Abstract
Parents and carers play a critical role in supporting their children while in hospital. Multiple qualitative studies have explored parental involvement in the care of hospitalised children. Administration of medication to young children can be difficult and cause anxiety and stress for children. Parents are often willing and able to assist, yet little is known about how often parents are given responsibility for medication administration in hospital.
We analysed data from a prospective direct observational study of nurses administering medication at a major paediatric referral hospital in Australia. Data from observations of 298 nurses preparing and administering 5137 medication doses to children on nine medical and surgical wards between 07:00 and 22:00 were analysed. Details of drugs administered, whether medications were left for parents/carers to administer, and if nurses observed the administration by parents, were recorded.
Parents were at their child’s bedside during 89.7% (n=4610) of observed medication administrations. Parents gave 20.3% (n=1045) of medications. In 14.3% (n=733), medications were left with parents to administer without a nurse present. In 6.1% (n=312) of doses, medications were given to parents, but the administration was observed by a nurse. Parents were most likely to be given medications to administer to young children (1–5 years), and the medications most frequently administered were analgesics and anti-epileptics.
Parents/carers are integrally involved in the administration of many medications to children in hospital. The extent of parents’ role and the impact on medication administration efficiency has been largely absent from the healthcare literature. Given that one in five medication doses is administered by parents, hospitals should recognise this contribution and consider if any additional support for parents is required.
Keywords: Paediatrics, Patient-centred care, Medication safety, Nurses
Introduction
The central involvement of families and parents/carers in the care of their child while in hospital is well recognised, and paediatric care is often described as a partnership between providers and families, conceptualised as ‘family-centred care’.1 2 Many qualitative studies have explored how relationships between care providers and parents of children in hospital are navigated and negotiated. A systematic review of parent participation in the care of hospitalised children reported on 26 studies of which 21 investigated health professionals’ or parents’ views about parent participation and five studies evaluated interventions.3 All studies used surveys and/or interviews to assess outcomes. The involvement of parents in care tasks is a common theme with both positive and negative consequences identified. Parents report the importance of their involvement in care to support their children and reduce anxiety. However, studies have also identified that expectations of parental involvement in performing care tasks can result in them feeling they need to be hyper-vigilant and assume responsibility for safe-guarding their child while in hospital.4 Quantitative evidence of the extent of parent’s involvement in specific care tasks is very limited.
Medication administration is a frequent form of care for children in hospital. Parents report that they want to be involved in administering medications, recognising that children may be reluctant to receive medication from nurses.5 To assist in the process, some hospitals have instituted policies which provide guidance for nurses and families about when and how this should occur.6 One English hospital asks parents to self-certify that they are competent to administer their child’s medication.7 A small study involving 30 parents of children in a UK hospital identified that supporting parents to administer a small defined list of medications could also reduce medication administration delays.8 However, how frequently parents are involved in medication tasks in hospital is unknown. A recent analysis of medication work practices in three English paediatric inpatient units identified that while families provide practical support in medication administration, they were ‘largely unacknowledged at an organisational level’.7
Using data from a direct observational study of nurses’ medication administration practices in a large paediatric hospital, we aimed to quantify the extent to which parents/carers were involved in the administration of medications to their children in hospital.
Methods
This was a prospective direct observational study of nurses administering medication to children in hospital, conducted as part of a stepped-wedge cluster randomised controlled trial to assess the impact of electronic medication systems on errors.9 Data were collected from nine general medical and surgical wards (excluding oncology, intensive care unit and the emergency department) in a 340-bed paediatric referral hospital in Sydney, Australia. In total, 298 nurses were observed preparing and administering 5137 medication doses to 1565 patients on weekdays and weekends between 07:00 and 22:00 by trained researchers. Details of drugs administered, including whether medications were left for parents (includes family members or carers) to administer, and if nurses observed the administration of the medications by parents, were recorded. Full details of the observational methods have been published previously.10 A secondary analysis was undertaken to assess the frequencies and proportions of medication doses left with parents, and those observed by nurses to be administered by a parent, by patient characteristics (eg, age, sex) and medication details (route, type, administration time).
Results
Overall parents were at their child’s bedside during 89.7%(n=4610) of observed medication administrations; 90.4% (3719/4113) on weekdays and 87.0% (891/1024) on weekends.
Parents were involved with 20.3%(n=1045) of dose administrations. In 6.1%(n=312) of doses, medications were given to parents, and the administration was observed by a nurse. In 14.3%(n=733) of dose administrations, medications were left with parents to administer, but a nurse was not present for the actual administration.
