Parents' Perspectives on Navigating the Work of Speaking Up in the NICU

What do patients and families observe about pediatric safety?: A thematic analysis of real-time narratives

OBJECTIVES

Data on inpatient safety are documented by hospital staff through incident reporting (IR) systems. Safety observations from families or patients are rarely captured. The Family Input for Quality and Safety (FIQS) study created a mobile health tool for pediatric patients and their families to anonymously report safety observations in real time during hospitalization. The study objectives were to describe these observations and identify domains salient to safety.

METHODS

In this observational study, we analyzed pediatric patient safety reports from June 2017 to April 2018. Participants were: English-speaking family members and hospitalized patients ≥13 years old. The analysis had two stages: 1) assessment of whether narratives met established safety event criteria and whether there were companion IRs; 2) thematic analysis to identify domains.

RESULTS

Of 248 enrolled participants, 58 submitted 120 narrative reports. Of the narratives, 68 (57%) met safety event criteria, while only one (0.8%) corresponded to a staff-reported IR. 25% of narratives shared positive feedback about patient safety efforts; 75% shared constructive feedback. We identified domains particularly salient to safety: 1) patients and families as safety actors; 2) emotional safety; 3) system-centered care; and 4) shared safety domains, including medication, communication, and environment of care. Some domains capture data that is otherwise difficult to obtain (#1-3), while others fit within standard healthcare safety domains (#4).

CONCLUSIONS

Patients and families observe and report salient safety events that can fill gaps in IR data. Healthcare leaders should consider incorporating patient and family observations-collected with an option for anonymity and eliciting both positive and constructive comments.

Content validity of a Safe Nursing Care Checklist for a neonatal unit

BACKGROUND

Nursing checklists have been shown to improve communication, reduce the occurrence of adverse events, and promote safe, quality care in different care settings. However, to date, there is no validated patient care safety checklist for nurses caring for infants in Neonatal Intensive Care Units (NICU).

AIM

To describe development and content validation of the "Safe Nursing Care Checklist for Infants Hospitalized in the Neonatal Intensive Care Unit".

STUDY DESIGN

Online Survey.

METHODS

Based upon an integrative literature review, we developed a checklist focused on safe nursing care for infants in the NICU. Nursing experts participated in three rounds of a content validation process where they rated the items online. An agreement level ≥0.90 was required for inclusion in the checklist. Forty- three expert nurses with experience working in the NICU and who were certified in neonatal nursing or had a master's or doctoratal degree in child health provided content validation of the patient care checklist.

RESULTS

The final checklist contained 45 items with content validation index scores greater than 90%. The instrument was structured into six dimensions including patient identification, effective communication, medication safety, infection prevention, fall prevention, and pressure injuries/skin injuries prevention.

CONCLUSION

Content validity was established for the "Safe Nursing Care Checklist for Infants Hospitalized in the Neonatal Intensive Care Unit" which can identify strengths and weaknesses in safe nursing care for infants in the NICU as well as direct educational interventions to promote nursing care based on scientific evidence.

RELEVANCE TO CLINICAL PRACTICE

This checklist can potentially be used by bedside nurses to promote provision of safe care to infants in the NICU and to guide corrective strategies and encourage evidence-based decision-making. Validation in the clinical setting is needed.

Neonatal outcomes from a quasi-experimental clinical trial of Family Integrated Care versus Family-Centered Care for preterm infants in U.S. NICUs

BACKGROUND

Family Integrated Care (FICare) benefits preterm infants compared with Family-Centered Care (FCC), but research is lacking in United States (US) Neonatal Intensive Care Units (NICUs). The outcomes for infants of implementing FICare in the US are unknown given differences in parental leave benefits and health care delivery between the US and other countries where FICare is used. We compared preterm weight and discharge outcomes between FCC and mobile-enhanced FICare (mFICare) in the US.

