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Family-centered care has become the new trend in the health care field that involves honoring the patient and families' perspectives and choices and supporting them in participating in care and decision making at whatever level they choose. Family presence on rounds is one of the guidelines instituted for evidence-based best practices for support of family in the delivery of patient-centered care in the intensive care unit (ICU) but identified as the least studied among all the other aspects of family-centered care in the ICU. From 1988 to 2010, only 1 research study on family presence was conducted in an adult ICU. The purpose of this article was to review research studies related to family presence on medical rounds; reviews that focus on both adults and pediatric patients in the critical and noncritical care settings are also included.
The 2001, Institute of Medicine's landmark publication, Crossing the Quality Chasmml: A New Health System for the 21st Century, set forth recommendations intrinsic to family-centered practice. Family-centered care is patient-centered care.1 Family-centered care incorporates a partnership between families and health care providers when caring for the patient. This care delivery model involves accommodation of families by involving them in appropriate decision making, supporting them as caregivers, making them welcome and comfortable in the care delivery setting, recognizing their needs and contributions, and improving their access to information. Patients and their families should be informed about any uncertainty, risks, and treatment options. Their personal and cultural beliefs should also be honored and incorporated into health care choices.
At the request of the Society of Critical Care Medicine and the American College of Critical Care Medicine (ACCM), the ACCM Task Force of 2004 to 2005 developed guidelines to define evidence-based best practices for support of families in the delivery of patient-centered care in the intensive care unit (ICU). Family presence on medical rounds is one of the guidelines recommended by ACCM but identified as the least studied among all the other aspects of family-centered care in the ICU.2,3 Family presence on rounds is defined as the attendance of family members in the patient's room during a discussion of the patient's medical condition by the health care team. Family presence also entails having the patient and family members participate in the discussion.4 The patient and the family are engaged and are the focal point of the rounds. Staff members are able to hear everyone's perspective and give input. The burden imposed by the challenges related to privacy and teaching of the resident teams is outweighed by the greater benefit of improving bidirectional communication between families and the health care team.2 The impact on staff satisfaction and the family's ability to participate in their care is significant, and it also fosters teamwork and empowers hospital staff.5 Family involvement also improves communication, shares decision making, and offers new learning for residents and students.6
The purpose of this article was to review research studies related to family presence on medical rounds. This article also includes reviews that focus on both adults and pediatric patients in the critical and noncritical care settings. Nurses may gain insight into the perceptions of patients, families, and members of the health care team regarding family presence on rounds and its impact and as an approach in optimizing patient care.
Nurses may gain insight into the perceptions of patients, families, and members of the health care team regarding family presence on rounds.
Throughout history, families have played a crucial role in the care of injured or critically ill members.2 Today, families of critically ill patients are not mere visitors or outsiders but members of the ICU world. In addition, there is also a growing awareness that families of ICU patients have specific needs and are being offered an increasingly active role in the care of critically ill members.7 Researchers have found that the basic needs of family members in ICUs are information, reassurance, support, and the ability to be near the patient.8 Family-centered care evolved in the late 1970s as an effort to fulfill those needs.
The Institute for Family-Centered Care (IFCC) is a nonprofit organization with a mission to advance the understanding and practice of patient- and family-centered care in partnership with patients, families, and health care professionals and to integrate these concepts into all aspects of health care. As described by the IFCC,9 patient- and family-centered care is grounded in mutually beneficial partnerships among patients, families, and providers and is a model of care that can be applied in any setting. Patient- and family-centered care involves treating patients and families with dignity and listening to and honoring their perspectives and choices; empowering them with information that is timely, complete, and accurate; and supporting the participation in care and decision making at whatever level they choose.10 Family-centered care emerged as an important concept in health care during the second half of the 20th century, a time of increasing awareness of the importance of meeting the psychosocial and developmental needs of children and of the role of families in promoting the health and well-being of their children.11
Pediatric and maternal-child units were among the first to embrace family-centered care, allowing fathers into delivery rooms. Family-centered care has since become the standard care model in pediatrics. In particular, within the pediatric ICU (PICU), family-centered care is largely focused on parental involvement and parental presence at the bedside.8,10-15 Parents assume the role of advocates for their children and support to other families. Furthermore, parents are involved in their child's care to the degree that they desire. Allowing parents to participate has been noted to reduce anxiety in both parents and child, improve child cooperation with procedures, improve activity level, and reduce length of stay.4
