Patient- and family-centered care of children in the emergency department

Observational Behavioral Coding in the Pediatric Emergency Department: Development of the Emergency Department Child Behavior Coding System

BACKGROUND

Despite improvements over the past decade, children continue to experience significant pain and distress surrounding invasive procedures in the emergency department (ED). To assess the impact of newly developed interventions, we must create more reliable and valid behavioral assessment tools that have been validated for the unique settings of pediatric EDs.

OBJECTIVE

This study aimed to create and test the Emergency Department Child Behavior Coding System (ED-CBCS) for the assessment of child distress and nondistress behaviors surrounding pediatric ED procedures.

METHODS

Via an iterative process, a multidisciplinary expert panel developed the ED-CBCS, an advanced time-based behavioral coding measure. Inter-rater reliability and concurrent validity were examined using 38 videos of children aged from 2 to 12 years undergoing laceration procedures. Face, Legs, Activity, Cry, Consolability (FLACC) scale scores were used to examine concurrent validity.

RESULTS

The final ED-CBCS included 27 child distress and nondistress behaviors. Time-unit κ values from 0.64 to 0.98 and event alignment κ values from 0.62 to 1.00 indicated good to excellent inter-rater reliability for all but one of the individual codes. ED-CBCS distress (B = 1.26; p < 0.001) and nondistress behaviors (B = -0.69, p = 0.025) were independently significantly associated with FLACC scores, indicating concurrent validity.

CONCLUSIONS

We developed a psychometrically sound tool tailored for pediatric ED procedures. Future work could use this measure to better identify behavioral targets and test the effects of interventions to relieve pediatric ED pain and distress.

Procedural sedation programme minimising adverse events: a 3-year experience from a tertiary paediatric emergency department

INTRODUCTION

A well-developed procedural sedation programme in the paediatric emergency department can minimise adverse events. We examined how adherence to current best evidence ensures safe delivery of paediatric sedation in a newly established tertiary paediatric hospital.

METHODS

Our sedation service uses a robust provider training and privileging system, standardised policy and procedures and rigorous data collection all within an evidence-based clinical governance process. We examined sedation data from the first 3 years of operation.

RESULTS

From July 2018 to May 2022, ketamine was used in 3388 of the 3405 sedations. The mean age of sedated children was 5.5 years (range 6 months to 17.8 years) and common indications were closed reduction of fractures and laceration repairs. A total of 148 (4.37%, 95% CI 3.68% to 5.06%) adverse events were documented, including 88 (2.59%, 95% CI 2.06% to 3.13%) cases of vomiting, 50 (1.48%, 95% CI 1.07% to 1.88%) cases related to airway and breathing with 40 (1.18%, 95% CI 0.82% to 1.54%) cases of oxygen desaturation, 6 (0.18%, 95% CI 0.04% to 0.32%) cases of laryngospasm, 4 (0.12%, 95% CI 0% to 0.23%) cases of apnoea.

CONCLUSION

This study presents a large single-centre dataset on the use of intravenous ketamine in paediatric procedural sedation. Adhering to international standards and benchmarks for provider skills and training, drug administration and monitoring facilities, with a strict clinical governance process, optimizes patient safety.

Nursing core competencies for postresuscitation care in Iran: a qualitative study

OBJECTIVE

This study explored nurses' perceptions of the core competencies required for providing postresuscitation care in both in-hospital and out-of-hospital cardiac arrest.

DESIGN

Qualitative conventional content analysis.

PARTICIPANTS

17 nurses selected with purposeful sampling method.

SETTING

Three educational hospitals in northwest of Iran.

DATA COLLECTION AND ANALYSIS

Semi-structured interviews were used for data collection and they were analysed using conventional content analysis.

RESULTS

Seven main categories have emerged from the data. The core competencies for nurses providing postresuscitation were identified as: quality assurance, providing evidence-based care, monitoring and presence, situation management, professionalism, positive attitude and providing family centred care.

CONCLUSIONS

The postresuscitation period is a unique and critical time requiring highly competent nursing care. Several core competencies for providing high-quality nursing care during postresuscitation period were identified through nurses' experience in caring for patients postresuscitation.

