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Translation and cultural adaptation of the quality of communication questionnaire for ICU family members in Korea
Heart & Lung xxx (2017) 1e6
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Translation and cultural adaptation of the quality of communication questionnaire for ICU family members in Korea Minjeong Jo, PhD, RN a, *, Mi-Kyung Song, PhD, RN, FAAN b, Marcia Van Riper, PhD, RN, FAAN c, Yang-Sook Yoo, PhD, RN a, George J. Knafl, PhD c, Linda Beeber, PhD, RN, CS c a
The Catholic University of Korea, College of Nursing, Seoul 06591, South Korea Emory University, Nell Hodgson Woodruff School of Nursing, Center for Nursing Excellence in Palliative Care, Atlanta, GA 30322, USA c University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC 27599, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 April 2017 Received in revised form 4 August 2017 Accepted 5 August 2017 Available online xxx
Background: There are no Korean instruments to assess the concepts associated with end-of-life communication quality. Objectives: To translate and culturally adapt the Quality of Communication (QOC) questionnaire into Korean and evaluate its acceptability and internal consistency. Methods: We first translated the QOC from English into Korean, then back-translated from Korean to English, and evaluated the cultural appropriateness of the items. We pretested and refined the Korean version of the QOC with 11 ICU family members. Subsequently, the Korean version of the QOC was administered to 62 family members of chronically critically ill patients recruited from 10 ICUs to evaluate its internal consistency. Results: Participants completed the Korean QOC without difficulty during the pretest, and it showed acceptable internal consistency (Cronbach’s alpha 0.85). Conclusion: This study provided preliminary evidence of the acceptability and reliability of the Korean QOC in ICU family members. Nonetheless, further evaluation, including item relevance and other psychometric properties, is warranted. Ó 2017 Elsevier Inc. All rights reserved.
Keywords: Communication Family Intensive care unit Instrument Translation
Background The number of chronically critically ill patients in Korea is growing. Although there is no universal definition, the term, chronic critical illness (CCI) is used for patients with prolonged dependence on mechanical ventilation.1 According to studies based on hospital medical records, CCI patients account for 5%e6% of all patients admitted to intensive care units (ICU) in Korea.2,3 Because these CCI patients are typically unable to communicate their needs or wishes about treatments at the end of life, treatment decision making primarily involves family members and clinicians.1,4 Accordingly, the quality of end-of-life communication between family members of ICU patients and clinicians (physicians or nurses) is emphasized in Korea.5 Poor family-clinician communication often results in family members not having an adequate Funding: This work was supported by Sigma Theta Tau International and the University of North Carolina at Chapel Hill. * Corresponding author. The Catholic University of Korea, College of Nursing, Seoul 06591, South Korea. E-mail address: [email protected] (M. Jo). 0147-9563/$ e see front matter Ó 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2017.08.002
understanding of the patient’s medical condition, prognosis, or the effectiveness of treatments.6 This may cause family members to choose to continue life-sustaining treatments that have little to no therapeutic benefit. Studies7e9 have indicated that family members who perceive that insufficient communication time has been allotted, or that information is difficult to comprehend, are at risk for symptoms of anxiety, depression, and stress. These findings suggest that poor family-clinician communication adversely affects both family members’ comprehension of patient treatment and their mental health. Systematic assessment is a first step to improve the quality of communication, yet there are currently no instruments in Korean for assessing concepts associated with end-of-life communication quality. The Quality of Communication (QOC) questionnaire designed for English-speakers in the United States was originally developed to assess patients’ perceptions of the quality of communication with their physicians.10 The QOC items were developed from qualitative interviews and focus groups involving patients with chronic obstructive pulmonary disease (COPD), cancer, and acquired immune deficiency syndrome as well as family members and clinicians.10,11
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M. Jo et al. / Heart & Lung xxx (2017) 1e6
Later, the QOC was used by the developers to measure family members’ perceptions of the quality of communication with physicians or nurse practitioners.12e14 The QOC contains 19 items asking the respondent to rate the clinician’s general communication skills and communication about end-of-life care on an 11-point Likert scale (0 ¼ poor, 10 ¼ absolutely perfect). Respondents are also offered two additional response options, “physician or nurse did not do this” and “I do not know.”11 The QOC consists of two subscales: the general communication skills scale and communication about end-of-life care scale.11 A summative score is computed by adding the individual item scores divided by the number of items (answered by the family member), and then multiplying that figure by 10 to generate a score ranging from 0 to 100. Higher scores indicate better perceived quality of communication.11 The psychometric characteristics of the QOC have been evaluated in samples of hospice patients and patients with COPD.11 The QOC subscales reported an acceptable internal consistency (a for general communication was 0.91 and for end-of-life care communication was 0.79).11 Construct validity was demonstrated with moderate correlations (r ¼ 0.54 to 0.74) with a single-item assessing the overall quality of clinician communication, quality of end-of-life care discussion, and quality of care separately.11 Translation and cultural adaptation of the QOC have not been performed in other languages. Considering the time and cost involved in developing a new instrument, modifying an existing instrument with demonstrated reliability and validity is a better option.15 Therefore, the purpose of this study was to translate and culturally adapt the QOC into Korean and assess its acceptability and internal consistency when administered to ICU family members in Korea.
in Korean and English and had not participated in either the forward or backward translation. The committee members independently assessed the appropriateness of the translation and evaluated its equivalence with the original version semantically, experientially, and conceptually. Pretesting and cognitive interviews We conducted cognitive interviews with 11 family members of ICU patients in Korea. Family members of adult patients in the ICU were invited to participate if they were: (1) 19 years old or older (the legal age of consent in Korea) and (2) self-identified as a primary care giver (defined as the family member most likely to provide pre-admission or post-discharge care giving)19 or the family decision-maker (defined as the family member most involved in the patient’s treatment decisions),20 and (3) “spokespersons” for the family who communicated with ICU physicians and/or nurses about the patient’s illness or treatment. The investigator approached willing family members during their ICU visits to assess their eligibility and interest in study participation. Family members who expressed interest in the study were contacted by the investigator after their ICU visit. Upon giving consent, family members completed surveys, including the Korean version of the QOC for physicians and nurses each and a sociodemographic profile. Once completed, family members were asked if there were any words or sentences that they had found difficult to understand. A probe technique was also used that asked family members probe questions such as “What do you mean?”15 Family members were asked to rephrase each item in their own words to elucidate their understandings of the items in an open-ended manner.
Methods Pilot testing and evaluation of internal consistency The study was approved by the Institutional Review Board at the University of North Carolina at Chapel Hill in the United States and by the three medical centers in Korea where the study was conducted. Translation and cultural adaptation In this study, two items, one to assess family members’ perceptions of quality in terms of information consistency and one to ask how much time was allocated to receive information from ICU physicians and nurses, were added to the QOC. This decision was made based on a Korean literature review, which suggested that receiving consistent information from ICU physicians and nurses, and having adequate opportunities to communicate with them, were identified as the priorities of ICU family members in Korea.5 Thus, the 21-item QOC was used for this study. Additionally, the rating instruction was changed from “How good was the physician or nurse at each of the communication behaviors?” to “How satisfied were you with each of the physician’s or nurse’s communication behaviors?” This change was made because, culturally, physicians in Korea are revered in the belief that they possess special knowledge or experience16 and thus family members often feel uncomfortable evaluating their communication behavior.17 To modify the QOC into a Korean version, we used the process recommended by Guillemin et al.,15,18 including forward translation, backward translation, committee review, and pretesting. Two bilingual translators whose first language was Korean translated the QOC into Korean (forward translation). Another two bilingual translators, but not those who had performed the forward translation, translated the QOC in Korean into English (backward translation). Three versions of the QOC (one translated into Korean, one back translated into English, and the original QOC) were then reviewed by a committee consisting of the first author, two nursing professors, one ICU physician, and one ICU nurse, who were fluent
Design and setting We conducted a cross-sectional survey with 62 family members of ICU patients. From December 2015 to April 2016, participants were recruited from 10 ICUs at three medical centers affiliated with the Catholic University in Korea. To identify family members of CCI patients, the following inclusion criteria were used for patients: (1) 19 years of age or older, and (2) chronically critically ill (i.e., failed to be weaned or not considered for weaning within three days of initiation of mechanical ventilation).21 The eligibility criteria for family members was the same as those described above. The ICU nursing staff first identified eligible patients and approached their family members during their ICU visits to assess their willingness to meet the investigator. The investigator approached the willing family members during their ICU visits to assess their eligibility and interest in study participation. Upon giving consent, family members completed the Korean version of the QOC for physicians and nurses each and a sociodemographic profile, in a private room near the ICU. With approval from the participating hospitals in Korea and family consent, bedside nurses collected patient age, gender, admitting diagnosis, length of ICU stay, and period of mechanical ventilator dependence from the electronic medical records. Data analysis All data were analyzed using SAS version 9.3 (SAS Institute Inc., Cary, NC). Descriptive statistics, including means, standard deviations (SD), and percentages, were computed to summarize the sample characteristics and QOC scores. The internal consistency of the Korean version of the QOC was evaluated by calculating Cronbach’s alpha (a) coefficients. Additionally, the inter-item and item-total correlations were computed to evaluate item discrimination and redundancy.
