Abstract
OBJECTIVES:
Although families positively perceive family-centered rounds (FCR), factors associated with engagement have been examined in few studies. Our objective for this study was to test the hypothesis that inviting the parent to speak and nurse presence are associated with parent engagement during FCR.
METHODS:
We conducted a cross-sectional study with English-speaking parents (N = 199) of inpatients on the pediatric hospital medicine service at an academic medical center. We used a standardized checklist to record outcomes of engagement (number of questions asked and participation occurrences), predictor variables (team invited parent to speak, nurse presence), and other encounter-related variables. Parents were surveyed to assess parent and child characteristics and experiences during FCR. We examined parent, child, and encounter characteristic associations with the above outcomes using bivariate analyses and (for those associated in bivariate analyses) Poisson regressions.
RESULTS:
Inviting the parent to speak was independently associated with the number of questions asked (incident rate ratio [IRR] 1.4; 95% confidence interval [CI] 1.1–1.7). Trusting the medical team was inversely associated with questions asked (IRR 0.8; 95% CI 0.6–0.97). Factors associated with total participation included invitation for the parent to speak (IRR 1.5; 95% CI 1.3–1.6), nurse presence (IRR 1.3; 95% CI 1.1–1.5), white race (IRR 1.2; 95% CI 1.1–1.4), clerkship student presentation (IRR 1.2; 95% CI 1.03–1.3), and parent inclusion in rounding arrangement (IRR 1.5; 95% CI 1.05–2).
CONCLUSIONS:
Parents present during FCR are more engaged when invited to speak. Nurse presence was associated with total parent participation. Future studies to inform interventions to optimize engagement are warranted.
Family-centered rounds (FCR) are interdisciplinary bedside rounds that include families as members of the team who participate in the discussion of the patient’s clinical course and plan of care.1 FCR are the most common type of rounds used in pediatric acute care settings.2 Benefits include increasing family engagement and satisfaction, improving parent comprehension of the care plan, improving communication and care coordination, and role modeling for trainees.2–5
Patient and family engagement in discussions of care has been emphasized given associations with improved satisfaction, understanding, and health outcomes.6 In some previous studies, researchers have examined factors associated with parent attendance during FCR5,7; in others, researchers have identified several factors that parents and pediatricians believe improve engagement, including an invitation for parents to speak or share concerns and nurse presence.8–12 One recent multicenter intervention associated with increased family engagement included inviting the parent and nurse to speak early in FCR as a key intervention component.13 However, previous studies have not isolated which factors are associated with objective measures of parental engagement.
The purpose of this study was to examine factors, including an explicit invitation for parents to speak and nurse presence, that were associated with objectively measured parent engagement during FCR. We hypothesized that an invitation for parents to speak and nurse presence would be associated with higher engagement.
Methods
Study Design, Setting, and Overview
This was a cross-sectional study of parents of children hospitalized on an acute care medical-surgical unit within a university-affiliated urban medical center on the pediatric hospital medicine (PHM) service between October 24, 2017, and November 30, 2018. FCR occur daily for all PHM patients (average of 8, range of 4–15 patients per day). The PHM team usually includes a hospitalist, a third-year resident, 2 interns, 3 clerkship students, a fourth-year medical student (acting intern), a clinical pharmacist, and a nurse. The PHM team invites parents daily to attend FCR. Parents receive a welcome booklet on admission that includes information on FCR. During FCR, clerkship students, acting interns, and interns present patients. Members of the PHM team receive basic training in FCR via an online module and other documents; this education emphasizes partnering with families as members of the care team, although no specific guidance is given about explicitly inviting the parent to share information about the child.
This study took place in tandem with a unit-wide quality improvement (QI) initiative aimed at improving communication during FCR. For this QI project, a research assistant (RA) observed FCR for all families when available during weekdays to collect encounter-related data (see below). After observing a rounding encounter in which the parent was present, RAs consecutively approached that parent the same morning to provide information about this research study. Parents who were eligible (see below) and agreed to participate provided verbal informed consent for (1) the use of rounding encounter data for research purposes and (2) the administration of a survey. No protected health information was collected; the electronic health record was not reviewed. Rounding observation data could be used for QI purposes per our institutional review board, which approved this study.