METHODS

In this quasi-experimental study, we enrolled preterm infant (≤ 33 weeks)/parent dyads from 3 NICUs into sequential cohorts: FCC or mFICare. Our primary outcome was 21-day change in weight z-scores. Our secondary outcomes were nosocomial infection, bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), and human milk feeding (HMF) at discharge. We used intention-to-treat analyses to examine the effect of the FCC and mFICare models overall and per protocol analyses to examine the effects of the mFICare intervention components.

FINDINGS

253 infant/parent dyads participated (141 FCC; 112 mFICare). There were no parent-related adverse events in either group. In intention-to-treat analyses, we found no group differences in weight, ROP, BPD or HMF. The FCC cohort had 2.6-times (95% CI: 1.0, 6.7) higher odds of nosocomial infection than the mFICare cohort. In per-protocol analyses, we found that infants whose parents did not receive parent mentoring or participate in rounds lost more weight relative to age-based norms (group-difference=-0.128, CI: -0.227, -0.030; group-difference=-0.084, CI: -0.154, -0.015, respectively). Infants whose parents did not participate in rounds or group education had 2.9-times (CI: 1.0, 9.1) and 3.8-times (CI: 1.2, 14.3) higher odds of nosocomial infection, respectively.

CONCLUSION

We found indications that mFICare may have direct benefits on infant outcomes such as weight gain and nosocomial infection. Future studies using implementation science designs are needed to optimize intervention delivery and determine acute and long-term infant and family outcomes.

CLINICAL TRIAL REGISTRATION

NCT03418870 01/02/2018.

How do hospital inpatients conceptualise patient safety? A qualitative interview study using constructivist grounded theory

BACKGROUND

Efforts to involve patients in patient safety continue to revolve around professionally derived notions of minimising clinical risk, yet evidence suggests that patients hold perspectives on patient safety that are distinct from clinicians and academics. This study aims to understand how hospital inpatients across three different specialties conceptualise patient safety and develop a conceptual model that reflects their perspectives.

METHODS

A qualitative semi-structured interview study was conducted with 24 inpatients across three clinical specialties (medicine for the elderly, elective surgery and maternity) at a large central London teaching hospital. An abbreviated form of constructivist grounded theory was employed to analyse interview transcripts. Constant comparative analysis and memo-writing using the clustering technique were used to develop a model of how patients conceptualise patient safety.

RESULTS

While some patients described patient safety using terms consistent with clinical/academic definitions, patients predominantly conceptualised patient safety in the context of what made them 'feel safe'. Patients' feelings of safety arose from a range of care experiences involving specific actors: hospital staff, the patient, their friends/family/carers, and the healthcare organisation. Four types of experiences contributed to how patients conceptualise safety: actions observed by patients; actions received by patients; actions performed by patients themselves; and shared actions involving patients and other actors in their care.

CONCLUSIONS

Our findings support the need for a patient safety paradigm that is meaningful to all stakeholders, incorporating what matters to patients to feel safe in hospital. Additional work should explore and test how the proposed conceptual model can be practically applied and implemented to incorporate the patient conceptualisation of patient safety into everyday clinical practice.

Family Input for Quality and Safety (FIQS): Using mobile technology for in-hospital reporting from families and patients

OBJECTIVE

Despite three decades of effort, ensuring inpatient safety remains elusive. Patients and family members are a potential source of safety observations, but systems gathering these are limited. Our goal was to test a system to gather safety observations from hospitalized patients and their family members via a real-time mobile health tool.

METHODS

We developed a mobile-responsive website for reporting safety observations. We piloted the tool during June 2017-April 2018 on the medical-surgical unit of a children's hospital. Participants were English-speaking family members and patients ≥13 years. We sent a daily text with a website link. We assessed: (1) face validity by comparing observations to incident reporting (IR) criteria and to hospital IRs and (2) associations between the number of safety observations/100 patient-days and participant characteristics using Poisson regression.

