study characteristics. These articles included 10 quantitative studies (Table 3),^20–29 9 qualitative studies (Table 4),^30–38 and 2 mixed-methods studies (Table 5).^39,40 Quantitative studies included experimental (randomized controlled trials,^21,23,29 a quasi-experimental pilot study,²⁰ and an interventional study²²) and non-experimental methods (cross-sectional observational^24,25 and prospective observational studies^26,27). All qualitative studies were cross-sectional; the majority utilized semi-structured individual interviews for data collection (n = 6/9, 67%)^30,34–38 and used thematic analysis to describe findings (n = 7/9, 78%).^31–37

Table 2.

Study characteristics.

1st author, Year	Study methods	Country, study setting, population, data collection month(s), and year(s)	Study purpose, brief intervention description (for experimental quantitative studies)
Quantitative studies (n = 10)
Experimental quantitative studies
Chen, Sullivan et al. (2021)	A prospective, non-randomized two-group pretest- posttest quasi- experiment pilot study	United States Medical, surgical, neurological, and cardiac ICUs (n = 4) at an academic tertiary hospital Family surrogates (n = 21 in intervention group; n = 20 in control group) of adult ventilated patients October 2020–February 2021	To investigate the feasibility, acceptability, and preliminary efficacy of a nurse-led communication intervention among surrogates in the intensive care unit (ICU) guided by the COMFORT (Connect; Options; Making meaning; Family caregivers; Openings; Relating; Team) communication model. Intervention: The control group received phone calls from healthcare providers in the ICU. The intervention group received phone calls from a COMFORT-trained ICU nurse with content based on the COMFORT communication model. The COMFORT model is a validated, effective training method used by nurses to provide palliative care to critically ill patients and their family members, focusing on seven basic health communication principles: Connect, Options, Making meaning, Family caregivers, Openings, Relating, Team
Kentish-Barnes et al. (2024)	Randomized control trial	France ICUs (n = 5) at five university hospitals Family members who were the surrogate decision-maker (n = 202 in intervention group; n = 202 in control group) of an adult ICU patient (n = 1130) February 2020–January 2023	To assess an intervention to improve outcomes for patients’ family using nurse facilitators to support, model, and teach communication strategies that enable patients and families to secure care aligned with patients’ goals over an acute episode of illness, beginning in the ICU. Intervention: The control group received communication with ICU healthcare staff. The intervention group received communication from ICU healthcare staff and additional communication with an ICU communication facilitator nurse who received training to (1) improve family's feeling of self-efficacy in communication, (2) help the family reflect on impact of communication on quality of care, and (3) help the family members with skill-building to resolve barriers in communication
Makwana et al. (2022)	Prospective interventional study	India ICU (n = 1) at a tertiary hospital The immediate relatives of COVID-19 intubated patients, admitted in ICU for less than 7 days (N = 283) April–July 2021	To determine the effect of virtual communication on the anxiety of a relative whose specific patient was hospitalized and isolated in a tertiary care center. Intervention: The intervention was a video call between the family member and the ICU patient, with the family member's anxiety measured before and after the intervention
Shariati et al. (2021)	Single-blinded, multicenter parallel randomized controlled trial	Iran ICUs (n = 3) at three hospitals Adult family members (n = 33 in intervention group; n = 34 in control group) of patients with COVID-19 admitted to the ICU May–August 2020	To identify the effect of web-based communication between a nurse and a family member of a patient with COVID-19 in the ICU on the family member's stress Intervention: The control group received phone calls from ICU nurses regarding the patient's condition. The intervention group could choose to receive phone or video calls via WhatsApp from an ICU nurse
Yuan et al. (2023)	Parallel group single-blind randomized controlled trial	China ICU (n = 1) at a university hospital Family members (n = 50 in intervention group; n = 48 in control group) of an ICU patient March–November 2020	To examine the effect of video visitation on patients’ anxiety and depression, the incidence of delirium, family's anxiety, and patients’ and family members’ satisfaction with visitation during the COVID-19 pandemic Intervention: The control group received phone calls from an ICU nurse regarding the patient's condition. The intervention group received video calls via WeChat from an ICU nurse, with an option to also use the video calls to communicate with the ICU patient
Observational quantitative studies
Fortunatti et al. (2023)	Exploratory cross-sectional observational study	Chile Medical–surgical ICU (n = 1) in a private teaching hospital Adult family members of critically ill patients (n = 42) November 2020–May 2021	To investigate the relationship between satisfaction with communication and perceived stress, depressive symptoms, and perceived social support among family members of critically ill
Galazzi et al. (2023)	Cross-sectional observational study	Italy ICUs (n = 6) in an urban academic medical center ICU patients who died of COVID-19 related causes (n = 70) and their family members (n = 56) February 2021	To describe end-of-life care for COVID-19 patients dying in an ICU. The secondary aim was to explore whether making video calls and allowing visits were associated with lower death-related stress in family members
Gorman et al. (2020)	Prospective observational study	Australia ICU (n = 1) at an urban university hospital Family members (n = 156) of postoperative cardiac surgery patients in the ICU (n = 91) Not reported	To test two key hypotheses: first, that we could efficiently deliver real-time SMS updates to families during their family member's stay in ICU, and second, that these SMS updates would be accepted and welcomed by these families