Parents were most often responsible for giving medications during the morning and evening periods and most frequently administered oral or inhalation medications (table 1). Parental involvement in medication administration was greatest for children aged 1 to <3 years (29.9% of all doses administered by parents) and for children between 3 and <6 years (24.3%) (table 1).
Table 1. Medications administered to children in hospital by parent/carers and nurses (n=5137).
| Variable | Nurse administered | % (95% CI) | Medications administered by parent/carer | Total dose administrations | |||||
| Yes: nurse observed | % (95% CI) | Yes: left with parent not observed | % (95% CI) | Yes: nurse observed or dose left with parent | % (95% CI) | ||||
| All dose administrations | 4092 | 79.7 (78.5–80.7) | 312 | 6.1 (5.5–6.8) | 733 | 14.3 (13.3–15.3) | 1045 | 20.3 (19.3–21.5) | 5137 |
| Time of dose administration | |||||||||
| Morning (07:00–9:59) | 1335 | 77.7 (75.6–79.6) | 107 | 6.2 (5.2–7.5) | 277 | 16.1 (14.5–17.9) | 384 | 22.3 (20.4–24.4) | 1719 |
| Day (10:00–15:59) | 1257 | 87.7 (85.9–89.3) | 97 | 6.8 (5.6–8.2) | 80 | 5.6 (4.5–6.9) | 177 | 12.3 (10.7–14.1) | 1434 |
| Evening (16:00–22:00) | 1500 | 75.6 (73.7–77.4) | 108 | 5.4 (4.5–6.5) | 376 | 19.0 (17.3–20.7) | 484 | 24.4 (22.6–26.3) | 1984 |
| High risk medicine* | |||||||||
| No | 3671 | 78.6 (77.4–79.7) | 274 | 5.9 (5.2–6.6) | 726 | 15.5 (14.5–16.6) | 1000 | 21.4 (20.3–22.6) | 4671 |
| Yes | 421 | 90.3 (87.3–92.7) | 38 | 8.2 (6.0–11.0) | 7 | 1.5 (0.7–3.1) | 45 | 9.7 (7.3–12.7) | 466 |
| Route of administration | |||||||||
| Oral | 2775 | 74.8 (73.4–76.1) | 297 | 8.0 (7.2–8.9) | 639 | 17.2 (16.0–18.5) | 936 | 25.2 (23.9–26.6) | 3711 |
| Inhalation/nasal | 93 | 50.3 (43.1–57.4) | 6 | 3.2 (1.5–6.9) | 86 | 46.5 (39.4–53.7) | 92 | 49.7 (42.6–56.9) | 185 |
| Rectal | 16 | 76.2 (54.9–89.4) | 0 | 0.0 (0.0–15.5) | 5 | 23.8 (10.6–45.1) | 5 | 23.8 (10.6–45.1) | 21 |
| Topical | 49 | 94.2 (84.4–98.0) | 2 | 3.8 (1.1–13.0) | 1 | 1.9 (0.1–10.1) | 3 | 5.8 (2.0–15.6) | 52 |
| Transdermal | 3 | 75.0 (30.1–98.7) | 0 | 0.0 (0.0–49.0) | 1 | 25.0 (1.3–69.9) | 1 | 25.0 (1.3–69.9) | 4 |
| Intravenous infusion | 791 | 99.6 (98.9–99.9) | 3 | 0.4 (0.1–1.1) | 0 | 0.0 (0.0–0.5) | 3 | 0.4 (0.1–1.1) | 794 |
| Intravenous injection | 242 | 99.6 (97.7–100.0) | 1 | 0.4 (0.0–2.3) | 0 | 0.0 (0.0–1.6) | 1 | 0.4 (0.0–2.3) | 243 |
| Other | 123 | 96.9 (92.2–98.8) | 3 | 2.4 (0.8–6.7) | 1 | 0.8 (0.0–4.3) | 4 | 3.1 (1.2–7.8) | 127 |
| Child with English as a second language | |||||||||
| Missing | 454 | 78.8 (75.3–82.0) | 47 | 8.2 (6.2–10.7) | 75 | 13.0 (10.5–16.0) | 122 | 21.2 (18.0–24.7) | 576 |
| No | 3213 | 78.9 (77.6–80.1) | 234 | 5.7 (5.1–6.5) | 624 | 15.3 (14.3–16.5) | 858 | 21.1 (19.9–22.4) | 4071 |
| Yes | 425 | 86.7 (83.4–89.5) | 31 | 6.3 (4.5–8.8) | 34 | 6.9 (5.0–9.5) | 65 | 13.3 (10.5–16.6) | 490 |
| Aboriginal or Torres Strait Islander child | |||||||||
| Missing | 454 | 78.8 (75.3–82.0) | 47 | 8.2 (6.2–10.7) | 75 | 13.0 (10.5–16.0) | 122 | 21.2 (18.0–24.7) | 576 |
| No | 3490 | 79.9 (78.6–81.0) | 259 | 5.9 (5.3–6.7) | 621 | 14.2 (13.2–15.3) | 880 | 20.1 (19.0–21.4) | 4370 |
