Exploring communication between parents and clinical teams following children's heart surgery: a survey in the UK

Team Communication and Expectations Following Pediatric Cardiac Surgery: A Multi-Disciplinary Survey

Patients and families desire an accurate understanding of the expected recovery following congenital cardiac surgery. Variation in knowledge and expectations within the care team may be under-recognized and impact communication and care delivery. Our objective was to assess knowledge of common postoperative milestones and perceived efficacy of communication with patients and families and within the care team. An 18-question survey measuring knowledge of expected milestones for recovery after four index operations and team communication in the postoperative period was distributed electronically to multidisciplinary care team members at 16 academic pediatric heart centers. Answers were compared to local median data for each respondent's heart center to assess accuracy and stratified by heart center role and years of experience. We obtained 874 responses with broad representation of disciplines. More than half of all respondent predictions (55.3%) did not match their local median data. Percent matching did not vary by care team role but improved with increasing experience (35.8% < 2 years vs. 46.4% > 10 years, p = 0.2133). Of all respondents, 62.7% expressed confidence discussing the anticipated postoperative course, 78.6% denoted confidence discussing postoperative complications, and 55.3% conveyed that not all members of their care team share a common expectation for typical postoperative recovery. Most respondents (94.6%) stated that increased knowledge of local data would positively impact communication. Confidence in communication exceeded accuracy in predicting the timing of postoperative milestones. Important variation in knowledge and expectations for postoperative recovery in pediatric cardiac surgery exists and may impact communication and clinical effectiveness.

Pain management communication between parents and nurses after pediatric outpatient surgery

PURPOSE

The purpose of this study was to explore parent-nurse pain management communication during a child's discharge process following pediatric outpatient surgery.

DESIGN AND METHODS

Thirty-two clinical encounters at discharge between parents (N = 40) and nurses (N = 25) at BC Children's Hospital were audio recorded and transcribed verbatim. Content analysis was applied on the audio recordings and corresponding transcripts using MAXQDA qualitative research software and Microsoft Excel.

RESULTS

Overall, nurses delivered pain management instructions at an average sixth grade readability level and frequently used communication elements of reassurance, optimism, and question-asking. Less consistent communication elements included open-ended questions, interruptions, and promotion of parental decision-making. Parents most frequently asked one to five questions, with pain medication being the most inquired topic.

CONCLUSIONS

Several strengths of the nurse communication approach were identified, and parent questions highlighted a need for greater understanding around pain medication.

PRACTICE IMPLICATIONS

These findings will help guide effective pain management communication and care for young patients and their families.

Parent mental health and family functioning following diagnosis of CHD: a research agenda and recommendations from the Cardiac Neurodevelopmental Outcome Collaborative

Diagnosis of CHD substantially affects parent mental health and family functioning, thereby influencing child neurodevelopmental and psychosocial outcomes. Recognition of the need to proactively support parent mental health and family functioning following cardiac diagnosis to promote psychosocial adaptation has increased substantially over recent years. However, significant gaps in knowledge remain and families continue to report critical unmet psychosocial needs. The Parent Mental Health and Family Functioning Working Group of the Cardiac Neurodevelopmental Outcome Collaborative was formed in 2018 through support from an R13 grant from the National Heart, Lung, and Blood Institute to identify significant knowledge gaps related to parent mental health and family functioning, as well as critical questions that must be answered to further knowledge, policy, care, and outcomes. Conceptually driven investigations are needed to identify parent mental health and family functioning factors with the strongest influence on child outcomes, to obtain a deeper understanding of the biomarkers associated with these factors, and to better understand how parent mental health and family functioning influence child outcomes over time. Investigations are also needed to develop, test, and implement sustainable models of mental health screening and assessment, as well as effective interventions to optimise parent mental health and family functioning to promote psychosocial adaptation. The critical questions and investigations outlined in this paper provide a roadmap for future research to close gaps in knowledge, improve care, and promote positive outcomes for families of children with CHD.

Early morbidities following paediatric cardiac surgery: a mixed-methods study

Background

Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%.

Objectives

We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.

Design and setting

Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.

Participants

The participants were children aged < 17 years.

Methods

We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.

Results

Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).

Limitations

Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.

Conclusions

Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.

Future work

National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.

Parental understanding of our communication of morbidity associated with paediatric cardiac surgery: a qualitative study

BACKGROUND

Following paediatric cardiac surgery, quality of life may be significantly impacted by morbidities associated with cardiac surgery. Parental understanding of the potential for postoperative morbidity is important for informed decision making. As part of a broader research study, we aimed to elicit parental understanding and experience of the communication of morbidities following their child's cardiac surgery, using traditional focus groups together with an online forum.

METHODS

The Children's Heart Federation set up and moderated a closed, anonymous online discussion group via their Facebook page, focusing on complications, information needs and methods of providing families with information. Additionally, we ran three focus groups with parents/carers, moderated by an experienced independent professional. Focus groups were recorded and transcribed and a single transcript was generated from the online forum. All transcripts were thematically analysed.

RESULTS

All data were collected in 2014. The forum ran over 3 months in 2014 and involved 72 participants. Focus groups involved 13 participants. Three broad themes were identified: (1) clinicians' use of language, (2) feeling unprepared for complications and (3) information needs of families.

CONCLUSIONS

Clinicians' language is often misunderstood, with wide variability in the way morbidities are described, and between differing teams looking after the same child. Information may not be easily absorbed or retained by families, who often felt unprepared for morbidities that arose after their child's heart surgery. Here, we propose key principles of good communication tailored to the individual receiving it.

Congenital Cardiac Surgery and Parental Perception of Risk: A Quantitative Analysis

INTRODUCTION

Interpretation of risk by parents of children undergoing congenital cardiac surgery is poorly documented. The available evidence highlights a dichotomy where clinicians suggest parents may not grasp the complexity and risk associated with procedures, while some parents suggest risk is unnecessarily overemphasized.

AIM

To quantify how risk is perceived by parents.

METHODS

One hundred six parents of children undergoing cardiac surgery were recruited and completed a Likert-type scale from 1 (perceived low risk) to 6 (perceived high risk), at 5 points: arrival at preadmission, post discussion with anethetist/surgeon, day of surgery, discharge from intensive care, and at outpatient follow-up. The surgical sample was stratified according to Risk Adjustment in Congenital Heart Surgery level.

ANALYSIS

Data were analyzed using Wilcoxon rank tests for differences in distributions of scores and Krippendorff α to examine the level of agreement.

RESULTS

Median parental risk scores varied over time, with no consistent risk scores observed. Maternal scores were consistently higher than paternal scores at every time point (P < .001). Postoperative complications resulted in a persistent rise in risk perception at follow-up (P < .001). Analysis of parental risk scores and objective measures of surgical risk highlighted poor agreement that was particularly marked at the extremes of risk.

CONCLUSIONS

Parents perceived higher risk scores than those reported by the clinical team. Mothers reported statistically significantly higher scores than their partners, highlighting potential tensions. In addition, the changing perception of risk over time emphasizes the need for flexible levels of support and information as parents navigate uncertainty.