Kebapcı et al. (2021)	Prospective observational study	Turkey ICU (n = 1) at a university hospital Relatives (n = 50) of adult ICU patients (n = 50) with a COVID-19 diagnosis and receiving respiratory support (high flow nasal cannula, non-invasive mechanical ventilation, or invasive mechanical ventilation support) July–December 2020	To evaluate anxiety immediately before and after structured Virtual Patient Visits by using a Visual Analogue Scale and to evaluate family anxiety, depression, and satisfaction on admission and at discharge
Rose et al. (2022)	Prospective observational study	United Kingdom ICUs from 37 hospitals Family members who experienced at least one virtual visit in an adult UK ICU (n = 2166) December 2020–May 2021	To evaluate family members’ markers of psychological well-being prior to and following their first virtual ICU visit and subsequent virtual visits and to measure the prevalence of depression anxiety and stress using validated measures
Qualitative studies (n = 9)
Bernild et al. (2021)	Data collection: Semi-structured individual interviews Analysis strategy: Reflexive content analysis	Denmark ICUs not described Family members of ICU patients across three regions of Denmark (n = 12) March–May 2020	To explore and understand how communication with healthcare professionals was experienced by family members to patients admitted to intensive care units with COVID-19
Chen, Wittenberg et al. (2021)	Data collection: In-depth, individual interviews Analysis strategy: thematic analysis	United States Medical ICU (n = 1) at an academic tertiary hospital Family members (n = 10) of patients with COVID-19 who is on a ventilator May–August 2020	To explore the experiences and support needs of family members of ventilated COVID-19 patients in the intensive care unit
Forsberg et al. (2024)	Design: Qualitative description Data collection: semi-structured focus group interviews Analysis strategy: Thematic content analysis	Sweden Medical ICU (n = 1) and surgical ICU (n = 1) at a regional country hospital Focus groups (n = 5) of family members (n = 14) of medical and surgical ICU patients March–July 2020	To describe how family members of critically ill patients experienced the COVID-19 visiting restrictions in Sweden
Fritz et al. (2021)	Data collection: Open-ended survey questions Analysis strategy: Thematic content analysis	France ICU (n = 1) in an urban university hospital Surrogate decision makers (N = 26), other family members (N = 21), of ICU patients requiring mechanical ventilation and sedation April 2020	To use a qualitative approach to describe the perceptions of patients’ families and health care providers of the practice of using a single daily telephone call for communication in the context of the COVID-19 pandemic
Greenberg et al. (2022)	Data collection: Qualitative semi-structured individual interview Analysis strategy: thematic content analysis	United States ICUs (n = 2) in an urban academic medical center Surrogate decision makers of ICU patients (n = 62) March–June 2020	The purpose of this study was to examine challenges experienced by surrogates of patients with COVID-19
Hochendoner et al. (2022)	Design: Descriptive phenomenology Data collection: Qualitative semi-structured interviews Analysis strategy: thematic analysis	United States Not described Family members of patients admitted to the ICU with COVID-19 (n = 74); recruited across 10 sites in four states February–June 2020	To qualitatively explore the experiences of family members of patients admitted to the ICU during times of strict visitation restriction to more fully understand the ramifications of physical distancing and develop recommendations to guide clinicians in supporting these families
Jungestrand et al. (2023)	Data collection: semi-structured individual interviews Analysis strategy: thematic analysis	Sweden General ICU (n = 1) at a regional university hospital Family members of ICU patients (n = 21) December 2020–June 2021	To explore the experience of in-person visiting restrictions imposed during the pandemic on family members of patients with COVID-19 admitted to an intensive care unit
Krewulack et al. (2022)	Data collection: semi-structured individual interviews Analysis strategy: thematic analysis	Canada ICU not specified ICU patients (n = 3); Family members of ICU patients (n = 8), ICU nurses (n = 17), ICU physicians (n = 13); recruited through social media and not associated with specific hospital July–October 2020	To describe the impact of restricted visitation policies on communication and to identify strategies that could be used to facilitate better communication within Canadian ICUs from the perspective of those affected
Sasangohar et al. (2020)	Data collection: semi-structured individual interviews Analysis strategy: sentiment analysis	United States ICU (n = 1) in one tertiary academic medical center Family members of ICU patients (n = 230) April 2020	To document and understand the barriers, challenges, concerns, feelings, and opportunities that family members of ICU patients have when using virtual-ICU technology to virtually visit an ICU patient during the COVID-19 pandemic
Mixed methods studies (n = 2)
Lopez-Soto et al. (2021)	Mixed methods (retrospective cohort study + qualitative interviews)	United Kingdom ICU (n = 1) in a tertiary urban hospital Family members and friends (n = 134) of patients admitted to the ICU for >7 days with COVID (n = 172) March–June 2020	To assess the impact of the FLT on the communication with patients’ family and friends (PFF), especially around end-of-life care, and their interaction with critical care clinicians
Zante et al. (2022)	Nonblinded, single-center, nonrandomized, prospective mixed-methods	Switzerland ICU (n = 1) in a tertiary academic medical center Adult relatives (n = 52) of ICU patients March 2020–February 2021	To utilize a convenience sample of relatives with technology available at home to use video calls (Video Call Group = VCG) or no technology available for video calls (Standard Care Group = SCG) to assess for differences in PTSD symptoms at 3 months

Table 3.

Communication findings—quantitative studies (n = 10).

