The effect of training and education at the emergency department 131 6 4.1 Strengths and limitations One strength of our study lies in the comprehensive examination of the intervention’s impact on all types of admitted patients, as opposed to exclusively focusing on critically ill individuals. This approach enhances the generalizability of our data. Moreover, our investigation delved into patient satisfaction rather than the sheer quantity of conversations, providing a nuanced perspective on the intervention’s outcomes. Our study is susceptible to recall bias due to its post-experience interview nature. However, we prioritized the patient’s recollection of the conversation over the specific details discussed. Additionally, almost half of the patients were excluded due to critical illness, cognitive impairment, or language barriers, precluding conclusions about these groups. COVID-19 restrictions limited family presence, hindering their role as proxies for patients. There may also be selection bias as critically ill patients unable to respond to the questionnaire were excluded from care decision conversations. The pre-post intervention study design may introduce effects from unexamined factors, however we explored the effect of time on our outcome, which showed to be insignificant. Because of the decision to implement both interventions at the same moment in time, we are unable to distinct which intervention (the patient leaflet or the physician training) is more effective. However, as mentioned before, only 12% of patients recalled receiving the leaflet. This suggest that the physician training contributed more to the significant improvement in patient-reported quality of communication than the patient leaflet. We did not separately evaluate the effect of different parts of the training either. However, in a previous study at the outpatient clinic, a physician training without this basis on care decision conversations showed to be ineffective in improving patient satisfaction.24 Although that study differed in terms of setting and outcome measurements from the current study, it indicates that the adjustments we made based on conversation analysis of authentic care decision conversations23 contributed to the effectiveness. This could be explained by an increased perceived relevance for the physician when authentic, recognizable sentences are provided and the interactional implications are discussed. Increasing the perceived relevance stimulates the retention of the gained knowledge/ skills.25–34
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