Journal of Perinatology (2014) 34, 143–148 & 2014 Nature America, Inc. All rights reserved 0743-8346/14 www.nature.com/jp
ORIGINAL ARTICLE
Views of parents and health-care providers regarding parental presence at bedside rounds in a neonatal intensive care unit MJ Grzyb1,2, H Coo1, L Ru¨hland1 and K Dow1,2 OBJECTIVE: To examine the views of parents and health-care providers regarding parental presence during neonatal intensive care rounds. STUDY DESIGN: Cross-sectional survey of parents whose children were admitted to a tertiary-care neonatal intensive care unit (n ¼ 81). Medical trainees (n ¼ 67) and nurses (n ¼ 28) were also surveyed. RESULT: The majority of parents reported that attending rounds reduced their anxiety and increased their confidence in the health-care team. Nurses were more likely than medical trainees to support parental presence at rounds (P ¼ 0.02). About three-quarters of medical trainees and nurses thought discussion is inhibited and 69% of trainees felt teaching is decreased when parents attend rounds. CONCLUSION: Most parents who attended rounds found the experience beneficial, but medical trainees’ views were mixed. The positive impact on parents, and the learning opportunities created in family-centered care and communication when parents are present on rounds, should be highlighted for trainees and other neonatal intensive care personnel. Journal of Perinatology (2014) 34, 143–148; doi:10.1038/jp.2013.144; published online 7 November 2013 Keywords: family-centered care; neonatology; rounds
INTRODUCTION Family-centered care is premised on the key role families have in the health and well-being of their children.1 The inclusion of family members on bedside rounds is a key component of this model of care, and the American Academy of Pediatrics and the Institute for Family-Centered Care issued a joint policy statement in 2003 recommending this be a standard practice.1 Parental attendance at bedside rounds in pediatric intensive care units has been shown to increase parents’ respect for physicians2 and their confidence in the health-care team,3 and to provide them with a clearer understanding of their child’s plan of care.4–6 It also helps them feel they are contributing members of the team.7,8 However, parents have also reported that being present during rounds may cause some anxiety and confusion5 and health-care providers worry it will inhibit discussions about the patient’s condition6,9 and impede teaching.6,9–11 A recent systematic review of family presence during rounds included only one study conducted in a neonatal intensive care unit (NICU).12 The complexity of care, extended length of stay and lack of privacy often encountered in the NICU make it a somewhat unique environment. The parents, moreover, constitute a distinct population: in addition to having a child in intensive care, they also have to contend with the emotional and physical effects of a recent birth. These factors could influence different groups’ views on parental presence at bedside rounds in the NICU versus their presence at rounds conducted in other hospital settings. Our objectives, therefore, were to describe the views and preferences of parents who attended rounds at least once during their child’s stay in a tertiary-care NICU; to ascertain why some parents did not attend rounds, in order to reveal logistical or psychosocial barriers amenable to intervention; and to compare the views of residents, 2
senior medical students and nurses on parental presence during NICU rounds. Ethics approval for this study was obtained from the Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board.
MATERIALS AND METHODS Setting Kingston General Hospital is a tertiary-care and teaching hospital in Kingston, Ontario (Canada). The NICU has 22 beds in four open bays and admits on average 415 neonates annually. During the admission process, the unit clerk or charge nurse ordinarily informs parents they are welcome to attend rounds, which are conducted each morning at patients’ beds and are attended by staff neonatologists, residents, medical students, the charge nurse and the infant’s nurse; other staff (for example, a dietician) occasionally take part. The start time of rounds can vary depending on how busy the unit is but most often they begin at 0930 hours and are usually completed within 2 h. Parents who attend rounds are encouraged to ask questions and the staff tries to involve them in the discussions about their child’s condition and care.
Study design and samples We conducted a cross-sectional survey of parents whose children were admitted to the NICU for at least 5 consecutive days over a 1-year period (‘study period’); a minimum stay of 5 days was specified to allow parents sufficient opportunity to attend rounds. Parents were not approached to participate if they were unable to communicate fluently in English, or if their child was under the care of child protection services or died while in the NICU. Residents and senior medical students (collectively referred to as ‘medical trainees’ or ‘trainees’ in this paper) who completed at least one NICU rotation during the study period were also surveyed, as were nurses who worked part- or full-time in the unit. The neonatologists were not
1 Department of Pediatrics, Queen’s University, Kingston, ON, Canada and Kingston General Hospital, Kingston, ON, Canada. Correspondence: Dr K Dow, Department of Pediatrics, Kingston General Hospital, 76 Stuart Street, Kingston, ON K7L 2V7, Canada. E-mail: [email protected] Received 31 July 2013; revised 7 October 2013; accepted 8 October 2013; published online 7 November 2013
Views of parental presence at neonatal rounds MJ Grzyb et al
144 surveyed as there were only three on staff at the time, one of whom was an investigator on this study (K Dow).
Survey instruments and data collection Parent survey and neonatal clinical data. The parent questionnaire was designed to be self-administered and incorporated items from previous surveys of family attendance at rounds.3,8 It asked whether parents attended rounds while their child was in the NICU and their reasons for not attending, if applicable. Those who attended rounds at least once were asked how frequently they attended and to respond to 17 statements on a five-point scale, soliciting their views on being present during rounds. The unit clerk distributed a study package to parents meeting the inclusion criteria shortly before their child’s discharge date. The information letter specified that only one parent was to complete the questionnaire. The research team did not follow-up with parents who did not return a questionnaire. Clinical data on the children of respondents and nonrespondents were abstracted from database records compiled for the Canadian Neonatal Network (http://www.canadianneonatalnetwork.org/portal/). Medical trainee and nurse surveys. Separate self-administered questionnaires for the medical trainees and nurses were designed for the study and incorporated issues raised in previous studies of health-care providers’ views on family presence at rounds.3,4,8,13 They contained statements to solicit views and preferences regarding parental attendance at rounds, with response options on a five-point scale. Most items were the same on both questionnaires to facilitate interprofessional comparisons. Both questionnaires also included a section for general comments and items to obtain basic contextual information: for medical trainees, year of traineeship (and specialty for residents), sex and how many times they had presented at bedside rounds with parents present; and for nurses, how long they had worked in neonatal intensive care and the year in which they became a registered nurse. At the beginning of the study period, copies of the nursing questionnaire were distributed to nurses’ mailboxes in the NICU and signs were posted in the staff lounge with a reminder to complete and return the questionnaires to the unit clerk. To ensure that all medical trainees who had done a rotation in the NICU were invited to participate, the medical trainee questionnaire was posted on Survey Gizmo toward the end of the study period and an e-mail was circulated by one of the investigators (M Grzyb, a resident) to inform trainees of the survey. An e-mail reminder was sent 1 month later.
Analysis The data were entered and analyzed in SPSS 18.0 (IBM, Armonk, NY, USA). Frequency distributions were generated for item responses to describe views on parental attendance at rounds. For inter- and intra-group comparisons, we dichotomized the responses as Agree or Neutral/ Disagree; although collapsing categories results in loss of information, cell
Table 1.
counts were very low in some cases and we were primarily interested in the proportion in agreement with the survey statements rather than in a comparison of the response distributions per se. Bivariate analyses (Pearson’s w2 or Fisher’s exact test (categorical variables); independent samples t-test or Mann–Whitney U-test (continuous variables)) were used to compare the following: 1) parent respondents and nonrespondents in terms of their children’s clinical characteristics; 2) parent respondents who did and did not attend rounds in terms of sociodemographic factors and their children’s clinical characteristics; and 3) medical trainees’ and nurses’ views on parental presence at rounds. We also examined whether nurses’ views were associated with the number of years since becoming a registered nurse. Logistic models were fit to regress the medical trainees’ dichotomized item responses to statements soliciting their views regarding parental attendance at rounds on the following variables, while controlling for sex (the latter was significantly associated, in exploratory analyses, with some item responses): 1) trainee status (resident, senior medical student); and 2) trainees’ past frequency of presenting at bedside rounds with parents in attendance (p10 times, 410 times). All references to significance are based on P-values of less than 0.05.