1st author, year	Source	Message	Channel		Outcome
1st author, year	Source	Message	Modality	Frequency and duration	Measure	Results
Experimental quantitative studies
Chen, Sullivan et al. (2021)	Control group: Communication from healthcare providers in the ICU Intervention group: Communication from COMFORT- trained ICU nurses	Not reported	Phone calls	Daily 20-min	Hospital Anxiety and Depression Scale (HADS)	HADS scores: – Unadjusted analyses did NOT demonstrate significant change in total anxiety/depression score by treatment group (difference, 3.37 points [95% CI, .1.25 to 7.99 points]; P = .153). – Anxiety/depression scores increased more for the surrogates in the intervention group than in the control group, although adjusted analyses* did NOT demonstrate differences between groups on the rate of change in anxiety/depression scores across time points.
Kentish-Barnes et al. (2024)	Control group: Open visitation with patient; communication with ICU healthcare staff and social worker/psychologist on request Intervention group: Communication with those listed in the control group, and ICU communication facilitator nurses	Not reported	Control group: In-person visitation (except during pandemic) Intervention Group: In-person visitation, phone calls, video- conferencing, text messages	Control group: Visitation frequency and duration not reported. Intervention Group: Contact at least every 48 h while in ICU. Communication duration not reported.	Hospital Anxiety and Depression Scale (HADS) Impact of Events Scale-6 (IES-6)	HADS scores: – No significant difference between the intervention and control groups in evolution of symptoms of depression over 6 months (P = 0.91), nor in symptoms of depression at 6 months [0.53 (95% CI—0.48; 1.55)]. – Both groups had similar global anxiety/depression scores and anxiety subscores, showing no effect of the intervention on psychological burden. IES-6 Scores: – Both groups had similar PTSD scores, showing no effect of the intervention on psychological burden.
Makwana et al. (2022)	Communication with ICU patient	Not reported	Video calls	Communication frequency and duration not reported	Hamilton Anxiety Scale (HAM-A)	– There was a significant decrease in the anxiety score after audio-visual communication (2.88 ± 2.34) than before the communication (4.77 ± 3.66) (P-value <.001) – Comparing anxiety scores before and after the video call showed that prevalence of anxiety decreased post communication. Mild to moderate anxiety prevalence decreased from 197 (69.71%) to 131 (46.27%), and moderate to severe anxiety prevalence decreased from 14 (4.93%) to 11 (3.81%).
Shariati et al. (2021)	Communication from ICU nurses	Not reported	Control group: Phone calls Intervention Group: Audio- and video- calls (via WhatsApp)	Daily 10–15 min	Perceived Stress Scale-14 (PSS-14)	PSS-14 scores: – Before the intervention, mean and standard deviation of perceived stress scores between the two groups were not significantly different (P = .26). – After the intervention, the mean perceived stress score in the intervention group was significantly lower than that of the control group (P < .001). – After the intervention, the mean perceived stress score in the control group was higher compared to before the intervention, although this increase was not statistically significant (P = .062).
Yuan et al. (2023)	Control group: Communication from ICU nurse Intervention group: Communication from ICU nurse and patient	Not reported	Control group: Phone calls Intervention Group: Video calls (via WeChat)	Daily 5–30 min	Self-Rating Anxiety Scale (SAS)	SAS scores: – At baseline, there were no statistically significant differences in anxiety score between the control [mean = 31.95 (SD ± 7.75)] and intervention group [mean = 34.10 (SD ± 8.99)]. – After the intervention, there were no statistically significant differences in anxiety (t = 0.496, P = .621) between the control group [mean = 31.58 (SD ± 7.67)] and the intervention group [mean = 32.40 (SD ± 8.58)]
Observational quantitative studies
Fortunatti et al. (2023)	Communication from the ICU physician (at least once via a phone call), liaison nurse and ICU patient (via video calls), and other interprofessional ICU team members including bedside nurse, physical therapist, and occupational therapist (via phone or video calls)	Not reported	Phone calls, ideo calls	“Sporadic” 5 min (median length, with IQR 5 min)	Patient Health Questionnaire-9 (PHQ-9) Perceived Stress Scale-10 (PSS-10)	PHQ-9 scores: – Median depression score revealed mild depressive symptoms (median = 9, IQR = 8) – Spearman's correlation revealed a weak negative correlation between depressive symptoms and number of communication events (rs = -0.014) or length of communication events (rs = -0.102). PSS-10 scores: – Perceived stress score revealed moderate stress (median = 16, IQR = 5.2) – Spearman's correlation revealed a weak positive correlation between perceived stress and number of communication (rs = 0.156) events or length of communication events (rs = 0.089).