RESULTS

We enrolled 235 patients (43.8% of 537 reviewed for eligibility), resulting in 8.15 safety reports/100 patient-days, most frequently regarding medications (29% of reports) and communication (20% of reports). Fifty-one (40% of 125) met IR criteria; only one (1.1%) had been reported via the IR system. Latinx participants submitted fewer observations than White participants (3.9 vs. 10.1, p = .002); participants with more prior hospitalizations submitted more observations (p < .001). In adjusted analyses, including measures of preference in decision making, and patient activation, the difference between Latinx and White participants diminished substantially (6.4 vs. 11.3, p = .16).

CONCLUSIONS

We demonstrated the feasibility of real-time patient and family-member technology-enabled safety observation reporting and elicited reports not otherwise identified. Variation in reporting may potentially exacerbate disparities in safety if not addressed.

What parents want to know about caring for their preterm infant: A longitudinal descriptive study

OBJECTIVES

To describe the characteristics of parent knowledge needs and skill acquisition over the course of their infant's neonatal intensive care unit hospitalization.

METHODS

148 parents/guardians of infants ≤33 week gestation enrolled during the usual care phase of a multi-site quasi-experimental study, completing weekly surveys about their learning needs for the coming week and skills learned in the past week.

RESULTS

The topics of most interest or concern for parents included feeding their infant and their infant's medical course. Knowledge needs varied by phase of hospitalization (early, middle, late) and by parent age, prior parenting experience, infant gestational age and hospital length of stay. The most common skills learned related to feeding and basic infant care. The number of skills parents reported learning each week varied by parent age, gender, and education.

CONCLUSIONS

Parents of preterm infants expressed specific learning needs and acquisition of skills that varied over the course of the hospitalization and by parent and infant characteristics.

PRACTICE IMPLICATIONS

The findings can be used to improve parent learning experiences so that they can become full partners in their infant's caregiving and are better prepared to care for their infant after discharge.

STUDY REGISTRATION

ClinicalTrials.gov, ID NCT03418870.

The functions of adequate communication in the neonatal care unit: A systematic review and meta-synthesis of qualitative research

OBJECTIVE

To assess the main functions of parent-provider communication in the neonatal (intensive) care unit (NICU) and determine what adequate communication entails according to both parents and health professionals.

METHODS

A systematic review and meta-synthesis of qualitative research. PubMed, Ebsco/PsycINFO, Wiley/Cochrane Library, Ebsco/CINAHL, Clarivate Analytics/Web of Science Core Collection, and Elsevier/Scopus were searched in October-November 2019 for records on interpersonal communication between parents and providers in neonatal care. Title/abstract screening and full-text analysis were conducted by multiple, independent coders. Data from included articles were analyzed using deductive and inductive thematic analysis.

RESULTS

43 records were included. Thematic analysis of data resulted in the development of the NICU Communication Framework, including four functions of communication (1. building/maintaining relationships, 2. exchanging information, 3. (sharing) decision-making, 4. enabling parent self-management) and five factors that contribute to adequate communication across these functions (topic, aims, location, route, design) and, thereby, to tailored parent-provider communication.

CONCLUSION

The NICU Communication Framework fits with the goals of Family Integrated Care to encourage parent participation in infants' care. This framework forms a first step towards the conceptualization of (adequate) communication in NICU settings.

PRACTICE IMPLICATIONS

Findings can be used to improve NICU communication in practice, in particular through the mnemonic TAILORED.

We Want to Know-A Mixed Methods Evaluation of a Comprehensive Program Designed to Detect and Address Patient-Reported Breakdowns in Care

BACKGROUND

Patients have important insights into care experiences, including breakdowns, but are often reluctant to speak up. The We Want to Know (WWTK) program was designed to make it easy for hospitalized patients to speak up about breakdowns in care and receive a response.

METHODS

The WWTK program was implemented from June 2014 through May 2017 at a large, community hospital in Baltimore. Core program features include (1) multiple channels for patients to report breakdowns, (2) campaign materials to increase patient awareness of the WWTK program, and (3) a specialist to facilitate resolution of breakdowns. This program was evaluated using mixed methods to assess the frequency and type of reported breakdowns, patient awareness of the program, and stakeholder perspectives.

