Your patient--my child: seven priorities for improving pediatric care from the parent's perspective

Call 4 Concern: the impact of a patient-and-relative-activated service

The aim of this project was to introduce and evaluate the Call 4 Concern© (C4C) service, which provides patients and relatives with direct access to critical care outreach services (CCOS). This allows patients and relatives an additional platform to raise concerns related to the clinical condition and facilitate early recognition of a deteriorating patient. The introduction of Call 4 Concern at a district general hospital was inspired by the Royal Berkshire Hospital, where staff have been pioneering the service in the UK since 2009. They were able to demonstrate the potential to prevent clinical deterioration and improve the patients' and relatives' experiences. The project was originally inspired by the Condition H(elp) system in the USA, which was set up following the death of an 18-month-old child who died of preventable causes. Similar tragic cases in the USA and the UK have prompted campaigning by affected families, resulting in the widespread adoption of comparable services. The project was rolled out in the authors' trust for all adult inpatients. There was a 2-week implementation phase to raise awareness. Between 22 February 2022 and 22 February 2023, the CCOS team received 39 C4C referrals, representing approximately 2.13% of the total CCOS activity. Clinical deterioration of a patient was prevented in at least three cases, alongside overwhelming positive feedback from service users.

Expanding Hospital Capacity during the COVID-19 Pandemic: The Family Voice Matters

During the initial COVID-19 response, this children’s hospital reduced its inpatient capacity by 52 beds with double rooms’ conversion to single patient occupancy, causing significant capacity constraints. To solve this challenge, the family perspective was engaged to safely redouble patient rooms and expand capacity as clinical activity increased during the COVID-19 response.

A Framework for Improving Parent Satisfaction With the Inpatient Pediatric Admission Process: Experience From a Low-Resource Setting

The objective for this initiative was to reduce parental anxiety and thus improve their satisfaction related to hospital admission by ensuring that the child’s management plan and basic amenities were communicated to the parents within the first hour of arrival at the Children’s Hospital inpatient unit. The intervention for this project was developed based on the Theory of Change framework. Effectiveness of the intervention was assessed by comparing change in parent-reported anxiety scores and improvement in patient satisfaction scores at 24 hours post-admission as an indicator of experience. The frequency of delivery of each individual message was also tracked and compared at baseline and post-intervention. The results showed a significant reduction in parental anxiety levels within the first 24 hours of admission (3.5 to 3.2, P = .01). The parent satisfaction score was significantly improved from baseline to post-intervention (4.00 vs 4.82 respectively; P < .001). Comparison between the baseline and post-intervention demonstrated a statistically significant (P < .001) increase in frequency of messages delivered. This initiative highlighted that reengineering the current system using existing resources to standardize admission communication along with an adequate monitoring and feedback plan can help reduce parental anxiety, thus improving parent satisfaction with the services.

Satisfaction With Health Care in Families Following a Diagnosis of Cleft Lip and/or Palate in the United Kingdom

OBJECTIVE

Having a child born with a cleft lip and/or palate (CL/P) poses several challenges for new parents and can have a significant psychological impact on the family as a whole. Previous research has indicated that dissatisfaction with health care is a risk factor for poor parental adjustment and family functioning. Yet, knowledge is lacking in regard to which aspects of care parents may be dissatisfied with. The current study aimed to comprehensively evaluate health-care satisfaction in families following a diagnosis of CL/P by utilizing data collected from a UK-wide birth cohort.

METHODS

Self-reported questionnaire data were obtained from 517 parent dyads enrolled in The Cleft Collective Birth Cohort Study. The "Pediatric Quality of Life Inventory-Healthcare Satisfaction Generic Module" was used as the primary outcome measure.

RESULTS

Overall, parents were satisfied with the care they had received. However, less favorable scores were identified in relation to the information parents had been given. A good degree of agreement between mothers and fathers was observed. However, marginal evidence suggested that fathers were significantly more dissatisfied than mothers regarding the "Communication" and "Inclusion of Family" subscales.

CONCLUSIONS

Although the findings of this large-scale study reflect overall health-care satisfaction, issues are raised in relation to the quality of information families received, particularly for fathers. In addition, fathers may feel less included in their child's treatment pathway. These findings offer practical suggestions as to which areas of care could be targeted by all health professionals to improve parents' health-care experiences and promote overall familial adjustment.