Galazzi et al. (2023)	Communication with consulting physician (phone calls), other ICU physician or ICU nurse and ICU patient (video calls)	Not reported	Phone calls, Video calls, In-person visitation	Daily (phone calls) Periodically for specific clinical events, e.g., worsening condition, death (phone calls) Sporadic (video calls) Under special circumstances (in-person visits)	Impact of Events Scale-Revised (IES-R)	Descriptive statistics: – Over one-third of family members (n = 21/56, 37.5%) requested hospital-provided or private psychological support. – Nearly all family members who made a video call (n = 27/28, 94.6%) said they would have done it again. – Nearly all family members who did not make a video call (n = 26/28, 92.9%) said they wished they had. IES-R scores: – A high PTSD score of ≥ 33 was found among approximately half of all adult children (n = 13/25, 52%) and nearly all spouses (n = 20/22, 90.9%). – The fitted model showed no statistical association between PTSD score and making an ICU visit or a video call (OR 0.93, 95% CI 0.24 to 3.65).
Gorman et al. (2020)	Communication from ICU nurse and/or ICU ward clerk	Not reported	SMS messages (via sendQuick)	“Periodic” messages sent for specific events (e.g., ICU admission, extubation)	Questionnaire including item about anxiety (non-validated instrument)	Descriptive statistics: – All family members surveyed either agreed (n = 47, 41%) or strongly agreed (n = 67, 59%) that the SMS services were reassuring. – Almost all family members disagreed (n = 82, 72%) or strongly disagreed (n = 31, 27%) that the SMS service made them feel anxious.
Kebapcı et al. (2021)	Communication with research nurse and ICU patient	Not reported	Video calls (via Zoom, FaceTime, WhatsApp)	Daily 5–10 min	Visual Analogue Scale for Anxiety (VAS-A) Hospital Anxiety and Depression Scale (HADS)	VAS-A score – Comparing anxiety scores before and after video calls, patient's relatives’ anxiety levels decreased significantly, from a mean of 5.70 to 3.53 (P < .001). – Comparing the anxiety scores of patient's relatives before and after video calls for different respiratory-subgroups (patients supported with basic face mask or high-flow nasal cannula, non-invasive mechanical ventilation, and invasive mechanical ventilation), there was a statistically significant decrease in the anxiety levels (P < .001). HADS Score: – The hospital-anxiety level of the patients’ relatives was statistically significantly lower after the patient's discharge/death than during the patient's ICU admission (P = .03) – The hospital-depression level of the patient's relatives had no significant difference (P = .21) after the patient's discharge/death versus during the patient's ICU admission. – Among relatives of patients who died versus did not die in the ICU, there was a statistically lower hospital-anxiety score among relatives of patients who did not die (P < .001), and no statistically significant difference between groups in hospital-depression scores (P = .394).
Rose et al. (2022)	Communication with ICU patient	Not reported	Video Calls (via app aTouchAway)	At least one virtual visit Communication duration not reported.	Depression, Anxiety and Stress Scale (DASS-21) Distress thermometer (DT) Discrete Emotions Questionnaire (DEQ)	DASS-21 scores: (measured once, immediately after the first virtual visit) – At baseline, family members’ median total depression, anxiety, and stress score was 18 (IQR = 2–42), indicating “mild” distress. – At baseline, 14% (n = 246/2166) family members had depression and anxiety scores greater than ≥ 60, indicating severe- to extremely-severe depression, anxiety, or stress and suggested a need for further psychiatric assessment. DT scores: – Prior to the first virtual visit, distress scores revealed family members felt “severe distress” (median = 7/10, SD 2.6). – Family members who had a second virtual visit (35%, n = 762/2153) had a significantly lower mean distress score of 5.4/10 (SD = 3.1) compared to baseline (P < .001). – The mean distress score for family members providing repeated ratings after the first virtual ICU visit was even lower, at 4.7/10 (SD = 2.8). – Among family members who provided two or more scores, the proportion of distress scores reflecting severe distress (≥7) continued to decrease over time (over duration of visits #2–10). DEQ Scores: – The most common emotion endorsed was feeling reassured (30% of family members endorsed feeling reassured “very much” or “an extreme amount”). – The second most common emotion endorsed was feeling sadness (28% of family members endorsed feeling sadness “very much” or “an extreme amount”). – The least common emotion endorsed was feeling angry (74% of family members endorsed feeling angry “not at all”). – The second least commonly experienced emotion was feeling fearful (38% of family members endorsed feeling fearful “not at all”)

