RESULTS
We examined 35 encounters; we excluded 13 encounters based on our
criteria. Collectively, 77 surveys were completed: 22 by providers (18
led by a neurointensivist care physician, four were led by resident or
advance practice provider), 22 by the observer, 22 by families, and 11
by nurses. Mean values are reported in Table 1 and responses in each
category in Figure 1 and Table 3.
Only 28 out of 231 responses to the first three questions (12%) were
Neutral, Disagree, or Strongly Disagree. Traditional measures of
inter-rater agreement (Krippendorf’s Alpha, Intra-Class Coefficients,
and Cronbach’s Alpha) are not well defined with so little dispersion.
For this reason, we defined concordance using the degree of difference
defined above (Table 2). Analysis of Questions 1-3 yielded 99
cross-comparisons per question and total 297 responses. Two hundred and
sixty-one responses demonstrated concordance and 36 showed discordance
(88% concordance, 12% discordance). Most responses for Questions 1 and
3 were in the “Strongly Agree” or “Agree” category. Concordance
between all groups was high, particularly for Questions 1 and 3 (96 and
94%, respectively), suggesting that all parties agreed on quality of
the communication. Question 2 on whether communication impacted
healthcare decisions had a lower rate of overall concordance (72%) than
the other two questions (p<0.01). This discordance was
greatest when comparing family/provider and family/nurse responses,
although there were no statistically significant differences between
pairs of responders. Analysis of exact concordance on the condensed
three-point scare yielded similar results (Table 4).
The discordance among participants for Question 1 did not affect
respondents’ general satisfaction with provider’s communication during
the encounter (Table 3). For encounters with complete concordance, 73%
of respondents strongly agreed that they were satisfied with the
provider’s communication. Among encounters with at least one discordant
crossmatch, that number was 70%. Even for encounters where three or
more cross-matched responses were discordant, participants answered
“Strongly Agree” for Question 1 regarding satisfaction with the
encounter 68% of the time.
Question 4a assessed the provider’s comfort with discussing the
patient’s prognosis with the family. All 22 providers reported that they
strongly agreed or agreed (n=16 and 6, respectively) that they were
comfortable discussing the prognosis with families. Question 4b assessed
the family’s general satisfaction with the care the patient received.
All respondents either strongly agreed or agreed (n=19 and 3,
respectively) that they were satisfied with the quality of care.
Questions 5-9 yielded 148 responses; six responses were recorded as none
or not sure. Some respondents provided multiple remarks (159 positive,
17 negative), yielding 176 keywords classified into six domains. Common
remarks involved educational content (46%), empathy (21%), and
engagement (19%) (Figure 2). The observer, families, and nurses
primarily focused on educational content and empathy (86%, 84%, and
73%, respectively). Providers commented on either educational content
or empathy in 49% of remarks. Providers and the observer noted the
“physical setting of the meeting” in 14% of remarks. Empathy was the
most frequently cited domain by families (31%) and the observer (30%).