Subjects
Inclusion criteria were an English-speaking parent or legal guardian present for FCR, parent age ≥18 years old, and the parent not being previously enrolled. We enrolled 1 parent per child; parents decided who would participate if ≥1 met inclusion criteria. Because >90% of parents were fluent in English and FCR processes were more standardized for this group, we enrolled only English-speaking parents.
Assessments
A literature review enabled identification of variables potentially associated with parent engagement in FCR as well as potential ways to define engagement.7,10,12,14 We held an informal focus group with 15 members of our family advisory council (FAC), which consisted of parents whose children had been hospitalized and who experienced FCR at our institution, during one of their regular meetings. During this session, we reviewed definitions for engagement to ensure they were of importance to parents. We also discussed variables potentially associated with engagement and identified additional metrics to ascertain. Because validated measures were generally not available, original survey questions were composed by the research team and piloted with our FAC; these parents discussed their impression of the meaning of the survey questions (ie, cognitive interviews) to ensure understandability. Modifications were made to questions as needed before study enrollment.
Rounding Observations
Before study initiation, RAs began to observe FCR in September 2017 and were trained in use of a structured data collection form. The form was piloted by study team members to ensure data collection was standardized. Enrollment began in October 2017 once RAs were trained.
Primary Outcome Variables
Primary outcomes were measures of parent engagement and participation recorded by RAs during FCR encounters, including (1) number of questions asked by parents and (2) total participation (defined as the number of times parents asked a question, provided additional information, corrected the medical team, or participated in decision-making; see Supplemental Table 5 for more details). RAs only recorded questions or other measures of participation on new topics. To ensure interrater reliability, 2 RAs observed a subset (n = 78) of encounters. Interrater reliability, assessed by using intraclass correlation coefficients (ICC) (one-way random-effects model, single rater), was high for number of questions asked (ICC 0.88; 95% confidence interval [CI] 0.81–0.92) and times participated (ICC 0.79; 95% CI 0.69–0.86). Measures of engagement (number of questions asked and total participation) were treated as continuous variables in the primary analyses. In a sensitivity analysis, we dichotomized parent engagement (median split) for our outcomes: (1) frequent (>2) or infrequent (≤2) questions and (2) frequent (>6) or infrequent (≤6) total participation.
Primary Predictor Variables
RAs observed the following during each rounding encounter: (1) whether the medical team invited parents to speak and (2) whether there was a nurse present for any portion of the encounter.
Additional Variables
RAs collected the following: level of the trainee (eg, clerkship student, intern) presenting the patient, number of members of the medical team at the start of FCR, if the parent was included in the rounding arrangement (eg, if team members arranged in a semicircle, was the parent within the semicircle), and the primary informational resource (eg, tablet, computer on wheels, paper notes) used by the trainee.
Survey
Parent survey questions (Supplemental Information) included if they had previously attended FCR and several statements rated on a 5-point Likert scale (strongly disagree to strongly agree): trust in the medical team, perceptions of eye contact from the team, and whether the team explained information in words they could understand. Answers were dichotomized into those who strongly agreed and those who chose other answers because most parents strongly agreed. Parents reported their sex, race and ethnicity, and education level as well as their child’s age, sex, health status,15 and hospital day (number of days since admission). Hospital day was dichotomized (≤1 day versus >1 day) given differences in parent understanding and preferences for FCR on the day of admission.16 Parent health literacy was evaluated by using the Newest Vital Sign (NVS), a validated 6-question assessment (dichotomized as low [scores of 0–3] and adequate [scores of 4–6]).17
Analyses
Bivariate analyses (Mann–Whitney U tests and Spearman correlations as outcomes not normally distributed) were performed to assess the relationship between all encounter, parent, and child characteristics and the outcomes of (1) number of questions asked and (2) total participation. Separate Poisson regressions with these 2 outcomes were conducted; predictor variables included whether the parent was invited to speak and whether there was a nurse present. Regressions also adjusted for other variables with P < .1 in bivariate analyses. In a sensitivity analysis, we examined the outcomes of parent (1) frequent (>2) or infrequent (≤2) questions and (2) frequent (>6) or infrequent (≤6) total participation. Associations between predictor variables and covariates and these outcomes were examined by using bivariate analyses (Fisher’s exact tests and Spearman correlations) and then logistic regressions (including predictor variables and/or other variables with P < .1 in bivariate analyses). Analyses were conducted by using SPSS version 25.0 (IBM SPSS Statistics, IBM Corporation, Armonk, NY).