M. Jo et al. / Heart & Lung xxx (2017) 1e6
Results Review of translation and cultural adaptation During the committee review of the translated original version of the QOC, three changes were made. In Item 15, “talking with you about what your patient dying might be like,” the term “dying” was replaced with the Korean term “임종 [imjong],” which is a euphemism for “dying.” This replacement was made as family members may feel uncomfortable with the direct translation of “dying.” Traditionally, open discussion of death and dying has been taboo in Korea.22 Additionally, two items, “asking about the things in life that are important to your patient (item 16)” and “respecting the things in life that are important to your patient (item 17),” were considered activities not commonly practiced during communication between family members and physicians or nurses in Korea, and were deemed too abstract for family members to answer. Thus, the phrase “such as values, beliefs, persons” was added in parentheses after each item to provide a supplementary explanation of “things in life.” Pretesting The mean (SD) age of patients was 64.2 (12.3), and seven were males. Nine were dependent on mechanical ventilation. The most common diagnoses leading to patients’ ICU admission were cardiovascular or respiratory conditions (n ¼ 7). The median ICU stay was seven days (IQR ¼ 43) with the median length of mechanical ventilation six days (IQR ¼ 21). The mean (SD) age of family members was 54.5 (13.8). Six were men and nine family members had completed at least high school education. The majority were either an adult child or spouse of the patient (n ¼ 9). The cognitive interviews took 15 min on average. Family members reported no difficulty and that all items were clear. There were no skipped items. Pilot testing and evaluation of internal consistency Characteristics of patients and family members The mean (SD) age of patients was 63.9 (16.3) (Table 1). Approximately half were women (n ¼ 33, 53.2%) and approximately 60% were married (n ¼ 39, 62.9%). The top three diagnoses leading to patients’ ICU admission were respiratory (n ¼ 19, 30.7%), neurologic (n ¼ 11, 17.7%), and neoplastic disorders (n ¼ 11, 17.7%). The median ICU stay was 10 days (IQR ¼ 8) with the median length of mechanical ventilation 9.5 days (IQR ¼ 8). The mean (SD) age of family members was 48.9 (14.1). Approximately two thirds of family members were women (n ¼ 43, 69.4%) and the majority had completed at least high school education (n ¼ 56, 90.6%). The majority were either an adult child or spouse of the patient (n ¼ 51, 82.3%). Responses to the Korean QOC The mean (SD) summative score of the Korean QOC for physicians was 49.1 (15.0). The mean scores for each item ranged from 0.5 to 8.5 and the mean score for item 21, rating overall quality of communication with the physician, was 7.6 ranging from 0 to 10 (Table 2). Five items assessing communication about patient dying, patient’s important things in life, and family member’s spiritual or religious beliefs (15, 16, 17, 18, and 19) had extremely low ratings for physicians (0.5e0.9). For these items, more than 80% of family members reported that physicians did not perform them (80.3%e88.7%). The mean (SD) summative score of the Korean QOC for nurses was 41.5 (13.0). The mean scores for each item ranged from 0.1 to 8.4 and the mean score for item 21, rating overall quality of communication with the nurse, was 7.8 ranging from 2.0 to 10.0. Eight items
3
Table 1 Characteristics of patients (N ¼ 62) and family members (N ¼ 62). Variable
Patients
Family members
n (%) Age, M (SD) Gender, M (SD) Male Female Education < High school High school graduate College graduate Marital status Never married Currently married Widowed Divorced Family member relationship to patient Spouse Parent Child Daughter-in-law or son-in-law Sibling Hospital length of stay, Median (IQR) ICU length of stay, Median (IQR) Days of mechanical ventilation use, Median (IQR) Primary ICU admission diagnosis Respiratory disease Neurologic disease Neoplastic disease Cardiovascular disease Renal disease Othera
63.9 (16.3)
48.9 (14.1)
29 (46.8) 33 (53.2)
19 (30.7) 43 (69.4) 6 (9.7) 18 (29.0) 38 (61.3)
6 (9.7) 39 (62.9) 16 (25.8) 1(1.6) 19 (30.7) 5 (8.1) 32 (51.6) 2 (3.2) 4 (6.5) 13.5 (17) 10.0 (8) 9.5 (8)
19 (30.7) 11 (17.7) 11 (17.7) 7 (11.3) 4 (6.5) 10 (16.1)
Note. ICU¼Intensive Care Unit. a Other includes acute duodenal ulcer, alcoholic ketoacidosis, bacteremia, chronic graft-versus-host disease, disseminated.
assessing communication about patient’s treatment preference, patient’s life expectancy, patient dying, patient’s important things in life, and family member’s spiritual or religious beliefs (11, 14, 15, 16, 17, 18, 19, and 20) had extremely low ratings (0.1e1.5) for nurses. For these items, more than 76% of family members reported that nurses did not perform them (76.1%e93.0%). Internal consistency and item-total correlation of the Korean QOC The Korean QOC showed acceptable Cronbach’s alpha coefficients (a ¼ 0.87 for QOC for physicians and a ¼ 0.85 for QOC for nurses). In the QOC for physicians, inter-item correlations ranged from 0.09 to 0.89 (Table 3). The item-total correlations ranged from 0.13 to 0.69 and two items assessing communication about family member’s spiritual or religious beliefs (18 and 19) had very low correlations with the total score (0.18 and 0.13 respectively). The Cronbach’s alpha coefficients were slightly higher (0.88 for both cases) without Items 18 or 19. In the QOC for nurses, inter-item correlations ranged from 0.02 to 0.98 (Table 4). The item-total correlations ranged from 0.10 to 0.71 and five items assessing communication about patient dying, patient’s important things in life, and family member’s spiritual or religious beliefs (15, 16, 17, 18, and 19) had very low correlations with the total score (0.10e0.19). The Cronbach’s alpha coefficients did not change when each of these items was omitted. Discussion This study has described the process of translating and adapting the QOC for the Korean context and its preliminary psychometric properties. Family members completed items of the Korean QOC without difficulty and reported that all items were clear during the
20
Table 2 Responses to the Korean version of the QOC.