Table 4.

Communication findings—qualitative studies (n = 9).

First author and year	Source	Message	Channel		Outcome
First author and year	Source	Message	Modality	Frequency and duration	Theme	Quotes
Bernild et al. (2021)	– Medically stable ICU patients (phone calls) – Healthcare providers in the ICU (phone calls and video calls)	– Not reported.	– Phone calls – Video calls (FaceTime)	– Phone call frequency was “arbitrary.” – Duration not reported	Theme 1: Anxiety with variations in communication source, message, and frequency – Family members felt scared with the uncertainty the type of update they would receive during a phone call with the healthcare team. Theme 2: not present	“Every time the phone rang, we were scared to death. Our nerves and adrenaline were running at high pressure for three weeks in a row, and we just sat waiting for them to call, and then when they did actually call, we were very scared”
Chen, Wittenberg et al. (2021)	– Healthcare providers (phone calls and video calls) – ICU patients (video calls)	– Family members felt frustrated by unclear communication with medical jargon. – Family members reported that timely and regular care updates and face-to-face visits would improve how informed they felt about COVID-19 care and treatment	– Phone calls – Video calls	– Frequency and duration not reported	Theme 1: Anxiety with variations in communication source, message, and frequency – Participants desired consistent, daily updates through different modalities including phone calls, text messages, online patient portal. Theme 2: Reassurance versus distress with communication modality – Video calls also were desired by some to feel connected to the patient, but also evoked feelings of stress and discomfort if the patient was unconscious or connected to machines.	“It was not necessarily a positive or pleasant experience. People were saying you feel so much better because you will be able to see him. I did not find that and I did not get any comfort from it.”
Forsberg et al. (2024)	– ICU patients (video visits) – Healthcare providers (phone calls) – In a few cases, relatives were permitted to visit patients if death was imminent (in-person visitation).	– Frequent communication with the healthcare team through daily phone calls helped families feel involved and reduced anxiety	– Phone calls – Video visits (and other “digital solutions”) – In-person visitation	– Sporadically (video-visit) – Rarely (in-person visits) – Duration not reported	Theme 1: Anxiety with variations in communication source, message, and frequency – It was difficult for family members to not know when phone calls from the healthcare team would occur, and they experienced worry if a phone call did not occur at the expected time. – Family members also avoided calling the healthcare team because they did not want to burden staff Theme 2: Reassurance versus distress with communication modality – Family members struggled with the uncertainty of whether their loved one's condition was worsening because they could not witness it directly.	"You wait for the phone to ring, but once it rings, it triggers my feelings and I become very worried”
Fritz et al. (2021)	– Communication with ICU healthcare providers	– Not reported.	– Phone calls	– Daily – Duration not reported	Theme 1: Anxiety with variations in communication source, message, and frequency – Some family members expressed anxiety with waiting for phone calls (19% of SDMs and 24% of other family members) – Some family members shared that the communication strategy of phone calls was reassuring (35% of SDMs and 33% of other family members) Theme 2: not present	Not applicable - the authors of this paper did not include qualitative quotes in their manuscript.
Greenberg et al. (2022)	– ICU healthcare providers (phone calls) – Patient's ICU nurse (video calls) – ICU patient (video calls)	– Not reported.	– Phone calls – Video calls	– Daily (phone calls) – Sporadic (additional communication for changes in patient's clinical status or procedural consent) – Intermittent (video-calls)	Theme 1: Anxiety with variations in communication source, message, and frequency – It was difficult for family members to wait for updates on their loved one and felt worried if the update was delayed – Family members also did not want to call providers too frequently and disrupt staff Theme 2: Reassurance versus distress with communication modality – Video calls helped to alleviate the stress of not being able to visit – Not being able witness care caused fear that the condition was worsening	“I think that the video [calls] really, really helped me because I felt like my mother could hear us, you know, and then I think that that's what caused her to want to fight and to try to [get] better.”
Hochendoner et al. (2022)	– Healthcare providers (phone calls, video calls) – ICU patients (video calls)	– Goals of care conversations – Updates from healthcare providers	– Daily phone call from provider – Video- conferencing	– Daily (phone calls)	Theme 1: Anxiety with variations in communication source, message, and frequency – Family members felt stress and anxiety waiting for phone calls and wanted a more consistent update schedule Theme 2: Reassurance versus distress with communication modality – Not being able to see care made family members feel alienated from care and led to feelings of distrust with providers – Video calls fostered feelings of togetherness with their loved one, reassurance in care, reduced stress, and facilitated a personal connection with the healthcare providers – Video calls also had challenges including stress seeing their loved one on life support, inefficiencies, and inconvenience. Family members recommended that with videoconferencing, providers prepared the family for what they would see on the video call. – Approximately one-third of the participants found videoconferencing to have more barriers or more stressful	“It was difficult for [the doctors] to give you a time of when they would call…some days they would call at noon and other days they would call at 3:00 P.M….your nerves get a little off when they still haven’t called and you’re waiting and stressing out over when they’re gonna call.”
Jungestrand et al. (2023)	– ICU nurses (phone calls) – ICU physicians	– Some family members felt their information needs were not met and did not feel included in care, leading to feeling powerless and hopelessness – family members wanted comprehensible and frequent communication on the patient's condition (ex. daily email updates)	– Phone calls – Video calls – In-person visits – Pre-recorded MP3 messages from the family members played for the patient by ICU staff	– Daily (phone calls)	Theme 1: Anxiety with variations in communication source, message, and frequency – Family members were reassured that were told to call anytime but perceived a lack of an ICU contact person – Waiting for a phone call was difficult for family members – Phone calls were a “lifeline” Theme 2: Reassurance versus distress with communication modality – Phone and video calls could not replace in-person visitation and restrictions led to reported uncertainty and psychological distress – Family members appreciated seeing their loved one via video call, but felt the patient may not benefit if sedated/intubated and caused feelings of sadness and worry if the patient was in poor health	“But this daily information that we received via phone calls from the family contact person, that information was, it has been incredibly good. I really, really appreciated it as a daughter […] we call after [hours] and so did they. They were very flexible, and I appreciated that”
Krewulack et al. (2022)	– ICU healthcare providers, ICU patients, family members	– Not reported	– Phone calls – Video calls – In-person meetings	– Not reported	Theme 1: Anxiety with variations in communication source, message, and frequency – Not receiving regular updates/not being able to get in contact with someone led to family members feeling worried and panicked Theme 2: Reassurance versus distress with communication modality – Not being able to see the care directly was troublesome for families as they could not be reassured that their loved one received the care they wanted, such as not dying alone	“Because we weren’t allowed ourselves in there, we have no assurance that that was actually done for every person that needed it or should have had some sort of somebody there so that they knew that they didn’t die alone…We have no assurance that that was actually done. Obviously, there's no video of it.”
Sasangohar et al. (2020)	– ICU patient, ICU nurse	– Not reported	– Video calls	– Frequency not reported. – 30 min (on average)	Theme 1: Anxiety with variations in communication source, message, and frequency – Several family members expressed frustration at not being able to speak with their loved one at an appointed time – Half of the family members desired on-demand access to the technology to initiate calls, as seeing and hearing their loved one brought “peace of mind” Theme 2: Reassurance versus distress with communication modality – Most family members expressed feelings of happiness, joy, gratitude and relief to be able to visit their loved one in the ICU, and felt it brought a sense of closure. – Some family members expressed feelings of sadness at seeing their family member intubated. – Some family members expressed resentment at being unable to physically touch or be present with their loved one, as video visits were “not the same.”	“So grateful that our whole family and close friends (17 family & friends) had the chance to gather and be united before they unplug all the lines and tubes for our loved one. We were able to pray, cry and sing together. It was really emotional and difficult especially with the current crisis we are all experiencing but we still feel peace and we are grateful that we were able to do this for the last time before he leaves us. He meant a lot to all of us and it pains us to let him go, but we have to.”