On the basis of preliminary analyses, in which the medical team invited the parent to speak in ∼25% of rounding encounters, ∼≥170 parents would need to be recruited to achieve 80% power (2-sided α = .05) to note a moderate effect size (d = 0.5) impact of inviting the parent to speak on measures of engagement.
Results
Sample Characteristics
RAs approached 247 parents (Fig 1). A total of 204 parents were eligible; 200 (98%) consented and were enrolled. One subject did not complete all assessments; 199 were included in the final analysis.
FIGURE 1.
Study flow diagram.
Enrolled parents were primarily women (80%) with greater than a high school education (70%) (Table 1); most (63%) had adequate health literacy. Approximately half the children were boys.
TABLE 1.
Parent, Child, and Encounter Characteristics (N = 199)
| Characteristic | Valuea |
|---|---|
| Parent | |
| Age, median (IQR), y | 36 (31–42) |
| Female sex, n (%) | 159 (80) |
| Race and ethnicity, n (%) | |
| White, non-Hispanic | 104 (52) |
| Hispanic | 43 (22) |
| Asian American, non-Hispanic | 21 (11) |
| Black, non-Hispanic | 20 (10) |
| Other | 10 (5) |
| Refused | 1 (1) |
| Education, n (%) | |
| Did not complete high school | 14 (7) |
| High school diploma or equivalent | 46 (23) |
| Some college (without bachelor’s degree) | 47 (24) |
| Bachelor’s degree | 45 (23) |
| Education beyond bachelor’s degree | 47 (24) |
| Previous experience attending FCR, n (%) | 89 (44) |
| Parent strongly agrees they trust their child’s doctors, n (%) | 132 (66) |
| Adequate health literacy (NVS score 4–6), n (%) | 125 (63) |
| Child | |
| Age, median (IQR), mo | 24 (5–108) |
| Male sex, n (%) | 102 (51) |
| Hospital day, median (IQR), d | 2 (1–4) |
| Health status as perceived by parent, n (%) | |
| Excellent | 52 (26) |
| Very good | 54 (27) |
| Good | 58 (29) |
| Fair | 25 (13) |
| Poor | 10 (5) |
| Encounter | |
| Primary person presenting patient, n (%) | |
| Clerkship student | 91 (46) |
| Acting intern | 21 (11) |
| Intern | 78 (39) |
| Third-year resident or attending physician | 9 (5) |
| No. team members at start of rounds, median (IQR) | 7 (6–8) |
| Parent included in rounding arrangement, n (%) | 191 (96) |
| Primary informational resource used by presenter, n (%) | |
| Tablet | 97 (49) |
| Computer on wheels | 21 (11) |
| Paper notes | 76 (38) |
| None | 5 (3) |
| Medical team encourages parent to speak, n (%) | 52 (26) |
| Nurse present, n (%) | 156 (78) |
| Parent strongly agrees doctor provided adequate eye contact, n (%) | 117 (59) |
| Parent strongly agrees information is easy to understand, n (%) | 127 (64) |
| Types of parent participation, median (IQR) | |
| Questions asked | 2 (1–3) |
| Provided additional information | 3 (2–6) |
| Corrected the medical team | 0 (0–0) |
| Participated in decision-making | 0 (0–1) |
Percentages may not add up to 100% after rounding.
Greater than 50% of parents strongly agreed that they trusted their child’s doctors, that the medical team made adequate eye contact, and that the information was easy to understand.
The medical team invited the parents to speak during 26% of encounters. The nurse was present for 78% of encounters.
Parents asked between 0 and 11 (median 2; interquartile range [IQR] 1–3) questions during an FCR encounter. Parents participated (eg, asked questions, provided additional information, corrected the medical team, participated in decision-making) between 0 and 40 (median 6; IQR 4–9) times (Table 1).