RESULTS Parent sample Over the study period, 176 neonates whose parents met the inclusion criteria were admitted to the NICU and 81 parent questionnaires (46%) were returned; all but 2 were completed by mothers. The birth weight, gestational age and Score for Neonatal Acute Physiology-Perinatal Extension-II14 were similar for the children of respondents and nonrespondents, but a higher proportion of children whose parents participated in the survey required ventilation (25 vs 14%; P ¼ 0.07) and they also tended to have a longer length of stay (median 16 vs 11 days; P ¼ 0.05). Sixty-four respondents (79%) attended rounds at least once during their child’s stay in the NICU. Of those, 8 (12%) did so every day, 17 (27%) at least three times a week (but not daily), 21 (33%) once or twice a week and 18 (28%) less than once per week. Table 1 compares their sociodemographic characteristics with those of parents who never attended rounds, as well as the clinical characteristics of their children. Among the parents who never attended rounds (n ¼ 17), three-quarters indicated they were not aware they could attend but would have had they known. Other reasons for not attending included difficulties in arranging child care (n ¼ 2); living too far from the hospital (n ¼ 1); no car (n ¼ 1); having another child at home (n ¼ 1); and the timing of rounds (n ¼ 1). Most of the parents who did not attend as frequently as
Sociodemographic characteristics of parent sample and neonatal clinical characteristics
Sociodemographic characteristics Age in years, mean (s.d.a) Some post-secondary education, n (%) Health professional, n (%) Neonatal clinical characteristics Birth weight in grams, mean (s.d.) Gestational age in weeks, median (IQ range) SNAPPE-II, median (IQ range) Required ventilation, n (%) Length of stay in dayse, median (IQ range)
Attended bedside rounds at least once (n ¼ 64)
Never attended bedside rounds (n ¼ 17)
P-value
29.0 (6.2) 52 (84a) 22 (36c)
30.1 (4.5) 14 (88b) 2 (13d)
0.51 1.0 0.12
2254.1 34.1 5.0 18 18.0
(867.6) (5.9) (18.0) (28) (30.0)
2241.8 35.3 0.0 2 10.0
(838.2) (5.0) (5.0) (12) (10.0)
0.96 0.27 0.06 0.22 0.01
Abbreviations: IQ, interquartile; SNAPPE-II: Score for Neonatal Acute Physiology-Perinatal Extension-II. a Based on 62 responses. b Based on 16 responses. c Based on 61 responses. d Based on 15 responses. e In Neonatal Intensive Care Unit at Kingston General Hospital.
Journal of Perinatology (2014), 143 – 148
& 2014 Nature America, Inc.
Views of parental presence at neonatal rounds MJ Grzyb et al
145 Table 2.
Views of parents who attended bedside rounds at least once during their child’s stay in the Neonatal Intensive Care Unit (n ¼ 64) n (%)
Statement
I liked being present during rounds. It was helpful to hear the entire presentation and discussion of my child during rounds. The discussion during rounds was more confusing than helpful. Introductions at rounds helped me identify the members of the health-care team. Being present during rounds gave me more confidence in the health-care team. If there is bad news, I would prefer that I be told after, not during, rounds. I would prefer for the plan of care to be explained to me by one individual after rounds. I felt comfortable asking questions during rounds. My being present for rounds improved the care of my child. If I had not been present for rounds I would have missed important information. I arranged my day so that I could be present for rounds. I found it upsetting when there was uncertainty expressed about the care or condition of my child during rounds. I felt ignored during rounds. I felt there were too many people present on rounds. I had adequate time to ask questions during rounds. Too many medical terms were used during rounds. Attending rounds helped me to be less worried about my child.
Strongly agree
Somewhat agree
Neutral
Somewhat disagree
Strongly disagree
57 (89) 54 (86)
6 (9) 7 (11)
1 (2) 2 (3)
0 (0) 0 (0)
0 (0) 0 (0)
1 28 42 16 15
(2) (44) (66) (25) (23)
4 17 14 8 10
(6) (27) (22) (12) (16)
7 12 7 12 20
(11) (19) (11) (19) (31)
18 4 1 9 9
(28) (6) (2) (14) (14)
34 2 0 19 10
(53) (3) (0) (30) (16)
35 18 26 18 6
(55) (28) (41) (29) (9)
18 10 17 12 16
(28) (16) (27) (19) (25)
5 26 9 20 22
(8) (41) (14) (32) (34)
4 5 6 4 8
(6) (8) (9) (6) (12)
2 5 6 8 12
(3) (8) (9) (13) (19)
3 1 27 5 32
(5) (2) (42) (8) (50)
4 10 19 6 22
(6) (16) (30) (9) (34)
8 16 8 12 6
(12) (25) (12) (19) (9)
15 8 8 19 3
(23) (12) (12) (30) (5)
34 29 2 22 1
(53) (45) (3) (34) (2)
Note: Sixty-one parents responded to all statements.
desired (n ¼ 36) were unaware they could join rounds daily (n ¼ 12) or found the timing of rounds inconvenient or unpredictable (n ¼ 8). Other reasons included child care issues (n ¼ 8); living too far from the hospital (n ¼ 5); no car (n ¼ 3); and high parking costs (n ¼ 1). The views of parents who attended rounds are provided in Table 2. Most parents reported a positive impact; for example, 88% indicated it increased their confidence in the health-care team and 84% felt it eased their anxiety. A small minority found the discussion during rounds more confusing than helpful (8%) and some thought too many medical terms were used (17%). Views were more polarized in several important areas, including whether bad news should be imparted during rounds and when the plan of care should be discussed, and whether it was upsetting when the health-care team expressed uncertainty about their child’s care or condition during rounds. Medical trainee and nurse samples Twenty-eight of 29 residents (97%) and 39 of 44 senior medical students (89%) completed the questionnaires. Two-thirds of the medical trainees were women, although the proportion was higher among residents (75%) than senior medical students (59%). Most of the residents were trainees in Pediatrics (n ¼ 22) with the remainder from Obstetrics and Gynecology (n ¼ 3) and Anaesthesia (n ¼ 3). The majority (n ¼ 20) were in their first or second year of training. Overall, 36% of medical trainees reported they had presented less than 5 times at bedside rounds with parents present, 26% had presented 5–10 times with parents present and 38% more than 10 times. Not unexpectedly, these distributions differed between residents and senior medical students: 75% of residents had presented more than 10 times at bedside rounds with parents present compared with 11% of senior medical students. The medical trainees’ views regarding parental presence at rounds are shown in Table 3. More than half (58%) felt that rounds take longer with parents present, but only 16% of those thought that was a problem. Almost three-quarters agreed that parental attendance on rounds improves communication with parents and 50% of residents thought it results in better patient care. However, & 2014 Nature America, Inc.
the majority also felt discussion is inhibited (73%) and there is less teaching (69%) with parents present. Substantial proportions (39% of residents, 59% of senior medical students) reported feeling selfconscious when presenting in front of parents, and 72% of residents and 89% of senior medical students indicated they do not like to discuss unfavorable prognoses when parents are present, with similarly high proportions of the opinion that bad news should be withheld and discussed with parents after rounds. Some of these views appeared to be influenced by how many times trainees had presented at rounds with parents present: if it was more than 10 times they were significantly less likely to feel self-conscious (P ¼ 0.04), to be uncomfortable talking about unfavorable prognoses (P ¼ 0.03) and to state that discussion is inhibited (P ¼ 0.01) with parents in attendance. Twenty-eight of 57 nurses (49%) completed the survey. They had an average of 14.2 years (s.d.: 10.5) of experience in neonatal intensive care and 79% worked full-time in the NICU. The mean length of time since becoming a registered nurse was 20.2 years (s.d.: 13.0 years). The responses to statements that were included on both the medical trainee and nurse questionnaires are shown in Table 4. As no significant differences were found in the proportion of residents and senior medical students who agreed with the statements that were common to both questionnaires (Table 3), their responses were combined for the statistical comparison with the nurse sample. Compared with the medical trainees, a significantly higher proportion of nurses preferred parents to be present during rounds (65 vs 38%; P ¼ 0.02) and felt their presence results in less time being spent outside rounds explaining the child’s condition and plan of care (68 vs 42%; P ¼ .02). ‘I think parents’ presence at rounds is the best forum to deliver information to parents’ was the only statement on the nurse questionnaire that was not included on the one for medical trainees; 11 of 27 nurses (41%) agreed with this statement (data not shown in tabular format). When the nursing responses were examined in relation to the mean number of years since becoming a registered nurse, significant differences were found for two items: ‘Patient care is improved when parents are present on rounds’ (Agree: 12.4 years Journal of Perinatology (2014), 143 – 148
Views of parental presence at neonatal rounds MJ Grzyb et al
146 Table 3.
Views of senior medical students (n ¼ 39) and residents (n ¼ 28) regarding parental attendance at bedside rounds
Statement
Trainee status
n (%) Strongly agree
Somewhat agree
Neutral
Somewhat disagree
Strongly disagree
I prefer parents to be present on rounds.
