Latta, Linda C. RN, PhD, CNAA; Dick, Ronald MD; Parry, Carol MA; Tamura, Glen S. MD, PhD
The care of pediatric patients on an inpatient unit at a teaching hospital presents a number of challenges. Both the nature of the care providers and the nature of the patients create unique communication challenges. Teaching hospitals involve multiple trainees in the care of each patient, which creates barriers to communicating consistently and accurately with patients and their families. Because patients are not adults, family members are nearly always involved in the care of the patient, but they are sometimes absent when care providers want to communicate with them. In addition, multiple family members may be involved, further complicating attempts to keep the family informed and involved.
Interdisciplinary rounds that include physicians, nurses, and care coordinators can address many of these communication issues. However, studies of the impact of interdisciplinary rounds on cost, quality of care, and length of stay (LOS) have been equivocal1–7 and have rarely been conducted with a pediatric patient population8 or at teaching hospitals.9
In February 2004 as part of a quality-improvement project, we instituted a system of interdisciplinary rounds on the inpatient medical unit at Children's Hospital and Regional Medical Center (CHRMC), a large teaching hospital for pediatric patients in Seattle. Before that time, rounds on the medical unit took place in a conference room and included only physicians. Initially, rounds were moved to the nursing cluster and included the attending physician, resident physicians, the patient's nurse, and a nursing care coordinator/discharge planner. After rounds, parents were generally informed of the results of rounds by each nurse and physician involved in the care of the patient separately. In the design of interdisciplinary rounds, it was the expectation that the nurse would inform the team of the family's concerns, and that by fully informing the patient's nurse of the physician's thinking about the patient and plan of care, the nurse would be able to more fully and accurately answer the family's questions. However, the initial family-satisfaction survey results indicated that these changes had not made an impact on the experiences of families. This led us to question whether these rounds were sufficiently family centered.
Family-centered care embraces a set of values and behaviors that recognize the central role of families in the lives of children and empowers families to be involved in the care of the pediatric patient. The American Academy of Pediatrics has embraced family-centered care and has called for the inclusion of families on rounds on the inpatient unit10; this inclusion in rounds introduces multiple opportunities for teaching the principles and practice of family-centered care to health professions learners. Despite this recommendation, however, little has been published regarding the impact of including families on rounds. Of the few studies published, only two focused on the attitudes of parents toward inclusion in rounds. In a study by Birtwistle et al11 conducted in a large pediatric hospital with large patient wards, parents expressed relatively neutral feelings towards participation in rounds. They were concerned about issues of confidentiality and the level of anxiety felt by their child when rounds were conducted at the bedside. In another study conducted on a neonatal unit and designed to determine parental preferences about participation in ward rounds,12 parents again raised concerns about confidentiality. Many claimed that sharing information between families regarding their child's condition was a frequent occurrence. Some believed participation in ward rounds to be an important opportunity to communicate with the medical team. Other published studies have focused on the response of adult patients and families related to inclusion on medical rounds.1,13
Despite the paucity of data, we were committed to improving the involvement of parents in decision making, and we elected to begin including families on rounds in July 2004. After this change, we instituted a qualitative study as a part of our quality-improvement project. The purpose of this study was to determine how parents responded to participation in interdisciplinary teaching rounds conducted in a large tertiary care children's teaching hospital.
This was a qualitative descriptive study based on data from semistructured interviews and qualitative analysis. We invited 18 parents of 18 children to be interviewed after their participation in rounds on the inpatient medical unit at CHRMC. Interviews with parents of hospitalized children being cared for by the inpatient medicine service were conducted by a member of the research team between December 2004 and April 2005. Residents and attending physicians at CHRMC are divided into three teams, and patients were recruited equally from all three teams.
The rounding process
The nurse associated with each patient informed that patient's family about the purpose and structure of rounds, including the content of the discussion, the roles of the various team members, and the timing. Nurses also helped families prepare questions for rounds and developed an understanding of each parent's questions and issues so they could prompt the parents if they were hesitant or forgot their questions during rounds.
Resident and attending physicians asked each family whether they wanted to be included on rounds. Interdisciplinary rounds included one attending physician, several resident physicians and medical students, the patient's nurse, a care coordinator, and a team coordinator. Several minutes before rounds on a particular patient, the team coordinator called the patient's nurse with information that rounds on his or her patient were about to begin.
When possible, rounds were held at the bedside. If patients were in isolation, the rounding team either conducted bedside rounds with proper isolation precautions or asked the family to come to the door or to the nursing cluster. Similarly, when there were privacy concerns in two-bed rooms, rounds were also conducted at the nursing cluster. When adolescent patients were involved, the team was asked to conduct rounds at the bedside whenever possible. Residents and attending physicians used their own judgment in determining when parents should not be included on rounds, for example, when there were significant psychosocial concerns such as child abuse or neglect that made inclusion of the family problematic.