RESULTS

WWTK specialists interviewed 4,676 patients; 822 (17.6%) reported a breakdown in care. Of these, 313 (38.1%) had not spoken with anyone at the hospital about the breakdown, and 547 (66.5%) described associated harm. There were also 55 patient-initiated reports to WWTK; 41 (74.5%) of these reported a care breakdown. Patients had not spoken with anyone at the hospital in 12 (29.3%) patient-initiated cases; 38 (92.7%) described associated harm. Hospital stakeholders found the level of detail and timeliness of reports to be helpful.

CONCLUSION

Active outreach to hospitalized patients detects substantially more breakdowns in care than patient-initiated reporting. Both approaches identify breakdowns that are consequential to patients and provide opportunities to respond to individual patients.

Comparison of family centered care with family integrated care and mobile technology (mFICare) on preterm infant and family outcomes: a multi-site quasi-experimental clinical trial protocol

Background

Family Centered Care (FCC) has been widely adopted as the framework for caring for infants in the Neonatal Intensive Care Unit (NICU) but it is not uniformly defined or practiced, making it difficult to determine impact. Previous studies have shown that implementing the Family Integrated Care (FICare) intervention program for preterm infants in the NICU setting leads to significant improvements in infant and family outcomes. Further research is warranted to determine feasibility, acceptability and differential impact of FICare in the US context. The addition of a mobile application (app) may be effective in providing supplemental support for parent participation in the FICare program and provide detailed data on program component uptake and outcomes.

Methods

This exploratory multi-site quasi-experimental study will compare usual FCC with mobile enhanced FICare (mFICare) on growth and clinical outcomes of preterm infants born at or before 33 weeks gestational age, as well as the stress, competence and self-efficacy of their parents. The feasibility and acceptability of using mobile technology to gather data about parent involvement in the care of preterm infants receiving FCC or mFICare as well as of the mFICare intervention will be evaluated (Aim 1). The effect sizes for infant growth (primary outcome) and for secondary infant and parent outcomes at NICU discharge and three months after discharge will be estimated (Aim 2).

Discussion

This study will provide new data about the implementation of FICare in the US context within various hospital settings and identify important barriers, facilitators and key processes that may contribute to the effectiveness of FICare. It will also offer insights to clinicians on the feasibility of a new mobile application to support parent-focused research and promote integration of parents into the NICU care team in US hospital settings.

Trial registration

ClinicalTrials.gov, ID NCT03418870. Retrospectively registered on December 18, 2017.

An Ethnography of Parents' Perceptions of Patient Safety in the Neonatal Intensive Care Unit

BACKGROUND

Parents of neonates are integral components of patient safety in the neonatal intensive care unit (NICU), yet their views are often not considered. By understanding how parents perceive patient safety in the NICU, clinicians can identify appropriate parent-centered strategies to involve them in promoting safe care for their infants.

PURPOSE

To determine how parents of neonates conceptualize patient safety in the NICU.

METHODS

We conducted qualitative interviews with 22 English-speaking parents of neonates from the NICU and observations of various parent interactions within the NICU over several months. Data were analyzed using thematic content analysis. Findings were critically reviewed through peer debriefing.

FINDINGS

Parents perceived safe care through their observations of clinicians being present, intentional, and respectful when adhering to safety practices, interacting with their infant, and communicating with parents in the NICU. They described partnering with clinicians to promote safe care for their infants and factors impacting that partnership. We cultivated a conceptual model highlighting how parent-clinician partnerships can be a core element to promoting NICU patient safety.

IMPLICATIONS FOR PRACTICE

Parents' observations of clinician behavior affect their perceptions of safe care for their infants. Assessing what parents observe can be essential to building a partnership of trust between clinicians and parents and promoting safer care in the NICU.

IMPLICATIONS FOR RESEARCH

Uncertainty remains about how to measure parent perceptions of safe care, the level at which the clinician-parent partnership affects patient safety, and whether parents' presence and involvement with their infants in the NICU improve patient safety.

