DISCUSSION
Our project shows a survey-based approach to investigate concordance in perceptions of communication among participants in family discussions and identify domains of communication in a Neurocritical care setting. Most participants in our cohort felt that treatment options were adequately conveyed and were satisfied with the communication, although the impact on healthcare decisions was reported lower than expected. Possible reasons could have been include preexisting religious beliefs, or prior plan of care discussion.
Education was the most frequently mentioned domain of communication in open-ended questions among all groups. Engagement and enlistment were not frequently mentioned by families. Remarks from families and the observer noted empathy which was notably absent in provider remarks. These findings led us to create an education module implemented as a part of our curriculum highlighting ways to improve communication. Given the extremely positive results of the pre-module surveys, post-module assessment was not felt to provide contributory information to boost initiatives to improve communication.
Our limitations included small sample size, restriction to English-speaking participants, inability to rule out selection bias or Hawthorne effect among respondents and high degree of competency presumed from attending physicians directing most conversations. It is possible that families with discomfort or conflict during these discussions refused consent for the study creating self-selection of satisfied respondents. Furthermore, conversations in family lounge areas mentioning the study may have affected expectations of family satisfaction and concordance.
This study did not assess other factors that influence patient decision-making (e.g. family religiosity, educational level of decision-makers, socioeconomic status). Such factors may underlie discordant provider and family perceptions of how provider communications influenced family decision-making.
Traditional summary measures of agreement like Krippendorf’s or Cronbach’s alpha, and intra-class coefficients were also considered. Krippendorf’s alpha calculated on the original data showed poor to moderate agreement beyond chance; the discrepancy between a high percent agreement and low Krippendorf’s alpha may indicate that the method performs best with responses that are more diverse.
Overall, our study showed high satisfaction among providers, families, and the observer regarding quality of communication during family discussions in the Neurocritical care unit.
Our study identified the variability in perceptions amongst various domains of communication. This was useful for designing and testing educational interventions involving family communication.