Do You Know My Child? Continuity of Nursing Care in the Pediatric Intensive Care Unit

The Nurse-Implemented Chronotherapeutic Bundle in Critically Ill Children, RESTORE Resilience (R2): Pilot Testing in a Two-Phase Cohort Study, 2017-2021

OBJECTIVES

Pilot test the nurse-led chronotherapeutic bundle in critically ill children, RESTORE Resilience (R2).

DESIGN

A two-phase cohort study was carried out from 2017 to 2021.

SETTING

Two similarly sized and organized PICUs in the United States.

PATIENTS

Children 6 months to 17 years old who were mechanically ventilated for acute respiratory failure.

INTERVENTIONS

R2 seven-item chronotherapeutic bundle, including: 1) replication of child's pre-hospital daily routine (i.e., sleep/wake, feeding, activity patterns); 2) cycled day-night light/sound modulation; 3) minimal effective sedation; 4) night fasting with bolus enteral daytime feedings; 5) early progressive mobility; 6) nursing care continuity; and 7) parent diaries.

MEASUREMENTS AND MAIN RESULTS

Children underwent environmental (light, sound) and patient (actigraphy, activity log, salivary melatonin, electroencephalogram) monitoring. Parents completed the Child's Daily Routine and Sleep Survey (CDRSS) and Family-Centered Care Scale. The primary outcome was post-extubation daytime activity consolidation (Daytime Activity Ratio Estimate [DARE]). Twenty baseline-phase (2017-2019) and 36 intervention-phase (2019-2021) participants were enrolled. During the intervention phase, nurses used the CDRSS to construct children's PICU schedules. Overall compliance with nurse-implemented R2 elements 1-5 increased from 18% (interquartile range, 13-30%) at baseline to 63% (53-68%) during the intervention phase (p < 0.001). Intervention participants were exposed to their pre-hospitalization daily routine (p = 0.002), cycled day-night light/sound modulation (p < 0.001), and early progressive mobility on more PICU days (p = 0.02). Sedation target identification, enteral feeding schedules, and nursing care continuity did not differ between phases. Parent diaries were seldom used. DARE improved during the intervention phase and was higher pre-extubation (median 62% vs. 53%; p = 0.04) but not post-extubation (62% vs. 57%; p = 0.56).

CONCLUSIONS

In the PICU, implementation of an individualized nurse-implemented chronotherapeutic bundle is feasible. Children who received the R2 bundle had increased pre-extubation daytime activity consolidation compared to children receiving usual care. Given variation in protocol adherence, further R2 testing should include interprofessional collaboration, pragmatic trial design, and implementation science strategies.

Examining nurses' humanistic behaviour ability and empathy levels in clinical practice: A descriptive and exploratory study

BACKGROUND

It is critical for nurses to provide healthcare services to healthy/sick individuals with a humanistic approach and with empathy.

AIMS

This research aimed to determine nurses' humanistic behaviour ability, empathy levels and related factors in clinical practice.

DESIGN

A descriptive cross-sectional and exploratory study.

METHODS

Probability sampling method was used, and 337 nurses working in two public hospitals were included in the study. Data was collected using the Humanistic Practice Ability of Nursing Scale and the Empathy Level Determination Scale. Structural equation model analysis and descriptive statistics were used to evaluate the hypothesised model. This study adhered to the STROBE checklist for reporting.

RESULTS

Nurses' humanistic ability and empathy level in nursing practices were found to be above average. Both the ability to act humanely in nursing practices and their empathy levels were found to be significantly higher in nurses who were married and had children. A significant relationship was found between empathy levels and humanistic behaviours. Accordingly, nurses' empathy levels positively affected their humanistic care behaviours, and the model established between the two concepts was found to be statistically appropriate.

CONCLUSIONS

Nurses' empathy levels positively affect their ability to act humanistically. The result of the model established between the two concepts also supports this. Care strategies should be developed that consider factors that will improve empathetic and humanistic behaviours in nurses and maximise individualised care practices.

IMPLICATIONS FOR THE PROFESSION

Increasing the awareness of nurses about the factors affecting humanistic behaviours and empathic attitudes while caring for individuals in clinical practice, will contribute to improving the quality of nursing care.

Health-illness transition processes in children with complex chronic conditions and their parents: a scoping review

BACKGROUND

The prevalence of complex chronic conditions (CCC), which cause serious limitations and require specialized care, is increasing. The diagnosis of a CCC is a health-illness transition for children and their parents, representing a long-term change leading to greater vulnerability. Knowing the characteristics of these transitional processes is important for promoting safe transitions in this population. This scoping review aimed to map the available evidence on health-illness transition processes in children with complex chronic conditions and their parents in the context of healthcare.

METHODS

Six databases were searched for studies focusing on children aged 0-21 years with CCC and their parents experiencing health-illness transition processes, particularly concerning adaptation to illness and continuity of care, in the context of healthcare. Studies within this scope carried out between 2013 and 2023 and written in Portuguese or English were identified. The articles were selected using the PRISMA methodology. The data were extracted to an instrument and then presented with a synthesizing approach supporting the interpretation of the results.

RESULTS

Ninety-eight methodologically broad but predominantly qualitative articles were included in this review. Children with CCC have specific needs associated with complex and dynamic health-illness transitions with a multiple influence in their daily lives. Several facilitating factors (p.e. positive communication and a supportive therapeutic relationship with parents and professionals, as well as involvement in a collaborative approach to care), inhibiting factors (p.e. the complexity of the disease and therapeutic regime, as well as the inefficient organization and coordination of teams) and both positive (p.e. well-being and better quality of life) and negative response patterns (p.e. negative feelings about the chronic illness) were identified. Some interventions to support the transitional process also emerged from the literature. Pediatric palliative care is seen as a good practice and an integrative approach for these children and families.

CONCLUSION

Health professionals play a fundamental role in supporting the transitional process and promoting positive response patterns. More significant investment is needed at the clinical and academic levels regarding production and dissemination of knowledge in this area to ensure the awareness of children with CCC and that their needs are fully enhanced.

REVIEW REGISTRATION

https://doi.org/10.17605/OSF.IO/QRZC8 .

Addressing gaps and enhancing experiences in support services for families of pediatric cancer survivors

BACKGROUND

Childhood cancer's enduring challenges extend beyond primary therapy. Diverse medical and psychosocial services are available to assist families in follow-up care. This interview study sought to gain a thorough understanding of family motives, satisfaction levels, and barriers to utilization.

METHODS

The design of this cross-sectional study involves a qualitative content analysis of semi-structured interviews. We interviewed parents of minor cancer survivors within the first 5 years after primary treatment.

RESULTS

Survivors readily accessed medical support services when necessary. While parents expressed overall satisfaction with the available services, there was a notable gap in their knowledge regarding appropriate psychosocial and family-orientated services. Barriers to access included geographical distances, time constraints, and the absence of childcare options.

CONCLUSION

There are familial challenges and burdens that fall outside the scope of conventional care services. Tailoring services to family-centered needs, providing more information and easier access to interventions might help to reduce barriers.