The American Academy of Pediatrics has recommended that conducting attending physician rounds, patient presentations, and rounds discussions in patients' rooms with the family be the standard practice.16 Parents of critically ill children highly value timely information and being invited to participate in medical rounds, which may reduce parental anxiety and improve communication between parents and the health care team.17 Family member inclusion in rounds also introduces multiple opportunities for teaching the principles and practice of family-centered care to health professions learners. Despite this recommendation, little information has been published regarding the impact of including families on medical rounds.18
Applying the best evidence to practice includes several steps. First, clinical questions should be asked in patient-intervention-comparison-outcome (PICO) format to yield the most relevant information and best evidence.19 A well-built question focuses the search and saves an inordinate amount of time in searching the literature for an answer to the question. The PICO format was used to identify a specific question for literature review. Using the PICO format clarifies and organizes the following:
P-patient population of interest: critical and noncritical pediatric and adult patients
I-intervention of interest: family presence on rounds
C-comparison of interest: noninclusion of family members
O-outcomes of interest: patient, family, and health care staff outcomes
For this review, the intervention "family presence on rounds" also refers to family-centered rounds (FCRs). Family-centered rounds are multidisciplinary rounds that occur inside patients' rooms, in the presence of patients and family members, and integrate patient and parent perspectives and preferences into clinical decision making.20 The comparative intervention "noninclusion of family members" refers to standard rounds in which case presentations and clinical discussions are conducted in the corridor or conference room, but only a brief visit is made to the patient's room for a physical examination and discussion. Discussions during standard rounds are conducted out of earshot from patients and families.20 The outcomes of interest for this study are the findings reported as impact of family presence on rounds from the perception of patients, parents, families, and the health care staff. The PICO question that guided this study is: "In critical and noncritical pediatric and adult patients (P), does family presence on rounds (I) compared with noninclusion of family members (C) lead to positive outcomes and increased satisfaction (O)?
A search of MEDLINE, CINAHL, OVID, PsychInfo, and Cochrane electronic databases and Central Register from 1988 to 2010 was undertaken. This range of time covered 22 years of reviewed literature on the topic. Only articles in English were identified in the search. Search terms used were "family presence and rounds," "family presence and medical rounds," "family presence and intensive care unit rounds," "family inclusion and rounds," "family inclusion and medical rounds," "family inclusion and intensive care unit rounds," "family members and medical rounds," "family members and intensive care unit rounds," and "family participation and rounds."
The original intent of this review was to determine the best available evidence for family presence in rounds in adult ICUs. However, the researcher found only 1 research study focused solely on family presence during rounds in adult ICUs. Studies were focused mostly in PICUs and medical units. Consequently, the scarcity of review material prompted the researcher to include both adult and pediatric population in both inpatient critical and noncritical areas. The Scottish Intercollegiate Guidelines Network emphasizes that clinical questions should be addressed even if little evidence may emerge from the review. If there is in fact no good evidence, then highlighting it as an area for research is a useful outcome in itself.21
The review set forth several inclusion criteria. First, a report has to be about family presence on rounds in pediatric and adult critical and noncritical care units. Individual reports had to have experimental or nonexperimental designs, including qualitative, quality improvement (QI) reports, and systematic reviews. The exclusion criterion included articles about family presence during end-of-life meetings and/or conferences in palliative care.
Initial literature searches with the refined PICO question yielded relevant literature, but paucity of review material was noted. Articles that were not relevant to the key questions, outcomes of interest, or setting or that failed to meet specific methodological criteria were removed. Documents such as dissertations, theses, and policy documents that can be difficult to access were not included. Ninety percent of the articles reviewed were excluded from the sample. The studies for this review were judiciously selected by the researcher and her mentor, a doctoral-prepared expert investigator with expertise in evidence-based practice and knowledge translation. Each abstract was read, and duplicate articles were eliminated. Full copies of articles considered to meet the inclusion criteria (on the basis of their title, subject of study, abstract, study population and design, intervention, and comparison) were obtained for review and analysis and independently assessed for methodological quality using the Scottish Intercollegiate Guidelines Network (SIGN) 50 methodology checklist. Any differences and disagreements in assessment were resolved by discussion between reviewers and the SIGN grading system. A final selection was completed, and articles that did not meet specific clinical criteria were rejected. A total of 113 articles were reviewed, and 19 were included as samples. The results of the literature search represent 10% of the total articles reviewed and are shown in Table 1 and Figure.