Table 5.

Communication findings—mixed methods studies (n = 2).

First author and year	Communication source	Communication message	Communication channel		Communication outcome
First author and year	Communication source	Communication message	Modality	Frequency and duration	Measure	Results
Lopez-Soto et al. (2021)	ICU patient and Family Liaison Team member (non-ICU healthcare professionals who volunteered to facilitate family communication)	- Receiving relevant and clear information regarding the patient's condition and the care they received was a way that patient friends and family felt connected to their loved ones	Phone calls and video calls	Daily	Quantitative mental health measures were not used. Qualitative descriptions of emotions and experiences were reported.	Quantitative results: - No quantitative mental health measures were used. Qualitative results: Theme 1: Anxiety with variations in communication source, message, and frequency - Most patient friends and family last saw their loved one slightly breathless; not being able to witness patient decline fostered feelings of disbelief, anger, unreality, frustration, and from one patient friend and family - suspicion of foul play - when told the patient was at the end of life. Theme 2: Reassurance versus distress with communication modality - The ability to see their relatives and friends with the help of a video call gave an opportunity to reconnect and feel as part of the patient's care, as they would have before the implementation of the visiting restrictions.” One patient friend/family called the video a “lifeline.” Quote: “They kept telling us he was stable. . . then they called us to tell us he was dead (. . .) how is this possible?”
Zante et al. (2022)	Not reported	– Updates about transitioning in and out of ICU, some families felt that there were “too many contacts” to keep track of	Control group: In-person visits and phone calls Intervention group: In-person visits and video calls Note on visits: In 1st wave of the pandemic, visits were only allowed at end-of-life. In 2nd wave of pandemic, visitation was allowed but restricted to one relative per day for a 1-h visit	Not reported	Impact of Events Scale—Revised (IES-R) Qualitative descriptions of emotions and experiences were reported.	Quantitative results: – No significant differences in PTSD were found between the Video Call Group and the Standard Care Group. Qualitative results: Theme 1: Not present Theme 2: Reassurance versus distress with communication modality – Family members noted that video calls reduced feelings of helplessness and increased feelings of greater closeness to the patient after/during the video call. – Some relatives expressed they were saddened or distressed at the sight of their loved ones in the ICU during the video calls. One relative suggested preparing relatives in advance of the video call by describing what kinds of treatments ICU patient is undergoing (e.g., intubation, extracorporeal membrane oxygenation) before the video call image shows the patient. Quote: “Seeing the patient creates closeness, it makes things easier.”

All included studies were published after 2020; studies before 2020 did not meet the inclusion criteria because they did not specifically report use of VC modalities (e.g., phone calls, video calls, text messaging, patient portal messages) in their title or abstract. Most included studies (n = 12/21, 57%) began data collection within the first 6 months of the COVID-19 pandemic or the subsequent 6 months of the pandemic (n = 8/21, 38%).

Half of the studies were conducted in multiple ICUs (n = 11/21, 52%). Most studies (n = 17/21, 81%) did not specify the type of ICU. Geographically, most studies were conducted in Europe (n = 9/21, 43%) or North America (n = 6/21, 29%).

SMCRO result: Communication source

The communication source was most commonly the ICU nurse (n = 19/21, 90%). However, ICU physicians (n = 13/21, 62%) and ICU patients (n = 12/21, 57%) were other reported communication sources.

SMCRO result: Communication message

In general, most studies did not report details about the communication message. For studies that did discuss message content, healthcare providers typically discussed routine updates or non-routine significant events such as worsening clinical status or death. Qualitative studies revealed that the clarity of the message was important to family members. Family members reported feeling frustrated and disappointed when communication from healthcare providers was unclear, contained medical jargon, or if they received insufficient information or were misinformed on the patient's status.^32,36 No studies reported the communication message between the patient and the family member.

SMCRO result: Communication channel

Modality

Most studies used one or two communication modalities (n = 17/21, 81%); few studies used three or more modalities (n = 4/21, 19%).^21,25,36,37 Phone calls, video calls, or a combination of both were used in nearly every study (n = 20/21, 95%). One study examined the use of text messages,²⁶ and three studies reported rare opportunities for in-person communication amidst visitor restrictions during the COVID-19 pandemic, such as visitation at end of life.^25,40

Frequency

Approximately half of the studies (n = 9/21, 43%) reported “daily” communication frequency. Other studies described communication frequency with vague terms, including “sporadic,”^24,31 “arbitrary,”³⁰ or “intermittent.”³⁴ Two studies described communication frequency as being based on specific events, such as obtaining procedural consent,³⁴ or ICU admission/discharge.²⁶ Three studies did not report communication frequency.^22,32,38

Duration

Approximately one-third of studies (n = 6/21, 29%) reported communication duration, with a range from 5 min^24,27,29 to 30 min.^20,29,38 In one qualitative study, some surrogate decision-makers felt communication on goals of care was “rushed.”³⁵

SMCRO result: Communication outcome

Measurement of mental health outcomes:

Quantitative and one mixed methods study used validated measures of mental health outcomes, including anxiety (n = 6/11, 55%), depression (n = 5/11, 46%), stress or distress (n = 4/11, 36%), and PTSD (2/11, 18%). Studies that used combined anxiety and depression scales, such as the Hospital Anxiety and Depression Scale (HADS)^20,21,27 or the Depression Anxiety and Stress Scale-21 (DASS-21),²⁸ typically did not report subscales to understand anxiety and depression separately. Mental health outcomes were almost always measured during ICU hospitalization, with only one study including additional data collection after discharge.²⁷