2.9 (4.0)
2.2 (3.6)
0.6 (1.9)
0.8 (2.3)
0.1 (0.8)
0.6 (2.1)
0.6 (2.1)
0.9 (2.5)
1.1 (0.6)
0.6 (2.2)
0.4 (1.7)
0.5 (2.0) 2.5 (3.9)
0.5 (1.8) 2.5 (3.9)
7.6 (2.3)
7.8 (2.1)
49.1 (15.0)
41.5 (13.0)
10 9 8 7 6 5 4 3
0.03 0.13 0.88 0.89** 0.11 0.18 0.88 0.10 0.07 0.44** 0.41 0.87 0.84** 0.16 0.05 0.44** 0.38 0.87 0.40** 0.33** 0.07 0.05 0.22 0.24 0.87 0.54** 0.20 0.13 0.02 0.02 0.51** 0.39 0.87 0.76** 0.73** 0.67** 0.56** 0.23 0.67** 0.67** 0.68** 0.58** 0.14 0.28* 0.31 0.12 0.05 0.16 0.21 0.07 0.03 0.28* 0.61 0.86 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Item-total correlation Cronbach’s alpha if item was deleted
2 1 Item
pretest. These findings suggest that the Korean QOC could be self-administered among family members of ICU patients. Our data also demonstrated that the Korean QOC showed acceptable internal consistency (a ¼ 0.87 for physicians and a ¼ 0.85 for nurses) as a Cronbach’s alpha coefficient of at least 0.70 is typically considered acceptable.23,24 Effective end-of-life communication between family members and clinicians is critical to improve the quality of ICU care. Family members’ unmet communication needs have been linked to their lack of understanding of the patient’s medical condition and treatments, lack of trust in clinicians, increased risk for symptoms of anxiety, depression, and stress, and dissatisfaction with ICU care.6,25e27 Since there have been no Korean instruments to assess family members’ perceptions about the quality of end-of-life communication with physicians and nurses, the Korean version of the QOC has significant implications for clinicians and researchers. The Korean QOC can aid in assessing family members’ satisfaction with clinicians’ communication behaviors, such as active listening, discussing prognoses, providing emotional support, and deliberating with family members about treatment decision-making as well as their perceptions of end-of-life communication in the ICU.
Table 3 Inter-item and item-total correlations of the Korean version of the QOC for physicians.
Note. QOC ¼ Quality of Communication. Response rating: 0 (not at all satisfied) to 10 (extremely satisfied). a,b Item 4 and 5 were added to the Korean version of the QOC. c,d Item 16 and 17 were revised to the Korean version of the QOC.
Note. QOC ¼ Quality of Communication. * p < 0.05; **p < 0.01.
5.8 (3.8)
12
2.7 (3.8)
11
4.3 (4.0)
13
14
15
(2.3) (2.1) (2.4) (3.1)
0.35** 0.18 0.21 0.25 0.10 0.10 0.45** 0.61 0.86
8.0 8.2 7.7 1.5
0.64** 0.23 0.25* 0.31* 0.38** 0.18 0.14 0.28* 0.51 0.87
7.9 8.4 7.7 3.3
0.36** 0.41** 0.41** 0.33* 0.39** 0.46** 0.01 0.09 0.52** 0.47 0.87
7.7 (2.3)
0.09 0.21 0.33 0.00 0.05 0.08 0.11 0.03 0.02 0.15 0.56 0.86
7.9 (2.3)
0.83** 0.19 0.23 0.39 0.09 0 0.06 0.09 0.03 0.02 0.26* 0.65 0.86
4.1 (4.2)
0.84** 0.71** 0.09 0.25 0.36 0.15 0.03 0.10 0.14 0.03 0.03 0.31* 0.65 0.86
6.1 (3.4)
0.82** 0.84** 0.74** 0.15 0.23 0.27 0.06 0.01 0.05 0.09 0.03 0.06 0.26* 0.63 0.86
6.9 (2.8)
0.26 0.19 0.18 0.04 0.37** 0.17 0.32 0.33** 0.16 0.04 0.03 0.11 0.10 0.18 0.33 0.87
6.7 (2.7)
0.15 0.71** 0.68** 0.65** 0.72** 0.24 0.23 0.31 0.13 0.02 0.15 0.17 0.12 0.10 0.29* 0.62 0.86
6.7 (3.1)
0.80 0.17 0.76** 0.79** 0.80** 0.81** 0.15 0.31* 0.41 0.14 0.10 0.13 0.12 0.11 0.12 0.32* 0.69 0.86
7.7 (2.3)
0.86** 0.66** 0.14 0.74** 0.78** 0.79** 0.78** 0.14 0.30* 0.42 0.11 0.03 0.14 0.17 0.11 0.12 0.30* 0.68 0.86
8.4 (1.8) 8.3 (2.0) 6.9 (3.1)
19
M (SD)
7.7 (2.0) 8.5 (1.7) 7.8 (2.1)
18
M (SD) 1.Using words that you can understand 2.Looking you in the eye 3.Giving you information about your patient’s illness and treatment 4.Providing you consistent information about your patient’s illness and treatmenta 5.Allowing enough time for communication about your patient’s illness and treatmentb 6.Including you in decisions about your patient’s illness and treatment 7.Answering all your questions about your patient’s illness and treatment 8.Listening to what you have to say 9.Caring about you as a person 10.Giving you his or her full attention 11.Asking about the kinds of treatments you patient would want if he or she could speak for himself or herself 12.Talking with you about your feeling that your patient might get sicker 13.Talking with you about when or how your patient might get sicker 14.Talking with you about how long your patient might have to live 15.Talking with you about what your patient dying might be alike 16.Asking about the things (values, beliefs, people, etc.) in life that are important to your patientc 17.Respecting the things (values, beliefs, people, etc.) in life that are important to your patientd 18.Asking about your spiritual or religious beliefs 19.Respecting your spiritual or religious beliefs 20.Helping you decide about the kinds of treatments your patient would want 21.Overall, how would you rate communication with the patient’s doctor/nurse Summative score
(2.3) (1.9) (2.2) (3.9)
Nurses
17
Physicians
16
Items
0.56 0.86
M. Jo et al. / Heart & Lung xxx (2017) 1e6
0.59** 0.59** 0.56** 0.21 0.62** 0.61** 0.66** 0.57** 0.18 0.30* 0.35 0.14 0.08 0.06 0.09 0.03 0.02 0.24 0.57 0.87
4
0.34 0.84 0.16 0.19 0.85 0.76** 0.02 0.10 0.85 0.34** 0.31* 0.18 0.10 0.85 1.00** 0.34** 0.31* 0.18 0.10 0.85 0.98** 0.98** 0.36** 0.32* 0.17 0.11 0.85 0.30* 0.29* 0.29* 0.05 0.34** 0.20 0.23 0.85 0.28* 0.10 0.12 0.12 0.05 0.17 0.33** 0.48 0.84 0.51** 0.20 0.08 0.09 0.09 0.05 0.18 0.25 0.51 0.84 51** 0.40** 0.23 0.14 0.14 0.14 0.16 0.31* 0.34** 0.46 0.84 0.16 0.21 0.18 0 0.15 0.15 0.15 0.02 0.06 0.05 0.55 0.84 0.73** 0.14 0.18 0.14 0.02 0.14 0.15 0.15 0.06 0.10 0.13 0.60 0.83 0.86** 0.72** 0.16 0.14 0.15 0.02 0.11 0.17 0.17 0.24 0.26 0.11 0.55 0.84 0.63** 0.61** 0.53** 0.15 0.24 0.18 0 0.10 0.14 0.14 0 0.07 0.12 0.59 0.83 0.24 0.22 0.21 0.22 0.36 0.28* 0.44** 0.23 0.03 0.04 0.04 0.04 0.07 0.25 43 0.84 0.04 0.73** 0.52** 0.59** 0.54** 0.19 0.31* 0.35** 0.02 0.04 0.05 0.05 0.07 0.04 0.22 0.71 0.83 0.65** 0.22 0.57** 0.39** 0.44** 0.40** 0.18 0.41** 0.26* 0.06 0.03 0.04 0.04 0.08 0.08 0.18 0.64 0.83 Note. QOC ¼ Quality of Communication. * p < 0.05; **p < 0.01.
0.96** 0.65** 0.19 0.59** 0.42** 0.44** 0.41** 0.16 0.35** 0.21 0.06 0.04 0.06 0.06 0.07 0.04 0.17 0.61 0.83 0.72** 0.43** 0.40** 0.54** 0.12 0.56** 0.81** 0.88** 0.65** 0.11 0.19 0.05 0.11 0.17 0.20 0.20 0.06 0.11 0.10 0.53 0.84
0.39** 0.37** 0.46** 0.20 0.44** 0.70** 0.72** 0.68** 0.16 0.25 0.16 0.08 0.08 0.12 0.12 0.03 0.02 0.18 0.57 0.84
6 5 4 3
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Item-total correlation Cronbach’s alpha if item was deleted
2 1 Items
Table 4 Inter-item and item-total correlations of the Korean version of the QOC for nurses.