The newly revised SIGN 50 methodology was used for categorization of levels of evidence found in this review (Tables 2 and 3). The levels of evidence for the selected sample research studies are summarized in Table 4.
Full copies of articles considered to meet the inclusion criteria were obtained for review and analysis.
A total of 19 reports that met the inclusion criteria were selected for the review. These studies included 2 randomized controlled trial (RCTs),22,23 1 quasi-experimental design,5 12 observational studies (prospective observational),3,16,17,24-31,32 1 qualitative descriptive,18 1 mixed-methods research,33 2 QI reports,6,34 and 4 anecdotal notes.35-38 Eight prospective observational studies were conducted in the PICU,3,16,17,23,25-27,33 1 in the neonatal ICU,24 6 in pediatric medical units,5,18,22,28,29,32 and 2 in an adult inpatient internal medicine ward.30,31 Of the 2 QI reports,6,34 one was a survey done in PICU,34 and one was in pediatric medical-surgical units.6 Sixteen study results were obtained through surveys,3,5,16,17,22-31,33,34 2 used semistructured interviews,6,18 and 1 study used survey and in-depth interviews.33
The 15 studies conducted in PICU,3,16,17,23,25-27,33 neonatal ICU,24 and pediatric medical units5,18,22,28,29,32 aimed at determining the practice,5,26 defining the perceptions,18,26,27,33 attitudes27,28,30 and parental preferences24 on parental and family presence on rounds and investigating its impact on parental/family,16-18,23,25,28 and health care staff satisfaction,3,5,17,26,28 factors associated with family satisfaction,16 residents' and students' teaching,3,16,25,31 length of rounds,3,5,16 patient care,25,31 privacy,3,16 decision making,25 communication,29,31 and nursing practice.25 The 2 RCTs22-23 and a quasi-experimental study5 intended to ascertain the differences in satisfaction and comfort between bedside case presentations and conference room presentations for parents23 (standard rounds vs bedside rounds22) of PICU patients' and residents' training.
Parents and family members from 3 prospective observational studies3,16,17 reported satisfaction with participation in rounds. One of these 3 studies16 investigated the impact of family presence on PICU rounds on family satisfaction, resident teaching, and length of rounds. The observer completed a standardized observation checklist that included total length of rounds, length of rounds for individual patients, attending physician's examination of the patients, and time spent teaching the residents. Family satisfaction was high, and time spent with individual patients was not increased by family presence. A pediatric unit in Riley Hospital for Children in Indianapolis, Indiana, presented a model of change by including parents in medical team rounds. The authors26 found that family satisfaction was unanimously improved. Families reported increased feelings of inclusion, respect, and having a better understanding of their child's care. Trainees recognized the value in patient care and family satisfaction, but some doubted their own training. These results were obtained from a survey of family members of patients and residents who had been present for rounds.
Phipps and colleagues3 in their research investigation found that family presence on rounds is beneficial, and it does not interfere with education and communication process. The authors suggested that this benefit emerged for 2 reasons. No difference in time was allotted to teaching regardless of whether families were present at the bedside, and the presence of family members on rounds did not significantly increase the amount of time spent on rounds. The Southern Illinois Trauma Center chose to include family members in daily work rounds, allowing total access to team deliberations. The authors29 concluded that families had a better understanding of the patient's condition and plan of care. Nurses indicated satisfaction with communication by the team and facilitation of relations with families. The authors17 of a study conducted in a large, urban tertiary children's hospital concluded that the health care staff learned pertinent information from the parents when they participated in the rounds. The most commonly cited information provided by parents was related to home-care regimen, medication and feeding, issues related to patient condition, medical history, hospital course, history of present illness, and social issues. Eighty-one percent of parents who chose to join the rounds reported that participation increased their overall satisfaction with their child's care. However, 88% of parents who did not choose to participate in rounds expressed that participation had the potential to increase parental confusion and anxiety.
Inclusion of parents on rounds was also seen positively by parents in an inpatient medical unit at a large academic children's hospital. This qualitative descriptive study was a part of a QI project18 that aimed to identify how the parents of children responded to participation in interdisciplinary rounds. Being able to communicate, understand the plan, and participate with the team in decision making about the child's care were the themes that emerged from this study. One nonrandomized trial5 conducted in an adolescent ward found that FCRs affected the medical decision-making discussion in 90% of the cases from the multidisciplinary staff members. The staff reported better understanding of the patient's medical plans, better ability to help families, and a greater sense of teamwork. Jarvis and colleagues25 found that parents were very supportive of involvement in decision making for their child because they learned more about their child's history and health and had a greater opportunity to offer input (96%), ask questions, and be a part of the discussion. Nurses responded that family presence on medical rounds increased communication with families and increased sense of parent education.