IMPACT

Existing need notwithstanding, families did not frequently utilize psychosocial services as they did medical ones. Identified barriers included lack of awareness, limited availability, long distances, and scheduling conflicts. While many studies primarily focus on adult patients or young adults, the present study examines the gaps and strengths in follow-up care for pediatric cancer survivors and their families. By acknowledging and addressing the unique challenges and strengths of families with pediatric cancer survivors, we can lead to a more tailored and effective follow-up approach that can enhance their overall well-being by minimizing barriers and providing targeted support.

Experiences of young people living with type 1 diabetes in transition to adulthood: The importance of care provider familiarity and support

BACKGROUND

During the developmental transition from childhood to adulthood, young people living with type 1 diabetes (T1D) are more likely to take less care of their chronic disease. Alongside the developmental transition, young people with T1D also experience an organisational transition in which the care responsibility changes from a family-based approach in paediatric care to an individualised approach in adult care. Little is known from the perspective of the young people about what their interactions with the healthcare providers mean during these transitions.

AIM

The aim of this study is to explore how young people living with T1D experience interactions with their care providers, and what it means for their developmental transition.

METHOD

Semi-structured interviews with 10 respondents aged 18-20 living with T1D who were recruited from a youth outpatient diabetes clinic in Denmark. Recorded audio data were transcribed and analysed using an interpretative phenomenological analysis approach.

RESULTS

Young people experience continuity in the relationship with the diabetes nurse from the paediatric clinic and a personal patient-provider relationship with their well-known and new care providers. This creates a feeling of familiarity and contributes to a seamless transition. The young people express that becoming more involved in diabetes treatment increases their willingness to take more responsibility for their own health. They also express that care providers should support them in managing their diabetes and talk about sensitive topics.

CONCLUSION

Continuity in the relationship with the diabetes nurse makes the transition from paediatric to adult care more satisfying and seamless. To support the developmental transition, care providers should gradually involve young people more in diabetes management and be supportive as they become more independent during the developmental transition.

Nurse experiences of partnership nursing when caring for children with long-term conditions and their families: A qualitative systematic review

AIM

To explore the experiences of partnership nursing among nurses when caring for children and young people with long-term conditions, and their families.

BACKGROUND

Partnership nursing is promoted as a positive model of care among paediatric nurses, where shared roles and decision-making, parental participation, mutual trust and respect, communication and negotiation are valued to create positive care experiences and enhance patient outcomes. Little is known about how nurses use partnership with both the patient and the parents in this triad to deliver partnership nursing.

DESIGN

A qualitative systematic review followed Joanna Briggs Institute meta-aggregation approach and has been reported according to PRISMA guidelines.

METHODS

A comprehensive systematic search was conducted in seven electronic databases. Studies were assessed according to a pre-determined inclusion criteria. Qualitative findings with illustrative participant quotes were extracted from included studies and grouped into categories to inform overall synthesised findings. Methodological quality assessment was conducted.

FINDINGS

A total of 5837 publications were screened, and 41 qualitative studies were included. Three overarching synthesised findings were identified: (1) Using education to promote feelings of safety and support, (2) Partnering to develop a strong therapeutic relationship and (3) Optimising communication underpinned by shared decision-making principles to deliver individualised care.

CONCLUSION

Nurses demonstrated successful partnership in their practice, but focused on developing dyadic nurse-parent and dyadic nurse-child partnerships. Future practice development that creates a three-way triadic partnership may aid therapeutic relationships and shared decision-making.

IMPLICATIONS FOR CLINICAL PRACTICE

Clinicians can reflect on how dyadic partnerships (focusing on the child or the parent) may exclude opportunities for coherent care. Further exploration in practice, policy and research as to how nurses determine child competency and child and parent level of engagement in triadic partnership may improve the potential of meaningful shared decision-making.

Parenting through place-of-care disruptions: A qualitative study of parents' experiences of neonatal care

INTRODUCTION

Neonatal care is complex, involving multiple people and technologies within a community of care. When preterm babies are cared for far from home and/or transferred between units, the whole community of care (and particularly parent participation) is disrupted. Although previous studies have captured subjective experiences of parents, there has been little research exploring the material practices undertaken by parents as a consequence of place-of-care decisions, or the social organisation of those practices.

METHODS

As part of a wider study exploring optimal place-of-care, semistructured interviews were conducted between July 2018 and October 2019 with 48 parents (36 families) with one or more preterm babies (born at 27-31 weeks gestation) cared for in a neonatal unit in the last 12 months.

FINDINGS

We highlight parents' labour-intensive and stressful work to: (1) parent in the neonatal care community (an oversight role that goes beyond contemporary notions of 'involvement'); (2) create continuity amid place-of-care disruptions; and (3) adapt to the managerial logics of neonatal care settings. Our analysis focuses on the work generated by managerial systems that organise place-of-care decision-making and other efficiency-focused practices. Parents are absorbed into negotiating institutional systems and diverted from routine parenting activities.

CONCLUSION

Those involved in the organisation and management of neonatal care should take account of how managerial systems impact parents' workload, ability to participate in their baby's community of care and, ultimately, on the wellbeing and development of babies and their families.

PATIENT OR PUBLIC CONTRIBUTION

The OPTI-PREM study embedded parents' experiences of neonatal care into the research, through a discrete workstream that employed qualitative methodology to capture parents' experiences-as reported in this paper. The OPTI-PREM project was also supported by a Bliss volunteer parent panel, which was involved in designing and overseeing the research. Bliss 'champion[s] the right for every baby born premature or sick to receive the best care by supporting families, campaigning for change and supporting professionals and enabling life-changing research' (https://www.bliss.org.uk/about-us/about-bliss). A representative of Bliss is a co-author of this manuscript, and a parent representative (named in the Acknowledgements) provided feedback during its preparation.

"A Life Slips Through Our Fingers" Experiences of Nurses Working in Pediatric Intensive Care Units About Children's Death: A Qualitative Study

Caring for a dying child can be an experience full of all kinds of negative emotions, pain and stress for the pediatric nurse. In this study, which was carried out in Turkey, we aimed to determine how nurses working in a pediatric intensive care unit remembered and made sense of their experiences regarding children's deaths. In-depth interviews were held with 13 nurses. The data were analyzed using the content analysis method. Three themes were identified. These were (1) Personal effects of death, (2) Difficulties in care, and (3) Coping with death. It was clear that the nurses were traumatised by their exposure to infant deaths. The findings showed that nurses experienced regret, fatigue and posttraumatic stress disorder. In addition, it was determined that nurses should be supported to cope with child deaths, which is a complicated process involving the child and the family, especially emotionally. Moreover, providing institutional support to nurses and referring them to cognitive-behavioral therapies may make it easier for them to cope with the emotional burden they carry, as well as the burnout they experience.

Continuity Strategies for Long-Stay PICU Patients: Consensus Statements From the Lucile Packard Foundation PICU Continuity Panel

OBJECTIVES

To develop consensus statements on continuity strategies using primary intensivists, primary nurses, and recurring multidisciplinary team meetings for long-stay patients (LSPs) in PICUs.

PARTICIPANTS

The multidisciplinary Lucile Packard Foundation PICU Continuity Panel comprising parents of children who had prolonged PICU stays and experts in several specialties/professions that care for children with medical complexity in and out of PICUs.