Bivariate Analyses
Parents asked more questions when invited to speak (median 3; IQR 1–4) in contrast to when not invited (median 2; IQR 0–2) (P = .007) (Table 2). Higher child age, greater trust in the medical team, and perception of adequate eye contact were associated with fewer questions asked. Nurse presence was not associated with the number of questions asked. Our sensitivity analysis examining associations with frequent (>2) question-asking yielded similar results (Supplemental Table 6).
TABLE 2.
Associations Between Parent, Child, and Encounter Characteristics and the Number of Questions Asked by Parents (Continuous Variable) During FCR: Bivariate Analysis
| Characteristic | Median (IQR) | z Score | Spearman Correlation Coefficient | Pa | |
|---|---|---|---|---|---|
| With Characteristic | Reference | ||||
| Parent sex female (reference: male) | 2 (1–3) | 2 (0–3) | 1.1 | — | .3 |
| Parent is of white race (reference: not white) | 2 (1–4) | 2 (0–3) | 1.9 | — | .06 |
| Parent received more than a high school education (reference: at least a high school education) | 2 (1–3) | 2 (1–3) | 0.04 | — | >.9 |
| Parent attended FCR in past (reference: no previous experience on FCR) | 2 (1–3) | 2 (0–3) | 1 | — | .3 |
| Parent strongly agrees they trust medical team (reference: trust rated lower than strongly agree) | 2 (0.25–3) | 3 (1–4) | −2.3 | — | .02 |
| Parent has adequate health literacy (reference: low health literacy) | 2 (1–4) | 2 (0–3) | 1.6 | — | <.1 |
| Child sex female (reference: male) | 2 (1–3) | 2 (1–3) | 0.2 | — | .9 |
| Child health excellent or very good (reference: good, fair, or poor) | 2 (1–3) | 2 (1–3) | 0.3 | — | .7 |
| Encounter taking place ≤1 d into hospital stay (reference: >1 d) | 2 (1–4) | 2 (0–3) | 0.7 | — | .5 |
| Clerkship student presented (reference: acting intern or physician presented) | 2 (0–3) | 2 (1–3) | 1 | — | .3 |
| Parent included in rounding arrangement (reference: parent not included) | 2 (1–3) | 2 (0.25–3) | 0.2 | — | .9 |
| Presenter used tablet as informational resource (reference: computer on wheels, paper notes, or no resource) | 2 (1–3) | 2 (1–3) | 1.1 | — | .3 |
| Medical team invites parent to speak (reference: does not invite parent) | 3 (1–4) | 2 (0–3) | 2.7 | — | .007 |
| Nurse present (reference: nurse not present) | 2 (1–3) | 1 (0–4) | 0.9 | — | .4 |
| Parent strongly agrees eye contact is adequate (reference: rates lower than strongly agree) | 2 (1–3) | 2 (1–4) | −2 | — | .04 |
| Parent strongly agrees that information presented is easy to understand (reference: rates lower than strongly agree) | 2 (1–3) | 2 (0.25–3) | 1 | — | .9 |
| Parent age (y) | — | — | — | −0.03 | .7b |
| Child age (mo) | — | — | — | −0.2 | .02b |
| No. team members present at start of rounds | — | — | — | −0.02 | .8b |
—, not applicable.
Mann–Whitney U test, unless otherwise specified.
Spearman correlation.
Parents participated more when invited to speak (median 8; IQR 5–12.75) compared with when not invited to speak (median 5; IQR 3–8) (P ≤ .001) (Table 3). Parents participated more when a nurse was present (median 7; IQR 4–10) compared with when a nurse was not present (median 5; IQR 3–7) (P = .01). Participation was also higher when parents were present in the rounding arrangement and when a clerkship student presented. Our sensitivity analysis examining associations with frequent (>6 times) total participation revealed similar associations (Supplemental Table 7).
TABLE 3.
