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\begin{document}

\title{Perceptions of Quality of Communication in Family Interactions in
Neurocritical Care}



\author[1]{Russell  Stewart}%
\author[2]{Kyle Hobbs}%
\author[3]{Kristopher Dixon}%
\author[4]{Roberto  Navarrete}%
\author[5]{Jannat Khan}%
\author[6]{Mary  Wren}%
\author[7]{Mollie Canzona}%
\author[3]{Aarti Sarwal}%
\affil[1]{University of South Carolina School of Medicine Greenville Campus}%
\affil[2]{Intermountain Medical Center}%
\affil[3]{Wake Forest School of Medicine}%
\affil[4]{University of Michigan}%
\affil[5]{Rush University Medical Center}%
\affil[6]{Washington University in St Louis School of Medicine}%
\affil[7]{Wake Forest University}%


\vspace{-1em}



  
  \date{May 16, 2024}


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\selectlanguage{english}
\begin{abstract}
Objective: To investigate concordance in perceptions of communication
among participants in family discussions and assess the importance of
different domains of communication in a neurocritical care unit.
Methods: Prospective observational study conducted in a neurocritical
care unit. Our study involved family discussions regarding plan of care
for patients admitted to the unit. All participants completed a survey.
The first 4 questions rated understanding of the discussion and general
satisfaction; the remaining questions were open-ended to assess quality
of communication by the physician leading the discussion. Responses were
scored and compared among participants using a Likert scale. A
difference of \textless{} 1 in scores among participants was rated as
concordance, while \textgreater{} 2 was designated as discordance. All
open-ended responses were classified into six domains. Results: We
observed 35 family discussions. Questions 1-3 yielded 99
cross-comparisons per question (total of 297 compared responses). Most
responses were either ``Strongly Agree'' or ``Agree''; with ``Neutral''
or ``Disagree'' responses being more prevalent in Question 2. Overall
concordance of responses between participants was 88\%. Education was
the most frequently cited domain of communication in response to
open-ended questions. Among family and neutral observers, empathy was
frequently listed, while providers more often listed family engagement.
Conclusion: Overall, satisfaction was high among providers, families,
and the observer regarding quality of communication during family
discussions in the unit. Perceptual differences emerged over whether
this communication impacted healthcare decision-making during that
encounter.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

Effective communication between healthcare providers and
patients/families is essential for patient-centered care and is pivotal
to patient/family decision-making, particularly in Neurocritical care,
because involvement of multispecialty providers can yield inconsistent
messages.\textsuperscript{1-3} Our study sought to assess differences in
perceptions about communication between providers and patients' families
in a Neurocritical care unit.

\textbf{METHODS}

\textbf{Participant Recruitment and Data Collection}

The study protocol was approved by the local Institutional Review Board.
Data was collected in a Neurocritical care unit at a tertiary-level
academic medical center. A neutral observer observed discussions between
providers and patients' families. The observer then discussed the study
with families or surrogate decision-makers and obtained informed
consent. Each member of the discussion -- provider, family, nurse, and
observer -- completed a questionnaire to evaluate the quality of
communication (Table 1).

We screened clinical encounters between July - August 2015 and June -
July 2016 where providers interacted with families to deliver medical
information, reviewed plan of care, or addressed goals of care. There
were no junior new trainees rotating in the ICU or participating in
family discussions hence this time was selected. Only encounters
involving English-speaking families of patients age 18 or older were
included. We excluded encounters where providers or families expressed
discomfort, the observer was absent, or families were grieving. We also
excluded encounters if a provider refused to complete surveys, or a
patient was deceased.

\textbf{Survey Instrument and Variables Collected}

The questionnaire administered was constructed after review of
literature (Table 1) .\textsuperscript{1,4-7} Each participant ranked
aspects of communication during the encounter on a Likert scale of
agreement. Questions 1-3 were answered by all participants. Question 4a
was answered by providers, Question 4b was answered only by families.
Questions 5-9 were open-ended and used to identify domains of
communication that affected participants' perception of quality of
communication.