DESIGN/METHODS

We used modified RAND Delphi methodology, with a comprehensive literature review, Delphi surveys, and a conference, to reach consensus. The literature review resulted in a synthesized bibliography, which was provided to panelists. We used an iterative process to generate draft statements following panelists' completion of four online surveys with open-ended questions on implementing and sustaining continuity strategies. Panelists were anonymous when they voted on revised draft statements. Agreement of 80% constituted consensus. At a 3-day virtual conference, we discussed, revised, and re-voted on statements not reaching or barely reaching consensus. We used Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of the evidence and rate the statements' strength. The Panel also generated outcome, process, and balancing metrics to evaluate continuity strategies.

RESULTS

The Panel endorsed 17 consensus statements in five focus areas of continuity strategies (Eligibility Criteria, Initiation, Standard Responsibilities, Resources Needed to Implement, Resources Needed to Sustain). The quality of evidence of the statements was low to very low, highlighting the limited evidence and the importance of panelists' experiences/expertise. The strength of the statements was conditional. An extensive list of potential evaluation metrics was generated.

CONCLUSIONS

These expert/parent-developed consensus statements provide PICUs with novel summaries on how to operationalize, implement, and sustain continuity strategies for LSP, a rapidly growing, vulnerable, resource-intensive population in PICUs.

A Qualitative Study of Nurses' Perspectives on Neonatologist Continuity of Care

BACKGROUND

Families and staff in neonatal intensive care units (NICUs) value continuity of care (COC), though definitions, delivery, and impacts of COC are incompletely described. Previously, we used parental perspectives to define and build a conceptual model of COC provided by neonatologists. Nursing perspectives about COC remain unclear.

PURPOSE

To describe nursing perspectives on neonatologist COC and revise our conceptual model with neonatal nurse input.

METHODS

This was a qualitative study interviewing NICU nurses. The investigators analyzed transcripts with directed content analysis guided by an existing framework of neonatologist COC. Codes were categorized according to previously described COC components, impact on infants and families, and improvements for neonatologist COC. New codes were identified, including impact on nurses, and codes were classified into themes.

RESULTS

From 15 nurses, 5 themes emerged: (1) nurses validated parental definitions and benefits of COC; (2) communication is nurses' most valued component of COC; (3) neonatologist COC impact on nurses; (4) factors that modulate the delivery of and need for COC; (5) conflict between the need for COC and the need for change. Suggested improvement strategies included optimizing staffing and transition processes, utilizing clinical guidelines, and enhancing communication at all levels. Our adapted conceptual model describes variables associated with COC.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Interdisciplinary NICU teams need to develop systematic strategies tailored to their unit's and patients' needs that promote COC, focused to improve parent-clinician communication and among clinicians. Our conceptual model can help future investigators develop targeted interventions to improve COC.

Distress and the Long-Stay Pediatric Intensive Care Unit Admission: A Longitudinal Study of Parents and the Medical Team

Prolonged critical illness in children has emotional consequences for both parents and providers. In this observational cohort study, we longitudinally surveyed anxiety and depression in parents and moral distress in pediatric intensive care unit (PICU) providers (attendings, fellows, and bedside registered nurses) and explored their trajectories and relationships. Anxiety/depression and provider moral distress were measured using the Hospital Anxiety and Depression Scale and the Moral Distress Thermometer, respectively. The relationships of parental and provider distress were evaluated using Spearman's correlations, and their trajectories and potentially associated variables were explored using quadratic random slope and intercept models. Predetermined associated factors included demographic and clinical factors, including parent psychosocial risk and intubation status. We found parental anxiety and depression decreased over their child's admission, and parental psychosocial risk was significantly associated with anxiety (coefficient = 4.43, p  < 0.001). Clinicians in different roles had different mean levels and trajectories of moral distress, with fellows reporting greater distress early in admissions and nurses later in admissions. Parental anxiety/depression and provider distress were significantly, though moderately, correlated. We conclude that anxiety and depression in parents of children with prolonged PICU admissions and the moral distress of their clinicians correlate and vary over time and by provider role.

Experiences of Parents of Children With Medical Complexity in the Pediatric Intensive Care Unit: A Scoping Review

BACKGROUND

Medical advances and decreased mortality rates in the pediatric intensive care unit have increased the number of children surviving illnesses they may not have survived previously. The term child with medical complexity is poorly defined.

OBJECTIVES

The purposes of this scoping review were to examine the experiences of parents of children with medical complexity in the pediatric intensive care unit and describe strategies to help support these parents.

RESULTS

Eight studies were eligible for inclusion. All were published from 2009 through 2021. One study was a quantitative observational study, 2 were mixed-methods studies, and 5 had a qualitative design. Parents experienced significant stress and depression. Sources of stress were parenting a child with complex chronic illness in the pediatric intensive care unit, uncertainty, communication between family members and clinicians, and lack of subspecialty communication. Strategies to assist parents included respecting parents' expertise and providing consistent and clear communication with family members and among subspecialty clinicians.

CONCLUSION

This review is the first to examine the experiences of parents of children with medical complexity in the pediatric intensive care unit. The study was limited by lack of available research and lack of consensus for the definition of child with medical complexity. However, this review describes strategies that nurses may find useful when caring for parents of children with medical complexity.

Hospital healthcare experiences of children and young people with life-threatening or life-shortening conditions, and their parents: scoping reviews and resultant conceptual frameworks

BACKGROUND

Patient experience is a core component of healthcare quality. Patient-reported experience measures (PREMs) are increasingly used to assess this, but there are few paediatric PREMs. This paper reports the first stage of developing two such measures, one for children and young people (0-18 years) (CYP) with a life-threatening or life-shortening condition (LT/LSC), and one for their parents. It comprised parallel scoping reviews of qualitative evidence on the elements of health service delivery and care that matter to, or impact on, CYP (Review 1) and parents (Review 2).

METHODS

Medline and PsychINFO (1/1/2010 - 11/8/2020) and CINAHL Complete (1/1/2010 - 4/7/2020) were searched and records identified screened against inclusion criteria. A thematic approach was used to manage and analyse relevant data, informed by existing understandings of patient/family experiences as comprising aspects of staff's attributes, their actions and behaviours, and organisational features. The objective was to identity the data discrete elements of health service delivery and care which matter to, or impact on, CYP or parents which, when organised under higher order conceptual domains, created separate conceptual frameworks.

RESULTS

18,531 records were identified. Sparsity of data on community-based services meant the reviews focused only on hospital-based (inpatient and outpatient) experiences. 53 studies were included in Review 1 and 64 in Review 2. For Review 1 (CYP), 36 discrete elements of healthcare experience were identified and organized under 8 higher order domains (e.g. staff's empathetic qualities; information-sharing/decision making; resources for socializing/play). In Review 2 (parents), 55 elements were identified and organized under 9 higher order domains. Some domains were similar to those identified in Review 1 (e.g. professionalism; information-sharing/decision-making), others were unique (e.g. supporting parenting; access to additional support).

CONCLUSIONS

Multiple and wide-ranging aspects of the way hospital healthcare is organized and delivered matters to and impacts on CYP with LT/LSCs, and their parents. The aspects that matter differ between CYP and parents, highlighting the importance of measuring and understanding CYP and parent experience seperately. These findings are key to the development of patient/parent experience measures for this patient population and the resultant conceptual frameworks have potential application in service development.