Associations Between Parent, Child, and Encounter Characteristics and the Number of Times the Parent Participates (Continuous Variable) During FCR: Bivariate Analysis
| Characteristic | Median (IQR) | z Score | Spearman Correlation Coefficient | Pa | |
|---|---|---|---|---|---|
| With Characteristic | Reference | ||||
| Parent sex female (reference: male) | 6 (4–9) | 5 (4–10) | 0.4 | — | .7 |
| Parent of white race (reference: not white) | 7 (4–10) | 5 (4–8) | 1.9 | — | .06 |
| Parent received more than a high school education (reference: at least a high school education) | 5 (4–9) | 6.5 (4–10) | 0.7 | — | .5 |
| Parent attended FCR in past (reference: no previous experience on FCR) | 6 (4–8.75) | 6 (4–10) | 0.1 | — | .9 |
| Parent strongly agrees they trust medical team (reference: trust rated lower than strongly agree) | 6 (4–9) | 6 (4–10) | 0.9 | — | .3 |
| Parent has adequate health literacy (reference: low health literacy) | 6 (4–10) | 5 (3–8) | 1.5 | — | .1 |
| Child sex female (reference: male) | 7 (4–10) | 5 (4–8.25) | 0.9 | — | .4 |
| Child health excellent or very good (reference: good, fair, or poor) | 6 (4–9.25) | 5 (4–9.5) | 0.5 | — | .6 |
| Encounter taking place ≤1 d into hospital stay (reference: >1 d) | 7 (4–10.5) | 5 (4–8) | 1.7 | — | .09 |
| Clerkship student presented (reference: acting intern or physician presented) | 7 (4–10) | 5 (3–8) | 2 | — | .045 |
| Parent included in rounding arrangement (reference: parent not included) | 6 (4–10) | 3.5 (2.25–6.5) | 1.7 | — | .08 |
| Presenter used tablet as informational resource (reference: computer on wheels, paper notes, or no resource) | 6 (3–9) | 5 (4–8) | 1.3 | — | .2 |
| Medical team invites parent to speak (reference: does not invite parent) | 8 (5–12.75) | 5 (3–8) | 3.8 | — | <.001 |
| Nurse present (reference: nurse not present) | 7 (4–10) | 5 (3–7) | 2.5 | — | .01 |
| Parent strongly agrees eye contact is adequate (reference: rates lower than strongly agree) | 5 (4–9) | 6 (4–10) | 0.8 | — | .4 |
| Parent strongly agrees that information presented is easy to understand (reference: rates lower than strongly agree) | 6 (4–9) | 6 (4–9.75) | 0.1 | — | .9 |
| Parent age (y) | — | — | — | 0.06 | .4b |
| Child age (mo) | — | — | — | −0.03 | .6b |
| No. team members present at start of rounds | — | — | — | 0.08 | .2b |
—, not applicable.
Mann–Whitney U test, unless otherwise specified.
Spearman correlation.
Multivariable Analyses
Inviting the parent to speak was associated with more questions asked (incident rate ratio [IRR] 1.4; 95% CI 1.1–1.7; P = .002) (Table 4). Parents who strongly agreed that they trusted the medical team asked fewer questions (IRR 0.8; 95% CI 0.6–0.97; P = .03). There were similar findings when the number of questions asked was analyzed as a dichotomous variable (Supplemental Table 8).
TABLE 4.
Associations Between Parent, Child, and Encounter Characteristics and Outcomes of the Number of Questions the Parent Asks and the Number of Times the Parent Participates: Multivariable Analysis
| Variable | IRR for No. Questions Asked (95% CI) | IRR for No. Times Parent Participates (95% CI) |
|---|---|---|
| Parent of white race (reference: not white) | 1.2 (0.998–1.5) | 1.2 (1.1–1.4)** |
| Parent strongly agrees they trust medical team (reference: trust rated lower than strongly agree) | 0.8 (0.6–0.97)* | 0.9 (0.8–1.04) |
| Parent has adequate health literacy (reference: low health literacy) | 1.2 (0.96–1.5) | 1.03 (0.9–1.2) |
| Medical team invites parent to speak (reference: does not invite parent) | 1.4 (1.1–1.7)** | 1.5 (1.3–1.6) |
| Parent strongly agrees eye contact is adequate (reference: rates lower than strongly agree) | 0.8 (0.7–1.002) | 0.9 (0.8–1.1) |
| Clerkship student presented (reference: acting intern or physician presented) | 1.2 (0.97–1.4) | 1.1 (1.03–1.3)* |
| Nurse present (reference: nurse not present) | 1.05 (0.8–1.3) | 1.3 (1.1–1.5)*** |
| Encounter taking place ≤1 d into hospital stay (reference: >1 d) | 1.04 (0.8–1.3) | 1.1 (0.998–1.3) |
| Parent included in rounding arrangement (reference: parent not included) | 1.05 (0.6–1.7) | 1.5 (1.05–2)* |
Poisson regression associations between listed variables and the observed number of questions asked and number of times the parent participates.