Senior medical students
3 (8)
12 (31)
13 (33)
11 (28)
0 (0)
Residents
4 (14)
7 (25)
13 (46)
4 (14)
0 (0)
Communication with parents is improved when they are present on rounds.
Senior medical students
5 (13)
20 (53)
5 (13)
6 (16)
2 (5)
Residents
9 (33)
13 (48)
3 (11)
2 (7)
0 (0)
Patient care is improved when parents are present on rounds.
Senior medical students
2 (5)
12 (31)
14 (36)
10 (26)
1 (3)
Residents
5 (18)
9 (32)
7 (25)
6 (21)
1 (4)
The amount of teaching I receive is decreased when parents are present on rounds.
Senior medical students
5 (13)
22 (56)
5 (13)
6 (15)
1 (3)
Residents
4 (14)
15 (54)
5 (18)
2 (7)
2 (7)
I feel self-conscious presenting cases in front of parents.
Senior medical students
6 (15)
17 (44)
6 (15)
7 (18)
3 (8)
Residents
2 (7)
9 (32)
5 (18)
8 (29)
4 (14)
I spend less time explaining patients’ status and plan of care outside of rounds when parents are present on rounds.
Senior medical students
4 (10)
11 (28)
11 (28)
13 (33)
0 (0.0)
Residents
2 (7)
11 (39)
8 (29)
5 (18)
2 (7)
Rounds take longer when parents are present.
Senior medical students
1 (3)
20 (51)
9 (23)
8 (21)
1 (3)
Residents
2 (7)
16 (57)
2 (7)
7 (25)
1 (4)
I think it is a problem that rounds take longer because parents are presentb
Senior medical students
0 (0)
3 (14)
3 (14)
13 (62)
2 (10)
Residents
0 (0)
3 (18)
1 (6)
11 (65)
2 (12)
New information that would otherwise be unknown is obtained when parents attend rounds.
Senior medical students
2 (5)
17 (45)
7 (18)
10 (26)
2 (5)
Residents
3 (11)
14 (50)
4 (14)
3 (11)
4 (14)
I don’t like to talk about unfavorable prognoses when parents attend rounds.
Senior medical students
13 (33)
22 (56)
3 (8)
1 (3)
0 (0)
Residents
3 (11)
17 (61)
5 (18)
3 (11)
0 (0)
I think bad news should be withheld until one team member can discuss it with the parents after rounds.
Senior medical students
12 (31)
19 (49)
5 (13)
3 (8)
0 (0)
Residents
11 (39)
9 (32)
6 (21)
2 (7)
0 (0)
I think discussion among staff about a patient’s condition is inhibited when parents attend rounds.
Senior medical students
5 (13)
24 (62)
7 (18)
2 (5)
1 (3)
Residents
4 (14)
16 (57)
3 (11)
4 (14)
1 (4)
P-valuea
0.65
0.10
0.17
0.92
0.08
0.79
0.31
1.00
0.38
0.05
0.54
0.58
Thirty-eight senior medical students and 25 residents responded to all statements. a Based on logistic regression where dependent variable dichotomized as Agree or Neutral/Disagree and controlling for sex. b Asked only to those who responded ‘Strongly agree’ or ‘Agree’ to Rounds take longer when parents are present.
(s.d.: 13.8 years) vs Neutral or Disagree: 25.0 years (s.d.: 10.3 years), P ¼ 0.01) and ‘I think it is a problem that rounds take longer because parents are present’ (Agree: 28.1 years (s.d.: 8.6 years) vs Neutral or Disagree: 14.5 years (s.d.: 14.0 years), P ¼ 0.01). DISCUSSION Family presence at bedside rounds has been lauded as a key component of the partnership and knowledge exchange Journal of Perinatology (2014), 143 – 148
between health-care providers and families that is at the core of family-centered care.1 However, concerns have been raised about the potential negative impacts of including family members on rounds.4–6 Some of the medical trainees and nurses we surveyed commented that the team’s discussion during rounds may be ‘confusing’ and ‘possibly overwhelming’ for parents (data not shown in tabular format). The responses from the parents in our study did not, generally, substantiate these concerns. Few thought the discussion during rounds was more confusing than helpful and & 2014 Nature America, Inc.
Views of parental presence at neonatal rounds MJ Grzyb et al
147 Table 4.
Comparison of medical trainees’ (n ¼ 67) and nurses’ (n ¼ 28) views regarding parental presence at bedside rounds n (%)
Statement Somewhat agree
Neutral
Somewhat disagree
Strongly disagree
P-valuea
19 (28) 15 (54)
26 (39) 6 (21)
15 (22) 4 (14)
0 (0) 0 (0)
0.02
Communication with parents is improved when they are present on rounds Medical trainees 14 (22) 33 (51) 8 (12) Nurses 5 (19) 18 (67) 2 (7)
8 (12) 2 (7)
2 (3) 0 (0)
0.19
16 (24) 5 (19)
2 (3) 4 (15)
0.93
I spend less time explaining patients’ status and plan of care outside of rounds when parents are present at rounds Medical trainees 6 (9) 22 (33) 19 (28) 18 (27) Nurses 4 (14) 15 (54) 1 (4) 8 (29)
2 (3) 0 (0)
0.02
Rounds take longer when parents are present Medical Trainees 3 (4) Nurses 11 (39)
Strongly agree I prefer parents to be present on rounds Medical trainees 7 (10) Nurses 3 (11)
Patient care is improved when parents are present on rounds Medical trainees 7 (10) 21 (31) Nurses 1 (4) 10 (37)
36 (54) 10 (36)
21 (31) 7 (26)
11 (16) 6 (21)
15 (22) 1 (4)
2 (3) 0 (0)
0.12
I think it is a problem that rounds take longer because parents are presentb Medical Trainees 0 (0) 6 (16) 4 (11) Nurses 3 (14) 4 (19) 3 (14)
24 (63) 8 (38)
4 (11) 3 (14)
0.19
2 (3) 0 (0)
0.71
I think discussion among staff about a patient’s condition is inhibited when parents attend rounds. Medical Trainees 9 (13) 40 (60) 10 (15) 6 (9) Nurses 9 (35) 11 (42) 3 (12) 3 (12) Note: Sixty-three medical trainees and 25 nurses responded to all statements. a Based on dichotomizing responses as Agree or Neutral/Disagree and using Pearson’s w2 or Fisher’s Exact test. b Asked only to those who responded ‘Strongly agree’ or ‘Agree’ to rounds take longer when parents are present.