Primary Intensivists and Nurses for Long-Stay Patients: A Survey of Practices and Perceptions at Academic PICUs

OBJECTIVES

To determine the prevalence of the utilization of primary intensivists and primary nurses for long-stay patients in large, academic PICU and ascertain how these practices are operationalized and perceived.

DESIGN

A cross-sectional survey.

SETTING

U.S. PICUs with accredited Pediatric Critical Care Medicine fellowships.

SUBJECTS

One senior physician and one senior nurse at each institution.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Separate but largely analogous questionnaires for intensivists and nurses were created using an iterative process to enhance content/face validity and readability. Sixty-seven intensivists (representing 93% of the 72 institutions with fellowship programs and their PICUs) and 59 nurses (representing 82%) responded. Twenty-four institutions utilize primary intensivists; 30 utilize primary nurses; and 13 utilize both. Most institutions use length of stay and/or other criteria (e.g., medical complexity) for eligibility. Commonly, not all patients that meet eligibility criteria receive primaries. Primary providers are overwhelmingly volunteers, and often only a fraction of providers participate. Primary intensivists at a large majority (>75%) of institutions facilitate information sharing and decision-making, attend family/team meetings, visit patients/families regularly, and are otherwise available upon request. Primary nurses at a similar majority of institutions provide consistent bedside care, facilitate information sharing, and attend family/team meetings. A large majority of respondents thought that primary intensivists increase patient/family satisfaction, reduce their stress, improve provider communication, and reduce conflict, whereas primary nurses similarly increase patient/family satisfaction. More than half of respondents shared that these practices can sometimes require effort (e.g., time and emotion), complicate decision-making, and/or reduce staffing flexibility.

CONCLUSIONS

Primary practices are potential strategies to augment rotating PICU care models and better serve the needs of long-stay and other patients. These practices are being utilized to varying extents and with some operationalization uniformity at large, academic PICUs.

A Focused Review of Long-Stay Patients and the Ethical Imperative to Provide Inpatient Continuity

Long-stay patients are an impactful, vulnerable, growing group of inpatients in today's (and tomorrow's) tertiary hospitals. They can outlast dozens of clinicians that necessarily rotate on and off clinical service. Yet, care from such rotating clinicians can result in fragmented care due to a lack of continuity that insufficiently meets the needs of these patients and their families. Using long-stay PICU patients as an example, this focused review discusses the impact of prolonged admissions and how our fragmented care can compound this impact. It also argues that it is an ethical imperative to provide a level of continuity of care beyond what is considered standard of care and offers a number of strategies that can provide such continuity.

Parent and Provider Perspectives on Primary Continuity Intensivists and Nurses for Long-Stay Pediatric Intensive Care Unit Patients

Rationale: Primary continuity intensivists and nurses for long-stay patients (LSPs) in pediatric intensive care units (PICUs) are understudied strategies used to mitigate the fragmented care of typical rotating care models. Objectives: To investigate the advantages and disadvantages of primary continuity intensivists and nurses for LSPs as perceived by their parents and PICU providers. Methods: We conducted a prospective cross-sectional mixed-methods study of the perspectives of parents whose children were admitted to a PICU for >10 days and had one or more complex chronic conditions regarding the care provided by their PICU intensivists and nurses. As part of a trial, patients had been randomized to care provided by a rotating on-service intensivist who changed weekly and by PICU nurses who changed every 12 hours (usual care group) or to care provided by the same on-service intensivist plus a primary continuity intensivist and primary nurses (primary group). In addition, PICU providers (intensivists, fellows, and nurses) were queried for their perspectives on primary intensivists and nurses. Novel questionnaires, assessed for content and face validity and for readability, were used. The parental questionnaire involved indicating their degree of agreement with 16 statements about their children's care. The provider questionnaire involved rating potential advantages of primary continuity intensivists and nurses and estimating the frequency of disadvantages. Descriptive statistics and divergent stack bar charts were used; parents' and providers' responses were compared, stratified by their children's group (usual care or primary) and provider role, respectively. Results: The parental response rate was 71% (120 completed questionnaires). For 10 of 16 statements, parents whose children had primary continuity intensivists and nurses indicated significantly more positive perceptions of care (e.g., communication, listening, decision making, problems due to changing providers). The provider response rate was 61% (117 completed questionnaires); more than 80% believed that primary intensivists and nurses were highly or very highly beneficial for LSPs. Providers perceived more benefits for patients/families (e.g., informational continuity, facilitating and expediting decision making) than for staff/institutions (e.g., staff satisfaction). Providers reported associated stress, expenditure of time and effort, and decreased staffing flexibility with primary practices. Conclusions: Perceived benefits of primary continuity intensivists and nurses by both parents and providers support more widespread adoption and study of these continuity strategies.

Group Concept Mapping Conceptualizes High-Quality Care for Long-Stay Pediatric Intensive Care Unit Patients and Families

OBJECTIVE

To describe and conceptualize high-quality care for long-stay pediatric intensive care unit (PICU) patients using group concept mapping (GCM).

STUDY DESIGN

We convened an expert panel to elucidate domains of high-quality care for this growing patient population for which transitory care models fail to meet their needs. Thirty-one healthcare professionals and 7 parents of patients with previous prolonged PICU hospitalizations comprised a diverse, interprofessional multidisciplinary panel. Participants completed the prompt "For PICU patients and families experiencing prolonged lengths of stay, high quality care from the medical team includes ______", with unlimited free text responses. Responses were synthesized into individual statements, then panelists sorted them by idea similarity and rated them by perceived importance. Statement analysis using GCM software through GroupWisdom generated nonoverlapping clusters representing domains of high-quality care.

RESULTS

Participants submitted 265 prompt responses representing 313 unique ideas, resulting in 78 final statements for sorting and rating. The resultant cluster map best representing the data contained 8 domains: (1) Family-Centered Care and Shared Decision Making, (2) Humanizing the Patient, (3) Clinician Supports and Resources, (4) Multidisciplinary Coordination of Care, (5) Family Well-Being, (6) Anticipatory Guidance and Care Planning, (7) Communication, and (8) Continuity of Care.

CONCLUSIONS

GCM empowered a panel of healthcare professionals and parents to explicitly describe and conceptualize high-quality care for patients and families experiencing prolonged PICU stays. This information will aid the effort to address shortcomings of transitory PICU care models.

Impact of Pediatric Intensive Care Unit Preadmission Huddle on Perceptions of Interprofessional Communication About Patient Safety

BACKGROUND

Preadmission discussions in the study institution's pediatric intensive care unit are not standardized and admission plans were thought to be disjointed, leading to a perceived lack of organization and preparation for the arrival of a critically ill child.

OBJECTIVE

To evaluate the impact of a new, formalized preadmission pediatric intensive care unit interdisciplinary huddle on clinician perceptions of interprofessional communication. The hypothesis was that preadmission huddles would improve unit clinicians' perceptions of interprofessional communication.

METHODS

Interprofessional pediatric intensive care unit clinicians (physicians, advanced practice providers, nurses, and respiratory therapists) completed surveys before and 7 months after preadmission interdisciplinary huddle implementation. Huddle compliance and perceptions of interprofessional communication in the unit were evaluated.