Communicating with patients about breakdowns in care: a national randomised vignette-based survey

BACKGROUND

Many patients are reluctant to speak up about breakdowns in care, resulting in missed opportunities to respond to individual patients and improve the system. Effective approaches to encouraging patients to speak up and responding when they do are needed.

OBJECTIVE

To identify factors which influence speaking up, and to examine the impact of apology when problems occur.

DESIGN

Randomised experiment using a vignette-based questionnaire describing 3 care breakdowns (slow response to call bell, rude aide, unanswered questions). The role of the person inquiring about concerns (doctor, nurse, patient care specialist), extent of the prompt (invitation to patient to share concerns) and level of apology were varied.

SETTING

National online survey.

PARTICIPANTS

1188 adults aged ≥35 years were sampled from an online panel representative of the entire US population, created and maintained by GfK, an international survey research organisation; 65.5% response rate.

MAIN OUTCOMES AND MEASURES

Affective responses to care breakdowns, intent to speak up, willingness to recommend the hospital.

RESULTS

Twice as many participants receiving an in-depth prompt about care breakdowns would (probably/definitely) recommend the hospital compared with those receiving no prompt (18.4% vs 8.8% respectively (p=0.0067)). Almost three times as many participants receiving a full apology would (probably/definitely) recommend the hospital compared with those receiving no apology (34.1% vs 13.6% respectively ((p<0.0001)). Feeling upset was a strong determinant of greater intent to speak up, but a substantial number of upset participants would not 'definitely' speak up. A more extensive prompt did not result in greater likelihood of speaking up. The inquirer's role influenced speaking up for two of the three breakdowns (rudeness and slow response).

CONCLUSIONS

Asking about possible care breakdowns in detail, and offering a full apology when breakdowns are reported substantially increases patients' willingness to recommend the hospital.

Neonatal Intensive Care Unit discharge preparedness among families with limited english proficiency

OBJECTIVE

We compared the Neonatal Intensive Care Unit discharge preparedness of families with and without Limited English Proficiency (LEP).

STUDY DESIGN

We performed a retrospective analysis of discharged families. Each family's discharge preparation was self-assessed on the day of discharge, and the discharging nurse assessed the family's overall emotional and technical discharge preparedness all on 9-point Likert scales. Families were considered not prepared for discharge if they rated themselves or the nurse rated their preparedness as <7 on the Likert scale.

RESULTS

Among 1307 discharged families, 90 had LEP. The odds of being prepared for discharge were the same for both groups (aOR = 0.62, 95% CI: 0.27-1.41; p = 0.258). In multivariable analyses, families with LEP were less likely to be prepared with technical baby care skills (aOR = 0.32, 95% CI: 0.13-0.81).

CONCLUSION

Families with LEP are at higher risk and may require special attention when preparing for NICU discharge.

We want to know: patient comfort speaking up about breakdowns in care and patient experience

OBJECTIVE

To assess patient comfort speaking up about problems during hospitalisation and to identify patients at increased risk of having a problem and not feeling comfortable speaking up.

DESIGN

Cross-sectional study.

SETTING

Eight hospitals in Maryland and Washington, District of Columbia.

PARTICIPANTS

Patients hospitalised at any one of eight hospitals who completed the Hospital Consumer Assessment of Healthcare Providers and Systems survey postdischarge.

MAIN OUTCOME MEASURES

Response to the question 'How often did you feel comfortable speaking up if you had any problems in your care?' grouped as: (1) no problems during hospitalisation, (2) always felt comfortable speaking up and (3) usually/sometimes/never felt comfortable speaking up.

RESULTS

Of 10 212 patients who provided valid responses, 4958 (48.6%) indicated they had experienced a problem during hospitalisation. Of these, 1514 (30.5%) did not always feel comfortable speaking up. Predictors of having a problem during hospitalisation included age, health status and education level. Patients who were older, reported worse overall and mental health, were admitted via the Emergency Department and did not speak English at home were less likely to always feel comfortable speaking up. Patients who were not always comfortable speaking up provided lower ratings of nurse communication (47.8 vs 80.4; p<0.01), physician communication (57.2 vs 82.6; p<0.01) and overall hospital ratings (7.1 vs 8.7; p<0.01). They were significantly less likely to definitely recommend the hospital (36.7% vs 71.7 %; p<0.01) than patients who were always comfortable speaking up.

