Parents of children in pediatric intensive care

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1 CE Online OPEN BEDSIDE ROUNDS FOR FAMILIES WITH CHILDREN IN PEDIATRIC INTENSIVE CARE UNITS By Charmaine Kleiber, RN, PhD, Tina Davenport, RN, MSN, and Barbara Freyenberger, RN, MSN. From University of Iowa College of Nursing (CK) and Children s Hospital of Iowa (TD, BF), Iowa City, Iowa. Parents of children in pediatric intensive care units (PICUs) place great importance on receiving information about their children s condition, having their questions answered, and talking with the physicians in charge of their children s care. 1 Although nurses often bridge the communication gap between parents and physicians, patients families understandably want the opportunity to speak directly with physicians about the medical plan of care. In the PICU at Children s Hospital of Iowa in Iowa City, the family visiting policy was a major obstacle to sharing information between parents and the physicians in a timely manner. Because families were not allowed to stay in the unit during medical rounds, nurses often felt caught in the middle between parents and physicians. When parents were allowed to reenter the unit after rounds, the physicians were busy with procedures, admissions, or rounds with other patients until late in the afternoon. Although the nurses could answer some of the parents questions, they did not have all of the information and thought that it was inappropriate for them to discuss prognosis or specific medical treatment options with the parents. In order to meet the parents need for communication and to alleviate the nurses discomfort with feeling caught in the middle, a group of PICU staff CE Online To receive CE credit for this article, visit and follow the online instructions. Corresponding author: Charmaine Kleiber, University of Iowa College of Nursing, 36 NB, Iowa City, IA 222 ( To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA Phone, (800) or (99) (ext 32); fax, (99) ; , nurse and physician leaders decided to pursue a quality improvement project to include parents in bedside medical rounds. Supporting Literature For 2 decades, research has shown that one of the most pressing needs of families of patients in ICUs is the need for information. 1- Parents of children in a PICU view the provision of information and communication with the healthcare team as key components of quality care. 6 In this era of quality monitoring, even the best hospitals must compete in a consumerdriven market. Few interventions designed to improve information flow between families of ICU patients and healthcare professionals have been reported. Curley 7 tested an intervention provided by a clinical nurse specialist who met daily with patients family members to answer questions and ask the parents for suggestions. The results of this intervention were positive, but the intervention has limited generalizability. Some institutions do not have a clinical nurse specialist in the PICU, and some clinical specialists may not be skilled in providing this type of intervention. In a follow-up study, 8 staff nurses provided the intervention. Significant effects were noted for reducing parents overall stress and improving the parents perception of their role in the ICU. Other researchers 9 tested a family conference intervention that was completed by the physician. The data suggested that the process improved satisfaction among patients family members, but the success of this intervention depends completely on the physician s behavior and willingness to take the time and effort to participate in family conferences. Individual family conferences certainly contribute to a clear and direct communication path between patients family members and physicians. In our PICU, care conferences are scheduled for long-term patients or extremely 92 AMERICAN JOURNAL OF CRITICAL CARE, September 2006, Volume 1, No.

2 complicated cases, but meetings are not scheduled for all patients. Our PICU nurse leaders were interested in developing an intervention that facilitated timely communication between patients parents and staff physicians. The unique aspect of an intervention that encourages family presence at medical rounds is that rounds occur routinely and require no extra scheduling of meetings. Participants are present at the same time and can share information accordingly. In this brief report, we describe the implementation and evaluation of a unitbased policy change to improve quality of care: encouraging open access to bedside rounds for families of patients in the PICU. Setting This unit-based policy change took place in the 12-bed PICU at Children s Hospital of Iowa in Iowa City. Major categories of patients were fairly evenly distributed among cardiac surgery/cardiology, neurosurgery/neurology, other surgery, and those with medical diagnoses including infectious or respiratory disease and hematological/oncological conditions. Of the 12 beds, 7 were in private rooms and were in an open bay. The standing visitation policy in the PICU was that parents called from the waiting room to the PICU when they wanted to visit and received permission from the nurse to enter the unit. Families were not allowed to stay in the unit during medical rounds, nursing change of shift, while patients were being admitted, or while procedures were being performed. Table 1 Guidelines for parents visiting the pediatric intensive In our effort to provide the best possible care for the patients and families in the PICU, our unit has implemented an open-door policy for visitation. We do ask families to follow these guidelines. 1. Please limit family visits to 2 visitors at the bedside at a time. 2. Please do not take food to the bedside. 3. There may be a few times when family members may be asked to remain in the family lounge. These times may occur when a. A new critically ill patient is admitted to the unit b. A surgical procedure is being performed at any bedside c. A patient s condition becomes unstable and requires emergency medical attention. Doctors rounds: every morning, the PICU staff doctor and resident doctors, along with the dietician, pharmacist, social worker, nurse, and respiratory therapist, review what has happened with your child in the past 2 hours and decide on the plan of care for the next day. Rounds also serve as a teaching opportunity for the resident doctors at this hospital. If you would like to listen to doctors rounds, ask questions, and talk to the doctors as they make the plan for the next day, you are welcome to come and stay by your child s bedside for that discussion. Rounds usually start at 9 AM and continue until every child s care has been discussed. Reprinted with permission from The Children s Hospital of Iowa, Iowa City. In the pediatric ICU, nurses often feel caught in the middle in communication between parents and physicians. Bedside rounds routinely occurred in the morning. The usual attendees were the staff physician, residents, medical students, nurses, respiratory therapists, and the pharmacist, dietician, and social worker. After a patient s progress was presented by a medical resident, the team discussed plans for treatment. As in all academic hospitals, the staff physicians used this opportunity to teach students about disease processes and potential problems. Preparation for Policy Change Before the open-access policy was implemented, educational sessions were held with the multidisciplinary PICU team members. The proposed change was presented to the PICU critical care subcommittee, which consists of unit staff physicians and representatives from nursing, pharmacy, respiratory therapy, dietary, and social services. Minutes from this meeting were disseminated to all members of the subcommittee so that absent members were informed about the change. Nurse leaders met with the PICU nursing staff at shift report for several weeks to ensure that all nurses were aware of the change and oriented to their role in educating parents about inclusion in rounds. In addition, posters describing the change were displayed in the report room, and informational flyers were placed in each nurse s mailbox. Although the nursing staff did not anticipate problems with the proposed change, the staff physicians voiced concerns about breaching patients confidentiality and increasing the time of rounds. Some thought that parents might ask numerous questions that would delay the progress of rounds from patient to patient. Staff physicians also feared that families would misinterpret AMERICAN JOURNAL OF CRITICAL CARE, September 2006, Volume 1, No. 93