7
8
9
10
11
12
13
14
15
16
17
18
19
20
M. Jo et al. / Heart & Lung xxx (2017) 1e6
5
Although the Korean QOC was well received and showed acceptable internal consistency in this study, we noticed several issues. The ratings of items assessing quality of communication about end-of-life care (i.e., talking about what the patient dying might be like or how long the patient might have to live) in both physicians and nurses were extremely low (0.1e1.5). These low ratings were mainly due to the fact that more than 76% of family members reported that physicians or nurses did not perform with respect to those items. The answer “physician or nurse did not do this” was replaced by a score of 0 based on the method of Engelberg et al.11 High rates of “physician or nurse did not do this” for items assessing quality of family-clinician communication about end-of-life care suggest an issue with the instrument, insofar as such items may not be culturally applicable. In Korean culture, communication about a patient’s poor prognosis is usually discouraged because openly discussing death and dying is taboo.22 In this cultural context, physicians and nurses may be uncomfortable with, or avoid, communicating in relation to expectations of patient survival and end-of-life treatment.28 Furthermore, the low ratings of nurses’ communication behavior may reflect the paternalistic medical practice model in Korea, wherein nurses may consider providing prognostic information to be the primary task of physicians and might therefore be reluctant to provide family members with that information.28 Unfortunately, our pretesting failed to detect this problem, perhaps because the pretesting using cognitive interviews focused on item clarity. We primarily used probe questions such as “What does the item mean?” and “Was this an item you felt comfortable answering?” However, Sidani et al.29 have suggested that the cultural relevance of each item should also be determined using questions such as “How important is the item in capturing the concept of interest as understood and/or experienced by you and people of your community?” Our study did not add questions of relevance during the cognitive interviews. We also found that inter-item and item-total correlations of several items assessing communication about end-of-life care such as the patient dying, the patient’s important things in life, and the family member’s spiritual or religious beliefs with physicians and nurses were not acceptable. This finding was based on our definition of discrimination, as items that have an item-total correlation of at least 0.30 and those with values of between 0.20 and 0.30 were defined as moderately discriminating.23 Additionally, interitem correlation between 0.30 and 0.70 are recommended, with correlations lower than 0.30 suggesting little congruence with the underlying construct and those higher than 0.70 suggesting redundancy.23 Our findings suggest that a more rigorous investigation of the item appropriateness, relevance, and redundancy of the Korean QOC should be conducted. Furthermore, the Korean version of the QOC ought to be validated with an assessment of multiple psychometric properties, as examining its internal consistency alone is insufficient to determine that this questionnaire is a valid instrument with which to assess Korean ICU family members’ perceptions of quality of communication with clinicians. Further evaluation for stability reliability (test-retest reliability), construct-related validity such as convergent or divergent, criterion validity, and responsiveness, is necessary. In addition, the education level of study participants needs to be carefully considered in future research. Although family members who reported lower educational attainment did not report any difficulties in completing the Korean version of the QOC, they made up a small proportion of the study sample, with the rest being relatively well educated. A further evaluation of the questionnaire on a Korean sample with different levels of education is warranted to support our findings. Despite these limitations, our findings provide preliminary evidence of the acceptability and reliability of the Korean version of the QOC when administered to
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ICU family members. Future studies in this area may include further evaluation of item relevance and construct validity in Korean populations. Conclusion This is the first study on the translation and cultural adaptation of the QOC questionnaire into Korean. The internal consistency of the Korean version of the QOC was acceptable overall but we found that some items warranted further evaluation. Future research should also include examining the construct validity of the measure in Korean populations. Acknowledgements The authors offer thanks to ICU nursing staffs from Catholic Medical Centers in Korea for their help and support for recruitment and data collection. References 1. Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. Am J Respir Crit Care Med. 2010;182:446e454. 2. Kim MH, Cho WH, Lee K, et al. Prognostic factors of patients requiring prolonged mechanical ventilation in a medical intensive care unit of Korea. Tubercu Respir Dis. 2012;73:224e230. 3. Lee K, Hong SB, Lim CM, Koh Y. Sequential organ failure assessment score and comorbidity: valuable prognostic indicators in chronically critically ill patients. Anaesth Intensive Care. 2008;36:528e534. 4. Nelson JE, Mercado AF, Camhi SL, et al. Communication about chronic critical illness. Arch Intern Med. 2007;167:2509e2515. 5. Yang S. A mixed methods study on the needs of Korean families in the intensive care unit. Aust J Adv Nurs. 2008;25:79e86. 6. Cox CE, Martinu T, Sathy SJ, et al. Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med. 2009;37:2888e2894. 7. Azoulay E, Pochard F, Kentish-Barnes N, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005;171:987e994. 8. Pochard F, Darmon M, Fassier T, et al. Symptoms of anxiety and depression in family members of intensive care unit patients before discharge or death: a prospective multicenter study. J Crit Care. 2005;20:90e96. 9. Pochard F, Azoulay E, Chevret S, et al. Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity. Crit Care Med. 2001;29:1893e1897. 10. Curtis JR, Engelberg RA, Nielsen EL, Au DH, Patrick DL. Patient-physician communication about end-of-life care for patients with severe COPD. Eur Respir J. 2004;24:200e205.
11. Engelberg R, Downey L, Curtis JR. Psychometric characteristics of a quality of communication questionnaire assessing communication about end-of-life care. J Palliat Med. 2006;9:1086e1098. 12. Curtis JR, Back AL, Ford DW, et al. Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomized trial. JAMA. 2013;310:2271e2281. 13. Majesko A, Hong SY, Weissfeld L, White DB. Identifying family members who may struggle in the role of surrogate decision maker. Crit Care Med. 2012;40: 2281e2286. 14. Stapleton RD, Engelberg RA, Wenrich MD, Goss CH, Curtis JR. Clinician statements and family satisfaction with family conferences in the intensive care unit. Crit Care Med. 2006;34:1679e1685. 15. Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of healthrelated quality of life measures: literature review and proposed guidelines. J Clin Epidemiol. 1993;46:1417e1432. 16. Kwon YC, Shin DW, Lee JH, et al. Impact of perception of socioeconomic burden on advocacy for patient autonomy in end-of-life decision making: a study of societal attitudes. Palliat Med. 2009;23:87e94. 17. Lee S, Lee WH, Kong BH, Kim IS, Kim S. Nurses’ perceptions of informed consent and their related roles in Korea: an exploratory study. Int J Nurs Stud. 2009;46: 1580e1584. 18. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25:3186e3191. 19. Douglas SL, Daly BJ. Caregivers of long-term ventilator patients: physical and psychological outcomes. Chest. 2003;123:1073e1081. 20. Douglas SL, Daly BJ, O’toole E, Hickman RL. Depression among Caucasian and non-Caucasian caregivers of the chronically critically ill. J Crit Care. 2010;25: e311e319. 21. Douglas SL, Daly BJ, Kelley CG, O’Toole E, Montenegro H. Impact of a disease management program upon caregivers of chronically critically ill patients. Chest. 2005;128:3925e3936. 22. Shin DW, Lee JE, Cho B, Yoo SH, Kim S, Yoo JH. End-of-life communication in Korean older adults: with focus on advance care planning and advance directives. Geriat Gerontol Int. 2016;16:407e415. 23. Nunnally JC, Bernstein IH. Psychometric Theory. 3rd ed. New York, NY: McGraw-Hill; 1994. 24. Terwee CB, Bot S, de Boer MR, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60:34e42. 25. Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007;356: 469e478. 26. Boyle DK, Miller PA, Forbes-Thompson SA. Communication and end-of-life care in the intensive care unit: patient, family, and clinician outcomes. Crit Care Nurs Q. 2005;28:302e316. 27. Adams JA, Bailey DE, Anderson RA, Docherty SL. Nursing roles and strategies in end-of-life decision making in acute care: a systematic review of the literature. Nurs Res Pract;. http://dx.doi.org/10.1155/2011/527834. Accessed 22 September 2016. 28. Jo K. Nurse’s conflict experience toward end-of-life medical decision-making. J Korean Acad Adult Nurs. 2010;22:488e498. 29. Sidani S, Guruge S, Miranda J, Ford-Gilboe M, Varcoe C. Cultural adaptation and translation of measures: an integrated method. Res Nurs Health. 2010;33: 133e143.