N. S, Clerc P, Carciumaru R, Alqurashi W, Rajagopal M, Kammerer E, Leung J, Wright B, Scott SD. Family caregivers' emotional and communication needs in Canadian pediatric emergency departments

OBJECTIVES

To describe the extent to which caregivers' emotional and communication needs were met during pediatric emergency department (PED) visits. Secondary objectives included describing the association of caregiver emotional needs, satisfaction with care, and comfort in caring for their child's illness at the time of discharge with demographic characteristics, caregiver experiences, and ED visit details.

STUDY DESIGN

Electronic surveys with medical record review were deployed at ten Canadian PEDs from October 2018 -March 2020. A convenience sample of families with children <18 years presenting to a PED were enrolled, for one week every three months, for one year per site. Caregivers completed one in-PED survey and a follow-up survey, up to seven days post-visit.

RESULTS

This study recruited 2005 caregivers who self-identified as mothers (74.3%, 1462/1969); mean age was 37.8 years (SD 7.7). 71.7% (1081/1507) of caregivers felt their emotional needs were met. 86.4% (1293/1496) identified communication with the doctor as good/very good and 83.4% (1249/1498) with their child's nurse. Caregiver involvement in their child's care was reported as good/very good 85.6% (1271/1485) of the time. 81.8% (1074/1313) of caregivers felt comfortable in caring for their child at home at the time of discharge. Lower caregiver anxiety scores, caregiver involvement in their child's care, satisfactory updates, and having questions adequately addressed positively impacted caregiver emotional needs and increased caregiver comfort in caring for their child's illness at home.

CONCLUSION

Approximately 30% of caregivers presenting to PEDs have unmet emotional needs, over 15% had unmet communication needs, and 15% felt inadequately involved in their child's care. Family caregiver involvement in care and good communication from PED staff are key elements in improving overall patient experience and satisfaction.

Caregiver Quality of Life During Pediatric Influenza-Like Illness: A Cross-Sectional Study During the COVID-19 Pandemic

The objective of this study was to quantify the quality of life (QoL) of caregivers with children with influenza-like illnesses (ILI) and to identify factors associated with worse QoL. This was a cross-sectional cohort study of caregivers in a pediatric emergency department with previously healthy young children with ILI. The primary outcome was caregiver QoL. Additional measures included health literacy, social support, and caregiver health status. Two hundred and eighty-one caregivers completed the study. And 41% reported overall QoL was worse during their child's illness. The median QoL score was 3.8 [3.1, 4.6] in a 7-point scale. Illness duration was associated with worse overall QoL score (0.128 worse for each additional day of illness). The median emotions domain score was 2.5 [1.5, 4.0], the worst of any domain. Caregivers who perceived worse illness severity had lower emotions domain scores (2.61 vs 6.00, P = .0269). Caregivers with adequate literacy had lower mean QoL scores (3.08 vs 4.44, P < .0001). Childhood illnesses worsen caregiver QoL. Factors associated with worse QoL were perception of illness severity and duration. Addressing caregiver QoL could mitigate the impact of childhood acute illnesses on caregiver wellbeing.

Factors Influencing Parental Decision-Making Regarding Analgesia for Children with Musculoskeletal Injury-Related Pain: A Qualitative Study

OBJECTIVES

To explore and understand parental decision-making relating to acute pain management for their children presenting to the emergency department.

STUDY DESIGN

This study employed one-on-one semistructured interviews. Parents of children with acute musculoskeletal injuries were recruited from 3 Canadian pediatric emergency departments. Interviews were conducted via telephone from June 2019 to March 2021. Verbatim transcription and thematic analyses occurred concurrently with data collection, supporting data saturation and theory development considerations.

RESULTS

Twenty-seven interviews were completed. Five major themes regarding pain care emerged: (1) my child's comfort is a priority, (2) every situation is unique, (3) opioids only if necessary, (4) considerations when choosing opioids, and (5) pain research is important. Overall, parents were highly comfortable with their assessment of their child's pain. Participants' willingness to use opioid analgesia for their children was primarily dependent on perceptions of injury and pain severity. Opioid-averse and opioid-accepting families had similar considerations when making analgesic decisions but weighed risks and benefits differently.