3 the teaching part of rounds and that the parents respect for the residents would be undermined. Physicians and nurses were assured that the effect of the change would be monitored and that their opinions would be solicited after the change had been pilot tested. A plan also was developed to educate parents about the purpose of medical rounds and how they could participate. Parents were provided with a pamphlet (Table 1), a pad of paper and a pencil for writing down questions, and a magnet imprinted with the PICU s tollfree telephone number. Nurses were expected to go over the pamphlet with parents of patients newly admitted to the PICU, encouraging parents to listen to rounds, write down questions, and ask questions at the end of their child s rounds. The nurses also were expected to help parents interpret the information and to be attentive to confidentiality. If parents were noticed listening to the discussion about another child, nurses were to redirect the parents attention by engaging them in conversation about their own children. Parents Surveys The quality improvement team searched for published surveys on this topic, and when none were found the team members developed original questions. Parents of PICU patients were invited to complete anonymous surveys as part of the quality improvement project. Surveys were given to parents as they left the PICU, usually when their child was being transferred to an intermediate or general care area of the hospital. Parents whose child died in the PICU or was in the PICU less than 2 hours were not surveyed. Because this change was a quality improvement project and not a research study, no descriptive data were collected about the parents. Including parents in patient rounds did not increase the length of rounds. Surveys were distributed to 69 parents before implementation of the, and 36 (2%) were returned. Six months after the implementation of, 79 surveys were distributed and 8 (61%) were returned. The results of the 2 surveys (Table 2) indicate that parents appreciated being present during rounds. The survey 6 months after implementation of included a question about whether parents were concerned about other families overhearing the discussion about their child s medical Table 2 Parents median scores on the surveys before and after implementation of in the pediatric intensive Statement/question I feel it would be (was) beneficial for me to be able to hear and ask questions about my child s care during doctor s rounds* A PICU doctor contacted me daily about the plan of care for my child* I was able to ask questions and have them explained by the PICU staff doctor daily* My child felt comfortable when I left the bedside during unit closed times* I felt comfortable leaving my child s bedside during unit closed times* Did you have any concerns about other families overhearing the discussion about your child s medical condition? Survey before (n = 36) condition; 92% indicated that they never or almost never felt that confidentiality was an issue. Parents written comments also were collected. One parent wrote, We feel that allowing parents to be part of rounds is wonderful. It helps us to be less worried during a very difficult time. Another wrote, Staying during rounds was very beneficial. Glad you changed to this. Hope this stays like this for our return visits. Still another shared, I valued greatly the opportunity to participate in my daughter s care regarding rounds. I felt like a contributing member of the team. Nurses Surveys The survey for nurses before implementation of the change focused on staff nurses perception of being caught in the middle of communication between physicians and parents. Nurses surveys after implementation of the change focused on the nurses perception of. Because this change was a quality improvement project and not a research study, approval of the institutional review board was not sought, and *-point scale, strongly disagree (1) to strongly agree (). -point scale, never (1) to always (). Survey 6 months after (n = 8) 1 9 AMERICAN JOURNAL OF CRITICAL CARE, September 2006, Volume 1, No.