Residents conducted rounds in the traditional manner, including discussion of the history, physical examination findings, and laboratory and radiology findings; assessing the patient's problems; and agreeing on a plan. They were instructed that it was acceptable that the medical discussion might include technical jargon that might not be understood by families, but that at the conclusion of the medical discussion, residents were to review the plan for the day with the family, using lay terminology.
Study design, setting, and selection of participants
We analyzed interview results using qualitative content analysis.14 No patients or family members other than parents were interviewed, and each parent participant was only interviewed once. The individual conducting the interviews (C.P.) was not a member of the patient-care team. A convenience sample of parents was identified to participate in the interview process. The individual conducting the interviews explained the nature and purpose of the interview and provided the parent an opportunity to choose whether or not to participate. Verbal consent to be interviewed was accepted as consent to participate.
One researcher conducted all parent interviews, using a 12-question survey tool developed by the researcher team (see List 1). Survey questions were designed to meet three objectives: to determine the experience of parents related to their participation in rounds, to determine what parents expected to accomplish during rounds, and to determine what style of communication is most helpful to parents to enable them to understand the plan of care for their child. We also elicited parents' responses about their satisfaction with rounds and what improvements could be made. Interviews were conducted individually with each parent participant and were tape recorded. Survey questions were used verbatim during each parent interview (see List 1). The responses were transcribed, and the original recordings were then destroyed. During the transcription process, the stenographer was instructed to remove names and other identifiers. Where appropriate, the name was replaced with “the patient,” “the parent,” or “the guardian.” The questions in the script did not seek diagnostic or other information that might allow identification of the patient, and no demographic information was collected. These transcripts were reviewed as part of a quality-improvement project, and information gained from the interviews was used to improve the rounding process by identifying the goals parents have for rounds, the barriers to achieving those goals, and the particular behaviors of physicians and other members of the health care team that facilitate or hinder the achievement of those goals.
Qualitative data analysis
Approval for analysis of the quality-improvement data was obtained from the institutional review board of CHRMC. Verbatim transcriptions of all interviews were used for qualitative content analysis.15 Investigators agreed on a coding format consisting of three general categories: quality of the parental experience, parental expectations, and quality of communication. Specific responses were then placed in one of these categories and given a code. One of the investigators (L.L.) reviewed all transcribed interviews and coded all responses. The researcher and three other reviewers (L.L., R.D.) recoded the responses according to the primary categories and compared and combined responses until 100% consensus on coding was achieved. Coded responses of all interviews were then placed in rank order according to the frequency responses in the text.16
Of the parents we invited to participate in the study, all 18 agreed to be interviewed.
Results of the content theme analysis are presented in Table 1. Three primary themes became apparent on the basis of their rank ordering. These themes were communication, participation, and teamwork. Of 290 total responses, communication was the most common theme that emerged, with a total of 152 responses coded under this general theme. Of these 152 responses, 66 were classified as exchange of information. This exchange, particularly information related to the plan of care, was identified as the most important aspect of communication during rounds. Parents repeatedly expressed their need to ask and respond to questions, hear what was happening currently, and be informed about the plan of care for the day and the future. Hearing the discussion of the entire group of providers was an important context for a number of parents.
Communication involves more than just an exchange of words. For communication to be effective, there must be communication that is understood by both sender and receiver. Eighty-six of the communication responses were categorized as communication leading to understanding. The most common response related to understanding had to do with getting questions answered in language that the parent understood. Use of lay terminology was identified as an approach that was particularly liked and important to parents to ensure their understanding. Understanding their child's condition was the most common response mentioned when parents were asked what they wanted to accomplish on rounds.
The second major theme was the importance of being able to participate in the rounding process. This theme was frequently expressed as a need to be included in rounds. Parents often stated they liked being invited to participate. They felt more comfortable when they were asked their opinion, their permission, or whether they had questions. One mother who was initially uncomfortable with participation mentioned that the nurse encouraged her involvement and “drew her into the circle,” which she responded to as warm, inviting, and encouraging. Other specific responses to comforting actions of the doctors or nurses clustered around being listened to, being respected as a parent with an important perspective to share, and being treated as an important member of the team.
Teamwork was the third-most-common theme. Seeing the team work together, hearing the discussion of their child's care by the entire team, and being included as a part of the team were mentioned 33 times in the course of the interviews. When caregivers arrived late to rounds, had a different rounding process on weekends, or were perceived to twist information to support individual opinions, these factors created a negative impression of the team's functioning.