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Translation and cultural adaptation of the quality of communication questionnaire for ICU family members in Korea Minjeong Jo, PhD, RN a, *, Mi-Kyung Song, PhD, RN, FAAN b, Marcia Van Riper, PhD, RN, FAAN c, Yang-Sook Yoo, PhD, RN a, George J. Knafl, PhD c, Linda Beeber, PhD, RN, CS c a
The Catholic University of Korea, College of Nursing, Seoul 06591, South Korea Emory University, Nell Hodgson Woodruff School of Nursing, Center for Nursing Excellence in Palliative Care, Atlanta, GA 30322, USA c University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC 27599, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 26 April 2017 Received in revised form 4 August 2017 Accepted 5 August 2017 Available online xxx
Background: There are no Korean instruments to assess the concepts associated with end-of-life communication quality. Objectives: To translate and culturally adapt the Quality of Communication (QOC) questionnaire into Korean and evaluate its acceptability and internal consistency. Methods: We first translated the QOC from English into Korean, then back-translated from Korean to English, and evaluated the cultural appropriateness of the items. We pretested and refined the Korean version of the QOC with 11 ICU family members. Subsequently, the Korean version of the QOC was administered to 62 family members of chronically critically ill patients recruited from 10 ICUs to evaluate its internal consistency. Results: Participants completed the Korean QOC without difficulty during the pretest, and it showed acceptable internal consistency (Cronbach’s alpha 0.85). Conclusion: This study provided preliminary evidence of the acceptability and reliability of the Korean QOC in ICU family members. Nonetheless, further evaluation, including item relevance and other psychometric properties, is warranted. Ó 2017 Elsevier Inc. All rights reserved.
Keywords: Communication Family Intensive care unit Instrument Translation
Background The number of chronically critically ill patients in Korea is growing. Although there is no universal definition, the term, chronic critical illness (CCI) is used for patients with prolonged dependence on mechanical ventilation.1 According to studies based on hospital medical records, CCI patients account for 5%e6% of all patients admitted to intensive care units (ICU) in Korea.2,3 Because these CCI patients are typically unable to communicate their needs or wishes about treatments at the end of life, treatment decision making primarily involves family members and clinicians.1,4 Accordingly, the quality of end-of-life communication between family members of ICU patients and clinicians (physicians or nurses) is emphasized in Korea.5 Poor family-clinician communication often results in family members not having an adequate Funding: This work was supported by Sigma Theta Tau International and the University of North Carolina at Chapel Hill. * Corresponding author. The Catholic University of Korea, College of Nursing, Seoul 06591, South Korea. E-mail address: [email protected] (M. Jo). 0147-9563/$ e see front matter Ó 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2017.08.002
understanding of the patient’s medical condition, prognosis, or the effectiveness of treatments.6 This may cause family members to choose to continue life-sustaining treatments that have little to no therapeutic benefit. Studies7e9 have indicated that family members who perceive that insufficient communication time has been allotted, or that information is difficult to comprehend, are at risk for symptoms of anxiety, depression, and stress. These findings suggest that poor family-clinician communication adversely affects both family members’ comprehension of patient treatment and their mental health. Systematic assessment is a first step to improve the quality of communication, yet there are currently no instruments in Korean for assessing concepts associated with end-of-life communication quality. The Quality of Communication (QOC) questionnaire designed for English-speakers in the United States was originally developed to assess patients’ perceptions of the quality of communication with their physicians.10 The QOC items were developed from qualitative interviews and focus groups involving patients with chronic obstructive pulmonary disease (COPD), cancer, and acquired immune deficiency syndrome as well as family members and clinicians.10,11
2
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Later, the QOC was used by the developers to measure family members’ perceptions of the quality of communication with physicians or nurse practitioners.12e14 The QOC contains 19 items asking the respondent to rate the clinician’s general communication skills and communication about end-of-life care on an 11-point Likert scale (0 ¼ poor, 10 ¼ absolutely perfect). Respondents are also offered two additional response options, “physician or nurse did not do this” and “I do not know.”11 The QOC consists of two subscales: the general communication skills scale and communication about end-of-life care scale.11 A summative score is computed by adding the individual item scores divided by the number of items (answered by the family member), and then multiplying that figure by 10 to generate a score ranging from 0 to 100. Higher scores indicate better perceived quality of communication.11 The psychometric characteristics of the QOC have been evaluated in samples of hospice patients and patients with COPD.11 The QOC subscales reported an acceptable internal consistency (a for general communication was 0.91 and for end-of-life care communication was 0.79).11 Construct validity was demonstrated with moderate correlations (r ¼ 0.54 to 0.74) with a single-item assessing the overall quality of clinician communication, quality of end-of-life care discussion, and quality of care separately.11 Translation and cultural adaptation of the QOC have not been performed in other languages. Considering the time and cost involved in developing a new instrument, modifying an existing instrument with demonstrated reliability and validity is a better option.15 Therefore, the purpose of this study was to translate and culturally adapt the QOC into Korean and assess its acceptability and internal consistency when administered to ICU family members in Korea.
in Korean and English and had not participated in either the forward or backward translation. The committee members independently assessed the appropriateness of the translation and evaluated its equivalence with the original version semantically, experientially, and conceptually. Pretesting and cognitive interviews We conducted cognitive interviews with 11 family members of ICU patients in Korea. Family members of adult patients in the ICU were invited to participate if they were: (1) 19 years old or older (the legal age of consent in Korea) and (2) self-identified as a primary care giver (defined as the family member most likely to provide pre-admission or post-discharge care giving)19 or the family decision-maker (defined as the family member most involved in the patient’s treatment decisions),20 and (3) “spokespersons” for the family who communicated with ICU physicians and/or nurses about the patient’s illness or treatment. The investigator approached willing family members during their ICU visits to assess their eligibility and interest in study participation. Family members who expressed interest in the study were contacted by the investigator after their ICU visit. Upon giving consent, family members completed surveys, including the Korean version of the QOC for physicians and nurses each and a sociodemographic profile. Once completed, family members were asked if there were any words or sentences that they had found difficult to understand. A probe technique was also used that asked family members probe questions such as “What do you mean?”15 Family members were asked to rephrase each item in their own words to elucidate their understandings of the items in an open-ended manner.
Methods Pilot testing and evaluation of internal consistency The study was approved by the Institutional Review Board at the University of North Carolina at Chapel Hill in the United States and by the three medical centers in Korea where the study was conducted. Translation and cultural adaptation In this study, two items, one to assess family members’ perceptions of quality in terms of information consistency and one to ask how much time was allocated to receive information from ICU physicians and nurses, were added to the QOC. This decision was made based on a Korean literature review, which suggested that receiving consistent information from ICU physicians and nurses, and having adequate opportunities to communicate with them, were identified as the priorities of ICU family members in Korea.5 Thus, the 21-item QOC was used for this study. Additionally, the rating instruction was changed from “How good was the physician or nurse at each of the communication behaviors?” to “How satisfied were you with each of the physician’s or nurse’s communication behaviors?” This change was made because, culturally, physicians in Korea are revered in the belief that they possess special knowledge or experience16 and thus family members often feel uncomfortable evaluating their communication behavior.17 To modify the QOC into a Korean version, we used the process recommended by Guillemin et al.,15,18 including forward translation, backward translation, committee review, and pretesting. Two bilingual translators whose first language was Korean translated the QOC into Korean (forward translation). Another two bilingual translators, but not those who had performed the forward translation, translated the QOC in Korean into English (backward translation). Three versions of the QOC (one translated into Korean, one back translated into English, and the original QOC) were then reviewed by a committee consisting of the first author, two nursing professors, one ICU physician, and one ICU nurse, who were fluent
Design and setting We conducted a cross-sectional survey with 62 family members of ICU patients. From December 2015 to April 2016, participants were recruited from 10 ICUs at three medical centers affiliated with the Catholic University in Korea. To identify family members of CCI patients, the following inclusion criteria were used for patients: (1) 19 years of age or older, and (2) chronically critically ill (i.e., failed to be weaned or not considered for weaning within three days of initiation of mechanical ventilation).21 The eligibility criteria for family members was the same as those described above. The ICU nursing staff first identified eligible patients and approached their family members during their ICU visits to assess their willingness to meet the investigator. The investigator approached the willing family members during their ICU visits to assess their eligibility and interest in study participation. Upon giving consent, family members completed the Korean version of the QOC for physicians and nurses each and a sociodemographic profile, in a private room near the ICU. With approval from the participating hospitals in Korea and family consent, bedside nurses collected patient age, gender, admitting diagnosis, length of ICU stay, and period of mechanical ventilator dependence from the electronic medical records. Data analysis All data were analyzed using SAS version 9.3 (SAS Institute Inc., Cary, NC). Descriptive statistics, including means, standard deviations (SD), and percentages, were computed to summarize the sample characteristics and QOC scores. The internal consistency of the Korean version of the QOC was evaluated by calculating Cronbach’s alpha (a) coefficients. Additionally, the inter-item and item-total correlations were computed to evaluate item discrimination and redundancy.
