BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics recommends family-centered rounds (FCR) as standard practice for the inpatient setting. To date, there is limited research investigating the attitudes of pediatric patients regarding this shift in practice. The goal of this study was to explore pediatric patients’ perspectives of their experiences during FCR.
METHODS: We conducted a qualitative descriptive study based on results from 22 semi-structured interviews of school-aged and adolescent inpatients from September 2012 through October 2013. English-speaking patients, aged 7 to 18 years, who participated in FCR were eligible for inclusion. Transcripts were initially analyzed by using a constant comparative method. After completion of this initial analysis, a third reviewer independently reviewed all transcripts to verify the accuracy of the final coding scheme.
RESULTS: The final coding scheme consisted of 5 main themes: team size, medical team interactions, content discussed on FCR, setting expectations, and timing and location of FCR. In general, patients expressed a wide array of positive, negative, and neutral impressions within each theme relating to their experiences with FCR.
CONCLUSIONS: Patient comments regarding their experience with FCR offer unique perspectives from previously studied participants, including physicians, nurses, students, and parents. Future research aimed at evaluating the bedside rounding process should incorporate patients’ views to realize the complete FCR experience.
The 2012 American Academy of Pediatrics policy statement on patient- and family-centered care recommends family-centered rounds (FCR) as standard practice for the inpatient setting.1 Recent research demonstrates that many institutions have embraced the migration of daily rounds from the conference room to the bedside.2 In response to this paradigm shift, there has been a substantial amount of qualitative and quantitative research evaluating both parent and medical staff opinions concerning the effects of FCR on patient care, education, and overall satisfaction.3–12
To date, there is limited research, however, specifically investigating pediatric patients’ attitudes and opinions regarding the implementation of FCR. In an effort to adhere to the first principle of the American Academy of Pediatrics’ 2012 policy statement, which promotes “listening to and respecting each child,”1 we performed qualitative interviews with school-aged and adolescent inpatients to better comprehend the full scope of FCR within inpatient pediatric practice. Our results contribute to efforts aimed at identifying the most effective means of delivering the highest quality experience to hospitalized children.
This study was a qualitative descriptive assessment of patient attitudes and opinions of FCR based on results from 22 semi-structured interviews of school-aged and adolescent inpatients admitted to Yale–New Haven Children’s Hospital between September 2012 and October 2013. Interviews were performed until researchers agreed that thematic saturation was reached.
The Rounding Process
The medical team that conducted FCR consisted of 1 to 2 medical students, 2 to 3 interns, 1 to 2 senior residents, 1 to 2 nurse/nursing students, 1 to 2 pharmacist/pharmacy students, and an attending physician. The patient’s care provider, who was either an intern or medical student, began FCR by providing the history of the present illness, a physical examination, diagnostic results, and overnight events. The patient’s nurse was then asked to provide input on any additional patient concerns and/or overnight events. The intern or student then presented an assessment of the patient’s condition and offered his or her plan.13
Further medical discussions, including didactic teaching, discussion of assessment and plans, and addressing patient/family concerns, occurred at the discretion of the team and changed on a patient-to-patient basis. Our institutional guidelines for FCR encourage the medical team to offer families the option to participate and to determine whether rounds take place at the bedside or elsewhere. The guidelines also suggest that the team introduce its members, explain the concept of FCR to the family, encourage participation, and speak in lay language.
Patient Selection and the Interview Process
Two researchers (A.B. and M.G.) performed qualitative interviews of the 22 school-aged and adolescent inpatients. Patients were eligible for interview if they were 7 to 18 years of age, English speaking, and participated in FCR for a new admission, which included a bedside presentation as outlined earlier. To identify eligible patients, the researcher checked the morning census on the general inpatient units via the electronic medical record and conferred with the resident team to determine if bedside FCR occurred. If these criteria were met, the researcher approached the patient and family to determine if they would participate in the interview process. The researchers did not participate in any portion of FCR for the patients they interviewed and were not involved in any medical care of the patient. For patients ≤12 years of age, the researchers asked the medical team their opinion of the patient’s developmental ability to participate in the interview process before approaching the family.
Interviews were semi-structured and included both specific and open-ended questions. The 9-question template for the interview is provided in the Appendix. Each interview began with the researcher asking the patient to describe his or her perception of the FCR process to initiate a discussion.14 All interviews were conducted in the patient’s hospital room, and family members were encouraged to remain present for the interview. Interviews were digitally recorded and transcribed verbatim by the interviewer, and all completed interviews were included in the analysis. The Yale University Human Investigation Committee provided approval for the patient interviews, and parents signed informed consent forms before study participation.