Patient- and relative-activated critical care outreach: a 7-year service review

Five years following the introduction of a whole-hospital, 24-hour critical care outreach (CCO) service, an additional service was introduced that enabled patients and their families to directly call the CCO team if they had concerns that were not being acknowledged by the patient's clinical team. The aim of this review was to report on 7 years of patient and family referrals using quantitative and free text data extracted from the CCO referral database. Information on demographics, frequency, nature and reason for the referrals have been reported that highlight the feasibility of such a service, and the potential to prevent patient deterioration. By tapping into the rich source of information from family concerns, future hospital services could be designed that could not only have an impact on patient outcome, but also positively influence the quality of the patient experience.

"The challenge of managing insecurities": Parents' experiences with the care for their child with congenital diaphragmatic hernia

PURPOSE

Last decennia remarkable advances have been made in decreasing the mortality rate of children with congenital diaphragmatic hernia (CDH), resulting in a relatively growing patient group with long-term complications and complex care needs. These consequences have a huge impact on the quality of life of both children and their families. To provide practical recommendations for improving the quality of care for this patient group, the present study sought to obtain insights into the experiences and needs of parents with a child with CDH.

DESIGN AND METHODS

A qualitative study was conducted on the experiences and needs of parents with a child with CDH living in the Netherlands. Data was obtained by means of a discourse analyses of 17 weblogs written by parents and three online focus groups with 8-12 parents per group (n = 29). The data was analysed thematically and structured by using the model of Lawoko (2007) on parental satisfaction with care.

RESULTS

Although parents were generally satisfied with the delivered care, they frequently encountered challenges in managing insecurities throughout the care process. Besides the unpredictable disease progress, insecurities were exacerbated by: (a) limited specialized knowledge of long-term consequences, (b) logistical problems, and (c) nontransparent communication. Providing security through, for instance, a clear care plan and by engaging parents in the decision-making process helped them feel more in control.

PRACTICE IMPLICATIONS

This study showed that parents' main challenge was to manage insecurities. Creating securities by providing a care plan and involving parents in the decision-making process helped parents to feel more in control. To improve quality of care for children with CDH, future measures should, therefore, focus on reducing insecurities by managing expectations, improving transparency and stimulating engagement.

The effect of an educational pre-operative DVD on parents' and children's outcomes after a same-day surgery: a randomized controlled trial

AIMS

To examine the effect of a pre-operative DVD on parents' knowledge, participation and anxiety and on children's distress, pain, analgesic requirements and length of recovery after same-day surgery.

BACKGROUND

Very few parents are adequately prepared to participate in their child's care during a same-day surgery. An educational DVD was developed to educate parents on how to actively support their child in the recovery room.

DESIGN

Single-blind, post-test randomized controlled trial. Study is registered at ClinicalTrials.gov NCT02766452.

METHODS

Between September 2011-September 2012, 123 parent-child dyads where the child underwent an ENT or dental same-day surgery were recruited in a Canadian paediatric hospital. Dyads were randomly assigned to either the intervention (DVD and standard preparation) or control group (standard preparation). Parents and children were videotaped in the recovery room where parental participation and anxiety and children's distress were measured. Data on parents' knowledge, children's postoperative pain, analgesic requirements and length of recovery were measured. Independent and paired t-tests, chi square and repeated measures anova were used to analyse the data.

RESULTS

Parents in the intervention group gained greater knowledge of and used more positive reinforcement and distraction and relaxation methods than those in the control group. Children's postoperative pain in the day-care surgery unit was significantly lower among the intervention group compared with the control group.

CONCLUSION

A pre-operative DVD can increase parents' participation in the recovery room and decrease children's postoperative pain.

Parental Physical Proximity in End-of-Life Care in the PICU

OBJECTIVE

Health professionals in PICUs support both child and parents when a child's death is imminent. Parents long to stay connected to their dying child but the high-tech environment and treatment implications make it difficult to stay physically close. This study explores in what sense physical aspects of end-of-life care in the PICU influence the parent-child relationship.