CONCLUSIONS

Parents assess and manage their children's pain globally and multimodally, with comfort being prioritized. For most parents, the desire to relieve their children's pain outweighed concerns of substance use disorder, misuse, and adverse events when making decisions about opioid analgesia for short-term use. These results can inform evidence-based family-centered approaches to co-decision-making of analgesic plans for children with acute pain.

Development and Psychometric Evaluation of a Caregiver Survey to Assess Family-Centered Care in the Emergency Department

OBJECTIVE

To develop and evaluate the psychometric properties of a family caregiver-reported survey that assesses family-centeredness of care in the context of pediatric emergency department (ED) encounters.

METHODS

We created a caregiver-reported scale, incorporated content expert feedback, and iteratively revised it based on cognitive interviews with caregivers. We then field tested the scale in a survey with caregivers. We dichotomized items using top-box scoring and obtained a summary score per respondent. Using a sample of 191 caregivers recruited from 9 EDs, we analyzed internal consistency reliability, dimensionality via item response theory modeling, and convergent validity with the ED Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

RESULTS

Feedback from the 9 experts led us to remove 4 items. We conducted 16 cognitive interviews and revised the survey in 4 rounds. An 11-item survey was field tested. Mean (standard deviation) respondent 11-item summary score was 77.2 (26.6). We removed 2 items given inconsistent response patterns, poor variability, and poor internal consistency, which increased coefficient alpha from 0.85 to 0.88 for the final scale. A multidimensional model fit the data best, but factor scores correlated strongly with summary scores, suggesting the latter are sufficient for quality improvement and future research. Regarding convergent validity, adjusted partial correlation between our scale's 9-item summary score and the ED CAHPS summary score was 0.75 (95% confidence interval 0.67-0.81).

CONCLUSIONS

Psychometric analyses demonstrated strong item performance, reliability, and convergent validity for the 9-item scale. This survey can be used to assess family-centered care in the ED for research and quality improvement purposes.

Trauma-informed and family-centered paediatric resuscitation: Defining domains and practices

Aim

For paediatric patients and families, resuscitation can be an extremely stressful experience with significant medical and psychological consequences. Psychological sequelae may be reduced when healthcare teams apply patient- and family-centered care and trauma-informed care, yet there are few specific instructions for effective family-centered or trauma-informed behaviours that are observable and teachable. We aimed to develop a framework and tools to address this gap.

Methods

We reviewed relevant policy statements, guidelines, and research to define core domains of family-centered and trauma-informed care, and identified observable evidence-based practices in each domain. We refined this list of practices via review of provider/team behaviours in simulated paediatric resuscitation scenarios, then developed and piloted an observational checklist.

Results

Six domains were identified: (1) Sharing information with patient and family; (2) Promoting family involvement in care and decisions; (3) Addressing family needs and distress; (4) Addressing child distress; (5) Promoting effective emotional support for child; (6) Practicing developmental and cultural competence. A 71-item observational checklist assessing these domains was feasible for use during video review of paediatric resuscitation.

Conclusion

This framework can guide future research and provide tools for training and implementation efforts to improve patient outcomes through patient- and family-centered and trauma-informed care.

Patient and family-centered care for children: A concept analysis

Background

Family-centered care has evolved into patient and family-centered care. Although this is not a new concept; however, its application to nursing practice is very challenging among nurses due to its ambiguity.

Objective

This study aimed to clarify the concept of patient and family-centered care for children.

Methods

Walker and Avant's concept analysis method was used. A literature search was also done using the following databases: Google Scholar, ProQuest, ScienceDirect, and Scopus, for articles published from 2011 to 2021.

Results

The defining attributes of patient and family-centered care are partnership, communication, respect, and compassion. Antecedents include patient and family involvement, readiness to collaborate and participate, competency and desire of the care professional team, supportive environment, and policies. Consequences of the patient and family-centered care include improved child outcomes and quality of life, promotion of patient safety, increased patient and family satisfaction, enhancement of humanistic values, reduction of hospitalization cost and length of stay, and decreased stress, anxiety, and depression in family members.