the majority felt comfortable asking questions (Table 2). For most, the experience helped them be less worried about their child (Table 2), and eight nurses commented that parents appeared less anxious after rounds (data not shown in tabular format). The medical trainees expressed somewhat mixed views: while almost three-quarters felt parental attendance on rounds improves communication with families and about half said it allows opportunity for new information to be imparted to the health-care team, only about 40% actually indicated a preference for parents to be present (Table 3). This may be partly due to a perceived reduction in teaching when parents attend rounds. The few studies that have examined this issue have reported inconsistent findings: in one study, the majority of the medical team members felt there was adequate time allotted for teaching,4 whereas another 33% of house staff and 50% of attending physicians thought the amount of teaching was decreased.5 Asking simply about ‘teaching’ may not capture important distinctions: for example, Rappaport et al.10 reported that residents felt there was a decrease in didactic teaching but an increase in the volume and quality of non-didactic teaching with parents present. In a qualitative study, medical students commented that family attendance at rounds provides unique learning opportunities in communication and ‘humanizing cognitive understanding of diseases.’15 Inevitably, much of bedside teaching will take on a new form with parents present. In addition to providing more opportunity to communicate with families while being observed by attending physicians, medical trainees will also be able to watch the latter group’s interactions with parents and, as noted by Rappaport et al.,16 be privy to questions that parents may direct only at senior members of the team. However, because this form of education is more subtle, it might be helpful for attending staff to debrief after rounding & 2014 Nature America, Inc.
to highlight non-didactic teaching moments that occur during interactions with families. Medical trainees’ ambivalence toward the inclusion of parents on rounds may also stem from a reluctance to talk about unfavorable prognoses with parents present; this may account for the high proportion who thought discussion is inhibited and that bad news should be withheld until rounds are completed (Table 3). Eight of the 23 trainees who provided open-ended comments echoed these concerns, with some describing rounds as an ‘intimidating’ environment during which it would be ‘frightening’ and ‘not fair’ for parents to receive bad news (data not shown in tabular format). It is worth noting, too, that parents were split on this issue. When asked if they preferred bad news to be withheld until after rounds, 37% agreed, whereas 44% disagreed (Table 2). Thus, it may be helpful for NICUs to develop guidelines around the issue of discussing an infant’s prognosis during rounds when parents are present, especially when that prognosis is not good. Feelings of self-consciousness may also influence medical trainees’ views: half of those surveyed stated they feel self-conscious presenting in front of parents, which may reflect some performance anxiety. This anxiety probably decreases with experience: as previously noted, trainees who had presented more than 10 times with parents present were significantly less likely to feel selfconscious (data not shown in tabular format). It may be worthwhile also to highlight for medical trainees that parents report greater confidence in the health-care team after attending rounds (Table 2).3 In other studies done in pediatric-care settings, health-care providers have indicated that rounds take longer with parents present;3,5 58% of the medical trainees and 75% of the nurses we surveyed were also of this opinion (Table 4). Of note, however, is that only 16% and 33% of those, respectively, thought that was a problem (Table 4). Moreover, this perception may not be reflective Journal of Perinatology (2014), 143 – 148
Views of parental presence at neonatal rounds MJ Grzyb et al
148 of reality: one study found no statistically significant difference in the duration of rounds with and without family members present,4 whereas another reported that the per-person rounding time, and the transition time, were significantly shorter when parents attended rounds.16 A higher proportion of nurses than medical trainees preferred parents to be present during rounds (Table 4). Some of the nurses’ views were associated with how much work experience they had: nurses who agreed that patient care is improved when parents attend rounds, or did not consider it a problem if the latter’s presence results in longer duration of rounding, had significantly fewer years in practice (data not shown in tabular format). It is unclear whether it is the longer work experience itself that influences these attitudes or, rather, that newer nursing curriculums place a greater emphasis on family-centered care, making recent graduates more open to this model of practice. When parents were asked why they had not attended rounds, the predominant reason given was simply a lack of awareness they could do so. Similarly, a large proportion who attended rounds, but with less frequency than desired, reported they did not know there was a standing invitation or they were uncertain about the timing of rounds (data not shown in tabular format). As previously mentioned, parents are informed they are welcome to attend bedside rounds when their child is admitted. The results of our study suggest this invitation could be made more explicit; moreover, as admission is a time when parents are likely overwhelmed with information, the invitation should be repeated throughout the child’s stay, ideally by multiple team members. The start time of rounds should be as consistent as possible; almost half of parents indicated they arranged their day so they could attend rounds (Table 2), and unpredictable timing appeared to be a barrier to some parents’ attendance (data not shown in tabular format). This study was limited by several factors. Because it was conducted in a single NICU, the findings may not be generalizable to those with different parent populations. While participants were aware their responses would remain anonymous, there may have been a tendency to respond in a more positive manner. There were also some differences between the parents who attended rounds and those who did not (Table 1), as well as between respondents and nonrespondents (data not shown in tabular format). Although not all of these differences were significant, they could be potentially important if parents’ views differ depending on characteristics such as their child’s length of stay in the NICU. A further limitation is that, to our knowledge, a validated scale to examine parents’ and healthcare providers’ views on parental presence during rounds does not exist; accordingly, we analyzed item responses, which increased the probability of chance findings. We did not adjust for multiple comparisons. Finally, one of our original objectives was to compare parents who attended rounds with those who did not in terms of perceptions of the quality of care provided and understanding of their child’s condition and plan of care. Unfortunately, two issues prevented such a comparison: the number of non-attendees was small, and the responses of both groups to these items were highly skewed to the positive (data not shown). Future studies could be designed to objectively measure the impact of family presence during rounds on specific outcomes, such as inhibition of discussion among medical team members or deferral of a teaching point. A mixed-methods approach may be useful: the inclusion of family members on rounds involves complex human experiences and emotions that are not, as noted in a recent systematic review, easily studied through quantitative methods,12 arguing for the inclusion of qualitative approaches to more fully explore the range of issues involved. There is also a need to develop methods for enhancing didactic teaching when
Journal of Perinatology (2014), 143 – 148
parents are included on rounds, and to devise guidelines around the issue of discussing a child’s condition, prognosis and plan of care when parents are present. CONCLUSION A high proportion of parents who attended rounds in the NICU expressed positive views of the experience. The views of medical trainees were more mixed, perhaps due to perceptions that education suffers and discussion is inhibited with parents present. The benefits to parents of attending rounds, and the learning opportunities provided in family-centred care and communication,17 should be emphasized for medical trainees and other health-care providers working in neonatal intensive care. CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGEMENTS We acknowledge the families and health-care providers at Kingston General Hospital who completed the surveys, and the Department of Pediatrics at Queen’s University (Kingston, Ontario) for providing financial support for the study.
REFERENCES 1 American Academy of Pediatrics. Family-centered care and the pediatrician’s role. Pediatrics 2003; 112: 691–696. 2 Lewis C, Knopf D, Chastain-Lorber K, Ablin A, Zoger S, Matthay K et al. Patient, parent, and physician perspectives on pediatric oncology rounds. J Pediatr 1988; 112: 378–384. 3 Aronson PL, Yau J, Helfaer MA, Morrison W. Impact of family presence during pediatric intensive care unit rounds on the family and medical team. Pediatrics 2009; 124: 1119–1125. 4 Phipps LM, Bartke CN, Spear DA, Jones LF, Foerster CP, Killian ME et al. Assessment of parental presence during bedside pediatric intensive care unit rounds: effect on duration, teaching, and privacy. Pediatr Crit Care Med 2007; 8: 220–224. 5 Cameron MA, Schleien CL, Morris MC. Parental presence on pediatric intensive care unit rounds. J Pediatr 2009; 155: 522–528. 6 Knoderer H. Inclusion of parents in pediatric subspecialty team rounds: attitudes of the family and medical team. Acad Med 2009; 84: 1576–1581. 7 Latta LC, Dick R, Parry C, Tamura GS. Parental responses to involvement in rounds on a pediatric inpatient unit at a teaching hospital: a qualitative study. Acad Med 2008; 83: 292–297. 8 Kleiber C, Davenport T, Freyenberger B. Open bedside rounds for families with children in pediatric intensive care units. Am J Crit Care 2006; 15: 492–496. 9 McPherson G, Jefferson R, Kissoon N, Kwong L, Rasmussen K. Towards the inclusion of parents on pediatric critical care unit rounds. Pediatr Crit Care Med 2011; 12: e255–e261. 10 Rappaport DI, Cellucci MF, Leffler MG. Implementing family-centered rounds: Pediatric residents’ perceptions. Clin Pediatr 2010; 49: 228–234. 11 Kalloghlian A. Parental presence during bedside pediatric intensive care unit rounds. Pediatr Crit Care Med 2007; 8: 291–292. 12 Cypress B. Family presence on rounds. Dimens Crit Care Nurs 2012; 31: 53–64. 13 Dellagrammaticas HD, Lacovidou N. Presence of parents during ward rounds: Experience from a Greek NICU [Letter]. Arch Dis Child Fetal Neonatal Ed 2006; 91: F466–F467. 14 Richardson D, Corcoran J, Escobar G, Lee S. SNAP-II and SNAPPE-II: Simplified newborn illness severity and mortality risk scores. J Pediatr 2001; 138: 92–100. 15 Black NMP, Kelly MN, Black EW, Sessums CD, DiPietro MK, Novak MA. Familycentered rounds and medical student education: a qualitative examination of students’ perceptions. Hosp Pediatr 2011; 1: 24–29. 16 Rappaport DI, Ketterer TA, Nilforoshan V, Sharif I. Family-centered rounds: Views of families, nurses, trainees, and attending physicians. Clin Pediatr 2012; 51: 260–266. 17 Sisterhen LL, Blaszak RT, Woods MB, Smith CE. Defining family-centered rounds. Teach Learn Med 2007; 19: 319–322.