DESIGN

Retrospective, qualitative interview study.

SETTING

Level 3 PICU in Erasmus Medical Center in the Netherlands.

PARTICIPANTS

Thirty-six parents of 20 children who had died in this unit 5 years previously.

MEASUREMENTS AND MAIN RESULTS

Parents vividly remembered the damage done to the child's physical appearance, an inevitable consequence of medical treatment. They felt frustrated and hurt when they could not hold their child. Yet they felt comforted if facilitated to be physically close to the dying child, like lying with the child in one bed, holding the child in the hour of death, and washing the child after death.

CONCLUSIONS

End-of-life treatment in the PICU presents both a barrier and an opportunity for parents to stay physically connected to their child. Parents' experiences suggest that aspects of physicality in medical settings deserve more attention. Better understanding of the significance of bodily aspects-other than pain and symptom management-improves end-of-life support and should be part of the humane approach to families.

Self-reported post-operative recovery in children: development of an instrument

RATIONALE, AIMS AND OBJECTIVES

According to the United Nations (1989), children have the right to be heard and to have their opinions respected. Since post-operative recovery is an individual and subjective experience and patient-reported outcome measures are considered important, our aim was to develop and test an instrument to measure self-reported quality of recovery in children after surgical procedures.

METHODS

Development of the instrument Postoperative Recovery in Children (PRiC) was influenced by the Quality of Recovery-24, for use in adults. Eighteen children and nine professionals validated the items with respect to content and language. A photo questionnaire was developed to determine whether the children's participation would increase compared with the text questionnaire. The final instrument was distributed consecutively to 390 children, ages 4-12 years, who underwent tonsil surgery at four hospitals in Sweden.

RESULTS

A total of 238 children with a mean age of 6.5 years participated. According to the parents, 23% circled the answers themselves and 59% participated to a significant degree. However, there was no significant difference in participation between those who received a photo versus a text questionnaire. Psychometric tests of the instrument showed that Cronbach's alpha for the total instrument was 0.83 and the item-total correlations for 22 of the items were ≥0.20.

CONCLUSION

Our results support use of the PRiC instrument to assess and follow-up on children's self-reported post-operative recovery after tonsil operation, both in clinical praxis as well in research.

Development and psychometric characteristics of the pediatric inpatient experience survey (PIES)

OBJECTIVE

To study the psychometric properties of the Pediatric Inpatient Experience Survey (PIES), a mail and phone survey for parent reporting of family-centered aspects of inpatient care experiences.

DESIGN

Two waves of cross-sectional survey data were collected by mail and phone in 2009 to design a measurement instrument with good psychometric characteristics. Additional cross-sectional data from a mail administration in 2011 confirmed the measurement domains.

SETTING

Free-standing pediatric hospital in the northeastern USA.

PARTICIPANTS

A convenience sample of English-speaking parents of hospitalized children, stratified by patient type (medical versus surgical) and previous stays at this hospital (yes versus no), constituted the instrument design phase. Four hundred and seventy-nine (63%) of those approached agreed to participate and were randomly assigned to mail or phone survey administration. Four hundred and one of these respondents completed the first wave of the survey and 354 respondents completed the second wave. A shortened instrument was mailed to parents randomly selected from patient discharge records. Data from 929 parents (response rate: 36.2%) were used for confirmatory analysis of the created measurement domains.

MAIN OUTCOME MEASURES

The main outcome measures of this psychometric validation study were individual item performance, test-retest reliability, internal consistency, and construct validity.

RESULTS

The resulting survey includes 61 items with 35 rating items with satisfactory test-retest reliability loading on eight domains. The factor structure was supported by Cronbach's alpha and confirmatory factor analysis. The survey supported construct validity in distinguishing between medical versus surgical and first time versus previous hospital stay groups known to differ with regard to satisfaction. Comparing mail and phone administrations, differences in scores were exacerbated in domain scores and showed the need for mode adjustment.

CONCLUSION

PIES shows satisfactory test-retest reliability, internal consistency, and construct validity. A new domain measuring emotional connectedness to staff and the hospital is highly correlated with overall satisfaction.