M. Jo et al. / Heart & Lung xxx (2017) 1e6
Results Review of translation and cultural adaptation During the committee review of the translated original version of the QOC, three changes were made. In Item 15, “talking with you about what your patient dying might be like,” the term “dying” was replaced with the Korean term “임종 [imjong],” which is a euphemism for “dying.” This replacement was made as family members may feel uncomfortable with the direct translation of “dying.” Traditionally, open discussion of death and dying has been taboo in Korea.22 Additionally, two items, “asking about the things in life that are important to your patient (item 16)” and “respecting the things in life that are important to your patient (item 17),” were considered activities not commonly practiced during communication between family members and physicians or nurses in Korea, and were deemed too abstract for family members to answer. Thus, the phrase “such as values, beliefs, persons” was added in parentheses after each item to provide a supplementary explanation of “things in life.” Pretesting The mean (SD) age of patients was 64.2 (12.3), and seven were males. Nine were dependent on mechanical ventilation. The most common diagnoses leading to patients’ ICU admission were cardiovascular or respiratory conditions (n ¼ 7). The median ICU stay was seven days (IQR ¼ 43) with the median length of mechanical ventilation six days (IQR ¼ 21). The mean (SD) age of family members was 54.5 (13.8). Six were men and nine family members had completed at least high school education. The majority were either an adult child or spouse of the patient (n ¼ 9). The cognitive interviews took 15 min on average. Family members reported no difficulty and that all items were clear. There were no skipped items. Pilot testing and evaluation of internal consistency Characteristics of patients and family members The mean (SD) age of patients was 63.9 (16.3) (Table 1). Approximately half were women (n ¼ 33, 53.2%) and approximately 60% were married (n ¼ 39, 62.9%). The top three diagnoses leading to patients’ ICU admission were respiratory (n ¼ 19, 30.7%), neurologic (n ¼ 11, 17.7%), and neoplastic disorders (n ¼ 11, 17.7%). The median ICU stay was 10 days (IQR ¼ 8) with the median length of mechanical ventilation 9.5 days (IQR ¼ 8). The mean (SD) age of family members was 48.9 (14.1). Approximately two thirds of family members were women (n ¼ 43, 69.4%) and the majority had completed at least high school education (n ¼ 56, 90.6%). The majority were either an adult child or spouse of the patient (n ¼ 51, 82.3%). Responses to the Korean QOC The mean (SD) summative score of the Korean QOC for physicians was 49.1 (15.0). The mean scores for each item ranged from 0.5 to 8.5 and the mean score for item 21, rating overall quality of communication with the physician, was 7.6 ranging from 0 to 10 (Table 2). Five items assessing communication about patient dying, patient’s important things in life, and family member’s spiritual or religious beliefs (15, 16, 17, 18, and 19) had extremely low ratings for physicians (0.5e0.9). For these items, more than 80% of family members reported that physicians did not perform them (80.3%e88.7%). The mean (SD) summative score of the Korean QOC for nurses was 41.5 (13.0). The mean scores for each item ranged from 0.1 to 8.4 and the mean score for item 21, rating overall quality of communication with the nurse, was 7.8 ranging from 2.0 to 10.0. Eight items
3
Table 1 Characteristics of patients (N ¼ 62) and family members (N ¼ 62). Variable
Patients
Family members
n (%) Age, M (SD) Gender, M (SD) Male Female Education < High school High school graduate College graduate Marital status Never married Currently married Widowed Divorced Family member relationship to patient Spouse Parent Child Daughter-in-law or son-in-law Sibling Hospital length of stay, Median (IQR) ICU length of stay, Median (IQR) Days of mechanical ventilation use, Median (IQR) Primary ICU admission diagnosis Respiratory disease Neurologic disease Neoplastic disease Cardiovascular disease Renal disease Othera
63.9 (16.3)
48.9 (14.1)
29 (46.8) 33 (53.2)
19 (30.7) 43 (69.4) 6 (9.7) 18 (29.0) 38 (61.3)
6 (9.7) 39 (62.9) 16 (25.8) 1(1.6) 19 (30.7) 5 (8.1) 32 (51.6) 2 (3.2) 4 (6.5) 13.5 (17) 10.0 (8) 9.5 (8)
19 (30.7) 11 (17.7) 11 (17.7) 7 (11.3) 4 (6.5) 10 (16.1)
Note. ICU¼Intensive Care Unit. a Other includes acute duodenal ulcer, alcoholic ketoacidosis, bacteremia, chronic graft-versus-host disease, disseminated.
assessing communication about patient’s treatment preference, patient’s life expectancy, patient dying, patient’s important things in life, and family member’s spiritual or religious beliefs (11, 14, 15, 16, 17, 18, 19, and 20) had extremely low ratings (0.1e1.5) for nurses. For these items, more than 76% of family members reported that nurses did not perform them (76.1%e93.0%). Internal consistency and item-total correlation of the Korean QOC The Korean QOC showed acceptable Cronbach’s alpha coefficients (a ¼ 0.87 for QOC for physicians and a ¼ 0.85 for QOC for nurses). In the QOC for physicians, inter-item correlations ranged from 0.09 to 0.89 (Table 3). The item-total correlations ranged from 0.13 to 0.69 and two items assessing communication about family member’s spiritual or religious beliefs (18 and 19) had very low correlations with the total score (0.18 and 0.13 respectively). The Cronbach’s alpha coefficients were slightly higher (0.88 for both cases) without Items 18 or 19. In the QOC for nurses, inter-item correlations ranged from 0.02 to 0.98 (Table 4). The item-total correlations ranged from 0.10 to 0.71 and five items assessing communication about patient dying, patient’s important things in life, and family member’s spiritual or religious beliefs (15, 16, 17, 18, and 19) had very low correlations with the total score (0.10e0.19). The Cronbach’s alpha coefficients did not change when each of these items was omitted. Discussion This study has described the process of translating and adapting the QOC for the Korean context and its preliminary psychometric properties. Family members completed items of the Korean QOC without difficulty and reported that all items were clear during the
20
Table 2 Responses to the Korean version of the QOC.