CONCLUSIONS

Patients frequently experience problems in care during hospitalisation and many do not feel comfortable speaking up. Creating conditions for patients to be comfortable speaking up may result in service recovery opportunities and improved patient experience. Such efforts should consider the impact of health literacy and mental health on patient engagement in patient-safety activities.

Next-of-kin involvement in improving hospital cancer care quality and safety - a qualitative cross-case study as basis for theory development

Background

Next-of-kin are an extension of healthcare professionals in all stages of cancer care. They offer care activities such as interpretations of symptoms, and reporting of negative or adverse effects of treatment, without any professional knowledge or skills. Their participation is often expected from healthcare professionals, managers, or the patient. However, there is limited knowledge of next-of-kin’s role in and contribution to quality and safety improvement in hospital cancer care. The aim of this study was to explore how managers and healthcare professionals understand the role of next-of-kin in cancer care, and what methods they use for next-of-kin involvement.

Methods

The study design was a comparative multiple embedded case study of cancer departments in two Norwegian university hospitals. Data collection methods consist of qualitative interviews with managers (13) and healthcare professionals (19) collected in 2016, and document analysis of policy documents and regulation. The interviews were analyzed according to a directed content analysis approach guided by the theoretical framework ‘Organizing for Quality’.

Results

Both hospitals have a strategy to involve next-of-kin in treatment and care but have no formal way of doing so. Managers and healthcare professionals in the two hospitals illuminated nine areas where next-of-kin are important stakeholders in improving quality and safety. These nine areas (e.g. nutrition, observations, transitions, pain treatment, information, palliative and terminal care) are common across the two hospitals. Key challenges in the next-of-kin involvement pertain to insufficient physical working conditions and room facilities, and lack of continuity of experienced nurses and consultants.

Conclusion

Hospital employees and managers regard next-of-kin as a safety net or a buffer that cannot be replaced by other stakeholders. This study shows a close collaboration between patient, next-of-kin and healthcare professionals in cancer care, but more effort should be invested in more systematic approaches for next-of-kin involvement in quality and safety improvement such as a guide for managers and healthcare professionals on methods and areas of involvement.

Thematic Analysis of Women's Perspectives on the Meaning of Safety During Hospital-Based Birth

OBJECTIVE

To explore women's birth experiences to develop an understanding of their perspectives on patient safety during hospital-based birth.

DESIGN

Qualitative description using thematic analysis of interview data.

PARTICIPANTS

Seventeen women ages 29 to 47 years.

METHODS

Women participated in individual or small group interviews about their birth experiences, the physical environment, interactions with clinicians, and what safety meant to them in the context of birth. An interdisciplinary group of five investigators from nursing, medicine, product design, and journalism analyzed transcripts thematically to examine how women experienced feeling safe or unsafe and identify opportunities for improvements in care.

RESULTS

Participants experienced feelings of safety on a continuum. These feelings were affected by confidence in providers, the environment and organizational factors, interpersonal interactions, and actions people took during risk moments of rapid or confusing change. Well-organized teams and sensitive interpersonal interactions that demonstrated human connection supported feelings of safety, whereas some routine aspects of care threatened feelings of safety.

CONCLUSION

Physical and emotional safety are inextricably embedded in the patient experience, yet this connection may be overlooked in some inpatient birth settings. Clinicians should be mindful of how the birth environment and their behaviors in it can affect a woman's feelings of safety during birth. Human connection is especially important during risk moments, which represent a liminal space at the intersection of physical and emotional safety. At least one team member should focus on the provision of emotional support during rapidly changing situations to mitigate the potential for negative experiences that can result in emotional harm.