Conclusion

Four attributes of patient and family-centered care, its antecedents, and consequences may aid researchers in better understanding the concept and its application in nursing practice. This concept can also be used to establish quality care delivery strategies and promote professional relationships between nurses, patients, and families in clinical settings.

Disparities in Family-Centered Care Among US Children and Youth with Special Healthcare Needs

Cross-sectional analyses of 4 nationally representative samples indicate disparities in family-centered care occur among US children and youth with special healthcare needs by race and ethnicity, family income and composition, insurance coverage, and healthcare setting. Measured confounds including children's health and impairment severity do not explain the disparities.

Contextual factors influencing parents' assessments of family-centred care in the paediatric emergency department: A qualitative study

AIM

To identify the contextual factors influencing parents' assessments of the family-centredness of care received during a paediatric emergency department visit.

DESIGN

A qualitative cross-sectional case study.

METHODS

We interviewed parents who were at their child's bedside during an emergency department encounter. We independently coded the first 3 transcripts and met to discuss the coding structure and to refine existing codes, add new codes and develop tentative categories. We repeated this process for every 3-5 transcripts until thematic saturation was reached.

RESULTS

We conducted 16 interviews and identified 2 themes: (1) Not all parents expected physicians to provide family-centred care in the emergency department and (2) feeling overwhelmed and powerless influenced parents' perceptions of family-centred care. Poor family-centred care worsened parents' sense of powerlessness and reinforced parents' low expectations from physicians. Similarly, low expectations and powerlessness exacerbated poor family-centred care. Interventions are needed to break this cycle and improve family-centredness of care.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

Patient safety is the foundation of high-quality health care and remains a critical priority for all clinicians caring for children. There are numerous aspects of pediatric care that increase the risk of patient harm, including but not limited to risk from medication errors attributable to weight-dependent dosing and need for appropriate equipment and training. Of note, the majority of children who are ill and injured are brought to community hospital emergency departments. It is, therefore, imperative that all emergency departments practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This technical report outlined the challenges and resources necessary to minimize pediatric medical errors and to provide safe medical care for children of all ages in emergency care settings.

Optimizing Pediatric Patient Safety in the Emergency Care Setting

This is a revision of the previous American Academy of Pediatrics policy statement titled "Patient Safety in the Emergency Care Setting," and is the first joint policy statement by the American Academy of Pediatrics, the American College of Emergency Physicians, and the Emergency Nurses Association to address pediatric patient safety in the emergency care setting. Caring for children in the emergency setting can be prone to medical errors because of a number of environmental and human factors. The emergency department (ED) has frequent workflow interruptions, multiple care transitions, and barriers to effective communication. In addition, the high volume of patients, high-decision density under time pressure, diagnostic uncertainty, and limited knowledge of patients' history and preexisting conditions make the safe care of critically ill and injured patients even more challenging. It is critical that all EDs, including general EDs who care for the majority of ill and injured children, understand the unique safety issues related to children. Furthermore, it is imperative that all EDs practice patient safety principles, support a culture of safety, and adopt best practices to improve safety for all children seeking emergency care. This policy statement outlines the recommendations necessary for EDs to minimize pediatric medical errors and to provide safe care for children of all ages.

Exploring the Stories of Parents' Experiences With Infant Hearing-Loss Screening and Diagnosis in the United States

OBJECTIVES

For the past 20 years, birthing hospitals in the United States have required newborns to undergo a hearing-loss screening before leaving the hospital. Since the initial newborn hearing screening mandates, there has been much outcome research documenting the successes and barriers of the programs. However, we know little about the experiences of their parents during the time between screening and diagnosis. We propose that elucidating the parents' experiences with newborn hearing-loss screening and diagnosis-via their own stories-is a first step toward understanding their varied experiences and has the potential to ultimately improve hearing healthcare for both children and their families. Thus, to better understand the early hearing screening and detection experience from hearing parents' perspectives, we asked the following research question: what are parents' experiences with their newborns' hearing-loss screening and diagnosis in the United States?