4 Table 3 Nurses median scores on the surveys before and after implementation of in the pediatric intensive Statement Parents routinely ask to talk to the PICU staff physician* Parents routinely ask for clarification of medical information received from the doctors* I routinely feel that I am caught in the middle between families and physicians* Parents benefit from being present during rounds* I spend less time explaining patients status and plan of care to families when the families are present during rounds* Parents should be present during rounds* Parents routinely participate in PICU staff physician rounds Survey before (n = 23) inferential statistical analyses were not done. In order to ensure anonymity, the nurses were asked to submit the surveys unsigned but to code their surveys with their mother s birth date. By coding the surveys, surveys from before and after implementation of open rounds could be matched to investigate changes over time. All 39 full-time and part-time PICU staff nurses were asked to complete the survey before the implementation, and 23 surveys (9%) were returned. Surveys were sent to staff nurses 6 months after open rounds were implemented, and 16 (36%) completed surveys were returned (Table 3). The median answers to the questions were similar on the 2 surveys except for the question about feeling caught in the middle. After were implemented, fewer nurses felt caught in the middle of communication between physicians and parents. Time Required for Rounds The assistant nurse manager of the PICU monitored the length of rounds with a stopwatch every day for 30 days before the implementation of *-point scale, strongly disagree (1) to strongly agree (). -point scale, almost never (1) to almost always (). Survey 6 months after (n = 16) 2 3 and for another 30 days 6 months after the change. The median time from starting rounds at the first bed to leaving the last bed was 12 minutes before open rounds were implemented and 13 minutes after implementation. The number of patients and mean severity of illness were comparable during the 2 data collection periods; 69 patients were in the unit during the 30 days before implementation and 79 patients in the 30 days after implementation. Staff Physicians Surveys Six months after the implementation of open rounds, all staff PICU physicians agreed (median = on a scale of 1 to ) that rounds were beneficial to patients parents and that they enhanced trust. Additional comments were that having parents present was a time-saver, decreasing time trying to find families to talk with them later in the day. Discussion Opening medical rounds to parents of children in the PICU was perceived as beneficial by staff physicians, nurses, and parents. Staff physicians concerns about confidentiality and the time required for rounds were not a problem. Parents who were present during rounds did not feel concerned about other families overhearing discussion of their children s cases, and the time required for rounds did not increase. Nurses had fewer reports of being caught in the middle between families and physicians. On both surveys, nurses indicated that they were routinely asked to clarify medical information. We are not surprised or disappointed with this finding. Conversely, we view this finding as an affirmation of the nurse s role as teacher and family advocate. Opening rounds to parents of children in the PICU was positively perceived by physicians, nurses, and parents. Another interesting finding is that nurses response was only a 3 to the statement Parents routinely participate in PICU staff physician rounds. Because of the way the question is stated, we do not know if nurses meant that parents did not attend the rounds or if they meant that the parents did not actively participate with questions. A suggestion for further investigation is to determine how comfortable parents are with participating in doctors rounds. Another area that would be interesting to explore is parents perception of the medical teaching that occurs during rounds. AMERICAN JOURNAL OF CRITICAL CARE, September 2006, Volume 1, No. 9

5 As with all surveys, these findings may be influenced by the number of participants who returned completed surveys. We suspect that the low return rate for nurses after implementation of may partially be due to the number of nurses who were new to the unit and thus were not present when the previous policy restricted parents visitation. However, 33% of the eligible nurses answered both surveys. With the parents surveys, it is possible that only parents who were particularly interested in staying at their child s bedside chose to return the surveys. This limitation is difficult to overcome in evaluating quality improvement projects. Opening the PICU to patients families during bedside rounds is a simple intervention that has beneficial effects for parents, children, and the healthcare team. Parents were able to spend more time at the bedside and were viewed as part of the team. The information and knowledge gained in medical rounds also better prepared them to care for their child after leaving the PICU. Parents were able to see how much time the healthcare team spent in planning the care of their child. The PICU nurses commented that children had improved mood and fewer emotional outbursts when parents left the unit. Healthcare professionals were reminded that each child should be treated within the context of family and that parents bring valuable information to the treatment plan. REFERENCES 1. Farrell MW, Frost C. The most important needs of parents of critically ill children: parents perceptions. Intensive Crit Care Nurs. 1992;8: Carter MC, Miles MS, Buford TH, Hassanein RS. Parental environmental stress in pediatric intensive care units. Dimens Crit Care Nurs. 198;: Daley L. The perceived needs of families with relatives in the ICU setting. Heart Lung. 198;113: Fisher MD. Identified needs of parents in a pediatric intensive care unit. Crit Care Nurse. 199;13: Kasper JW, Nyamathi AM. Parents of children in the pediatric intensive care units: what are their needs? Heart Lung. 1988;17: Co JP, Ferris TG, Marino BL, Homer CJ, Perrin JM. Are hospital characteristics associated with parents views of pediatric inpatient care quality? Pediatrics. 2003;111: Curley MAQ. Effects of the nursing mutual participation model of care and parental stress in the pediatric intensive care unit. Heart Lung. 1988; 17: Curley MAQ, Wallace J. Effects of the nursing mutual participation model of care on parental stress in the pediatric intensive care unit: a replication. J Pediatr Nurs. 1992;7: Whitmer M, Hughes B, Hurst SM, Young TB. Innovative solutions: family conference progress note. Dimens Crit Care Nurs. 200;2: AMERICAN JOURNAL OF CRITICAL CARE, September 2006, Volume 1, No.

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