Qualitative Data Analysis
Each transcript was initially reviewed by using the constant comparative method, which is a qualitative technique used to gain in-depth knowledge of a specific topic.15 After each transcript was independently coded, consensus coding was performed in which both authors reviewed each transcript, discussing disagreements until consensus was reached. After several rounds of consensus coding, a preliminary coding scheme was developed and used for subsequent coding. After every transcript had been consensus coded, the first author applied the final coding scheme to all transcripts, which the second author then reviewed to confirm agreement. After completion of this analysis, a third reviewer with extensive qualitative research experience (Dr Andrea Asnes) independently reviewed all transcripts to verify the accuracy of the final coding scheme.
Table 1 provides demographic information on the patients who participated in the interviews. Results from the content analysis were divided into 5 main themes, each of which contains multiple subthemes pertaining to patients’ overall impressions (Table 2). In general, patients expressed a wide array of thoughts and feelings pertaining to their experiences with FCR, and the subthemes reflect positive, negative, and neutral attitudes toward certain aspects of FCR. Pertinent quotations are provided throughout these sections to illustrate cited themes and subthemes.
Theme 1: Team Size
Patients expressed varying opinions on team size. Many children felt “safe, comfortable, and cared for” in the presence of a large team. They liked knowing that there were many providers working in a collaborative fashion to fix their problem. For example, a 15-year-old male patient noted, “I had 4 doctors, and they were bouncing ideas off each other and thinking of the best way to help me. I felt comfortable because I knew that these doctors were going to find the best course of action.” Children also noted that more informed caretakers meant there were more people to evaluate their status throughout the day, which added to feelings of safety and receiving superior care.
A 17-year-old female patient with a chronic condition suggested feelings of hope and confidence with seeing so many physicians in her room. She said, “I’ve been so frustrated for however long this has been going on, and it was really nice to finally get people that were going to be determined to find out what was going on.” Patients also thought that the bigger team added to overall efficiency and coordination by limiting repetition. A 17-year-old female patient noted, “one doctor at a time is slow, and you have to explain your story to each of them. This is much more efficient.”
Conversely, many patients expressed concerns with the team size being too big. Having so many people in the room made many children feel anxious and/or uncomfortable. A 15-year-old female patient noted, “There were a ton of people. I felt overwhelmed.” Another patient added, “When they asked questions I had to address all of them, so that can get a little intimidating.” Another patient hinted at concerns for privacy and stated that the experience was “intrusive.”
Theme 2: Medical Team Interactions
Patients also provided a wide array of responses to the types of relationships established by the medical team on FCR. Many patients thought the medical team seemed “friendly and nice,” citing behaviors that contributed to this impression as simple as smiling and being gentle when examining a potentially painful finding. Other children described how introductions made the team seem friendly and helped alleviate some of the awkward feelings associated with FCR. For instance, a 13-year-old female patient said, “It was at first kind of weird, because 8 other people came in, and they were surrounding my bed. It wasn’t bad because they introduced themselves, and they were really friendly.” In general, patients liked when the medical team addressed them as well as their family, asked both medical and nonmedical questions, and sought their input. These actions helped the patients feel like they were dealing with a group of respectful providers who took their patient’s problems seriously.
Patients also noted that the physicians were attentive and informative. Taking notes was mentioned multiple times as helping to create a professional environment in which important information was being documented. Patients also appreciated when team members took the time to explain assessments clearly, and they found visual aids to be useful adjuncts. A 17-year-old female patient noted, “She drew the stone in my kidney, and it was nice to have that visualized.” Finally, some patients found discussions on FCR to be interesting and a potential learning opportunity. A 7-year-old female patient stated, “I learned what was in my body, and what was wrong and how to solve it. I’m especially happy that I learned a lot because I missed so many days of school.”
Conversely, certain behaviors created negative patient experiences. Some patients cited feeling anxious and/or uncomfortable during FCR, suggesting that they felt on display for the medical team. A 17-year-old female commented, “I felt like I was on Grey’s Anatomy. They had all doctors come in and observe me like I was a specimen. It was awkward because they were staring at me.” Another child negatively commented on the proxemics of FCR, stating that the medical team stood too close to his bed. Children also expressed feelings of anxiety and fear when they did not understand what a physician was saying. A 9-year-old male patient said, “It was a little scary, because some of the things I didn’t really understand.” He continued, “For some of the big words that kids won’t understand, they should describe the word and ask the kids if they know what the words mean.”