DESIGN

The present study employed a prospective, cross-sectional qualitative design. Specifically, we gathered stories from 13 hearing parents who each have a child born in the United States and diagnosed with hearing loss no later than 14 mo of age between the years of 2016 and 2020. We used thematic analysis to uncover common themes across parent narratives. Saturation was reached at interview no. 4; thus no further sampling was needed.

FINDINGS

Two major themes emerged from the data: (1) hearing healthcare experiences and (2) parents' early experiences during the period between their child's newborn hearing-loss screening and diagnosis. Subthemes were also uncovered. Three emergent subthemes related to health-care experiences included: (1) downplayed newborn hearing screening referrals, (2) clinician-centered care, and (3) medical expenses and health coverage. The three subthemes of the second theme were as follows: (1) parent-to-parent support, (2) "mom guilt," and (3) a new reality.

CONCLUSION

The present study's narrative accounts from parents about their infants' early hearing detection experiences revealed several, different subthemes that emerged from the same, mandated newborn experience in US families. These findings highlight important moments throughout the hearing-loss screening and detection process, which could benefit from more effective, family-centered hearing healthcare. This knowledge also facilitates the field's move toward improved education of future and current providers and regarding family-centered approach, which could address concerns and expectations of new parents at the very start of their newborns' hearing-loss journeys.

Design and implementation of a novel patient-centered empowerment approach for pain optimisation in children undergoing major surgery

Background

Paediatric surgery is a stressful experience for patients and caregivers. While standardised protocols are the norm, patient-centred approaches are needed to empower patients/caregivers for an optimal perioperative pain experience. To address this gap, we employed a patient-centred approach using design thinking (DT) methodology to develop insights, map processes, identify opportunities and design solutions for individualised empowerment tools.

Methods

In consultation with DT experts, a multidisciplinary team of stakeholders (healthcare providers, patients who underwent pectus excavatum/scoliosis surgery and their caregivers), were invited to participate in surveys, interviews and focus groups. The project was conducted in two sequential stages each over 24 weeks—involving 7 families in stage 1 and 16 patients/17 caregivers in stage 2. Each stage consisted of three phases: design research (focus groups with key stakeholders to review and apply collective learnings, map processes, stressors, identify influencing factors and opportunities), concept ideation (benchmarking and co-creation of new solutions) and concept refinement.

Results

In stage 1, mapping of stress/anxiety peaks identified target intervention times. We identified positive and negative influencers as well as the need for consistent messaging from the healthcare team in our design research. Current educational tools were benchmarked, parent-child engagement dyads determined and healthcare-based technology-based solutions conceived. The ‘hero’s journey’ concept which has been applied to other illness paradigms for motivation successfully the was adapted to describe surgery as a transformative experience. In stage 2, patient and caregiver expectations, distinct personas and responses to perioperative experience were categorised. Educational tools and an empowerment tool kit based on sensorial, thinking, relaxation and activity themes, tailored to parent/child categories were conceptualised.

Conclusion

DT methodology provided novel family centred insights, enabling design of tailored empowerment toolkits to optimise perioperative experience. Adapting the hero’s journey call to adventure may motivate and build resilience among children undergoing surgery.

When and how do healthcare professionals introduce specialist palliative care to the families of children with life-threatening conditions in Taiwan? A qualitative study

BACKGROUND

Specialist palliative care (SPC) is often needed to manage complex or refractory problems in children with life-threatening conditions during end-of-life. This study explores the perceptions of healthcare professionals (HPs) to determine the triggers leading to and experiences with introducing SPC among families of children with life-threatening conditions.

METHODS

A secondary analysis of 13 semi-structured interviews with HPs conducted from September 2019-June 2020 was carried out in a pediatric ward and a neonatal and pediatric intensive care unit in Taiwan. A thematic analysis was conducted. Competence Theory was used to guide the research questions and the interpretive framework.

FINDINGS

Seven nurses, four pediatricians, one psychologist, and one respiratory therapist were interviewed. The need for shared knowledge regarding wishes for care and end-of-life decision-making were found to be the indicators for introducing SPC, along with having a fear of causing harm to the family-professional relationship and the patient. HPs value harmony in the form of clarifying misconceptions, building trust, and holding the moral bottom line. The theme of 'seeking the competent self' encompasses the values and expectations related to improving skills and creating a sense of fulfillment as HPs achieve good quality care.