Qualitative studies and two mixed methods studies reported emotions, experiences, and perceptions of family members using VC. Nearly all qualitative results (n = 10/11, 91%) found that some family members experienced negative emotional responses to the communication message and channel of VC, including feelings of anxiety, stress, psychological distress, worry, panic, fear, frustration, sadness, hopelessness, powerlessness, discomfort, and distrust.^{30–32,34–37,39,40} Fewer studies reported positive emotional responses to using VC, which included feelings of reassurance, involvement, togetherness, and appreciation,^{31,35,36,39,40} or reductions in anxiety and stress.^31,34,35,40

How does virtual communication relate to the mental health of family members of intensive care unit patients?

Among the quantitative results, all demonstrated that mental health outcomes either improved or did not worsen with use of VC (Table 6). Improvements were found in anxiety, depression, stress, and distress after interventions testing the use of video calls,^{22–24,27,28} and one study found that video calls were superior to phone calls in terms of reducing anxiety.²³ The use of text messages was rare but appeared to be helpful, with family members from one study indicating that text messages providing routine updates on patient status changes (e.g., extubation, ICU discharge) made them feel “reassured” and did not make them feel anxious.²⁶

Quantitative results that found no change in mental health outcomes used mixed anxiety-depression scales^20,21,28 or evaluated for changes in PTSD. Of note, all studies that measured PTSD used multiple communication modalities and described in-person visitation to the ICU for special circumstances, such as when the patient was approaching the end of life.^21,25,40 It is unclear how these visitations or the patient being near the end of life might have changed mental health outcomes of participants in these studies.

Meta-synthesis of qualitative results revealed two themes relating to the emotions of family members using VC: anxiety with communication uncertainty, and reassurance versus distress with phone calls.

Theme 1. Anxiety with variations in communication source, message, and frequency

Family member' anxiety was related to variations in communication source, message, and frequency. Family members expressed negative emotions if there was no clear communication source for them to call as a point of contact, or if they perceived that calling placed an excessive burden on busy healthcare providers to give an update.^31,34,36 Additionally, family members reported feeling worried about the communication message, fearing the information they may receive.^30,31,41 If information provided contradicted prior updates, family members could develop distrust or doubt the message and the messenger. One family member in Lopez-Soto's study shared their confusion, “They kept telling us he was stable … then they called us to tell us he was dead … how is this possible?”³⁸

Family members expressed both positive and negative emotional responses to communication frequency. It was difficult for family members to wait for a phone call, particularly if they did not know when to expect a call, if calls were inconsistent, or if an expected call was delayed.^31,34–37 Family members strongly desired regular, predictable updates.^32,36 Family members felt reassured when they were told to call any time,³⁶ with one study recommending daily email updates on the patient's condition to ease family anxieties. Studies that reported daily phone or video call updates demonstrated reductions in feelings of anxiety as well as feelings of involvement in care and appreciation.^31,35,36

Theme 2. Reassurance versus distress with communication modality

Communication modality affected the anxiety of family members. A combination of visitor restrictions and use of phone calls did not allow family members to directly see the patient or healthcare team; this led to worry and distress about the patient's condition,^31,34,36,39 feelings of distrust with the patient's providers,³⁵ and a lack of reassurance that the patient received appropriate end-of-life care.^37,39

Video call modalities resulted in mixed emotions. Family members appreciated video calls, which let them see the patient,³⁶ helped them feel connected to the patient and the healthcare team,^32,35,39,40 and provided reassurance regarding the care that the patient received,³⁵ which subsequently alleviated stress^34,35 and feelings of helplessness.⁴⁰ However, family members also reported negative emotional responses from video calls, such as stress, sadness, worry, and discomfort when seeing the environment of the ICU and that the patient was in poor health, intubated, on life support, and/or connected to medical equipment.^32,35,36,40

Discussion

This systematic review with meta-synthesis examines how aspects of VC used between adult ICU patients, healthcare providers, and family members of ICU patients relate to mental health outcomes among these family members. We found that VC with family members typically occurs daily and that the communication sources were usually ICU healthcare providers, often nurses or less commonly physicians or the ICU patient. Phone and video calls were the most common modalities. The most notable finding of this review is that virtual communication was associated with either a positive or neutral effect on mental health outcomes measured with validated scales; however, meta-synthesis revealed that virtual communication may increase negative emotions experienced by family members of ICU patients.

All but one of the studies collected data during the first year of the COVID-19 pandemic. This timing suggests academic interest in the effects of VC, likely in reaction to the limited in-person visitation that occurred during the COVID-19 pandemic. Moreover, increased comparative research may have occurred because the pandemic offered a natural experiment for examining VC compared to in-person and phone communication prior to the pandemic.

Our findings of daily communication between ICU healthcare providers and family members reflect ICU communication practices and guidelines from before the pandemic.⁴² However, in agreement with the findings of Meiers et al. (2024),¹³ this review found that communication shifted to predominantly virtual instead of in-person modalities, reflecting a significant change from typical ICU communication practices. Text messages with family members were less frequently used, which was surprising given the increased acceptance and use of secure text-messaging between healthcare providers.^41,43 Text messages offer the benefit of asynchronous communication, which may be more convenient for healthcare providers⁴¹; however, this modality lacks audio and visual input, which family members found very reassuring in many of the qualitative studies included in this review. Another consideration is access to VC technologies—some studies excluded family members from study participation due to limited technology access, such as not having a smartphone or computer,^23,27,29,31 not having internet access,²⁷ or not having specific smartphone applications such as WhatsApp.^23,28,29 This discrepancy in access to VC technologies represents an additional area to consider for equitable study design, and an additional area to consider by clinicians communicating with family members of ICU patients.

