Parents' Perspectives on "Keeping Their Children Safe" in the Hospital

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.

Parents' and nurses' perceptions and behaviours of family-centred care during periods of busyness

PURPOSE

Busyness as a construct within modern healthcare is complex and multidimensional. To date, few studies have sought to explore how busyness influences family-centred care. This study explored the influence of busyness on the delivery of family-centred care for nurses and parents.

DESIGN AND METHOD

Ethnography was selected as the research design. The study site was a metropolitan tertiary hospital inpatient paediatric unit in Sydney, Australia. Semi-structured interview and non-participant observation techniques were used for data collection. Ten paediatric nurses and 10 parents were interviewed and 40 h of non-participant observations were undertaken. The COREQ was used to report the study.

RESULTS

The findings are presented as three key themes: (i) 'Supporting family-centred care' in which participants detail beliefs about the nurse-parent relationships and how despite busyness nurses sought out moments to engage with parents; (ii) 'Being present at the bedside' identified the challenges in optimising safety and how parents adapted their way of being and interacting on the unit; and (iii) 'The emotional cost of busyness' and how this influenced nurse-parent interactions, care delivery and family-centred care.

CONCLUSIONS

The ethnography has given shape to social understandings of busyness, the complexities of paediatric nursing and family-centred care. The culture of care changed in moments of busyness and transformed parent and nursing roles, expectations and collaborative care that at time generated internal emotional conflict and tension.

PRACTICE IMPLICATIONS

Given the increasing work demands across health systems, new agile ways of working need to ensure maintenance of a family-centred approach. Strategies need to be developed during periods of busyness to better support collaborative connections and the well-being of paediatric nurses and parents. At an organisational level, fostering a positive workplace culture that shares a vision for family-centred care and collaboration is essential.

PATIENT OR PUBLIC CONTRIBUTION

Parents of sick children admitted to an acute paediatric inpatient ward were invited to be a participant in a single interview. Parents were aware of the study through ward advertisement and informal discussions with the researchers or senior clinical staff. Engagement with parents was important as healthcare delivery in paediatrics is focused on the delivery of family-centred care. To minimise the risk of child distress and separation anxiety, children were present during the parent interview. Whist children and young people voices were not silenced during the interview process, for this study the parent's voice remained the focus. While important, due to limited resources, parents were not involved in the design analysis or interpretation of the data or in the preparation of this manuscript.

DATA SHARING

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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.

Engagement of Families in the Care of Hospitalized Pediatric Patients: A Scoping Review

This scoping review was conducted to examine the range, nature, and extent of the published family engagement literature specific to the pediatric acute care setting to highlight future research and practice development opportunities. Included studies (N = 247) revealed global relevance. Engagement strategies ranged from more passive such as allowing/encouraging families to be present at the bedside to more active strategies aimed at promoting mutual and reciprocal nurse-patient interactions. Family engagement is distinguished by a mutually beneficial partnership of families with health care team members and care organizations. Future research in the area of family engagement in pediatric nursing should focus on determining the core engaging health professional behaviors and engaged parent outcomes; extending the knowledge base related to mutually beneficial partnerships between families and health care teams; developing effectiveness studies to determine the optimal engaging actions by teams to achieve parent engagement; and measuring the influence of engagement on parent and infant/child outcomes.

Scoping review of patients' attitudes about their role and behaviours to ensure safe care at the direct care level

BACKGROUND

To improve harm prevention, patient engagement in safety at the direct care level is advocated. For patient safety to most effectively include patients, it is critical to reflect on existing evidence, to better position future research with implications for education and practice.

METHODS

As part of a multi-phase study, which included a qualitative descriptive study (Duhn & Medves, 2018), a scoping review about patient engagement in safety was conducted. The objective was to review papers about patients' attitudes and behaviours concerning their involvement in ensuring their safe care. The databases searched included MEDLINE, CINAHL and EMBASE (year ending 2019).

RESULTS

This review included 35 papers about "Patient Attitudes" and 125 papers about "Patient Behaviours"-indicative of growing global interest in this field. Several patterns emerged from the review, including that most investigators have focused on a particular dimension of harm prevention, such as asking about provider handwashing, and there is less known about patients' opinions about their role in safety generally and how to actualize it in a way that is right for them. While patients may indicate favourable attitudes toward safety involvement generally, intention to act or actual behaviours may be quite different.

CONCLUSION

This review, given its multi-focus across the continuum of care, is the first of its kind based on existing literature. It provides an important international "mapping" of the initiatives that are underway to engage patients in different elements of safety and their viewpoints, and identifies the gaps that remain.

Patient safety: perception of family members of hospitalized children

OBJECTIVES

to know the meaning attributed by family members to the health safety of pediatric patients, with attention to the possibilities of their collaboration.

METHODS

this qualitative study was conducted with eighteen family members of children hospitalized in a pediatric unit, from January to July 2018. Symbolic Interactionism was used as a theoretical framework, and Inductive Content Analysis as method.