DISCUSSION

Discussions about SPC facilitate better communication and decision-making. Careful attention should be paid to the needs related to clarifying misconceptions and protecting the child's right to life when SPC is suggested.

APPLICATION TO PRACTICE

Communication, empathy, and conflict resolution training may be helpful with developing HP competencies related to introducing SPC.

Intimate Partner Violence, Clinical Indications, and Other Family Risk Factors Associated With Pediatric Abusive Head Trauma

Over half of fatal pediatric traumatic brain injuries are estimated to be the result of physical abuse, i.e., abusive head trauma (AHT). Although intimate partner violence (IPV) is a well-established risk for child maltreatment, little is known about IPV as an associated risk factor specifically for AHT. We performed a single-institution, retrospective review of all patients (0-17 years) diagnosed at a Level 1 pediatric trauma center with head trauma who had been referred to an in-hospital child protection team for suspicion of AHT between 2010 and 2016. Data on patient demographics, hospitalization, injury, family characteristics, sociobehavioral characteristics, physical examination, laboratory findings, imaging, discharge, and forensic determination of AHT were extracted from the institution's forensic registry. Descriptive statistics (mean, median), chi-square and Mann-Whitney U tests were used to compare patients with fatal head injuries to patients with nonfatal head injuries by clinical characteristics, family characteristics, and forensic determination. Multiple logistic regression was used to estimate adjusted odds ratios for the presence of IPV as an associated risk of AHT while controlling for other clinical and family factors. Of 804 patients with suspicion for AHT in the forensic registry, there were 240 patients with a forensic determination of AHT; 42 injuries were fatal. There were 101 families with a reported history of IPV; 64.4% of patients in families with reported IPV were <12 months of age. IPV was associated with a twofold increase in the risk of AHT (Exp(β) = 2.3 [p = .02]). This study confirmed IPV was an associated risk factor for AHT in a single institution cohort of pediatric patients with both fatal and nonfatal injuries. Identifying IPV along with other family factors may improve detection and surveillance of AHT in medical settings and help reduce injury, disability, and death.

Usability Testing of a Patient-Centered Mobile Health App for Supporting and Guiding the Pediatric Emergency Department Patient Journey: Mixed Methods Study

BACKGROUND

Patient experience in emergency departments (EDs) remains often suboptimal and can be a source of stress, particularly in pediatric settings. In an attempt to support patients and their families before, during, and after their visit to a pediatric ED, a mobile health (mHealth) app was developed by a multidisciplinary team based on patient-centered care principles.

OBJECTIVE

This study aims to evaluate the usability (effectiveness, efficiency, and satisfaction) of a new mHealth app, InfoKids, by potential end users through usability testing.

METHODS

The app was assessed through an in-laboratory, video-recorded evaluation in which participants had to execute 9 goal-oriented tasks, ranging from account creation to the reception of a diagnostic sheet at the end of the emergency care episode. Effectiveness was measured based on the task completion rate, efficiency on time on task, and user satisfaction according to answers to the System Usability Scale questionnaire. Think-aloud usability sessions were also transcribed and analyzed. Usability problems were rated for their severity and categorized according to ergonomic criteria.

RESULTS

A total of 17 parents participated in the study. The overall completion rate was 97.4% (149/153). Overall, they reported good effectiveness, with the task successfully completed in 88.2% (135/153) of cases (95% CI 83%-93%). Each task, with the exception of the first, created difficulties for some participants but did not prevent their completion by most participants. Users reported an overall good to excellent perceived usability of the app. However, ergonomic evaluation identified 14 usability problems occurring 81 time. Among these, 50% (7/14) were serious as their severity was rated as either major or catastrophic and indicated areas of improvements for the app. Following the suggested usability improvements by participants, mitigation measures were listed to further improve the app and avoid barriers to its adoption.

CONCLUSIONS

Usability of the InfoKids app was evaluated as good to excellent by users. Areas of improvement were identified, and mitigation measures were proposed to inform its development toward a universal app for all ED patients visiting a digitalized institution. Its contribution could also be useful in paving the way for further research on mobile apps aimed at supporting and accompanying patients in their care episodes, as research in this area is scarce.