| Yes | 148 | 77.5 (71.1–82.8) | 6 | 3.1 (1.4–6.7) | 37 | 19.4 (14.4–25.6) | 43 | 22.5 (17.2–28.9) | 191 |
| Patient age | |||||||||
| <1 | 668 | 80.7 (77.8–83.2) | 51 | 6.2 (4.7–8.0) | 109 | 13.2 (11.0–15.6) | 160 | 19.3 (16.8–22.2) | 828 |
| 1 to <3 | 525 | 70.1 (66.7–73.3) | 100 | 13.4 (11.1–16.0) | 124 | 16.6 (14.1–19.4) | 224 | 29.9 (26.7–33.3) | 749 |
| 3 to <6 | 462 | 75.7 (72.2–79.0) | 61 | 10.0 (7.9–12.6) | 87 | 14.3 (11.7–17.3) | 148 | 24.3 (21.0–27.8) | 610 |
| 6 to <12 | 878 | 77.3 (74.8–79.6) | 60 | 5.3 (4.1–6.7) | 198 | 17.4 (15.3–19.7) | 258 | 22.7 (20.4–25.2) | 1136 |
| 12 to <16 | 1183 | 87.6 (85.7–89.2) | 28 | 2.1 (1.4–3.0) | 140 | 10.4 (8.8–12.1) | 168 | 12.4 (10.8–14.3) | 1351 |
| ≥16 | 376 | 81.2 (77.4–84.5) | 12 | 2.6 (1.5–4.5) | 75 | 16.2 (13.1–19.8) | 87 | 18.8 (15.5–22.6) | 463 |
| Patient sex | |||||||||
| Male | 1980 | 77.8 (76.1–79.4) | 188 | 7.4 (6.4–8.5) | 377 | 14.8 (13.5–16.2) | 565 | 22.2 (20.6–23.9) | 2545 |
| Female | 2112 | 81.5 (79.9–82.9) | 124 | 4.8 (4.0–5.7) | 356 | 13.7 (12.5–15.1) | 480 | 18.5 (17.1–20.1) | 2592 |
| Medications by Anatomical Therapeutic Chemical (ATC) classification | |||||||||
| Analgesics (N02) | 894 | 83.1 (80.7–85.2) | 123 | 11.4 (9.7–13.5) | 59 | 5.5 (4.3–7.0) | 182 | 16.9 (14.8–19.3) | 1076 |
| Anti-epileptics (N03) | 211 | 63.2 (57.9–68.2) | 20 | 6.0 (3.9–9.1) | 103 | 30.8 (26.1–36.0) | 123 | 36.8 (31.8–42.1) | 334 |
| Antibacterials for systemic use (J01) | 641 | 88.8 (86.3–90.9) | 22 | 3.0 (2.0–4.6) | 59 | 8.2 (6.4–10.4) | 81 | 11.2 (9.1–13.7) | 722 |
| Psycholeptics (N05) | 216 | 74.2 (68.9–78.9) | 20 | 6.9 (4.5–10.4) | 55 | 18.9 (14.8–23.8) | 75 | 25.8 (21.1–31.1) | 291 |
| Drugs for acid-related disorders (A02) | 171 | 71.5 (65.5–76.9) | 12 | 5.0 (2.9–8.6) | 56 | 23.4 (18.5–29.2) | 68 | 28.5 (23.1–34.5) | 239 |
| Diuretics | 118 | 67.8 (60.6–74.3) | 10 | 5.7 (3.2–10.3) | 46 | 26.4 (20.4–33.4) | 56 | 32.2 (25.7–39.4) | 174 |
| Vitamins (A11) | 232 | 81.4 (76.5–85.5) | 3 | 1.1 (0.4–3.0) | 50 | 17.5 (13.6–22.4) | 53 | 18.6 (14.5–23.5) | 285 |
| Drugs for constipation (A06) | 104 | 68.9 (61.1–75.7) | 5 | 3.3 (1.4–7.5) | 42 | 27.8 (21.3–35.4) | 47 | 31.1 (24.3–38.9) | 151 |
| Blood substitutes and perfusion solutions (B05) | 132 | 75.9 (69.0–81.6) | 1 | 0.6 (0.0–3.2) | 41 | 23.6 (17.9–30.4) | 42 | 24.1 (18.4–31.0) | 174 |
| Anti-inflammatory and anti-rheumatic products (M01) | 105 | 74.5 (66.7–80.9) | 17 | 12.1 (7.7–18.5) | 19 | 13.5 (8.8–20.1) | 36 | 25.5 (19.1–33.3) | 141 |
| Corticosteroids for systemic use (H02) | 159 | 84.1 (78.2–88.6) | 11 | 5.8 (3.3–10.1) | 19 | 10.1 (6.5–15.2) | 30 | 15.9 (11.4–21.8) | 189 |
| Mineral supplements (A12) | 125 | 82.8 (76.0–88.0) | 2 | 1.3 (0.4–4.7) | 24 | 15.9 (10.9–22.6) | 26 | 17.2 (12.0–24.0) | 151 |
| Other | 984 | 81.376.3–86.6) | 66 | 5.54.2–6.9) | 160 | 13.211.3–15.4) | 226 | 18.716.3–21.3) | 1210 |
High-risk medications were defined by the hospital as anti-infectives, potassium and other electrolytes, insulin, narcotics/opioids and sedatives, chemotherapy agents and heparin, and other anti-coagulants.