& 2014 Nature America, Inc.
ORIGINAL ARTICLE
Views of parents and health-care providers regarding parental presence at bedside rounds in a neonatal intensive care unit MJ Grzyb1,2, H Coo1, L Ru¨hland1 and K Dow1,2 OBJECTIVE: To examine the views of parents and health-care providers regarding parental presence during neonatal intensive care rounds. STUDY DESIGN: Cross-sectional survey of parents whose children were admitted to a tertiary-care neonatal intensive care unit (n ¼ 81). Medical trainees (n ¼ 67) and nurses (n ¼ 28) were also surveyed. RESULT: The majority of parents reported that attending rounds reduced their anxiety and increased their confidence in the health-care team. Nurses were more likely than medical trainees to support parental presence at rounds (P ¼ 0.02). About three-quarters of medical trainees and nurses thought discussion is inhibited and 69% of trainees felt teaching is decreased when parents attend rounds. CONCLUSION: Most parents who attended rounds found the experience beneficial, but medical trainees’ views were mixed. The positive impact on parents, and the learning opportunities created in family-centered care and communication when parents are present on rounds, should be highlighted for trainees and other neonatal intensive care personnel. Journal of Perinatology (2014) 34, 143–148; doi:10.1038/jp.2013.144; published online 7 November 2013 Keywords: family-centered care; neonatology; rounds
INTRODUCTION Family-centered care is premised on the key role families have in the health and well-being of their children.1 The inclusion of family members on bedside rounds is a key component of this model of care, and the American Academy of Pediatrics and the Institute for Family-Centered Care issued a joint policy statement in 2003 recommending this be a standard practice.1 Parental attendance at bedside rounds in pediatric intensive care units has been shown to increase parents’ respect for physicians2 and their confidence in the health-care team,3 and to provide them with a clearer understanding of their child’s plan of care.4–6 It also helps them feel they are contributing members of the team.7,8 However, parents have also reported that being present during rounds may cause some anxiety and confusion5 and health-care providers worry it will inhibit discussions about the patient’s condition6,9 and impede teaching.6,9–11 A recent systematic review of family presence during rounds included only one study conducted in a neonatal intensive care unit (NICU).12 The complexity of care, extended length of stay and lack of privacy often encountered in the NICU make it a somewhat unique environment. The parents, moreover, constitute a distinct population: in addition to having a child in intensive care, they also have to contend with the emotional and physical effects of a recent birth. These factors could influence different groups’ views on parental presence at bedside rounds in the NICU versus their presence at rounds conducted in other hospital settings. Our objectives, therefore, were to describe the views and preferences of parents who attended rounds at least once during their child’s stay in a tertiary-care NICU; to ascertain why some parents did not attend rounds, in order to reveal logistical or psychosocial barriers amenable to intervention; and to compare the views of residents, 2
senior medical students and nurses on parental presence during NICU rounds. Ethics approval for this study was obtained from the Queen’s University Health Sciences and Affiliated Teaching Hospitals Research Ethics Board.
MATERIALS AND METHODS Setting Kingston General Hospital is a tertiary-care and teaching hospital in Kingston, Ontario (Canada). The NICU has 22 beds in four open bays and admits on average 415 neonates annually. During the admission process, the unit clerk or charge nurse ordinarily informs parents they are welcome to attend rounds, which are conducted each morning at patients’ beds and are attended by staff neonatologists, residents, medical students, the charge nurse and the infant’s nurse; other staff (for example, a dietician) occasionally take part. The start time of rounds can vary depending on how busy the unit is but most often they begin at 0930 hours and are usually completed within 2 h. Parents who attend rounds are encouraged to ask questions and the staff tries to involve them in the discussions about their child’s condition and care.
Study design and samples We conducted a cross-sectional survey of parents whose children were admitted to the NICU for at least 5 consecutive days over a 1-year period (‘study period’); a minimum stay of 5 days was specified to allow parents sufficient opportunity to attend rounds. Parents were not approached to participate if they were unable to communicate fluently in English, or if their child was under the care of child protection services or died while in the NICU. Residents and senior medical students (collectively referred to as ‘medical trainees’ or ‘trainees’ in this paper) who completed at least one NICU rotation during the study period were also surveyed, as were nurses who worked part- or full-time in the unit. The neonatologists were not
1 Department of Pediatrics, Queen’s University, Kingston, ON, Canada and Kingston General Hospital, Kingston, ON, Canada. Correspondence: Dr K Dow, Department of Pediatrics, Kingston General Hospital, 76 Stuart Street, Kingston, ON K7L 2V7, Canada. E-mail: [email protected] Received 31 July 2013; revised 7 October 2013; accepted 8 October 2013; published online 7 November 2013
Views of parental presence at neonatal rounds MJ Grzyb et al
144 surveyed as there were only three on staff at the time, one of whom was an investigator on this study (K Dow).
Survey instruments and data collection Parent survey and neonatal clinical data. The parent questionnaire was designed to be self-administered and incorporated items from previous surveys of family attendance at rounds.3,8 It asked whether parents attended rounds while their child was in the NICU and their reasons for not attending, if applicable. Those who attended rounds at least once were asked how frequently they attended and to respond to 17 statements on a five-point scale, soliciting their views on being present during rounds. The unit clerk distributed a study package to parents meeting the inclusion criteria shortly before their child’s discharge date. The information letter specified that only one parent was to complete the questionnaire. The research team did not follow-up with parents who did not return a questionnaire. Clinical data on the children of respondents and nonrespondents were abstracted from database records compiled for the Canadian Neonatal Network (http://www.canadianneonatalnetwork.org/portal/). Medical trainee and nurse surveys. Separate self-administered questionnaires for the medical trainees and nurses were designed for the study and incorporated issues raised in previous studies of health-care providers’ views on family presence at rounds.3,4,8,13 They contained statements to solicit views and preferences regarding parental attendance at rounds, with response options on a five-point scale. Most items were the same on both questionnaires to facilitate interprofessional comparisons. Both questionnaires also included a section for general comments and items to obtain basic contextual information: for medical trainees, year of traineeship (and specialty for residents), sex and how many times they had presented at bedside rounds with parents present; and for nurses, how long they had worked in neonatal intensive care and the year in which they became a registered nurse. At the beginning of the study period, copies of the nursing questionnaire were distributed to nurses’ mailboxes in the NICU and signs were posted in the staff lounge with a reminder to complete and return the questionnaires to the unit clerk. To ensure that all medical trainees who had done a rotation in the NICU were invited to participate, the medical trainee questionnaire was posted on Survey Gizmo toward the end of the study period and an e-mail was circulated by one of the investigators (M Grzyb, a resident) to inform trainees of the survey. An e-mail reminder was sent 1 month later.