'With every fibre of their being': Perspectives of healthcare professionals caring for children with non-malignant life-limiting conditions

BACKGROUND

Children with non-malignant life-limiting conditions (NMLLCs) constitute the largest proportion of children requiring palliative care. In part, due to technological advances, growing numbers of such children are experiencing improved survival. Care is mostly provided at home by the family, with significant professional input at different points in the child's life trajectory. This study explored the experience of healthcare professionals caring for this cohort of children.

METHODS

A qualitative descriptive study design using single-occasion one-to-one semi-structured interviews collected data from 12 healthcare professionals' including nurses, social workers and doctors. Data were analysed using thematic analysis.

RESULTS

The findings highlighted the unfailing determination and dedication of healthcare professionals who provided care despite challenges with what seemed like 'with every fibre of their being'. Three key themes marked such strength and commitment; those were 'being there', 'being focused' and 'being strong'. 'Being there' explicitly highlighted expert care that was individualized and responsive to the child and family's unique needs. The provision of such care was often threatened and potentially compromised by the intricacies and challenges associated with children's palliative care (CPC) and service provision. 'Being focused' captured the sense that the healthcare professionals remained entirely focused on providing expert care despite these challenges. 'Being strong' epitomized the personal and professional impact on healthcare professionals who are working in this area and the manner in which they sustain themselves in 'being focused' and in 'being there'.

CONCLUSIONS

The healthcare professionals demonstrated their unwavering commitment to deliver quality care required by children and families, however against a background of issues relating to organizational constraints. The findings have implications for education/service providers such as the need for specific palliative care education at both pre-registration level and continuing professional development.

Development of a Parent-Reported Outcome Measure for Febrile Infants ≤60 Days Old

OBJECTIVE

We aimed to develop a parent-reported outcome measure for febrile infants 60 days or younger evaluated in the emergency department.

METHODS

We conducted a 3-part study: (1) individual, semistructured interviews with parents of febrile infants 60 days or younger to generate potential items for the measure; (2) expert review with pediatric emergency medicine physicians and member checking with parents, who rated each item's clarity and relevance using 4-point scales; and (3) cognitive interviews with a new sample of parents, who gave feedback and rated the measure's ease of use on a 4-point scale. The measure was iteratively revised during each part of the development process.

RESULTS

In part 1, we interviewed 24 parents of 21 infants. Interviews revealed several themes: parents' experiences with medical care, communication, and decision making; parents' emotions, particularly worry, fear, and stress; the infant's outcomes valued by parents; and the impact of the infant's illness on the family. From these themes, we identified 22 potential items for inclusion in the measure. In part 2, 10 items were revised for clarity based on feedback from physicians and parents, primarily under the domains of parents' emotions and the infant's outcomes. In part 3, we further revised the measure for clarity and added an item. The final measure included 23 items and was rated as excellent in its ease of use.

CONCLUSIONS

The 23-item parent-reported outcome measure includes the experiences and outcomes important to parents. Further studies are needed to evaluate the measure's psychometric properties.

National Estimates of Workplace Telehealth Use Among Emergency Nurses and All Registered Nurses in the United States

INTRODUCTION

The goal of this research was to quantify the baseline status of prepandemic workplace emergency nursing telehealth as a key consideration for ongoing telehealth growth and sustainable emergency nursing care model planning. The purpose of this research was to: (1) generate national estimates of prepandemic workplace telehealth use among emergency and other inpatient hospital nurses and (2) map the geographic distribution of prepandemic workplace emergency nurse telehealth use by state of nurse residence.

METHODS

We generated national estimates using data from the 2018 National Sample Survey of Registered Nurses. Data were analyzed using jack-knife estimation procedures coherent with the complex sampling design selected as representative of the population and requiring analysis with survey weights.

RESULTS

Weighted estimates of the 161 865 emergency nurses, compared with 1 191 287 other inpatient nurses revealed more reported telehealth in the workplace setting (49% vs 34%) and individual clinical practice telehealth use (36% vs 15%) among emergency nurses. The geographic distribution of individual clinical practice emergency nurse telehealth use indicates greatest adoption per 10 000 state residents in Maine, Alaska, and Missouri with more states in the Midwest demonstrating emergency nurse adoption of telehealth into clinical practice per population than other regions in the United States.