2.9 (4.0)
2.2 (3.6)
0.6 (1.9)
0.8 (2.3)
0.1 (0.8)
0.6 (2.1)
0.6 (2.1)
0.9 (2.5)
1.1 (0.6)
0.6 (2.2)
0.4 (1.7)
0.5 (2.0) 2.5 (3.9)
0.5 (1.8) 2.5 (3.9)
7.6 (2.3)
7.8 (2.1)
49.1 (15.0)
41.5 (13.0)
10 9 8 7 6 5 4 3
0.03 0.13 0.88 0.89** 0.11 0.18 0.88 0.10 0.07 0.44** 0.41 0.87 0.84** 0.16 0.05 0.44** 0.38 0.87 0.40** 0.33** 0.07 0.05 0.22 0.24 0.87 0.54** 0.20 0.13 0.02 0.02 0.51** 0.39 0.87 0.76** 0.73** 0.67** 0.56** 0.23 0.67** 0.67** 0.68** 0.58** 0.14 0.28* 0.31 0.12 0.05 0.16 0.21 0.07 0.03 0.28* 0.61 0.86 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Item-total correlation Cronbach’s alpha if item was deleted
2 1 Item
pretest. These findings suggest that the Korean QOC could be self-administered among family members of ICU patients. Our data also demonstrated that the Korean QOC showed acceptable internal consistency (a ¼ 0.87 for physicians and a ¼ 0.85 for nurses) as a Cronbach’s alpha coefficient of at least 0.70 is typically considered acceptable.23,24 Effective end-of-life communication between family members and clinicians is critical to improve the quality of ICU care. Family members’ unmet communication needs have been linked to their lack of understanding of the patient’s medical condition and treatments, lack of trust in clinicians, increased risk for symptoms of anxiety, depression, and stress, and dissatisfaction with ICU care.6,25e27 Since there have been no Korean instruments to assess family members’ perceptions about the quality of end-of-life communication with physicians and nurses, the Korean version of the QOC has significant implications for clinicians and researchers. The Korean QOC can aid in assessing family members’ satisfaction with clinicians’ communication behaviors, such as active listening, discussing prognoses, providing emotional support, and deliberating with family members about treatment decision-making as well as their perceptions of end-of-life communication in the ICU.
Table 3 Inter-item and item-total correlations of the Korean version of the QOC for physicians.
Note. QOC ¼ Quality of Communication. Response rating: 0 (not at all satisfied) to 10 (extremely satisfied). a,b Item 4 and 5 were added to the Korean version of the QOC. c,d Item 16 and 17 were revised to the Korean version of the QOC.
Note. QOC ¼ Quality of Communication. * p < 0.05; **p < 0.01.
5.8 (3.8)
12
2.7 (3.8)
11
4.3 (4.0)
13
14
15
(2.3) (2.1) (2.4) (3.1)
0.35** 0.18 0.21 0.25 0.10 0.10 0.45** 0.61 0.86
8.0 8.2 7.7 1.5
0.64** 0.23 0.25* 0.31* 0.38** 0.18 0.14 0.28* 0.51 0.87
7.9 8.4 7.7 3.3
0.36** 0.41** 0.41** 0.33* 0.39** 0.46** 0.01 0.09 0.52** 0.47 0.87
7.7 (2.3)
0.09 0.21 0.33 0.00 0.05 0.08 0.11 0.03 0.02 0.15 0.56 0.86
7.9 (2.3)
0.83** 0.19 0.23 0.39 0.09 0 0.06 0.09 0.03 0.02 0.26* 0.65 0.86
4.1 (4.2)
0.84** 0.71** 0.09 0.25 0.36 0.15 0.03 0.10 0.14 0.03 0.03 0.31* 0.65 0.86
6.1 (3.4)
0.82** 0.84** 0.74** 0.15 0.23 0.27 0.06 0.01 0.05 0.09 0.03 0.06 0.26* 0.63 0.86
6.9 (2.8)
0.26 0.19 0.18 0.04 0.37** 0.17 0.32 0.33** 0.16 0.04 0.03 0.11 0.10 0.18 0.33 0.87
6.7 (2.7)
0.15 0.71** 0.68** 0.65** 0.72** 0.24 0.23 0.31 0.13 0.02 0.15 0.17 0.12 0.10 0.29* 0.62 0.86
6.7 (3.1)
0.80 0.17 0.76** 0.79** 0.80** 0.81** 0.15 0.31* 0.41 0.14 0.10 0.13 0.12 0.11 0.12 0.32* 0.69 0.86
7.7 (2.3)
0.86** 0.66** 0.14 0.74** 0.78** 0.79** 0.78** 0.14 0.30* 0.42 0.11 0.03 0.14 0.17 0.11 0.12 0.30* 0.68 0.86
8.4 (1.8) 8.3 (2.0) 6.9 (3.1)
19
M (SD)
7.7 (2.0) 8.5 (1.7) 7.8 (2.1)
18
M (SD) 1.Using words that you can understand 2.Looking you in the eye 3.Giving you information about your patient’s illness and treatment 4.Providing you consistent information about your patient’s illness and treatmenta 5.Allowing enough time for communication about your patient’s illness and treatmentb 6.Including you in decisions about your patient’s illness and treatment 7.Answering all your questions about your patient’s illness and treatment 8.Listening to what you have to say 9.Caring about you as a person 10.Giving you his or her full attention 11.Asking about the kinds of treatments you patient would want if he or she could speak for himself or herself 12.Talking with you about your feeling that your patient might get sicker 13.Talking with you about when or how your patient might get sicker 14.Talking with you about how long your patient might have to live 15.Talking with you about what your patient dying might be alike 16.Asking about the things (values, beliefs, people, etc.) in life that are important to your patientc 17.Respecting the things (values, beliefs, people, etc.) in life that are important to your patientd 18.Asking about your spiritual or religious beliefs 19.Respecting your spiritual or religious beliefs 20.Helping you decide about the kinds of treatments your patient would want 21.Overall, how would you rate communication with the patient’s doctor/nurse Summative score
(2.3) (1.9) (2.2) (3.9)
Nurses
17
Physicians
16
Items
0.56 0.86
M. Jo et al. / Heart & Lung xxx (2017) 1e6
0.59** 0.59** 0.56** 0.21 0.62** 0.61** 0.66** 0.57** 0.18 0.30* 0.35 0.14 0.08 0.06 0.09 0.03 0.02 0.24 0.57 0.87
4
0.34 0.84 0.16 0.19 0.85 0.76** 0.02 0.10 0.85 0.34** 0.31* 0.18 0.10 0.85 1.00** 0.34** 0.31* 0.18 0.10 0.85 0.98** 0.98** 0.36** 0.32* 0.17 0.11 0.85 0.30* 0.29* 0.29* 0.05 0.34** 0.20 0.23 0.85 0.28* 0.10 0.12 0.12 0.05 0.17 0.33** 0.48 0.84 0.51** 0.20 0.08 0.09 0.09 0.05 0.18 0.25 0.51 0.84 51** 0.40** 0.23 0.14 0.14 0.14 0.16 0.31* 0.34** 0.46 0.84 0.16 0.21 0.18 0 0.15 0.15 0.15 0.02 0.06 0.05 0.55 0.84 0.73** 0.14 0.18 0.14 0.02 0.14 0.15 0.15 0.06 0.10 0.13 0.60 0.83 0.86** 0.72** 0.16 0.14 0.15 0.02 0.11 0.17 0.17 0.24 0.26 0.11 0.55 0.84 0.63** 0.61** 0.53** 0.15 0.24 0.18 0 0.10 0.14 0.14 0 0.07 0.12 0.59 0.83 0.24 0.22 0.21 0.22 0.36 0.28* 0.44** 0.23 0.03 0.04 0.04 0.04 0.07 0.25 43 0.84 0.04 0.73** 0.52** 0.59** 0.54** 0.19 0.31* 0.35** 0.02 0.04 0.05 0.05 0.07 0.04 0.22 0.71 0.83 0.65** 0.22 0.57** 0.39** 0.44** 0.40** 0.18 0.41** 0.26* 0.06 0.03 0.04 0.04 0.08 0.08 0.18 0.64 0.83 Note. QOC ¼ Quality of Communication. * p < 0.05; **p < 0.01.
0.96** 0.65** 0.19 0.59** 0.42** 0.44** 0.41** 0.16 0.35** 0.21 0.06 0.04 0.06 0.06 0.07 0.04 0.17 0.61 0.83 0.72** 0.43** 0.40** 0.54** 0.12 0.56** 0.81** 0.88** 0.65** 0.11 0.19 0.05 0.11 0.17 0.20 0.20 0.06 0.11 0.10 0.53 0.84
0.39** 0.37** 0.46** 0.20 0.44** 0.70** 0.72** 0.68** 0.16 0.25 0.16 0.08 0.08 0.12 0.12 0.03 0.02 0.18 0.57 0.84
6 5 4 3
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Item-total correlation Cronbach’s alpha if item was deleted
2 1 Items
Table 4 Inter-item and item-total correlations of the Korean version of the QOC for nurses.