RESULTS

Of 265 eligible pediatric intensive care unit admissions, 69 huddles (26.0%) occurred. The postintervention survey revealed increased odds (odds ratio [95% CI]) of responding "strongly agree" or "agree" to questions about the opportunity to "communicate effectively with health care team members" (2.42 [1.10-5.34]), "respond to feedback from health care team members" (2.54 [1.23-5.24]), and "convey knowledge to other health care team members" (2.71 [1.31-5.61]) before an admission.

DISCUSSION

This study introduced a formalized huddle that improved pediatric intensive care unit clinicians' perceived communication with other health care team members in the preadmission period.

CONCLUSIONS

Future studies are needed to determine if this perceived improvement in communication significantly affects health care outcomes of critically ill children or if these results are generalizable to other pediatric intensive care unit settings.

Enhancing Parents' Well-Being after Preterm Birth-A Qualitative Evaluation of the "Transition to Home" Model of Care

There are few programs available aimed at preventing short- and long-term negative consequences after preterm birth and covering the entire care continuum. The “Transition to Home (TtH)” model is such a program, offering structured, individual support for families with preterm infants before and after hospital discharge. This study gathers and examines the parents’ views of receiving support from an interprofessional team under the TtH model of care during hospitalization and after discharge. Using a qualitative explorative design, 39 semi-structured interviews with parents were analyzed thematically. From this analysis, three main themes were identified: (1) TtH and the relevance of continuity of care; (2) Enhancement of parents’ autonomy and self-confidence; (3) Perception of interprofessional collaboration. Within these themes, the most relevant aspects identified were continuity of care and the appointment of a designated health care professional to anchor the entire care continuum. Emotional support complemented by non-medical approaches, along with strength-based and family resource-oriented communication, also emerged as key aspects. Continuous, family-centered care and well-organized interprofessional collaboration promote the well-being of the family after a premature birth. If the aspects identified in this study are applied, the transition from hospital to home will be smoothened for the benefit of affected families.

A Single-Centered Randomized Controlled Trial of Primary Pediatric Intensivists and Nurses

Background: For long-stay patients (LSP) in pediatric intensive care units (PICU), frequently rotating providers can lead to ineffective information sharing and retention, varying goals and timelines, and delayed decisions, likely contributing to prolonged admissions. Primary intensivists (one physician serves as a consistent resource for the patient/family and PICU providers) and primary nurses (a small team of PICU nurses provide consistent bedside care) seek to augment usual transitory PICU care, by enhancing continuity and, potentially, decreasing length of stay (LOS). Methods: A single-centered, partially blinded randomized controlled trial of primary intensivists and nurses versus usual care. PICU patients admitted for or expected to be admitted for >10 days and who had ≥1 complex chronic condition were eligible. A block randomization with 1:1 allocation was used. The primary outcome was PICU LOS. Multiple secondary outcomes were explored. Results: Two hundred LSPs were randomized-half to receive primaries and half to usual care. The two groups were not significantly different in their baseline and admission characteristics. LSPs randomized to receive primaries had a shorter, but non-significant, mean LOS than those randomized to usual care (32.5 vs. 37.1 days, respectively, p = .19). Compared to LSPs in the usual care group, LSPs in the primary group had fewer unplanned intubations. Among LSPs that died, DNR orders were more prevalent in the primary group. Other secondary outcome and balance metrics were not significantly different between the two groups. Conclusion: Primary intensivists and nurses may be an effective strategy to counteract transitory PICU care and serve the distinctive needs of LSPs. However, additional studies are needed to determine the ways and to what extent they may accomplish this.

The Child With Severe Chronic Illness in the ICU: A Concise Review

OBJECTIVES

Children with severe chronic illness are a prevalent, impactful, vulnerable group in PICUs, whose needs are insufficiently met by transitory care models and a narrow focus on acute care needs. Thus, we sought to provide a concise synthetic review of published literature relevant to them and a compilation of strategies to address their distinctive needs.

DATA SOURCES

English language articles were identified in MEDLINE using a variety of phrases related to children with chronic conditions, prolonged admissions, resource utilization, mortality, morbidity, continuity of care, palliative care, and other critical care topics. Bibliographies were also reviewed.

STUDY SELECTION

Original articles, review articles, and commentaries were considered.

DATA EXTRACTION

Data from relevant articles were reviewed, summarized, and integrated into a narrative synthetic review.

DATA SYNTHESIS

Children with serious chronic conditions are a heterogeneous group who are growing in numbers and complexity, partly due to successes of critical care. Because of their prevalence, prolonged stays, readmissions, and other resource use, they disproportionately impact PICUs. Often more than other patients, critical illness can substantially negatively affect these children and their families, physically and psychosocially. Critical care approaches narrowly focused on acute care and transitory/rotating care models exacerbate these problems and contribute to ineffective communication and information sharing, impaired relationships, subpar and untimely decision-making, patient/family dissatisfaction, and moral distress in providers. Strategies to mitigate these effects and address these patients' distinctive needs include improving continuity and communication, primary and secondary palliative care, and involvement of families. However, there are limited outcome data for most of these strategies and little consensus on which outcomes should be measured.

CONCLUSIONS

The future of pediatric critical care medicine is intertwined with that of children with serious chronic illness. More concerted efforts are needed to address their distinctive needs and study the effectiveness of strategies to do so.

COVID-19 pandemic: the impact on Canada’s intensive care units

The COVID-19 pandemic has exposed the precarious demand-capacity balance in Canadian hospitals, including critical care where there is an urgent need for trained health care professionals to dramatically increase ICU capacity.

The impact of the pandemic on ICUs varied significantly across the country with provinces that implemented public health measures later and relaxed them sooner being impacted more severely. Pediatric ICUs routinely admitted adult patients. Non-ICU areas were converted to ICUs and staff were redeployed from other essential service areas. Faced with a lack of critical care capacity, triage plans for ICU admission were developed and nearly implemented in some provinces.

Twenty eight percent of patients in Canadian ICUs who required mechanical ventilation died. Surviving patients have required prolonged ICU admission, hospitalization and extensive ongoing rehabilitation. Family members of patients were not permitted to visit, resulting in additional psychological stresses to patients, families, and healthcare teams. ICU professionals also experienced extreme psychological stresses from caring for such large numbers of critically ill patients, often in sub-standard conditions. This resulted in large numbers of health workers leaving their professions.

This pandemic is not yet over, and it is likely that new pandemics will follow. A review and recommendations for the future are provided.

Continuity of care for children with chronic conditions after discharge: a constructivist grounded theory

ABSTRACT Objectives: to understand the meaning of continuity of care for children with chronic conditions through transitional care from hospital to home. Methods: this is a qualitative study, conducted from a Constructivist Grounded Theory perspective. Purposive and theoretical sampling were used to recruit 35 participants, including nurses, professionals from the interprofessional hospital team, and actors responsible for healthcare in the home context. The research was conducted at two large hospitals, between March and September 2019. Semi-structured interviews were conducted. Data analysis was carried out using initial and focused coding, according to constructivist grounded theory. Results: the substantive theory that emerged from this study was named “Postponing the next hospitalization”. Eight categories-concepts and 18 elements were derived from the data to support the substantive theory. Final Considerations: transitional care from hospital to home acts as a reminder for the resumption of continuity of care after discharge.

Parental Perspectives on Neonatologist Continuity of Care

BACKGROUND

Continuity of care (COC) is highly regarded; however, data about benefits are mixed. Little is known about components, parental views, or the value COC may provide to neonatal intensive care unit (NICU) infants and families.