In addition to the major content themes, responses were reviewed for identification of overall satisfaction with the rounding process. All participants described the experience as positive, and all but one felt comfortable with the process. One participant expressed nervousness about participation in rounds. Two were initially uncomfortable but were made to feel comfortable by the team. The majority named many things they liked about participating and had few negative comments.
The goals of the managerial team in charge of the project were to engage the family in decision making, reduce misunderstandings, and improve communication between physicians, nurses, and families regarding the plan of care. To ascertain whether parental expectations were congruent with the goals of the project, we asked parents about their expectations regarding rounds. They were further asked whether these expectations were met.
Consistent with our goal of engaging parents in the discussion about their child's care, parents frequently voiced an expectation that they would be a part of the care team, be able to share their perspective, and have their questions answered. These responses suggest that many parents were interested in becoming engaged in a dialogue with the care team and saw their involvement in rounds as a means to attaining that goal. Parents also frequently stated that rounds effectively allowed this engagement to occur. In particular, they claimed they were able to share or exchange information with the team and ask questions. No parents expressed dissatisfaction with the level of engagement with the team on rounds. These findings suggest that rounds were effective in meeting parental expectations regarding engagement.
As noted above, resident physicians focused their communication efforts with the family around transmitting the plan for the day. Interestingly, although many parents expressed an understanding of the plan as one goal of rounds, the most common goal they voiced was a desire to understand their child's medical condition and to better understand the medical team's perspective on their child's condition. Thus, parental expectations were focused on the “assessment” portion of the presentation, in contrast to the formal structure of rounds, which was focused around the “plan.” Parents expressed that the team successfully explained the plan for the day and what the families should expect to occur. In contrast, no parents specifically stated that rounds provided them with a better understanding of their child's condition, although many parents felt that the team was able to explain details or test results. Together, these responses indicate that both the desire of parents and the ability of rounds to enhance the family's understanding of their child's condition were not as well met as the family's expectations regarding understanding the plan of care.
Another commonly stated expectation was that rounds would improve the family's perception that care for their child was well coordinated. In a teaching hospital, it is inevitable that the multiple care givers (attending physician, resident physicians, medical students, and nurses) will often communicate a somewhat different perspective to the families. Parents frequently expressed an expectation that rounds would provide an opportunity for families to hear the whole group discuss their child's status and care plan, and to see the group build consensus and work as a team. Congruent with this expectation, the most commonly expressed positive response regarded the ability of rounds to provide families with a forum to hear the whole discussion at once. No parents expressed any discomfort with different caregivers (residents, attending physicians, and nurses) presenting different treatment options and discussing them in their presence. These results suggest that inclusion on rounds allowed families to observe directly that the care providers were working as a team.
Suggestions for improvement
We further asked parents to specifically enumerate behaviors and communication styles of the team that they felt worked well for them, and we elicited suggestions for improvement. Consistent with our instructions to the team, a majority of parents expressed that the plan of care had been explained, and no parents expressed dissatisfaction with communication of the plan of care.
Although we had not specifically instructed team members to use lay terminology, several parents indicated that the team had in fact used lay terminology during rounds, whereas others indicated that they would have preferred the team use more lay terminology. This result suggests that consistently employing lay terminology on rounds would better meet parental needs.
Including nurses on rounds was identified as a strategy that enhanced communication. Parents frequently looked to the nurses to continue to explain what they heard in rounds, and to assist them in interpreting the plan for the day. Having a written plan was also seen as an enhancement to communication by parents, allowing nurses on second or third shifts the option to refer to the plan and reinforce earlier communication about what was going to happen and why.
Expressions of empathy by the team were rarely assessed by parents in either a positive way or a negative way. This suggests that development of rapport and expressions of empathy are neither expectations nor results of parental inclusion on rounds, suggesting that one-on-one interactions with families might be a more appropriate forum for meeting parental needs in this regard.
Most parents had suggestions for how to improve the function of the team on rounds. The most common complaint about rounds was a delay in getting information. This might have been attributable to results that were still pending, or to team members not having results at the time of rounds.
Other concerns were only occasionally expressed. One parent expressed dissatisfaction with the number of people on rounds. Two parents were dissatisfied with having to wait for the doctors and with latecomers. Of note, although half of the parents expressed that they had not been prepared for rounds by the staff, only two parents expressed a desire to be better prepared for rounds. Of the 18 subjects we interviewed, 15 indicated that their expectations of participation in rounds were met. Areas of dissatisfaction included not enough time with physicians, not being told what was wrong with their child, and not being notified when rounds were going to occur.