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Although the Korean QOC was well received and showed acceptable internal consistency in this study, we noticed several issues. The ratings of items assessing quality of communication about end-of-life care (i.e., talking about what the patient dying might be like or how long the patient might have to live) in both physicians and nurses were extremely low (0.1e1.5). These low ratings were mainly due to the fact that more than 76% of family members reported that physicians or nurses did not perform with respect to those items. The answer “physician or nurse did not do this” was replaced by a score of 0 based on the method of Engelberg et al.11 High rates of “physician or nurse did not do this” for items assessing quality of family-clinician communication about end-of-life care suggest an issue with the instrument, insofar as such items may not be culturally applicable. In Korean culture, communication about a patient’s poor prognosis is usually discouraged because openly discussing death and dying is taboo.22 In this cultural context, physicians and nurses may be uncomfortable with, or avoid, communicating in relation to expectations of patient survival and end-of-life treatment.28 Furthermore, the low ratings of nurses’ communication behavior may reflect the paternalistic medical practice model in Korea, wherein nurses may consider providing prognostic information to be the primary task of physicians and might therefore be reluctant to provide family members with that information.28 Unfortunately, our pretesting failed to detect this problem, perhaps because the pretesting using cognitive interviews focused on item clarity. We primarily used probe questions such as “What does the item mean?” and “Was this an item you felt comfortable answering?” However, Sidani et al.29 have suggested that the cultural relevance of each item should also be determined using questions such as “How important is the item in capturing the concept of interest as understood and/or experienced by you and people of your community?” Our study did not add questions of relevance during the cognitive interviews. We also found that inter-item and item-total correlations of several items assessing communication about end-of-life care such as the patient dying, the patient’s important things in life, and the family member’s spiritual or religious beliefs with physicians and nurses were not acceptable. This finding was based on our definition of discrimination, as items that have an item-total correlation of at least 0.30 and those with values of between 0.20 and 0.30 were defined as moderately discriminating.23 Additionally, interitem correlation between 0.30 and 0.70 are recommended, with correlations lower than 0.30 suggesting little congruence with the underlying construct and those higher than 0.70 suggesting redundancy.23 Our findings suggest that a more rigorous investigation of the item appropriateness, relevance, and redundancy of the Korean QOC should be conducted. Furthermore, the Korean version of the QOC ought to be validated with an assessment of multiple psychometric properties, as examining its internal consistency alone is insufficient to determine that this questionnaire is a valid instrument with which to assess Korean ICU family members’ perceptions of quality of communication with clinicians. Further evaluation for stability reliability (test-retest reliability), construct-related validity such as convergent or divergent, criterion validity, and responsiveness, is necessary. In addition, the education level of study participants needs to be carefully considered in future research. Although family members who reported lower educational attainment did not report any difficulties in completing the Korean version of the QOC, they made up a small proportion of the study sample, with the rest being relatively well educated. A further evaluation of the questionnaire on a Korean sample with different levels of education is warranted to support our findings. Despite these limitations, our findings provide preliminary evidence of the acceptability and reliability of the Korean version of the QOC when administered to
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ICU family members. Future studies in this area may include further evaluation of item relevance and construct validity in Korean populations. Conclusion This is the first study on the translation and cultural adaptation of the QOC questionnaire into Korean. The internal consistency of the Korean version of the QOC was acceptable overall but we found that some items warranted further evaluation. Future research should also include examining the construct validity of the measure in Korean populations. Acknowledgements The authors offer thanks to ICU nursing staffs from Catholic Medical Centers in Korea for their help and support for recruitment and data collection. References 1. Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. Am J Respir Crit Care Med. 2010;182:446e454. 2. Kim MH, Cho WH, Lee K, et al. Prognostic factors of patients requiring prolonged mechanical ventilation in a medical intensive care unit of Korea. Tubercu Respir Dis. 2012;73:224e230. 3. Lee K, Hong SB, Lim CM, Koh Y. Sequential organ failure assessment score and comorbidity: valuable prognostic indicators in chronically critically ill patients. Anaesth Intensive Care. 2008;36:528e534. 4. Nelson JE, Mercado AF, Camhi SL, et al. Communication about chronic critical illness. Arch Intern Med. 2007;167:2509e2515. 5. Yang S. A mixed methods study on the needs of Korean families in the intensive care unit. Aust J Adv Nurs. 2008;25:79e86. 6. Cox CE, Martinu T, Sathy SJ, et al. Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med. 2009;37:2888e2894. 7. Azoulay E, Pochard F, Kentish-Barnes N, et al. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med. 2005;171:987e994. 8. Pochard F, Darmon M, Fassier T, et al. Symptoms of anxiety and depression in family members of intensive care unit patients before discharge or death: a prospective multicenter study. J Crit Care. 2005;20:90e96. 9. Pochard F, Azoulay E, Chevret S, et al. Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity. Crit Care Med. 2001;29:1893e1897. 10. Curtis JR, Engelberg RA, Nielsen EL, Au DH, Patrick DL. Patient-physician communication about end-of-life care for patients with severe COPD. Eur Respir J. 2004;24:200e205.
11. Engelberg R, Downey L, Curtis JR. Psychometric characteristics of a quality of communication questionnaire assessing communication about end-of-life care. J Palliat Med. 2006;9:1086e1098. 12. Curtis JR, Back AL, Ford DW, et al. Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: a randomized trial. JAMA. 2013;310:2271e2281. 13. Majesko A, Hong SY, Weissfeld L, White DB. Identifying family members who may struggle in the role of surrogate decision maker. Crit Care Med. 2012;40: 2281e2286. 14. Stapleton RD, Engelberg RA, Wenrich MD, Goss CH, Curtis JR. Clinician statements and family satisfaction with family conferences in the intensive care unit. Crit Care Med. 2006;34:1679e1685. 15. Guillemin F, Bombardier C, Beaton D. Cross-cultural adaptation of healthrelated quality of life measures: literature review and proposed guidelines. J Clin Epidemiol. 1993;46:1417e1432. 16. Kwon YC, Shin DW, Lee JH, et al. Impact of perception of socioeconomic burden on advocacy for patient autonomy in end-of-life decision making: a study of societal attitudes. Palliat Med. 2009;23:87e94. 17. Lee S, Lee WH, Kong BH, Kim IS, Kim S. Nurses’ perceptions of informed consent and their related roles in Korea: an exploratory study. Int J Nurs Stud. 2009;46: 1580e1584. 18. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25:3186e3191. 19. Douglas SL, Daly BJ. Caregivers of long-term ventilator patients: physical and psychological outcomes. Chest. 2003;123:1073e1081. 20. Douglas SL, Daly BJ, O’toole E, Hickman RL. Depression among Caucasian and non-Caucasian caregivers of the chronically critically ill. J Crit Care. 2010;25: e311e319. 21. Douglas SL, Daly BJ, Kelley CG, O’Toole E, Montenegro H. Impact of a disease management program upon caregivers of chronically critically ill patients. Chest. 2005;128:3925e3936. 22. Shin DW, Lee JE, Cho B, Yoo SH, Kim S, Yoo JH. End-of-life communication in Korean older adults: with focus on advance care planning and advance directives. Geriat Gerontol Int. 2016;16:407e415. 23. Nunnally JC, Bernstein IH. Psychometric Theory. 3rd ed. New York, NY: McGraw-Hill; 1994. 24. Terwee CB, Bot S, de Boer MR, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60:34e42. 25. Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007;356: 469e478. 26. Boyle DK, Miller PA, Forbes-Thompson SA. Communication and end-of-life care in the intensive care unit: patient, family, and clinician outcomes. Crit Care Nurs Q. 2005;28:302e316. 27. Adams JA, Bailey DE, Anderson RA, Docherty SL. Nursing roles and strategies in end-of-life decision making in acute care: a systematic review of the literature. Nurs Res Pract;. http://dx.doi.org/10.1155/2011/527834. Accessed 22 September 2016. 28. Jo K. Nurse’s conflict experience toward end-of-life medical decision-making. J Korean Acad Adult Nurs. 2010;22:488e498. 29. Sidani S, Guruge S, Miranda J, Ford-Gilboe M, Varcoe C. Cultural adaptation and translation of measures: an integrated method. Res Nurs Health. 2010;33: 133e143.