\textbf{Analysis}

For each encounter, numerical values for each response were compared
among respondents (Table 1 and Figure 1). The degree of difference (DOD)
was calculated to capture concordance e.g. Question 3 states: ``The
family understands the treatment options explained to them.'' If the
family's response was ``Disagree,'' a value of 4 was coded. If the
physician's response was ``Strongly Agree,'' a value of 1 was coded, and
the DOD was three. A DOD [?] one was considered concordance, while a DOD [?]
two was considered discordance (Table 2).

Each pair of responses for each of the first three questions was coded
as concordant or discordant. A repeated measures logistic regression
model was fit with terms for the subject, the pair of responders (e.g.,
family and provider, nurse and observer, etc.) and the question,
allowing a comparison of the rates of concordance between the questions,
and between the pairs of responders, while adjusting for the correlation
among responses.

Additionally, data from Questions 1-3 were reanalyzed using a
three-point scale where ``Strongly Agree'' and ``Agree'' was classified
as ``Agree''; ``Neutral'' remained the same; and ``Disagree'' and
``Strongly Disagree'' were classified as ``Disagree''.

Finally, responses to open-ended questions were divided into 6 domains,
initially using the Bayer Institute for Health Care Communication E4
Model -- Education, Empathy, Engagement, and
Enlistment.\textsuperscript{8} Each comment was analyzed by a blinded
scorer using these domains. Post-hoc analysis revealed several comments
addressing Speech Mechanics and Settings; these domains were added,
resulting in six domains for the analysis. (Figure 2)

\textbf{Data Availability Statement}

Anonymized data will be shared by request from any qualified
investigator.

\textbf{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\textless{}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\%).

\textbf{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.

\textbf{References}

1. Hwang DY, Yagoda D, Perrey HM, et al. Assessment of satisfaction with
care among family members of survivors in a neuroscience intensive care
unit. J Neurosci Nurs 2014;46:106-16.

2. Christakis NA, Iwashyna TJ. Attitude and self-reported practice
regarding prognostication in a national sample of internists. Arch
Intern Med 1998;158:2389-95.

3. Hemphill JC, 3rd, White DB. Clinical nihilism in neuroemergencies.
Emerg Med Clin North Am 2009;27:27-37, vii-viii.

4. Aslakson RA, Wyskiel R, Thornton I, et al. Nurse-perceived barriers
to effective communication regarding prognosis and optimal end-of-life
care for surgical ICU patients: a qualitative exploration. J Palliat Med
2012;15:910-5.

5. Fassier T, Azoulay E. Conflicts and communication gaps in the
intensive care unit. Curr Opin Crit Care 2010;16:654-65.

6. Kaner E, Heaven B, Rapley T, et al. Medical communication and
technology: a video-based process study of the use of decision aids in
primary care consultations. BMC Med Inform Decis Mak 2007;7:2.

7. Fumis RR, Nishimoto IN, Deheinzelin D. Families' interactions with
physicians in the intensive care unit: the impact on family's
satisfaction. J Crit Care 2008;23:281-6.

8. Keller VF, Carroll JG. A new model for physician-patient
communication. Pat Educ Couns 1994;23:131-40.

\textbf{Acknowledgements~}

We are grateful to the Biostatistics Core of Clinical Translational
Science Institute at Wake Forest Baptist Medical Center for support with
statistical analysis. Additionally, we are grateful to the Medical
Student Research Program supported in part by T35DK007400 training
grant, which provided support for medical students to participate in the
study through the summer.

\textbf{Figure Legends}

\textbf{Figure 1.} Figure 1a shows the responses to Q1 (``I am generally
satisfied with the provider's communication with the family''). Figure
1b shows the responses to Q2 (The conversation impacted the family's
healthcare decisions). Figure 1c shows the responses to Q3 (The family
understands treatment options explained by the provider).

\textbf{Figure 2.} Figure 2a shows the total percentage of open-ended
remarks made in each domain. Figure 2b shows the percentage of remarks
made in each domain categorized by participant group. Figure 2c shows
the descriptive remarks by participants in survey with examples of
domain assignment.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Perceptions-Figure-1/Perceptions-Figure-1}

\end{center}
\end{figure}

\selectlanguage{english}
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