PURPOSE

To describe parents' perspectives on definitions, reasons they value, and suggested improvements regarding COC provided by neonatologists.

METHODS

We performed a qualitative study of in-person, semistructured interviews with parents of NICU infants hospitalized for 28 days or more. We analyzed interview transcripts using content analysis, identifying codes of parental experiences, expressed value, and improvement ideas related to neonatologist COC, and categorizing emerging themes.

RESULTS

Fifteen families (15 mothers and 2 fathers) described 4 themes about COC: (1) longitudinal neonatologists: gaining experience with infants and building relationships with parents over time; (2) background knowledge: knowing infants' clinical history and current condition; (3) care plans: establishing patient-centered goals and management plans; and (4) communication: demonstrating consistent communication and messaging. Parents described benefits of COC as decreasing knowledge gaps, advancing clinical progress, and decreasing parental stress. Suggested improvement strategies included optimizing staffing and sign-out/transition processes, utilizing clinical guidelines, and enhancing communication. Using parent input and existing literature, we developed a definition and conceptual framework of COC.

IMPLICATIONS FOR PRACTICE

NICUs should promote practices that enhance COC. Parental suggestions can help direct improvement efforts.

IMPLICATIONS FOR RESEARCH

Our COC definition and conceptual framework can guide development of research and quality improvement projects. Future studies should investigate nursing perspectives on NICU COC and the impact of COC on infant and family outcomes.

Primary palliative care integrated model in paediatric ICU: an international cross-sectional study

OBJECTIVES

Numbers are rising of chronically and critically ill, technology-dependent children, who are admitted to paediatric intensive care units (PICUs). An integrated model of care (IMOC), that combines paediatric critical care and primary paediatric palliative care (PPC), in which either approach varies depending on the disease trajectory and is provided by the critical care team, might be a fundamental component of the best available standard of care for patients with life-threatening conditions. The objective of this study is to assess how PICUs around the world, implement an IMOC.

METHODS

International multicentre cross-sectional observational study. Data was gathered from 34 PICUs from 18 countries in the Americas, Europe, Asia and Africa. Provision of primary PPC was studied for each child admitted at the PICU. We evaluated score differences in each domain of the Initiative for Paediatric Palliative Care (IPPC) curriculum with multilevel generalised linear models.

RESULTS

High-income country (HIC) units made up 32.4% of the sample, upper-middle income countries (UMICs) 44.1%, lower-middle income/lower income countries (LMIC/LICs) 23.5%. HICs had four statistically significantly higher IPPC scores compared with UMICs (domains: 1 holistic care; 2 family support, 3B family involvement; 6B grief/bereavement healthcare provider support) and two compared with LMIC/LICs (domains: 6A grief/bereavement family support; 6B grief/bereavement healthcare provider support).HICs had a statistically significant overall higher IPPC score than UMICs. Adjusting for patient/centre characteristics, shorter shifts and multiple comorbidities were associated with higher IPPC scores.

CONCLUSIONS

All centres offered some PPC provision and partially applied an IMOC. These results are encouraging, however, differences related to income and patients/unit evidence opportunities for improvement.

TRIAL REGISTRATION NUMBER

ISRCTN12556149.

Parents' experiences during and after their child's stay in the paediatric intensive care unit - A qualitative interview study

BACKGROUND

Having a child admitted to the paediatric intensive care unit (PICU) is often an emotional and stressful experience for parents.

AIM

The aim of the study was to explore parents' experiences during and after their child's hospitalization in the PICU and to investigate whether parents have a need for post-PICU follow-up.

MATERIAL AND METHODS

The research design was a qualitative study inspired by Ricoeur's phenomenological-hermeneutic approach. The context of the study was a six-bed PICU in a university hospital in Denmark. In 2017, semi-structured interviews were conducted with four couples and three mothers six to 14 weeks after their child had been discharged from the PICU. The data were analysed and interpreted through Ricoeur's three analytical levels and presented in themes and subthemes.

FINDINGS

Three themes were identified in the analytical process: "The challenging PICU stay", "The value of a network" and "The uncertain post-PICU trajectory".

CONCLUSION

Information, dialogue and interaction with familiar health professionals, the diary written by PICU nurses, the parents' personal network and social media supported the parents during and after the PICU stay. The parents expressed that post-PICU follow-up was not the most essential but that follow-up initiatives may be arranged individually.

Situational Analysis

Situational analysis is not commonly used in nursing research; however, its usefulness in examining complicated phenomena that are locally situated makes it an effective approach to emergency nursing problems. This paper describes the situational analysis approach as an extension of the grounded theory method and uses 3 studies to demonstrate the effectiveness of this qualitative approach.

Parents' experiences of caring for their child in a Paediatric Intensive Care Unit: A literature review

The objective is to identify the available literature on parents' experiences in caring for children in the Paediatric Intensive Care Unit (PICU). Original research on parents experience in caring their child in PICU were identified from five online databases, namely CINAHL, Science Direct, Proquest, Cochrane, and Pubmed (2008-2018) using the terms "parent," "experience," "children", "paediatric intensive care" and "caring." We included articles addressing the parent's experiences while their child was admitted to PICU their needs and participation in the care of the child. Twenty-two papers have met the criteria for inclusion. Further review of these articles resulted in summarised topics - PICU parents' experience, parental stressors, and parental needs. Current research demonstrates a diversity of parent's experiences while caring for their child; however, little is known about interventions to improve and support parents who are in a difficult situation when their child being treated in PICU.

Children living with long-term conditions: A meta-aggregation of parental experiences of partnership nursing

AIM

To explore how parents of children with long-term conditions experience partnership in paediatric and neonatal nursing care and to identify existing partnership barriers and facilitators.

BACKGROUND

Parent-nurse partnership is fundamental to paediatric and neonatal nursing. Partnership is characterised by five attributes: parental participation, negotiation, mutual trust and respect, shared roles and decision-making, and communication. Little is known about the parental experiences of partnership nursing specific to children living with a long-term condition.

DESIGN

A qualitative meta-aggregation review following Joanna Briggs Institute meta-aggregation approach.

METHODS

A comprehensive search was conducted in six electronic databases. Studies were assessed according to the inclusion and exclusion criteria. Qualitative findings with illustrative quotes from included studies were extracted and grouped into categories which informed the synthesised findings. This review has been reported according to the PRISMA guidelines.

FINDINGS

A total of 4,404 studies were screened, 162 full-text studies were assessed against the inclusion and exclusion criteria, and a total of six studies were included. The meta-aggregation developed three overarching synthesised findings which were as follows: (a) empowering parents to become involved, (b) effective communication to recognise mutual expertise and (c) collaborative nurse-family relationships.

CONCLUSION

Parents valued collaboration where both parents and nurses are recognised equally for their skills and expertise. A power struggle existed between parents and nurses when expertise was not recognised. Parents appreciated nurses who empowered them to develop new skills and knowledge in the care of their own child.

RELEVANCE TO CLINICAL PRACTICE

Nurses need to recognise the skills and knowledge that parents have surrounding the care requirements of their own children. Collaboration and negotiation are key to successful partnership between nurses and parents. Nurses need to frequently reflect on how they are successfully partnering with both parents and children and ensure all parties in the nurse/parent/child triad feel supported and empowered.