There were mixed results determining the relationship between VC and the mental health of family members of ICU patients, reflecting similar incidental findings from a scoping review by Solomon et al. (2024).¹⁴ We found that VC resulted in either improved or resulted in no difference in measured mental health outcomes, with no studies demonstrating worsened mental health outcomes from VC. The strength of these correlations varied across studies, but comparison was limited due to a lack of measures or scales of VC patterns. Additionally, the lack of studies reporting worsened mental health outcomes may not reflect a true lack of negative emotional consequences of VC, since qualitative evidence connected VC with both positive and negative feelings of family members. Family members reported that VC was both a “lifeline” to the patient and healthcare providers and simultaneously distressing in that they were limited to “visiting” the critically ill patient through a video screen. Family members may experience negative emotions resulting from the communication message shared about the critically ill patient; however, our findings suggest that the communication channel may also be associated with negative emotions in the context of limited in-person visitation. So, while VC may not change or worsen a person's measured mental health (e.g., symptoms of anxiety measured on a validated scale), VC may affect emotions (e.g., feelings of anxiety or worry). This is important, as repeated negative emotions (e.g., persistent worry) may signal risk for a future mental health outcome (e.g., generalized anxiety disorder).

Clinical, policy, and research recommendations

Our results suggest that healthcare providers can do more to ease the stress of family members. We found evidence of family members’ strong preference for daily updates at a predictable time, with a clear point-of-contact in the ICU for communication, and a clear message without medical jargon or vague information. Specific clinical policy recommendations are listed in Table 7.

Table 6.

Summary of communication modality and positive, neutral, or negative mental health outcomes from the quantitative studies.

Table 7.

Clinical policy recommendations to improve communication.

Aspect of communication	Systematic review finding regarding communication challenge	Clinical policy recommendation to improve communication
Source	Unclear point of contact in the ICU	Provide a clear point-of-contact;^a consider texting or e-portal messaging for each shift who the point of contact is (the nurse and physician's name and phone number)
Message	Unclear message from ICU healthcare providers	Communicate without medical jargon, use the correct level of detail, and leave space for family members to ask clarifying questions. Consider healthcare provider training on communication strategies and skills (e.g., Vital Talk)
Channel (frequency)	Family members are unsure on what time it is appropriate to call the ICU, feel like they might “bother” ICU healthcare providers	Ensure family members they are always welcome to call, or provide specific “calling hours” (e.g., between 2 and 5 pm) for family members to call^a
Channel (frequency)	Anxiety from waiting for a phone- or video-call update	Send a brief automated SMS or patient-portal message at a preset time of day with a brief patient status update
Channel (frequency and modality)	Family members are unclear when and how they should communicate (phone vs. video call vs. text message)	Document family communication preferences in the electronic health record including both communication modality and frequency^a
Channel (modality)	Anxiety from not being able to visit the ICU patient	Use video calls whenever possible for family members who cannot be physically present in the ICU
Channel (modality)	Distress from seeing ICU equipment via a video call	Use expectation-setting as a communication strategy, such as prompting family members on what to anticipate in terms of the ICU setting and equipment prior to using the video camera to show the patient and their surroundings

These recommendations could be added to an overall “communication orientation” to the ICU for family members as part of the admission process.

Future research should consider testing VC strategies individually and bundled together to address common communication challenges in ICU settings. For example, Gorman et al. (2020) received positive feedback from families receiving brief text messages as a communication strategy; however, more research may be necessary to determine the practicability of this solution across care settings and illness scenarios. We found limited data exploring VC between families and the ICU patient, which may have additional implications in the mental health of family members, and is another area to explore in future research.

Limitations and strengths

There were few papers to review, perhaps due to not including databases such as EMBASE or PsycINFO, or perhaps due to this topic being under-researched. We excluded any non-English language articles due to resource limitations, and therefore may have missed data from studies published in other languages—we identified one study from a South American country, and no studies from African countries, so information from these regions is lacking. Our study is strengthened by meta-synthesis, which is helpful for collating qualitative findings, but some richness of the qualitative data is lost in deriving themes. Additional strengths of our systematic review with meta-synthesis include the focus on understanding how VC was related to mental health outcomes of family members and the use of a communication theory-based approach. Using the adapted SMCRO Model of Communication provides a strong foundation for addressing our research question and future communication science.

Conclusion

A recent increase in the use of VC between family members, ICU patients, and healthcare providers necessitates understanding how VC might affect the mental health of family members. Although it is not possible to change the communication “message,” findings from this review suggest that modifications in communication frequency, duration, and modality could lead to better mental health outcomes among family members of ICU patients.

Footnotes

Acknowledgments

The authors would like to acknowledge Ms. Ja’Lynn Gray for helping to review titles and abstracts for this manuscript.

ORCID iDs

Claire M Petchler

Elaina Parrillo

Marlena C Fisher

Suratsawadee Kruahong

Rebecca J Wright

Katherine A Ornstein

Martha Abshire Saylor

Ethical considerations

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

No new data were created in this study. Data sharing is not applicable to this article.

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