* P < .05; ** P < .01; *** P < .001.
Factors independently associated with higher total parent participation were invitation for the parent to speak (IRR 1.5; 95% CI 1.3–1.6; P < .001), nurse presence (IRR 1.3; 95% CI 1.1–1.5; P < .001), white parent race (IRR 1.2; 95% CI 1.1–1.4; P = .001), student presentation (IRR 1.1; 95% CI 1.03–1.3; P = .01), and parent presence in the rounding arrangement (IRR 1.5; 95% CI 1.05–2.0; P = .03) (Table 4). An invitation to speak and nurse presence were the only variables assessed as a dichotomous outcome that were associated with total participation (Supplemental Table 8).
Discussion
In this study, we found that parents asked more questions and participated more overall in FCR discussions when invited by the medical team to speak. Parents participated more overall when their nurse was present. Parents who trusted the medical team asked fewer questions. Our primary analysis also revealed that white race (parent), a student-led presentation, and parent inclusion in the rounding arrangement were associated with higher total parental participation.
Some of the most actively engaged parents in our study were those whom the team explicitly invited to speak (eg, “Please feel free to interrupt if there is anything you want to add.”) at the beginning of FCR. Parents also had higher participation in our primary analysis when physically included in the rounding arrangement as a member of the team. Previous work has revealed that parents value being included as a member of the care team and asked for input8; such practices likely increase parent attendance during FCR.9 Some parents may not feel comfortable participating in rounds even when invited.18 Care teams should ensure that the rounding environment allows for parents to feel like they can speak up and stand or sit with other members of the team if they choose to, but they should recognize that not actively participating should also be an option.9,18–20 It is possible that some bias may exist in terms of which parents were invited to speak in our study (eg, more complex patients). Because a verbal invitation to participate only occurred in one-quarter of encounters in our study, additional training should be provided to care team members about the benefits of explicitly inviting parents to speak at the beginning of FCR. Further research is needed to determine the most effective strategies to use to invite families to participate and feel like their input is valued.
Our results revealed that nurse presence was associated with higher total parental participation (asking questions, providing additional information, correcting the medical team, and participating in decision-making) but not with a high number of questions asked when examined separately. Previous studies have revealed that nurses fill the role of advocate to help parents express their concerns and ask relevant questions during FCR.8,9,11 Additional research is needed to understand why nurse presence was not associated with the number of questions asked. One may speculate that there may be other factors driving parents to ask questions: nurses who are present might answer questions before rounds or nurses may be reminding parents about important items to discuss during FCR. Nurse presence during FCR has other benefits, including earlier discharge times and more efficient interdisciplinary communication.21 Inpatient teams should be educated about the potential benefits of including nurses during FCR and ensure that rounds are scheduled at a time that works for all team members. The benefits of the presence of other hospital staff during FCR (eg, social workers, pharmacists) is largely unstudied and can be a focus of future research.
In our study, we also found that parents who trusted the medical team asked fewer questions during FCR. Our results are supported by one previous study that found that participants who trusted their clinical team did not engage in tracking their medication schedules or reading about upcoming procedures because they believed that their physicians would do so.22 Trust is also linked to treatment adherence,23,24 which may lead to fewer questions being asked. It is possible that parents who trust the medical team may not feel the need to ask questions about their child’s condition or plan of care. Regardless of the level of trust, all parents have valuable input and should be invited to take an active role during FCR. Interestingly, parent perception of poor eye contact was associated with asking questions in unadjusted analyses but not after adjusting for trust, suggesting that survey questions were measuring similar concepts and parents are less likely to trust physicians who make poor eye contact. This supports previous work linking trust and eye contact.25 Medical teams should make every effort to look up from their notes to maximize eye contact and invite participation, which will likely enable a more trusting relationship with the family.