Recognizing Differences in Hospital Quality Performance for Pediatric Inpatient Care

BACKGROUND

Hospital quality-of-care measures are publicly reported to inform consumer choice and stimulate quality improvement. The number of hospitals and states with enough pediatric hospital discharges to detect worse-than-average inpatient care remains unknown.

METHODS

This study was a retrospective analysis of hospital discharges for children aged 0 to 17 years from 3974 hospitals in 44 states in the 2009 Kids' Inpatient Database. For 11 measures of all-condition or condition-specific quality, we assessed the number of hospitals and states that met a "power standard" of 80% power for a 5% level significance test to detect when care is 20% worse than average over a 3-year period. For this assessment, we approximated volume as 3 times actual 2009 admission volumes.

RESULTS

For all-condition quality, 1380 hospitals (87% of all pediatric discharges) and all states met the power standard for the family experience-of-care measure; 1958 hospitals (95% of discharges) and all states met the standard for adverse drug events. For condition-specific quality measures of asthma, birth, and mental health, 203 to 482 hospitals (52%-90% of condition-specific discharges) met the power standard and 40 to 44 states met the standard. One hospital and 16 states met the standard for sickle cell disease. No hospital and ≤27 states met the standard for the remaining measures studied (appendectomy, cerebrospinal fluid shunt surgery, gastroenteritis, heart surgery, and seizure).

CONCLUSIONS

Most children are admitted to hospitals in which all-condition measures of quality have adequate power to show modest differences in performance from average, but most condition-specific measures do not. Policies regarding incentives for pediatric inpatient quality should take these findings into account.

Evaluating the feasibility of a parent-briefing intervention in a pediatric acute care setting

PURPOSE

The purpose of this study was to test the feasibility of a parent-briefing intervention for parents of hospitalized children with complex healthcare needs.

DESIGN AND METHODS

A phase I, single-group, posttest study. There were 18 physicians, 25 nurses, and 31 parents who participated in the study. Participants were asked to sit while carrying out the briefings with parents. Parents and clinicians completed a feasibility questionnaire post briefings.

RESULTS

Sixty-eight briefings were carried out. Parents and nurses evaluated the briefings in a favorable manner, whereas physicians' ratings were mixed.

PRACTICE IMPLICATIONS

Further inquiry is recommended to understand the effects of a structured communication intervention on parent-professional decision-making practices.

Bourdieu at the bedside: briefing parents in a pediatric hospital

The philosophy of family-centered care (FCC) promotes partnerships between families and staff to plan, deliver, and evaluate services for children and has been officially adopted by a majority of pediatric hospitals throughout North America. However, studies indicated that many parents have continued to be dissatisfied with their decision-making roles in their child's care. This is particularly salient for parents of children with chronic ongoing complex health problems. These children are dependent upon medical technology and require frequent hospitalizations during which parents must contribute to difficult decisions regarding their child's care. Given this clinical issue, an alternative theoretical perspective was explored to redress this problem. Pierre Bourdieu's theoretical concepts of field, capital, and habitus were used to analyze the hierarchical relationships in pediatric acute care hospitals and to design a briefing intervention aimed at improving parents' satisfaction with decision making in that health care setting.

"I was able to still be her mom"--parenting at end of life in the pediatric intensive care unit

OBJECTIVES

The death of a child in the pediatric intensive care unit is perhaps one of the most devastating and challenging experiences a parent can ever endure. This article examines how parents of children dying in the pediatric intensive care unit understood their role and discusses implications for clinical care and policy.

DESIGN

Retrospective, qualitative study.

SETTING

Two pediatric intensive care units located in children's hospitals within academic medical centers in the northeastern United States.

SUBJECTS

Parents of 18 children who died in the pediatric intensive care unit.

INTERVENTIONS

Semistructured telephone interviews, digitally recorded and transcribed.

MEASUREMENTS AND MAIN RESULTS

Many of the factors deemed important by the parents related to their capacity to be a "good parent" to their child throughout his or her stay in the pediatric intensive care unit. Specifically, parents sought meaningful ways to express and assert their parenthood across three domains: 1) providing love, comfort, and care; 2) creating security and privacy for the family; and 3) exercising responsibility for what happens to one's child.