Analysis The data were entered and analyzed in SPSS 18.0 (IBM, Armonk, NY, USA). Frequency distributions were generated for item responses to describe views on parental attendance at rounds. For inter- and intra-group comparisons, we dichotomized the responses as Agree or Neutral/ Disagree; although collapsing categories results in loss of information, cell
Table 1.
counts were very low in some cases and we were primarily interested in the proportion in agreement with the survey statements rather than in a comparison of the response distributions per se. Bivariate analyses (Pearson’s w2 or Fisher’s exact test (categorical variables); independent samples t-test or Mann–Whitney U-test (continuous variables)) were used to compare the following: 1) parent respondents and nonrespondents in terms of their children’s clinical characteristics; 2) parent respondents who did and did not attend rounds in terms of sociodemographic factors and their children’s clinical characteristics; and 3) medical trainees’ and nurses’ views on parental presence at rounds. We also examined whether nurses’ views were associated with the number of years since becoming a registered nurse. Logistic models were fit to regress the medical trainees’ dichotomized item responses to statements soliciting their views regarding parental attendance at rounds on the following variables, while controlling for sex (the latter was significantly associated, in exploratory analyses, with some item responses): 1) trainee status (resident, senior medical student); and 2) trainees’ past frequency of presenting at bedside rounds with parents in attendance (p10 times, 410 times). All references to significance are based on P-values of less than 0.05.
RESULTS Parent sample Over the study period, 176 neonates whose parents met the inclusion criteria were admitted to the NICU and 81 parent questionnaires (46%) were returned; all but 2 were completed by mothers. The birth weight, gestational age and Score for Neonatal Acute Physiology-Perinatal Extension-II14 were similar for the children of respondents and nonrespondents, but a higher proportion of children whose parents participated in the survey required ventilation (25 vs 14%; P ¼ 0.07) and they also tended to have a longer length of stay (median 16 vs 11 days; P ¼ 0.05). Sixty-four respondents (79%) attended rounds at least once during their child’s stay in the NICU. Of those, 8 (12%) did so every day, 17 (27%) at least three times a week (but not daily), 21 (33%) once or twice a week and 18 (28%) less than once per week. Table 1 compares their sociodemographic characteristics with those of parents who never attended rounds, as well as the clinical characteristics of their children. Among the parents who never attended rounds (n ¼ 17), three-quarters indicated they were not aware they could attend but would have had they known. Other reasons for not attending included difficulties in arranging child care (n ¼ 2); living too far from the hospital (n ¼ 1); no car (n ¼ 1); having another child at home (n ¼ 1); and the timing of rounds (n ¼ 1). Most of the parents who did not attend as frequently as
Sociodemographic characteristics of parent sample and neonatal clinical characteristics
Sociodemographic characteristics Age in years, mean (s.d.a) Some post-secondary education, n (%) Health professional, n (%) Neonatal clinical characteristics Birth weight in grams, mean (s.d.) Gestational age in weeks, median (IQ range) SNAPPE-II, median (IQ range) Required ventilation, n (%) Length of stay in dayse, median (IQ range)
Attended bedside rounds at least once (n ¼ 64)
Never attended bedside rounds (n ¼ 17)
P-value
29.0 (6.2) 52 (84a) 22 (36c)
30.1 (4.5) 14 (88b) 2 (13d)
0.51 1.0 0.12
2254.1 34.1 5.0 18 18.0
(867.6) (5.9) (18.0) (28) (30.0)
2241.8 35.3 0.0 2 10.0
(838.2) (5.0) (5.0) (12) (10.0)
0.96 0.27 0.06 0.22 0.01
Abbreviations: IQ, interquartile; SNAPPE-II: Score for Neonatal Acute Physiology-Perinatal Extension-II. a Based on 62 responses. b Based on 16 responses. c Based on 61 responses. d Based on 15 responses. e In Neonatal Intensive Care Unit at Kingston General Hospital.
Journal of Perinatology (2014), 143 – 148
& 2014 Nature America, Inc.
Views of parental presence at neonatal rounds MJ Grzyb et al
145 Table 2.
Views of parents who attended bedside rounds at least once during their child’s stay in the Neonatal Intensive Care Unit (n ¼ 64) n (%)
Statement
I liked being present during rounds. It was helpful to hear the entire presentation and discussion of my child during rounds. The discussion during rounds was more confusing than helpful. Introductions at rounds helped me identify the members of the health-care team. Being present during rounds gave me more confidence in the health-care team. If there is bad news, I would prefer that I be told after, not during, rounds. I would prefer for the plan of care to be explained to me by one individual after rounds. I felt comfortable asking questions during rounds. My being present for rounds improved the care of my child. If I had not been present for rounds I would have missed important information. I arranged my day so that I could be present for rounds. I found it upsetting when there was uncertainty expressed about the care or condition of my child during rounds. I felt ignored during rounds. I felt there were too many people present on rounds. I had adequate time to ask questions during rounds. Too many medical terms were used during rounds. Attending rounds helped me to be less worried about my child.
Strongly agree
Somewhat agree
Neutral
Somewhat disagree
Strongly disagree
57 (89) 54 (86)
6 (9) 7 (11)
1 (2) 2 (3)
0 (0) 0 (0)
0 (0) 0 (0)
1 28 42 16 15
(2) (44) (66) (25) (23)
4 17 14 8 10
(6) (27) (22) (12) (16)
7 12 7 12 20
(11) (19) (11) (19) (31)
18 4 1 9 9
(28) (6) (2) (14) (14)
34 2 0 19 10
(53) (3) (0) (30) (16)
35 18 26 18 6
(55) (28) (41) (29) (9)
18 10 17 12 16
(28) (16) (27) (19) (25)
5 26 9 20 22
(8) (41) (14) (32) (34)
4 5 6 4 8
(6) (8) (9) (6) (12)
2 5 6 8 12
(3) (8) (9) (13) (19)
3 1 27 5 32
(5) (2) (42) (8) (50)
4 10 19 6 22
(6) (16) (30) (9) (34)
8 16 8 12 6
(12) (25) (12) (19) (9)
15 8 8 19 3
(23) (12) (12) (30) (5)
34 29 2 22 1
(53) (45) (3) (34) (2)
Note: Sixty-one parents responded to all statements.
desired (n ¼ 36) were unaware they could join rounds daily (n ¼ 12) or found the timing of rounds inconvenient or unpredictable (n ¼ 8). Other reasons included child care issues (n ¼ 8); living too far from the hospital (n ¼ 5); no car (n ¼ 3); and high parking costs (n ¼ 1). The views of parents who attended rounds are provided in Table 2. Most parents reported a positive impact; for example, 88% indicated it increased their confidence in the health-care team and 84% felt it eased their anxiety. A small minority found the discussion during rounds more confusing than helpful (8%) and some thought too many medical terms were used (17%). Views were more polarized in several important areas, including whether bad news should be imparted during rounds and when the plan of care should be discussed, and whether it was upsetting when the health-care team expressed uncertainty about their child’s care or condition during rounds. Medical trainee and nurse samples Twenty-eight of 29 residents (97%) and 39 of 44 senior medical students (89%) completed the questionnaires. Two-thirds of the medical trainees were women, although the proportion was higher among residents (75%) than senior medical students (59%). Most of the residents were trainees in Pediatrics (n ¼ 22) with the remainder from Obstetrics and Gynecology (n ¼ 3) and Anaesthesia (n ¼ 3). The majority (n ¼ 20) were in their first or second year of training. Overall, 36% of medical trainees reported they had presented less than 5 times at bedside rounds with parents present, 26% had presented 5–10 times with parents present and 38% more than 10 times. Not unexpectedly, these distributions differed between residents and senior medical students: 75% of residents had presented more than 10 times at bedside rounds with parents present compared with 11% of senior medical students. The medical trainees’ views regarding parental presence at rounds are shown in Table 3. More than half (58%) felt that rounds take longer with parents present, but only 16% of those thought that was a problem. Almost three-quarters agreed that parental attendance on rounds improves communication with parents and 50% of residents thought it results in better patient care. However, & 2014 Nature America, Inc.