White parents had higher total participation in our primary analysis. Although the relationship between race and engagement during FCR has not been examined in previous studies, race and FCR attendance were not associated in one PICU study.7 Physicians are generally less likely to engage in patient-centered communication with Black patients.26,27 The mechanism for higher participation in white families is unknown but may be a function of implicit or external biases28 or health literacy, a mediator of health disparities in patient activation.29 Health literacy, measured by the NVS in our study, was not independently associated with engagement. It is possible that there may be aspects of health literacy that impact participation in FCR not captured by the NVS, which focuses on numeracy and document literacy.30
In our primary analysis, we also found that parents participated more when a clerkship student presented. Because parents value contributing to bedside teaching,31 parents may have participated more in our study because they were interested in contributing to education. Students may also omit information that parents wish to include, although it was found in a previous study conducted in the PICU that fourth-year student rounding presentations were more complete when compared with those of interns.32
Our study has limitations. Generalizability is limited because our study was at a single site and included English-speaking parents only. In future work, researchers should examine FCR at multiple sites and with families with limited English proficiency (LEP). Rounds with LEP families are important to study further because they may include families less often compared with English-proficient families.5,33 We focused on factors associated with engagement for parents present during FCR; additional work is needed to explore how to best engage parents who are not present. The definition of parent participation during FCR is subjective; individual RAs may have counted participation differently. On the other hand, RAs received training, and interrater reliability was high. In addition, although we examined objective measures of engagement in this study, there are other ways to assess engagement that we did not measure, such as the parent or medical team’s perception of engagement. There may be other factors that were not measured, including the diagnosis and previous admission for a similar disease process, that affect parent participation. Additionally, because parents of children with medically complexity often want to share their perspectives with their care team,34,35 they may be more likely to participate in FCR. In future work, researchers should gather data on the child’s medical conditions and explore how to best engage the parents of children with medically complexity during FCR. Finally, some factors, such as eye contact, perceived child health status, and understanding of information presented, were assessed by survey and may be subject to social desirability bias.
Conclusions
Parents present during FCR in our study were more engaged in rounding discussions when invited to speak; there was higher participation overall when a nurse was present. Future work focused on education regarding the importance of actively engaging parents and nurses in FCR is needed, as are studies in which the impact of engagement on other variables is examined, including comprehension of the plan of care. Furthermore, creating a process to optimize FCR for all families, especially those with LEP, may result in improved outcomes, safety, and satisfaction.
Acknowledgments
We thank the New York University Langone FAC and the Sala Institute for Child and Family Centered Care for their input in reviewing metrics to be included in rounding observations and our survey. We also acknowledge the following research assistants for administering the surveys: Sadia Alam, Apeksha Ashok Kumar, Juan Betancur Paez, Jenniffer de Leon, Michael Guerrero-Calderon, Zufarna Jagmohan, Amanpreet Kaur, Rashmika Mohunsing, Sabrina Muhanna, Montserrat Pinto, Cassandra Rodriguez, Nicole Schulick, Jacob Sherman, Reyna Solano, John Varriano, and Sebastian Villegas.
Footnotes
Dr Glick conceptualized and designed the study, designed the data collection instruments, coordinated and supervised data collection, conducted the initial analyses, and drafted the initial manuscript; Drs Goonan and Gold-von Simson conceptualized and designed the study; Mr Kim and Mr Londoño helped to draft the initial manuscript and collected data; Dr Sandmeyer helped to design the data collection instrument and collected data; and all authors reviewed and revised the manuscript and approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Dr Glick is funded in part by the New York University Clinical and Translational Science Awards grants 5KL2TR001446 and UL1TR001445 (National Center for Advancing Translational Sciences). Dr Gold-von Simson is funded in part by the New York University Clinical and Translational Science Awards grant UL1TR001445 (National Center for Advancing Translational Sciences) and by grants R25DK119114-01A1 and T35DK007421 (National Institute of Diabetes and Digestive and Kidney Diseases). The funder or sponsor did not participate in the work. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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