RESULTS

child hospitalization poses risks to possible incidents and adverse events. Participants and professionals are responsible for patient safety. Thus, their actions focus on error prevention. Therefore, they seek information and observe in a vigil way professional care in classic aspects of safety. They conceive essential and favoring safety the approach centered on children and family members. Final Considerations: family members recognized the chances of errors and care damage, identified themselves as support in minimizing damage and were in partnership with the professional, increasing chances of effecting safety.

Exploring Australian parents' knowledge and awareness of pediatric inpatient falls: A qualitative study

PURPOSE

While there has been extensive published research into adult inpatient falls, less is known about pediatric falls in Australia. Falls pose a safety risk to pediatric patients potentially causing harm, increased length of stay, and death. Parents play a central role in reducing falls-related incidents given that, as parents, they provide care and/or oversee care delivered to their child at the bedside. Developing a better understanding of what parents and carers know about falls and associated risks, particularly those hospital-naïve, is central to developing family centered strategies and targeted education to meet the needs of parents. Our study aimed to explore Australian parents' knowledge and awareness of pediatric inpatient falls.

DESIGN

Qualitative methods utilizing descriptive thematic analysis.

METHODS

Parents of children and/or young people hospitalized during the last 6 months were eligible to participate. Potential participants attending the outpatient clinics of two tertiary pediatric outpatient clinics hospitals in Sydney, Australia were invited to participate in the study. Willing participants consented to complete a face to face in-depth interview. Open-ended questions sought to explore participants' knowledge, knowledge acquisition, and awareness of inpatient falls. Interviews were digitally recorded and transcribed verbatim. Data familiarization and open coding were completed by researchers independently. Researchers explored and discussed emerging categories until patterns emerged and a consensus of dominant themes were agreed upon.

RESULTS

Interviews were conducted with mothers (n = 17), fathers ( n = 4), or both parents together (n = 2) of a child or a young person who had been recently hospitalized. Four dominant themes emerged from the data namely: Supervision: falls won't happen, unexpected, parent priorities, and ways of learning about inpatient falls and risks. Despite parents' awareness of falls risk, parents were unaware that falls occur within a hospital setting and did not prioritize "falls prevention" during admission.

PRACTICE IMPLICATIONS

Findings have implications for nursing practice, particularly in the delivery, content, and timing of falls prevention education.

The Practice of Respect in the ICU

Although "respect" and "dignity" are intuitive concepts, little formal work has addressed their systematic application in the ICU setting. After convening a multidisciplinary group of relevant experts, we undertook a review of relevant literature and collaborative discussions focused on the practice of respect in the ICU. We report the output of this process, including a summary of current knowledge, a conceptual framework, and a research program for understanding and improving the practice of respect and dignity in the ICU. We separate our report into findings and proposals. Findings include the following: 1) dignity and respect are interrelated; 2) ICU patients and families are vulnerable to disrespect; 3) violations of respect and dignity appear to be common in the ICU and overlap substantially with dehumanization; 4) disrespect may be associated with both primary and secondary harms; and 5) systemic barriers complicate understanding and the reliable practice of respect in the ICU. Proposals include: 1) initiating and/or expanding a field of research on the practice of respect in the ICU; 2) treating "failures of respect" as analogous to patient safety events and using existing quality and safety mechanisms for improvement; and 3) identifying both benefits and potential unintended consequences of efforts to improve the practice of respect. Respect and dignity are important considerations in the ICU, even as substantial additional research remains to be done.

Perspectives on Patient and Family Engagement With Reduction in Harm: The Forgotten Voice

BACKGROUND

Despite continued efforts to improve safety in hospitals, hospital-acquired harm persists. Strategies have been identified to establish patient-centered care and improve patient engagement with care. However, the relationship of patient and family engagement to reduction of harm is not well understood, with limited findings available in current literature.

PURPOSE

This qualitative study explored the perceptions and attitudes of patients and family members and several clinical disciplines toward patient engagement in reducing preventable harm in hospitalized patients.

METHODS

We conducted 8 focus groups at 2 nonprofit hospitals with several constituencies: patients/families, registered nurses, physician hospitalists, and pharmacists/physical therapists.

RESULTS

Thematic analysis of transcripts revealed multiple themes from different perspectives, including: family presence increases safety, the hospital environment is intimidating, and communication is essential, but I am not being heard.

CONCLUSIONS

The rich data suggest a significant opportunity for reducing risk and harm by more actively engaging patients and families in the effort. Increasing patient acuity and complexity of care furthers the need for partnering with patients and families more intentionally for increased safety.

The Role of Felt or Enacted Criticism in Parents' Decision Making in Differing Contexts and Communities: Toward a Formal Grounded Theory

Felt or enacted criticism was identified as a significant influence on White British parents' decision making during acute childhood illness in a substantive grounded theory "Containing acute childhood illness within family life." These parents sought to avoid further criticism, sometimes leading to delayed consultation. Using Glaserian grounded theory principles, we conducted a secondary analysis of data from three studies, to establish the transferability and modifiability of the original theory to other settings and communities in Ireland and England. Felt or enacted criticism was found to operate across the childhood age range, social groups, and settings. Parent's strategies to avoid criticism reduced contacts with health professionals, access to support and, more worryingly, communication about their child's health. These findings demonstrate the wider applicability, or "work" in Glaser's terms, of the concept in the English speaking Western world. Findings indicate the need for nurses to identify and mitigate sources of criticism.