Discussion and Conclusions
Although the American Academy of Pediatrics10 has called for inclusion of parents on rounds, this practice is not commonly in place in children's hospitals, and, to our knowledge, little has been published on the subject. This has created particular challenges for teaching hospitals that are charged with instructing the next generation of physicians in the principles of family-centered care but that have not traditionally included parents in the central decision-making interaction of the day: ward rounds. As a part of a series of quality-improvement initiatives to improve family-centered care, parents began to be included in rounds mid-2004 at CHRMC. Anecdotal feedback had indicated that families were experiencing involvement in rounds as positive. The qualitative data from our parent interviews confirm this notion and provide more substantive guidance for the ongoing improvement efforts directed toward increasing parental involvement and satisfaction with the process.
Parents participating in the interdisciplinary rounds on the inpatient medical unit overwhelmingly liked the experience. The quality of the experience did not seem to be affected by caregivers' preparation for rounds. Parents particularly liked the opportunity to communicate directly with providers and to participate in the rounding process. Being actively included and treated as a member of the team was also well received. This finding supports the value of a family-centered approach, empowering parents and other caregivers to become more involved in decision making regarding the care of their child.
The concern about confidentiality of patient information when rounds are held at the bedside identified in some published studies11,12 was not raised by parents in this study. A recent remodel at CHRMC has resulted in elimination of four-bed rooms, leaving some two-bed rooms and many private rooms. Every effort was made to have confidential discussions in private settings. The geography of the unit and our efforts to ensure confidentiality apparently removed any concerns about confidentiality. Additionally, none of the respondents raised concerns about increased anxiety on the part of their child. In fact, one parent felt that the interaction of the parent with the interdisciplinary team in the presence of the child would reduce the child's anxiety. Concerns of some providers reported in the literature that parents would be confused by participation in rounds were not supported by our findings.
The obvious benefit of inclusion of parents on rounds is the opportunity for direct communication. Parents come to rounds with a desire to understand their child's condition and understand their child's plan of care. Few parents expressed any sense of discomfort with participating in rounds, and many found that participating in rounds with the entire team present was comforting. Parents found that careful explanations of the plan of care were most helpful when they were descriptive and directed to the parents' level of understanding. Our results indicate that there were particular behaviors by providers that were important in meeting parental expectations, including inviting parents to participate, encouraging them to ask questions, involving them in decision making, and minimizing the use of technical medical terminology. In implementing parent-centered rounds, it is important to carefully prepare providers so that these behaviors can be incorporated into the interaction with parents on rounds. Failing to prepare providers risks inviting parents to rounds but not including them in the rounding interaction.
Qualitative data provided in interviews with parents, nurses, and physicians can provide a clear picture of the perceptions of each of the groups involved as to how they are affected by multidisciplinary team rounds. On the one hand, the high participation rate (18/18 parents approached agreed to participate) limits the possibility of a selection bias; yet, on the other hand, the small sample size of this study leaves open the possibility of some selection bias. Additionally, it was not designed to provide any quantifiable data on how interdisciplinary rounds affect cost, quality of care, or length of stay. These issues need to be addressed in further studies to fully understand the impact of interdisciplinary rounds involving parents. Additionally, the issue of impact on patient safety needs to be studied. National patient-safety goals being implemented by the Joint Commission on Accreditation of Health Care Organizations emphasize the need for improved communication between care providers and caregivers. In theory, participation of parents during interdisciplinary rounds should improve communication and, thereby, improve patient safety and quality of care. Improved communication should also enhance prevention of omissions or duplication of needed care, thus reducing cost and length of stay. Our plan is to design further studies to quantify the impact of parental participation in rounds on family satisfaction and other quality and safety patient outcome indicators.
When we began including parents on rounds, we recognized that there was limited time for rounds and that inclusion of parents might significantly prolong rounds if parents had many questions or comments, or if a prolonged explanation was required. To address this issue, if the amount of time for one patient was becoming excessive, residents and attending physicians were instructed to tell the parents that one or more team members would return after rounds to address any remaining issues. Using this approach, only one parent noted that the amount of time for rounds was insufficient, which suggests that this strategy did not adversely affect the ability of families to have their questions answered.
In the often confusing setting of a teaching hospital, the inclusion of parents on interdisciplinary rounds provides an opportunity to improve communication and increase parental participation in care, and to instruct residents in the principles and practice of family-centered care. Directly communicating with the entire team to learn the condition of their child and the plan of care is of high importance to parents. The team need only extend the invitation to participate, and most families will happily engage in the rounding process. When the team works together to encourage parents' presence, and communicates with them in a way they can understand, positive outcomes are experienced by parents.