In a study24 that aimed to discover parental preferences about being present during ward rounds, most parents (73%) wanted to be present at rounds and viewed their participation to be an important dimension of their parenting role. Some families expressed concerns about violations of privacy. The authors24 also suggested a mixture of concerns about communication, practicalities, issues of ethics, and confidentiality, but the authors concluded that family presence on rounds was an opportunity to communicate with the health care team. Confidentiality was also a matter of concern for some family members, but many parents expected some sharing of information between families in the unit. In contrast, family members in another study3 did not perceive a violation of their privacy by participating in rounds. The same study also concluded no significant difference between time spent on rounds in the presence or absence of family members.
Other study findings were varied when viewing the perceptions of the health care staff regarding family presence on rounds in pediatrics. One study16 found that 52% of residents perceived that teaching was decreased when families are present. In another study,17 in 32% of rounding events, at least 1 health care provider believed that parental presence limited discussion whereas Jarvis and colleagues25 concluded that medical students were less enthusiastic about teaching from attending physicians and making fewer medical errors with parental presence on rounds. Authors of a study32 suggested that although concerns persisted about didactic teaching and efficiency, house staff cited improved relationships with other providers, increased parent/family satisfaction, decreased need for plan clarification, and improved "nondidactic" teaching. The most important factor associated with resident satisfaction was the attending physician.
Investigators of an RCT22 found that bedside case presentations with parental presence seems to satisfy parents without causing too much discomfort for residents, a possible teaching strategy in university hospitals. Another RCT22 of 35 parents and their children compared a standard rounding procedure in a pediatric oncology unit with bedside rounds alternating 2-week blocks for 4 months. Parents preferred bedside rounds to standard rounds and perceived increased opportunities to obtain information and ask questions. The findings suggested that bedside rounds have a positive impact on parent's attitude toward physicians, and they contribute certain aspects to resident education. Anecdotal notes on family presence during rounds also revealed positive reports on family presence on rounds that includes FCRs allows for education of medical students and residents as well as the development of a unified care plan,35 increases bedside clinical teaching,36 increases staff satisfaction and improves health outcomes,37 and enhances communication and collaboration.38
The 2 QI reports focused on improving the quality of care through encouraging family presence on rounds as an important aspect of family-centered care in PICU and pediatric medical-surgical units. At Cincinnati Children's Hospital, the authors6 found that 85% of families choose to be actively involved in rounds. These pediatric hospitalists have enthusiastically adopted FCRs supported by the development of a training program with video vignettes. In addition, a 12-bed PICU at Children's Hospital of Iowa pursued a QI project that included parents in bedside rounds, and the authors34 concluded that this simple intervention has beneficial effects for parents, children, and the health care team. The benefits included parents able to spend more time at bedside and thus were viewed as part of the team, allowing them better knowledge of the child's condition and less emotional outbursts among children when parents left the unit.
Only 2 studies30,31 of 17 reviewed that investigated family presence on rounds were conducted in the adult patient population. Authors from 1 study30 conducted in an internal medicine department suggested that nurses, physicians, patients, and relatives expressed positive attitude toward participation of family members in rounds after having undergone the experience. Positive attitude referred to improvement in receiving information regarding the disease, participation in decision making, formal discussions with physicians, family stress, communication with staff, and staff's attitude toward the patient. The only study31 conducted in medical ICU queried whether family attendance at interdisciplinary family rounds would enhance communication. The findings indicated that certain elements of satisfaction were improved but not overall satisfaction. Structured interdisciplinary rounds can improve some families' satisfaction, but some families feel rushed to make decisions.
In summary, compared with noninclusion of family members, family presence on rounds may lead to positive outcomes and increased satisfaction among patients, family members, and the health care staff. Most study results reported by investigators were positive, although some research findings are negative (refer to Tables 5 and 6 for summary of findings). Quality improvement reports yielded positive results as well.