CONCLUSIONS

Parents' ability to fulfill the essential features of their role as parents of children dying in the pediatric intensive care unit shapes how they perceive the quality of the experience. Pediatric intensive care unit clinical care and policies can and should uphold and protect these features enabling parents to feel that, despite the outcome, they had done their best on behalf of their children.

Parent participation in decision-making in health-care services for children: an integrative review

AIM

To describe and synthesize previous research on parents' perceptions of their participation in decision making in child health-care services.

BACKGROUND

Health policy in the area of user involvement emphasizes parent participation in decision-making (DM), thus ensuring that services are provided in accordance with their child's needs and enhancing parents' control over their child's health-care services.

METHOD

A systematic literature search, covering the period January 2000 to February 2011, found 18 studies that met the inclusion criteria. The analysis process involved data extraction, reduction, comparison and synthesizing.

FINDINGS

Three themes emerged: (1) relational factors and interdependence, (2) personal factors and attitudes and (3) organisational factors.

CONCLUSIONS

Parents highlighted the importance of the parent-health professional relationship, professionals' competence and the possibility of varying the degree of participation in decision making. Challenges involved asymmetry in authority and power, professionals' attitudes and competence and organisational shortcomings in health-care services. Health professionals need to become more aware of their critical role and responsibility in involving parents in DM.

IMPLICATIONS FOR NURSING MANAGEMENT

Health professionals' attitudes and competence can be improved by knowledge of user involvement and research and facilitating the inclusion of parents in decision making by influencing the culture, routines and resources in the health service.

Four wishes for Aubrey

In the critical care environment, what begins as cure-oriented and life-extending treatment may become unsuccessful in overcoming the patient's increasingly complex pathophysiology. A case from the neonatal intensive care unit is presented and used to elaborate upon care transitions toward palliative and supportive care that can be rendered in the hospital, at home or in a hospice facility. Successful transitions may rest upon anticipatory guidance by the primary physician and team, or a consultant, to facilitate and enable parents and team members alike in addressing the hard realities that cure, or even successful ICU discharge, is unlikely. A simple mechanism of addressing and accommodating a family's wishes is provided.

Unaccompanied hospitalized children: nurses' search for understanding

PURPOSE

To explore the experiences and feelings of pediatric nurses who care for hospitalized children that are unaccompanied by their parents.

DESIGN AND METHODS

This phenomenological study consisted of interviews with 12 pediatric nurses. Verbatim transcriptions were reviewed with participants and analyzed.

FINDINGS

Pediatric nurses viewed the circumstances of unaccompanied hospitalized children through the perspective of their own life-worlds. They used both cognitive and emotional constructs to describe the phenomenon. Nurses' perceptions were affected by day-to-day contingencies of their life worlds which come through the four dimensions of space, mind/body, time, and relationships. These perceptions affected their assessment of parents' situated contexts. Nurses' assessments could lead to negative judgments of parents because they worried about ill effects on the unaccompanied children. Meanwhile,nurses often perceived that parents demonstrated trust when they relegated their child's care to them.

CONCLUSIONS

Pediatric nurses dealt with increased emotional work while remaining compassionate with their patients. Nurses indicated that they needed to understand their own life-worlds and that parents' day-to-day contingencies may affect parents' ability to remain with their hospitalized children. Participants were aware of judgmental attitudes which could interfere with the development of therapeutic relationships with parents, and therefore, with hospitalized children.

Evaluation of the Built Environment: Staff and Family Satisfaction Pre- and Post-Occupancy of the Children's Hospital

Objective:

To evaluate and compare the impact of an existing and newly built hospital environment on family and staff satisfaction related to light, noise, temperature, aesthetics, and amenities, as well as safety, security, and privacy.

Background:

The United States is engaged in an unprecedented healthcare building boom driven by the need to replace aging facilities, understand the impact of the built environment on quality and safety, incorporate rapidly emerging technologies, and enhance patient- and family-centered care. More importantly, there is heightened attention to creating optimal physical environments to achieve the best possible outcomes for patients, families, and staff.

Methods:

Using a pre-post descriptive survey design, all nursing, social work, therapy staff, and families on selected inpatient units were invited to participate. A demographic form and Family and Staff Satisfaction Surveys were developed and administered pre- and post-occupancy of the new facility.