Parents of children with English as a second language were less likely to be given medication to administer to their children (13.3%: 95% CI 10.5 to 16.6 of doses; 65/490) compared with other children (21.1%: 95% CI 19.9 to 22.4; 858/4071 doses). Parents of Indigenous children (Aboriginal or Torres Strait Islander) and non-Indigenous children were similarly involved in medication administration (respectively 22.5% (95% CI 17.2 to 28.9) vs 20.1 (95% CI 19.0 to 21.4)), although this information was not available for 11.2% (n=576) of administrations.
In terms of volume, parents were most frequently involved in the administration of analgesics. For specific medication groups, parents were frequently involved in the administration of antiepileptics (36.8% of all doses), diuretics (32.2%) and drugs for acid-related conditions (28.5%) (table 1). Of medications left with parents 9.7% (n=45) were high risk, the majority (84.4%, n=38) of which were administered in the presence of a nurse.
Discussion
Our results confirm a high level of parental presence, while children are in hospital and regular involvement in medication administration. One in five medication doses was given by parents, most (70.4%) without the presence of a nurse. A small proportion of these medications were high risk, but most of these were administered in the presence of a nurse. We could identify no similar study against which to compare our findings, and thus the generalisability of these results is unknown. In an observational study of 2000 medication administrations conducted in 2012 in a UK paediatric hospital, 64 (3.2%) medication doses were observed to be given by a parent but not observed by a nurse. All were classified as errors because this was a deviation from hospital policy.11 No data on overall parental involvement in medication administration were reported.
Our previous analysis of factors associated with medication administration errors among this sample showed that the presence of a parent at the bedside was not associated with reduced errors,12 but it is highly likely that children are more comfortable taking medications from their parents.5 Our findings demonstrate that parents/carers’ involvement in medication administration reduces the demands on nurses, yet quantification of their contribution to supporting the hospital workforce is largely absent in the literature. Involvement of parents can also assist in improving medication adherence after discharge. The lower level of involvement of parents of children with English as a second language may be a missed opportunity to support these parents to gain a greater understanding of their child’s medications.13 Hospitals should consider how best to support parents’ involvement in medication administration.
Footnotes
Funding: National Health and Medical Research Council (NHMRC) Partnership Project Grant with Sydney Children’s Hospital Network (1094878) Elizabeth Blackburn Leadership Fellowship (JIW GNT1174021).
Patient consent for publication: Not applicable.
Ethics approval: This study involved human participants and was approved by the Ethics approval and was granted by the Sydney Children’s Hospital Network Human Research Ethics Committee HREC/15/SCHN/370. Participants gave informed consent to participate in the study before taking part.
Provenance and peer review: Not commissioned; externally peer reviewed.
Contributor Information
Johanna I Westbrook, Email: johanna.westbrook@mq.edu.au.
Ling Li, Email: ling.li@mq.edu.au.
Tim Badgery-Parker, Email: Tim.badgery-parker@mq.edu.au.
Erin Fitzpatrick, Email: Erin.fitzpatrick@mq.edu.au.
Virginia Mumford, Email: virginia.mumford@mq.edu.au.
Alison Merchant, Email: Alison.Merchant@mq.edu.au.
Magdalena Z Raban, Email: magda.raban@mq.edu.au.
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