the majority also felt discussion is inhibited (73%) and there is less teaching (69%) with parents present. Substantial proportions (39% of residents, 59% of senior medical students) reported feeling selfconscious when presenting in front of parents, and 72% of residents and 89% of senior medical students indicated they do not like to discuss unfavorable prognoses when parents are present, with similarly high proportions of the opinion that bad news should be withheld and discussed with parents after rounds. Some of these views appeared to be influenced by how many times trainees had presented at rounds with parents present: if it was more than 10 times they were significantly less likely to feel self-conscious (P ¼ 0.04), to be uncomfortable talking about unfavorable prognoses (P ¼ 0.03) and to state that discussion is inhibited (P ¼ 0.01) with parents in attendance. Twenty-eight of 57 nurses (49%) completed the survey. They had an average of 14.2 years (s.d.: 10.5) of experience in neonatal intensive care and 79% worked full-time in the NICU. The mean length of time since becoming a registered nurse was 20.2 years (s.d.: 13.0 years). The responses to statements that were included on both the medical trainee and nurse questionnaires are shown in Table 4. As no significant differences were found in the proportion of residents and senior medical students who agreed with the statements that were common to both questionnaires (Table 3), their responses were combined for the statistical comparison with the nurse sample. Compared with the medical trainees, a significantly higher proportion of nurses preferred parents to be present during rounds (65 vs 38%; P ¼ 0.02) and felt their presence results in less time being spent outside rounds explaining the child’s condition and plan of care (68 vs 42%; P ¼ .02). ‘I think parents’ presence at rounds is the best forum to deliver information to parents’ was the only statement on the nurse questionnaire that was not included on the one for medical trainees; 11 of 27 nurses (41%) agreed with this statement (data not shown in tabular format). When the nursing responses were examined in relation to the mean number of years since becoming a registered nurse, significant differences were found for two items: ‘Patient care is improved when parents are present on rounds’ (Agree: 12.4 years Journal of Perinatology (2014), 143 – 148
Views of parental presence at neonatal rounds MJ Grzyb et al
146 Table 3.
Views of senior medical students (n ¼ 39) and residents (n ¼ 28) regarding parental attendance at bedside rounds
Statement
Trainee status
n (%) Strongly agree
Somewhat agree
Neutral
Somewhat disagree
Strongly disagree
I prefer parents to be present on rounds.
Senior medical students
3 (8)
12 (31)
13 (33)
11 (28)
0 (0)
Residents
4 (14)
7 (25)
13 (46)
4 (14)
0 (0)
Communication with parents is improved when they are present on rounds.
Senior medical students
5 (13)
20 (53)
5 (13)
6 (16)
2 (5)
Residents
9 (33)
13 (48)
3 (11)
2 (7)
0 (0)
Patient care is improved when parents are present on rounds.
Senior medical students
2 (5)
12 (31)
14 (36)
10 (26)
1 (3)
Residents
5 (18)
9 (32)
7 (25)
6 (21)
1 (4)
The amount of teaching I receive is decreased when parents are present on rounds.
Senior medical students
5 (13)
22 (56)
5 (13)
6 (15)
1 (3)
Residents
4 (14)
15 (54)
5 (18)
2 (7)
2 (7)
I feel self-conscious presenting cases in front of parents.
Senior medical students
6 (15)
17 (44)
6 (15)
7 (18)
3 (8)
Residents
2 (7)
9 (32)
5 (18)
8 (29)
4 (14)
I spend less time explaining patients’ status and plan of care outside of rounds when parents are present on rounds.
Senior medical students
4 (10)
11 (28)
11 (28)
13 (33)
0 (0.0)
Residents
2 (7)
11 (39)
8 (29)
5 (18)
2 (7)
Rounds take longer when parents are present.
Senior medical students
1 (3)
20 (51)
9 (23)
8 (21)
1 (3)
Residents
2 (7)
16 (57)
2 (7)
7 (25)
1 (4)
I think it is a problem that rounds take longer because parents are presentb
Senior medical students
0 (0)
3 (14)
3 (14)
13 (62)
2 (10)
Residents
0 (0)
3 (18)
1 (6)
11 (65)
2 (12)
New information that would otherwise be unknown is obtained when parents attend rounds.
Senior medical students
2 (5)
17 (45)
7 (18)
10 (26)
2 (5)
Residents
3 (11)
14 (50)
4 (14)
3 (11)
4 (14)
I don’t like to talk about unfavorable prognoses when parents attend rounds.
Senior medical students
13 (33)
22 (56)
3 (8)
1 (3)
0 (0)
Residents
3 (11)
17 (61)
5 (18)
3 (11)
0 (0)
I think bad news should be withheld until one team member can discuss it with the parents after rounds.
Senior medical students
12 (31)
19 (49)
5 (13)
3 (8)
0 (0)
Residents
11 (39)
9 (32)
6 (21)
2 (7)
0 (0)
I think discussion among staff about a patient’s condition is inhibited when parents attend rounds.
Senior medical students
5 (13)
24 (62)
7 (18)
2 (5)
1 (3)
Residents
4 (14)
16 (57)
3 (11)
4 (14)
1 (4)
P-valuea
0.65
0.10
0.17
0.92
0.08
0.79
0.31
1.00
0.38
0.05
0.54
0.58
Thirty-eight senior medical students and 25 residents responded to all statements. a Based on logistic regression where dependent variable dichotomized as Agree or Neutral/Disagree and controlling for sex. b Asked only to those who responded ‘Strongly agree’ or ‘Agree’ to Rounds take longer when parents are present.
(s.d.: 13.8 years) vs Neutral or Disagree: 25.0 years (s.d.: 10.3 years), P ¼ 0.01) and ‘I think it is a problem that rounds take longer because parents are present’ (Agree: 28.1 years (s.d.: 8.6 years) vs Neutral or Disagree: 14.5 years (s.d.: 14.0 years), P ¼ 0.01). DISCUSSION Family presence at bedside rounds has been lauded as a key component of the partnership and knowledge exchange Journal of Perinatology (2014), 143 – 148
between health-care providers and families that is at the core of family-centered care.1 However, concerns have been raised about the potential negative impacts of including family members on rounds.4–6 Some of the medical trainees and nurses we surveyed commented that the team’s discussion during rounds may be ‘confusing’ and ‘possibly overwhelming’ for parents (data not shown in tabular format). The responses from the parents in our study did not, generally, substantiate these concerns. Few thought the discussion during rounds was more confusing than helpful and & 2014 Nature America, Inc.