Results:

Pre/post mean scores for staff satisfaction improved on all survey subscales with statistically significant improvement ( p < .05) in most areas. The most improvement was seen with layout of the patient room, natural light, storage and writing surfaces, and comfort and appeal. Family satisfaction demonstrated statistically significant improvement on all subscales (p ≤ .01), especially for natural light, quiet space, parking, and the child's room as a healing environment.

Conclusions:

Families and staff reported greater satisfaction with the newly built hospital environment compared to the old facility. Study results will help guide future architectural design decisions, attract and retain staff at a world-class facility, and create the most effective healing environments.

Children's best and worst experiences during hospitalisation

THE STUDY RATIONALE: In earlier research on paediatric nursing care, children's views have received only scant attention. As a rule, it is the parents' opinions that are solicited, but these are not necessarily accurate representations of what children think.

AIM

To describe school-age children's best and worst experiences during hospitalisation.

METHODOLOGICAL DESIGN AND JUSTIFICATION

Data were collected by using sentence completion. Using the method of content analysis, the answers were coded and main and subcategories identified. A total of 388 Finnish children aged 7-11 years from all Finnish university hospitals (n = 5) who stayed at least overnight at paediatric or surgical wards (n = 23) were included in the study.

RESULTS

Children's best experiences were related to people, their characteristics, activities, environment and outcomes. Especially entertainment activities and objects were mentioned among best experiences. The worst experiences were related to people, feelings, activities and environment. As patients, children felt symptoms of illness and separation in an environment where someone conducted physical care and treatment activities, especially procedures perceived as unpleasant.

CONCLUSIONS

Paediatric care should be improved especially by taking into account children's best experiences and by utilising them to minimise or eliminate worst experiences. Children's own views should be used in strategic planning, purchasing, space design and other key initiatives. Children are more likely to be less stressed if their views are taken into consideration and they are allowed to take part in their health care in accordance with their rights.

A systematic review of decision support needs of parents making child health decisions

OBJECTIVE

To identify the decision support needs of parents attempting to make an informed health decision on behalf of a child.

CONTEXT

The first step towards implementing patient decision support is to assess patients' information and decision-making needs.

SEARCH STRATEGY

A systematic search of key bibliographic databases for decision support studies was performed in 2005. Reference lists of relevant review articles and key authors were searched. Three relevant journals were hand searched.

INCLUSION CRITERIA

Non-intervention studies containing data on decision support needs of parents making child health decisions.

DATA EXTRACTION AND SYNTHESIS

Data were extracted on study characteristics, decision focus and decision support needs. Studies were quality assessed using a pre-defined set of criteria. Data synthesis used the UK Evidence for Policy and Practice Information and Co-ordinating Centre approach.

MAIN RESULTS

One-hundred and forty nine studies were included across various child health decisions, settings and study designs. Thematic analysis of decision support needs indicated three key issues: (i) information (including suggestions about the content, delivery, source, timing); (ii) talking to others (including concerns about pressure from others); and (iii) feeling a sense of control over the process that could be influenced by emotionally charged decisions, the consultation process, and structural or service barriers. These were consistent across decision type, study design and whether or not the study focused on informed decision making.

Patient and family advocacy: working with individuals with comorbid mental illness and developmental disabilities and their families

There are many factors to consider when working with individuals with mental illness and developmental disabilities and their families. Working in collaboration with individuals and their families using a patient- and family-centered care approach is vital. This approach informs the professional's values and practice patterns thereby allowing them to help the individual and family deal with common challenges and stresses such as establishing relationships with care providers, ensuring coordination of care, family concerns, knowledge of important systems of care, and the need for advocacy.

Quality of pediatric nursing care in Finland: children's perspective

This study assessed the quality of pediatric nursing care as perceived by children (N = 388) aged 7 to 11 in Finland. The children rated as excellent the nursing environment, the nurses' humanity and trustworthiness, and caring and communication. They were most critical about the nurses' entertainment activities such as playing with them. Children's age and type of admission were both related to the amount of information they received. The instrument used in the study needs to be developed and tested further.