Inpatient Unit Leaders' Perspectives on Parent Engagement in Neonatal and Pediatric Intensive Care: A Secondary, Qualitative Analysis

BACKGROUND

Hospital unit leaders help set the unit's priorities and are responsible for guiding the unit mission and philosophy of care; however, the perspective of leaders in facilitating parent engagement within intensive care units is limited.

PURPOSE

The purpose of this study was to explore how medical and nursing unit leaders facilitate parent engagement in intensive care settings.

METHODS

Qualitative secondary analysis of 16 semistructured interviews of unit leadership (medical directors and nurse managers). Directed content analysis explored themes within the interviews using systematic strategies to ensure rigor.

FINDINGS

Unit leadership described 3 main features of care delivery necessary for supporting parent engagement: (1) culture of care, (2) relationships in care, and (3) environment of care. Communication among providers and parents and timing of decision-making were key areas addressed, along with concerns about physical space limiting parent engagement. Unit leaders discussed how the 3 main features (unit culture, relationships, and physical space) of care delivery were interconnected to optimize parent engagement.

IMPLICATIONS FOR PRACTICE

Overall, unit leaders recognized the importance of each feature of care delivery in facilitating engagement. Parent engagement is ultimately influenced by the optimization of delivering inclusive care: the physical space, the policies surrounding medical and nursing care, and the overall culture of the unit.

IMPLICATIONS FOR RESEARCH

Future research needs to explore best practices around relationship building and managing space limitations. Further clarification of the needs and expectations of both parents and providers surrounding parent engagement in intensive care settings is needed.

A meta-ethnographic study of fathers' experiences of caring for a child with a life-limiting illness

BACKGROUND

There is a growing body of qualitative studies examining parents' experiences of caring for a child with a life-limiting condition, coinciding with recent evidence that indicates an increasing incidence of paediatric life-limiting conditions. However, research focusing on fathers' needs remains sparse and is often diluted among a predominant 'mother's voice', raising questions about whether practices in clinical settings meet fathers' needs.

AIM

To provide an in-depth assembly of the current state of knowledge around fathers' experiences of caring for their children diagnosed with life-limiting conditions and understand the implications for healthcare services and policies.

DESIGN

A meta-ethnography was conducted to synthesise findings from existing qualitative studies exploring fathers' experiences of caring.

DATA SOURCES

Four electronic databases (PubMed, PsycINFO, CINAHL and Science Direct) were searched up until April 2020. Qualitative studies exploring fathers' care experience and published in English language were included. The Critical Appraisal Skills Programme (CASP) checklist was employed for study quality appraisal. No temporal limits were used.

RESULTS

Sixty-three studies met the inclusion criteria. Thirty life-limiting conditions were included. Based on responses from 496 fathers, a conceptual model was developed which translates key experiences within the fathers' caregiving journeys. The overarching concepts identified were: the paradox of support, challenges in the caring process, 'nobody thinks of men', impact on family life and the fall of the curtain: an irrevocably altered world. These and associated sub-concepts are discussed, with recommendations for future research and practice provided.

CONCLUSION

The findings indicate the value of a family-oriented approach to develop psychosocial interventions and support channels for fathers, thus empowering them whilst reducing the care-giving burden on the family unit.

Sources of Stress, Family Functioning, and Needs of Families With a Chronic Critically Ill Child: A Qualitative Study

PICU hospitalization is particularly stressful for families. When it is prolonged and the prognostic is uncertain, it can significantly and negatively affect the whole family. To date, little is known on how families with a chronic critically ill (CCI) child are affected. This national study explored the specific PICU-related sources of stress, family functioning and needs of families of CCI patients during a PICU hospitalization. This descriptive qualitative study was conducted in the eight pediatric intensive care units in Switzerland. Thirty-one families with a child meeting the CCI criteria participated in semi-structured interviews. Interviews, including mothers only (n = 12), fathers only (n = 8), or mother and father dyads (n = 11), were conducted in German, French, or English by two trained researchers/clinical nurses specialists. Interviews were recorded, transcribed verbatim, and analyzed using deductive and inductive content analyses. Five overarching themes emerged: (1) high emotional intensity, (2) PICU-related sources of stress, (3) evolving family needs, (4) multi-faceted family functioning, and (5) implemented coping strategies. Our study highlighted the importance of caring for families with CCI children. Parents reported high negative emotional responses that affect their family functioning. Families experience was highly dependent on how HCPs were able to meet the parental needs, provide emotional support, reinforce parental empowerment, and allow high quality of care coordination.

The impact of eligibility for primary attendings and nurses on PICU length of stay

PURPOSE

To examine whether primary attendings and/or nurses impact pediatric intensive care unit (PICU) length of stay (LOS) in long-stay patients (LSP).

MATERIALS AND METHODS

Retrospective observational cross-sectional study from 2012 to 2016 of 29,170 LSP (LOS ≥ 10 days) admitted to 64 PICUs that participated in the Virtual Pediatric Systems, LLC. Generalized linear mixed models were used to examine the association between being eligible for primary practices and LOS. Secondary outcomes of proportions of limitations and withdrawal of aggressive, life-sustaining interventions were also explored.

RESULTS

After controlling for several factors, being eligible for primary nurses and for primary attendings and nurses were associated with significantly lower mean LOS (8.9% and 9.7% lower, respectively), compared to not being eligible for any primary practice. Being eligible for primary attendings was associated with significantly higher mean LOS (9.6% higher). When the primary attendings were used for larger proportions of LSP, the practice was associated with significantly lower mean LOS. Limitations and withdrawal of aggressive interventions were more common in LSPs cared for in PICUs that utilized primary attendings.

CONCLUSIONS

The findings of lower LOS in LSP who were eligible for primary practices should induce more rigorous research on the impact of these primary practices.

Implications of continuity of care on infant caloric intake in the neonatal intensive care unit

OBJECTIVE

To estimate the association of continuity of neonatologist care with caloric intake and growth velocity (GV) in very low birth weight (VLBW) infants.

STUDY DESIGN

We created a daily continuity index (DCI) defined as the number of days the neonatologist worked in the previous week. We estimated the independent associations between this index and infants' daily caloric intake (kcal/kg/day) and GV (g/kg/day) through the first 6 weeks of life using regression analyses.

RESULTS

Twenty-eight neonatologists cared for 115 infants over 4643 patient-days. The DCI was independently associated with increased caloric intake (β = 1.27 kcal/kg/day per each day of continuity, p < 10^-4); this effect was magnified (β = 3.33, p < 10^-4) in the first 2 weeks. No association was observed between the index and GV.

CONCLUSIONS

Neonatologist continuity may contribute to caloric intake in VLBW infants. Quality metrics focused on this area of health care delivery warrant further discovery.

Compassion in Pediatric Healthcare: A Scoping Review

PROBLEM

Compassion has been described as a central construct or essential feature of quality healthcare and is as important to patients' and families' overall healthcare experience as the health interventions and treatments they receive. However, there is little shared understanding of what constitutes compassion, how it is delivered within a pediatric setting, and pediatric patients' and families perspectives and preferences for receiving it.