Although the Institute of Medicine, the IFCC, the Society of Critical Care Medicine, the ACCM, and the American Academy of Pediatrics emphasize the importance of patient-centered care that includes family-centered care, family presence on medical rounds remains the least studied area of family-centered care. From 1988 to 2010, only 1 study was conducted on family presence and rounds in adult ICUs. In general, data are limited by the lack of research studies conducted on this topic in general. Most trials completed were quantitative, descriptive, and observational studies. Also, the SIGN grading system as a methodology used for this systematic review is rigid with little flexibility. Its emphasis on RCTs as criterion standard is not particularly well suited to the family presence on rounds literature, which has few RCTs and is composed of mostly observational studies. These limitations are compounded by lack of reliable outcome measures related to effectiveness of family presence on rounds. Therefore, it is difficult to achieve recommendations with the majority of SIGN ratings of 2- (and only 2 ratings of 1-) on the topic of family presence on rounds as the grading system is intended to place greater weight on the quality of the evidence supporting each recommendation and to emphasize that the body of evidence should be considered as a whole and not rely on a single study to support each recommendation. Consequently, because of the paucity of high-quality published evidence to address the key question, a number of research recommendations are made. Further research is needed to elucidate these gaps in the research. Family presence on rounds is also a topic where RCTs may not be feasible or practical to undertake. Research methodologies such as quasi-experimental, preimplementation and postimplementation, and outcomes research studies that will examine the impact of family presence on other aspects of care should be conducted. In addition, a clinical practice guideline focused on family presence needs to be in place in most institutions. To date, only AACM has developed specific guidelines for evidence-based best practices in support of families in the delivery of patient-centered care in the ICU that include families on rounds.2
Only 5 of the 17 studies have addressed nurses' perceptions of the importance of family presence on medical rounds. Assessment of nurses' attitudes and beliefs about the importance and benefits of family presence to patients, families, and the health care staff is vital in helping to establish evidence-based guidelines. Critical care nurses, especially advanced practice nurses, should initiate and plan research studies in this understudied area of critical care. Advanced practice nurses and bedside critical care nurses should also collaborate with the health care staff to develop and evaluate strategies that might foster the inclusion of family members in all aspects of care, especially on medical rounds.
Assessment of nurses' attitudes and beliefs about the importance and benefits of family presence to patients, families, and the health care staff is vital in helping to establish evidence-based guidelines.
Family presence on rounds is a subject that cannot be easily studied by quantitative methodology. Randomization of participants to the intervention of participating or not participating in rounds may not be always feasible. The perceptions of patients, family members, and the health care staff can also be best illuminated using qualitative approach. Only 2 studies18,33 in this review used qualitative methodology through interviews to determine the perceptions of participants about family presence on rounds. Formulating study questions that are qualitative in nature might be a helpful start for nurse researchers. Qualitative questions are meaning questions that are rarely asked in evidence-based reviews.19 Questions asked by qualitative researchers are influenced by a focus in understanding of human experiences and the contexts of which the experiences occur. Although evidence-based questions are often considered in the areas of etiology, diagnosis, therapy, prevention, and prognosis, qualitative questions are part of clinical inquiry and are appropriate.19 These types of questions may be asked to determine meaning, to provide insight and scope to a phenomenon, and to appreciate a specific population's experience.
Advocates of qualitative research are often troubled by the use of hierarchies of evidence that assume RCTs as the criterion standard in inquiry, which thereby devalues or excludes qualitative studies from many systematic reviews, from any consideration at all, or let alone consideration as best evidence.39 Qualitative studies are ranked lower in hierarchy of evidence, along with descriptive, evaluative, and case studies. These methodologies are considered weaker forms of evidence compared with other research designs that examine interventions. The sheer proliferation of qualitative health research has made qualitative findings difficult to dismiss and has generated urgent calls to incorporate them into the evidence-based practice process. Nurse researchers should further establish frameworks or systems for the critical appraisal of qualitative research and use its findings in evidence-based literature reviews.39
Family-centered rounds hold a potential to create a patient-centered environment, enhance medical and nursing education, and improve patient outcomes.35 Further research on family presence on rounds is warranted. Well-designed research studies such as outcomes research conducted by advanced practice nurses attending to family-centered care will strengthen the level of evidence on this subject. Studies that determine the patient's, family's, and health care staff's perceptions of care following FCRs using qualitative research methodologies are also needed. At the same time, evidence must extend beyond the current emphasis on empirical research and randomized clinical trials to the kinds of evidence generated from qualitative studies. Qualitative evidence is important in that it incorporates patient's voices into the process of evidence-based practice especially if the clinical question cannot be answered by an RCT.19 There is a need to balance scientific knowledge gained through empirical research and evidence from qualitative studies. Finally, techniques such as clinical practice guidelines are needed to encourage patients and families in the implementation of FCRs at the institutional level.
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