Views of parental presence at neonatal rounds MJ Grzyb et al
147 Table 4.
Comparison of medical trainees’ (n ¼ 67) and nurses’ (n ¼ 28) views regarding parental presence at bedside rounds n (%)
Statement Somewhat agree
Neutral
Somewhat disagree
Strongly disagree
P-valuea
19 (28) 15 (54)
26 (39) 6 (21)
15 (22) 4 (14)
0 (0) 0 (0)
0.02
Communication with parents is improved when they are present on rounds Medical trainees 14 (22) 33 (51) 8 (12) Nurses 5 (19) 18 (67) 2 (7)
8 (12) 2 (7)
2 (3) 0 (0)
0.19
16 (24) 5 (19)
2 (3) 4 (15)
0.93
I spend less time explaining patients’ status and plan of care outside of rounds when parents are present at rounds Medical trainees 6 (9) 22 (33) 19 (28) 18 (27) Nurses 4 (14) 15 (54) 1 (4) 8 (29)
2 (3) 0 (0)
0.02
Rounds take longer when parents are present Medical Trainees 3 (4) Nurses 11 (39)
Strongly agree I prefer parents to be present on rounds Medical trainees 7 (10) Nurses 3 (11)
Patient care is improved when parents are present on rounds Medical trainees 7 (10) 21 (31) Nurses 1 (4) 10 (37)
36 (54) 10 (36)
21 (31) 7 (26)
11 (16) 6 (21)
15 (22) 1 (4)
2 (3) 0 (0)
0.12
I think it is a problem that rounds take longer because parents are presentb Medical Trainees 0 (0) 6 (16) 4 (11) Nurses 3 (14) 4 (19) 3 (14)
24 (63) 8 (38)
4 (11) 3 (14)
0.19
2 (3) 0 (0)
0.71
I think discussion among staff about a patient’s condition is inhibited when parents attend rounds. Medical Trainees 9 (13) 40 (60) 10 (15) 6 (9) Nurses 9 (35) 11 (42) 3 (12) 3 (12) Note: Sixty-three medical trainees and 25 nurses responded to all statements. a Based on dichotomizing responses as Agree or Neutral/Disagree and using Pearson’s w2 or Fisher’s Exact test. b Asked only to those who responded ‘Strongly agree’ or ‘Agree’ to rounds take longer when parents are present.
the majority felt comfortable asking questions (Table 2). For most, the experience helped them be less worried about their child (Table 2), and eight nurses commented that parents appeared less anxious after rounds (data not shown in tabular format). The medical trainees expressed somewhat mixed views: while almost three-quarters felt parental attendance on rounds improves communication with families and about half said it allows opportunity for new information to be imparted to the health-care team, only about 40% actually indicated a preference for parents to be present (Table 3). This may be partly due to a perceived reduction in teaching when parents attend rounds. The few studies that have examined this issue have reported inconsistent findings: in one study, the majority of the medical team members felt there was adequate time allotted for teaching,4 whereas another 33% of house staff and 50% of attending physicians thought the amount of teaching was decreased.5 Asking simply about ‘teaching’ may not capture important distinctions: for example, Rappaport et al.10 reported that residents felt there was a decrease in didactic teaching but an increase in the volume and quality of non-didactic teaching with parents present. In a qualitative study, medical students commented that family attendance at rounds provides unique learning opportunities in communication and ‘humanizing cognitive understanding of diseases.’15 Inevitably, much of bedside teaching will take on a new form with parents present. In addition to providing more opportunity to communicate with families while being observed by attending physicians, medical trainees will also be able to watch the latter group’s interactions with parents and, as noted by Rappaport et al.,16 be privy to questions that parents may direct only at senior members of the team. However, because this form of education is more subtle, it might be helpful for attending staff to debrief after rounding & 2014 Nature America, Inc.
to highlight non-didactic teaching moments that occur during interactions with families. Medical trainees’ ambivalence toward the inclusion of parents on rounds may also stem from a reluctance to talk about unfavorable prognoses with parents present; this may account for the high proportion who thought discussion is inhibited and that bad news should be withheld until rounds are completed (Table 3). Eight of the 23 trainees who provided open-ended comments echoed these concerns, with some describing rounds as an ‘intimidating’ environment during which it would be ‘frightening’ and ‘not fair’ for parents to receive bad news (data not shown in tabular format). It is worth noting, too, that parents were split on this issue. When asked if they preferred bad news to be withheld until after rounds, 37% agreed, whereas 44% disagreed (Table 2). Thus, it may be helpful for NICUs to develop guidelines around the issue of discussing an infant’s prognosis during rounds when parents are present, especially when that prognosis is not good. Feelings of self-consciousness may also influence medical trainees’ views: half of those surveyed stated they feel self-conscious presenting in front of parents, which may reflect some performance anxiety. This anxiety probably decreases with experience: as previously noted, trainees who had presented more than 10 times with parents present were significantly less likely to feel selfconscious (data not shown in tabular format). It may be worthwhile also to highlight for medical trainees that parents report greater confidence in the health-care team after attending rounds (Table 2).3 In other studies done in pediatric-care settings, health-care providers have indicated that rounds take longer with parents present;3,5 58% of the medical trainees and 75% of the nurses we surveyed were also of this opinion (Table 4). Of note, however, is that only 16% and 33% of those, respectively, thought that was a problem (Table 4). Moreover, this perception may not be reflective Journal of Perinatology (2014), 143 – 148
Views of parental presence at neonatal rounds MJ Grzyb et al
148 of reality: one study found no statistically significant difference in the duration of rounds with and without family members present,4 whereas another reported that the per-person rounding time, and the transition time, were significantly shorter when parents attended rounds.16 A higher proportion of nurses than medical trainees preferred parents to be present during rounds (Table 4). Some of the nurses’ views were associated with how much work experience they had: nurses who agreed that patient care is improved when parents attend rounds, or did not consider it a problem if the latter’s presence results in longer duration of rounding, had significantly fewer years in practice (data not shown in tabular format). It is unclear whether it is the longer work experience itself that influences these attitudes or, rather, that newer nursing curriculums place a greater emphasis on family-centered care, making recent graduates more open to this model of practice. When parents were asked why they had not attended rounds, the predominant reason given was simply a lack of awareness they could do so. Similarly, a large proportion who attended rounds, but with less frequency than desired, reported they did not know there was a standing invitation or they were uncertain about the timing of rounds (data not shown in tabular format). As previously mentioned, parents are informed they are welcome to attend bedside rounds when their child is admitted. The results of our study suggest this invitation could be made more explicit; moreover, as admission is a time when parents are likely overwhelmed with information, the invitation should be repeated throughout the child’s stay, ideally by multiple team members. The start time of rounds should be as consistent as possible; almost half of parents indicated they arranged their day so they could attend rounds (Table 2), and unpredictable timing appeared to be a barrier to some parents’ attendance (data not shown in tabular format). This study was limited by several factors. Because it was conducted in a single NICU, the findings may not be generalizable to those with different parent populations. While participants were aware their responses would remain anonymous, there may have been a tendency to respond in a more positive manner. There were also some differences between the parents who attended rounds and those who did not (Table 1), as well as between respondents and nonrespondents (data not shown in tabular format). Although not all of these differences were significant, they could be potentially important if parents’ views differ depending on characteristics such as their child’s length of stay in the NICU. A further limitation is that, to our knowledge, a validated scale to examine parents’ and healthcare providers’ views on parental presence during rounds does not exist; accordingly, we analyzed item responses, which increased the probability of chance findings. We did not adjust for multiple comparisons. Finally, one of our original objectives was to compare parents who attended rounds with those who did not in terms of perceptions of the quality of care provided and understanding of their child’s condition and plan of care. Unfortunately, two issues prevented such a comparison: the number of non-attendees was small, and the responses of both groups to these items were highly skewed to the positive (data not shown). Future studies could be designed to objectively measure the impact of family presence during rounds on specific outcomes, such as inhibition of discussion among medical team members or deferral of a teaching point. A mixed-methods approach may be useful: the inclusion of family members on rounds involves complex human experiences and emotions that are not, as noted in a recent systematic review, easily studied through quantitative methods,12 arguing for the inclusion of qualitative approaches to more fully explore the range of issues involved. There is also a need to develop methods for enhancing didactic teaching when
Journal of Perinatology (2014), 143 – 148
parents are included on rounds, and to devise guidelines around the issue of discussing a child’s condition, prognosis and plan of care when parents are present. CONCLUSION A high proportion of parents who attended rounds in the NICU expressed positive views of the experience. The views of medical trainees were more mixed, perhaps due to perceptions that education suffers and discussion is inhibited with parents present. The benefits to parents of attending rounds, and the learning opportunities provided in family-centred care and communication,17 should be emphasized for medical trainees and other health-care providers working in neonatal intensive care. CONFLICT OF INTEREST The authors declare no conflict of interest.
ACKNOWLEDGEMENTS We acknowledge the families and health-care providers at Kingston General Hospital who completed the surveys, and the Department of Pediatrics at Queen’s University (Kingston, Ontario) for providing financial support for the study.
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