Theme 3: Content Discussed on FCR
Patients also displayed differing opinions regarding the level of content discussed on FCR. Although some liked hearing the recap of the history of the present illness, others thought it was “boring.” For people who liked hearing the recap, they thought it was important for the team to have accurate information to provide the best care. For example, a patient commented, “They got points established that they needed to. My pediatrician was here, and she was going off what the doctor was saying.” Other patients thought it was helpful to refresh their own memory, appreciating that a night in the hospital can be confusing. The majority of opinions regarding the importance of hearing the plan for the day were positive, with children stating that they “liked knowing what would happen” and realizing the importance of being an active, adult-like participant in their own care.
From a negative standpoint, some patients felt discouraged upon hearing bad news and receiving no simple answers to their problems. A 17-year-old female patient noted, “some of the news wasn’t very good, so I was somewhat disheartened and no one really knew what to do next. It was a lot of open-ended conclusions and more confusion. It was kind of a mess this morning.” Another patient was upset that the content discussed on FCR did not address her main concern regarding pain control. She became increasingly ambivalent about the FCR process as her pain continued to be ignored, saying “I was in too much pain to really care after a while.”
Theme 4: Setting Expectations for FCR
Children also displayed mixed emotions associated with how well prepared they felt for FCR. Patients said they were “comfortable” and “fine with having it” after being given expectations of what to expect with FCR. One patient noted that the attempt to set expectations was anxiety provoking in itself, but, in the end, the experience was not a bad one: “They told me last night that 10 doctors were going to be surrounding my bed; it sounded like it was going to be awkward, but it wasn’t.”
Other patients noted feeling unprepared for what to expect on FCR and were “caught by surprise,” stating “I wasn’t expecting that.” An 8-year-old male patient spent most of FCR in fear that his peripheral intravenous line would be accessed because the expectations of what to expect on FCR were not made clear. Other patients suggested that they did not understand why the team was so large and felt unprepared for this aspect of FCR. A lack of clearly defined roles of team members contributed to the confusion as well. For example, a 17-year-old female patient stated, “I don’t know much about why all those people came into my room. It seemed like only 2 or 3 people were talking, but there was like 12 people in here.”
Theme 5: Timing and Location of FCR
The majority of responses within the timing and location theme focused on complaints that rounds occurred too early. Children expressed issues with being asleep, “confused” from just waking up, and/or feeling more “overwhelmed/surprised” in the morning. Although it is reasonable to presume that they would prefer rounds at a later time, at least 1 patient noted, “there must be a reason that you come in at that time. I guess you can’t start your day at noon.” In terms of location, all interviews were conducted at the bedside, but 1 patient noted that having the team talk outside her door for an extended period of time caused extreme anxiety. When the team entered, the patient was crying because she thought they were talking about sending her to surgery.
Previous research suggests there are substantial discrepancies in physician, parent, and children’s understanding of disease and perceptions of medical care.16,17 Applying this concept to FCR, we begin to appreciate the value in considering our patients’ unique perspectives on the way we deliver their care. To date, only 1 study dedicated to evaluating pediatric patients’ opinions of bedside rounds has been identified. This study, published in 1987, evaluated the experience of 22 inpatients with bedside rounds on a pediatric oncology ward, and it raised early awareness about the differences between children’s and parents’ views of these rounds.18
To our knowledge, our study is the first qualitative analysis exclusively devoted to evaluating general pediatric inpatients’ opinions of FCR because the majority of previous research focused on other stakeholders’ perceptions of FCR. Given our study’s qualitative nature, it mainly serves as a building block to generate hypotheses regarding what criteria may be important to consider when developing and quantitatively evaluating FCR practices.
In general, our results suggest that children’s experience with FCR is wide-ranging. Although some patients expressed positive impressions of FCR, others reported feeling anxious or scared. Some patients liked having a large number of medical personnel on rounds, but others felt overwhelmed by the size of the team. These results are in-line with previous research emphasizing the importance of tailoring FCR to the patient and suggest the need for further studies identifying efficient and effective means of doing so.13
In evaluating the specific themes, the most frequent patient comments pertained to team size. Previous research addressing team size suggests the importance of a multidisciplinary approach, with patients, nurses, and parents citing improved clarity in communication when all stakeholders are present for FCR.8,10,11,13 Given this research, our institution makes it a priority to have all stakeholders participate in FCR, sometimes leading to team sizes that include >10 members. Although some children were able to see the value in having such a large team, many other children expressed feelings of anxiety. This discrepancy in responses suggests the need for further studies exploring ways to modify team size to foster a balance between patient comfort and comprehensive medical rounds.