ELIGIBILITY CRITERIA

Studies that (1) described the nature of the existing literature on compassion in pediatric healthcare; (2) summarized key concepts in the existing evidence base that pertain to compassion in pediatric healthcare; and 3) identified factors that are associated with compassion in pediatric healthcare were eligible for inclusion in this review.

SAMPLE

Twenty-nine papers were included in the review.

RESULTS

Findings revealed several factors are associated with compassion in pediatric healthcare, including continuity of care, communication, and coordination of care. Most notably, identified studies treated compassion in a subsidiary fashion, and this review revealed no studies that provided a patient-informed evidence-based definition of compassion in the pediatric healthcare setting.

CONCLUSION

Future research is required to generate a comprehensive and accurate understanding of the terms 'compassion' and 'compassionate care' when used in the context of pediatric healthcare.

IMPLICATIONS

This research will inform the therapeutic processes and ultimately enable the development of strategies to improve the delivery of compassionate healthcare to pediatric patients.

Parental Perspectives on Roles in End-of-Life Decision Making in the Pediatric Intensive Care Unit: An Integrative Review

PROBLEM

Little is known about how parents perceive their role or the role of health care providers (HCPs) during end-of-life decision making (EOL DM) in the context of the pediatric intensive care unit (PICU).

ELIGIBILITY CRITERIA

The authors searched CINAHL, PubMed, Ovid Medline, Web of Science, Social Science Database, PsycINFO, and Google scholar for English language studies performed in the United States related to parental perception of parental or HCP roles in EOL DM in the PICU since 2008.

SAMPLE

Eleven studies of parents and health care providers (HCPs) of critically ill children in the PICU and/or receiving inpatient pediatric palliative care, and bereaved parents of PICU patients.

RESULTS

Most parents reported belief that EOL DM is within the domain of parental role, a minority felt it was a physician's responsibility. Parental EOL DM is rooted more firmly in emotion and perception and a desire to be a 'good parent' to a child at EOL in the way they see fit than HCP recommendations or 'medical facts'. Parents need HCPs to treat them as allies, communicate well, and be trustworthy.

CONCLUSIONS

Role conflict may exist between parents and HCPs who are prioritizing different attributes of the parental role. The role of the nurse in support of parental role in the PICU is not well-elucidated in the extant literature.

IMPLICATIONS

Future research should focus on what parents need from HCPs, especially nurses, to support their parental role, and factors that facilitate the development of trust and good communication.

Parent perceptions of the impact of the Paediatric Intensive Care environment on delivery of family-centred care

OBJECTIVES

To examine parent perception of how the physical and cultural environment of the paediatric intensive care unit impacted the implementation of family-centred care as outlined by the Institute for Patient and Family Centered Care.

RESEARCH DESIGN

A qualitative descriptive design utilizing secondary analysis from a longitudinal study. Sixty-one interviews with three mothers and three fathers (31 interviews with mothers, 30 interviews with fathers) of infants with complex congenital heart defects treated in a paediatric intensive care unit were subjected to secondary analysis via content analysis. The previously completed individual interviews with parents took place at least monthly ranging from soon after birth of their infant to one year of age or infant death, whichever occurred first.

FINDINGS

The family-centred care core concepts of information sharing, participation, respect and dignity were present in parent interviews. Parents indicated that the physical and cultural environment of the pediatric intensive care unit impacted their perceptions of how each of the core concepts was implemented by clinicians. The unit environment both positively and negatively impacted how parents experienced their infant's hospitalisation.

CONCLUSION

In the paediatric intensive care unit, family centred care operationalised as policy differed from actual parent experiences. The impact of the physical and cultural environment should be considered in the delivery of critical care, as the environment was shown to impact implementation of each of the core concepts.

Children's complex care needs: a systematic concept analysis of multidisciplinary language

Complex care in the arena of child health is a growing phenomenon. Although considerable research is taking place, there remains limited understanding and agreement on the concept of complex care needs (CCNs), with potential for ambiguity. We conducted a systematic concept analysis of the attributes, antecedents, and consequences of children's CCNs from a multidisciplinary perspective. Our data sources included PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO. Inclusion criteria included publications in peer-reviewed journals between January 1990 and December 2017, written in the English language. One hundred and forty articles were included. We found that children's CCNs refer to multidimensional health and social care needs, in the presence of a recognized medical condition or where there is no unifying diagnosis.Conclusion: Children's CCNs are individual and contextualized, are continuing and dynamic, and are present across a range of settings, impacted by family and healthcare structures. There remain extensive challenges to caring for these children and their families, precluding the possibility that any one profession can possess the requisite knowledge or scope to singularly provide high-quality competent care. What is Known: • Complex care is a growing phenomenon and population prevalence figures show that there is an increasing number of children with complex care needs (CCNs). However, the concept has not been systematically analyzed before, leaving it generally ill-defined and at times confusing. What is New: • This is the first time this concept has been systematically analyzed and this analysis provides a much-needed theoretical framework for understanding the multidimensional nature of CCNs in children. • Children's CCNs refer to multidimensional health and social care needs in the presence of a recognized medical condition or where there is no unifying diagnosis. They are individual and contextualized, are continuing and dynamic, and are present across a range of settings, impacted by family and healthcare structures. It is clear that the very nature of CCNs precludes the possibility that any one profession or discipline can possess the requisite knowledge or scope for high-quality competent care for this population.

Staffing and workforce issues in the pediatric intensive care unit

The health care industry is in the midst of incredible change, and unfortunately, change is not easy. The intensive care unit (ICU) plays a critical role in the overall delivery of care to patients in the hospital. Care in the ICU is expensive. One of the best ways of improving the value of care delivered in the ICU is to focus greater attention on the needs of the critical care workforce. Herein, we highlight three major areas of concern-the changing model of care delivery outside of the traditional four walls of the ICU, the need for greater diversity in the pediatric critical care workforce, and the widespread problem of professional burnout and its impact on patient care.

When and Why Do Neonatal and Pediatric Critical Care Physicians Consult Palliative Care?

BACKGROUND

Parents of children admitted to neonatal and pediatric intensive care units (ICUs) are at increased risk of experiencing acute and post-traumatic stress disorder. The integration of palliative care may improve child and family outcomes, yet there remains a lack of information about indicators for specialty-level palliative care involvement in this setting.

OBJECTIVE

To describe neonatal and pediatric critical care physician perspectives on indicators for when and why to involve palliative care consultants.

METHODS

Semistructured interviews were conducted with 22 attending physicians from neonatal, pediatric, and cardiothoracic ICUs in a single quaternary care pediatric hospital. Transcribed interviews were analyzed using content and thematic analyses.

RESULTS

We identified 2 themes related to the indicators for involving palliative care consultants: (1) palliative care expertise including support and bridging communication and (2) organizational factors influencing communication including competing priorities and fragmentation of care.

CONCLUSIONS

Palliative care was most beneficial for families at risk of experiencing communication problems that resulted from organizational factors, including those with long lengths of stay and medical complexity. The ability of palliative care consultants to bridge communication was limited by some of these same organizational factors. Physicians valued the involvement of palliative care consultants when they improved efficiency and promoted harmony. Given the increasing number of children with complex chronic conditions, it is important to support the capacity of ICU clinical teams to provide primary palliative care. We suggest comprehensive system changes and critical care physician training to include topics related to chronic illness and disability.