Provider Perspectives on Partnering With Parents of Hospitalized Children to Improve Safety

BACKGROUND AND OBJECTIVES

There is increasing emphasis on the importance of patient and family engagement for improving patient safety. Our purpose in this study was to understand health care team perspectives on parent-provider safety partnerships for hospitalized US children to complement a parallel study of parent perspectives.

METHODS

Our research team, including a family advisor, conducted semistructured interviews and focus groups of a purposive sample of 20 inpatient pediatric providers (nurses, patient care technicians, physicians) in an acute-care pediatric unit at a US urban tertiary hospital. We used a constant comparison technique and qualitative thematic content analysis.

RESULTS

Themes emerged from providers on facilitators, barriers, and role negotiation and/or balancing interpersonal interactions in parent-provider safety partnership. Facilitators included the following: (1) mutual respect of roles, (2) parent advocacy and rule-following, and (3) provider quality care, empathetic adaptability, and transparent communication of expectations. Barriers included the following: (1) lack of respect, (2) differences in parent versus provider risk perception and parent lack of availability, and (3) provider medical errors and inconsistent communication, lack of engagement skills and time, and fear of overwhelming information. Providers described themes related to balancing parent advocacy with clinician's expertise, a provider's personal response to challenges to the professional role, and parents balancing relationship building with escalating safety concerns.

CONCLUSIONS

To keep children safe in the hospital, providers balance perceived challenges to their personal and professional roles continuously in interpersonal interactions, paralleling parent concerns about role ambiguity and trust. Understanding these shared barriers to and facilitators of parent-provider safety partnerships can inform system design, parent education, and professional training.

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.

Are Parents Who Feel the Need to Watch Over Their Children's Care Better Patient Safety Partners?

OBJECTIVES

Many parents report needing to watch over their child's hospital care to prevent mistakes. In this study, we assessed whether needing to watch over care predicts parent performance of recommended safety behaviors to reduce medication errors and health care-associated infections.

METHODS

At admission, we surveyed 170 parents about their need to watch over care, demographics, and hospitalization factors. At discharge, parents were surveyed about medication awareness and hand hygiene behaviors. Logistic regression was used to examine how parents' need to watch over care predicted each behavior, adjusting for demographics and hospitalization factors.

RESULTS

Thirty-eight percent of parents reported needing to watch over care. Most parents (77%) reported frequently or very frequently asking providers for drug names or doses. Fewer parents asked to check drug or infusion accuracy (29%) or to show or read aloud medication labels (21%). Few parents reminded providers to clean hands (4%), but most stated they would be comfortable asking (82%) and likely to speak up if a provider did not (78%). After adjustment, parents needing to watch over care were significantly more likely to ask providers to check drug or infusion accuracy (adjusted odds ratio = 4.59, 95% confidence interval 2.14-9.94) and for drug name or dose (adjusted odds ratio = 3.04, 95% confidence interval 1.25-7.39).

CONCLUSIONS

Parents who report the need to watch over care are more likely to perform behaviors specific to safe medication use (but not hand hygiene) compared with those not reporting this need. Opportunities exist to engage parents as safety partners by leveraging their need to watch over care toward system-level safety initiatives.

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

OBJECTIVE

To describe parents' perspectives and likelihood of speaking up about safety concerns in the NICU and identify barriers and facilitators to parents speaking up.

DESIGN

Exploratory, qualitatively driven, mixed-methods design.

SETTING

A 50-bed U.S. academic medical center, open-bay NICU.

PARTICIPANTS

Forty-six parents completed questionnaires, 14 of whom were also interviewed.

METHODS

Questionnaires, interviews, and observations with parents of newborns in the NICU were used. The qualitative investigation was based on constructivist grounded theory. Quantitative measures included ratings and free-text responses about the likelihood of speaking up in response to a hypothetical scenario about lack of clinician hand hygiene. Qualitative and quantitative analyses were integrated in the final interpretation.

RESULTS

Most parents (75%) rated themselves likely or very likely to speak up in response to lack of hand hygiene; 25% of parents rated themselves unlikely to speak up in the same situation. Parents engaged in a complex process of Navigating the work of speaking up in the NICU that entailed learning the NICU, being deliberate about decisions to speak up, and at times choosing silence as a safety strategy. Decisions about how and when to speak up were influenced by multiple factors including knowing my baby, knowing the team, having a defined pathway to voice concerns, clinician approachability, clinician availability and friendliness, and clinician responsiveness.

CONCLUSION

To engage parents as full partners in safety, clinicians need to recognize the complex social and personal dimensions of the NICU experience that influence parents' willingness to speak up about their safety concerns.