With regard to content discussed on FCR, previous research from the PICU suggests discomfort with delivering bad news on bedside rounds.12 Our patients’ comments supported this notion, as they expressed feelings of despair while hearing disheartening news and/or having no clear answers for persistent problems. Alternatively, many other patients expressed positive comments upon hearing the full medical presentation and plan. This discrepancy in responses again suggests the importance of tailoring FCR to the individual, and it further supports the need for investigations of strategies aimed at modifying FCR on a case-by-case basis.
Patients also frequently commented on the time of day FCR took place. To our knowledge, no previous research has examined the impact of timing of rounds on the patient’s experience, as other stakeholders may be more used to rounds traditionally occurring at early hours. Although some children in our study seemed to understand why rounds needed to happen early in the morning, many other patients described difficulty paying attention, confusion, and sleepiness (given the early timing of rounds). These comments suggest a need for further research exploring the interplay of timing of FCR and the desire to balance medical team workflow with successful engagement of patients on rounds.
Finally, it is essential to note the impact that subtle physician behaviors had on our patients’ FCR experience. Patients were truly affected by how attentive, empathic, and friendly the team appeared on rounds. Simple behaviors and actions, such as note taking, limiting pain during the physical examination, speaking directly to the patient, and/or using lay language, had a significant effect on our patients’ impression of FCR. Moving forward, additional studies are warranted to evaluate specific physician behaviors that might help maximize the patient experience on FCR.
Limitations to our study include a lack of assessment of non–English-speaking patients. Therefore, results cannot be generalized to these patients whose experience with FCR may be different. In addition, we have no means of assuring adherence with institutional guidelines for FCR, meaning that patient experience may have been affected by differing team styles. Lastly, these results represent the experience of a single institution and may not be generalizable to all institutions.
Pediatric patients’ opinions should be considered when investigating the overall impact of FCR on the inpatient experience. In this qualitative analysis, pediatric patients prioritized themes relating to team size, physician interaction styles, content discussed, setting expectations, timing, and location as the most notable elements contributing to their FCR experience. Analyzing the comments and themes provides potential areas for additional research to investigate best practices for FCR.
We acknowledge Dr Andrea Asnes for her work in reviewing all transcripts and assessing the accuracy of our finalized coding scheme.
APPENDIX: Semi-Structured Template for Patient Interviews
(1) Have patient close his or her eyes and think back to this morning’s rounding experience. Can you tell me what the bedside morning rounds were like?
(2) How did you feel during the rounding experience?
(3) What did you think of the experience?
(4) What were some good things about bedside rounds?
(5) What were some bad things about bedside rounds?
(6) What did you think of the process from your child’s perspective? How do you think she/he did with bedside rounds?
(7) Any comments you would like to add to what your parents said?
(8) Would you recommend we make any changes to bedside rounds?
(9) Any final thoughts on your experience with rounds?
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- ↵Committee on Hospital Care and Institute for Patient- and Family-Centered Care. Patient- and family-centered care and the pediatrician’s role. Pediatrics. 2012;129(2):394–404
- Mittal VS,
- Sigrest T,
- Ottolini MC,
- et al
- Nagappan S,
- Hartsell A,
- Chandler N
- Landry MA,
- Lafrenaye S,
- Roy MC,
- Cyr C
- Rappaport DI,
- Ketterer TA,
- Nilforoshan V,
- Sharif I
- Rosen P,
- Stenger E,
- Bochkoris M,
- Hannon MJ,
- Kwoh CK
- Bhansali P,
- Birch S,
- Campbell JK,
- et al
- Kuo DZ,
- Sisterhen LL,
- Sigrest TE,
- Biazo JM,
- Aitken ME,
- Smith CE
- Aronson PL,
- Yau J,
- Helfaer MA,
- Morrison W
- Muething SE,
- Kotagal UR,
- Schoettker PJ,
- Gonzalez del Rey J,
- DeWitt TG
- McCracken G
- Glaser BG,
- Strauss AL
- Susman EJ,
- Hersh SP,
- Nannis ED,
- et al
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