DISCUSSION

By quantifying prepandemic national telehealth use, the results provide corroborating evidence to the potential long-term adoptability and sustainability of telenursing in the emergency nursing specialty. The results also implicate the need to proactively define emergency nursing telehealth care model standards of practice, nurse competencies, and reimbursement.

Parent-Child Agreement on the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID)

OBJECTIVE

Multiple informants are often used in the assessment of child psychopathology; however, parent-child agreement is low in child psychiatry. The objective of this exploratory study was to assess informant agreement on the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID) in a clinical sample of children with mental disorders and their parents, and to examine health and demographic factors associated with agreement.

METHOD

MINI-KID results were analyzed for 88 parent-child dyads. Children were between 8-17 years old and were receiving in- or outpatient services for at least one mental disorder at a pediatric hospital. Kappas were calculated to assess parent-child agreement and logistic regression models were used to identify factors associated with agreement.

RESULTS

Agreement was low to moderate (κ=0.19-0.41) across the MINI-KID modules. Household income was associated with agreement for major depression, generalized anxiety, and attention-deficit hyperactivity disorder. Recruitment setting and parent psychological distress were associated with agreement for generalized anxiety and separation anxiety, respectively. Age, sex, and child disability/impairment were not associated with agreement.

CONCLUSIONS

Parent-child agreement on the MINI-KID was low to moderate, and few factors were associated with agreement. These initial findings reaffirm the need for multiple informants when assessing psychopathology in children and can be used by health professionals to facilitate parent-child discussions in clinical settings in child psychiatry.

Brief Report: The Experiences of Families of Children with an Autism Spectrum Disorder When Seeking Patient-and Family-Centered Care

Patient-and family-centered care (PFCC) is a partnership among healthcare professionals, patients, and families that is grounded in mutual respect and is an approach that impacts delivery of care, decision-making, and information sharing. PFCC should be implemented for all, including individuals with Autism Spectrum Disorders (ASD), who experience adverse medical encounters despite increased prevalence and healthcare utilization. Insights into the experiences of families during medical experiences can inform clinical practice by increasing healthcare professionals' understanding of the population. Using a mixed-methods approach, the perspectives of 40 families were analyzed. The themes include barriers and opportunities to improve upon the delivery of PFCC, which help to advance healthcare interactions and inform solution-based initiatives to facilitate medical visits that may benefit all patients.

Feeling Informed Versus Being Informed: Mixed-Methods Analysis of Family Perceptions and Behavior Following a Pediatric Emergency Department Visit

PURPOSE

To examine perceptions of family-centered care, satisfaction, and quality of communication with health professionals during a pediatric emergency department visit, and to evaluate the perceived usefulness of the information received and whether provider treatment recommendations were followed after discharge.

DESIGN

Embedded mixed methods design with two concurrent phases. Participants in phase 1 were 385 adult relatives of children (age 6 days-17 years, mean 5.0 years, SD 4.5) seen in a pediatric emergency department. On the day of the visit, relatives completed questionnaires exploring perceptions of family-centered care, satisfaction (CSQ-8), and quality of communication with professionals (ad hoc instrument). For phase 2, we conducted daily structured telephone interviews with 37 of these parents over the six consecutive days following the emergency visit.

RESULTS

Satisfaction with the visit was significantly related to the perception of family-centered care (B = 0.25; 95% CI [0.20, 0.29]; p < .001). Follow-up interviews revealed that 45.9% (n = 17) of families did not follow the prescribed treatment and 32.4% (n = 12) made a further appointment with their primary care pediatrician. Qualitative analysis suggested that families lacked certain information from care providers.

CONCLUSIONS

Elements of a family-centered approach were rated positively and families believed that the information they received was useful. Importantly, more than half of the families who were followed up by telephone had doubts about provider treatment recommendations.

PRACTICE IMPLICATIONS

Family-centered care in the pediatric emergency department could enhance communication and help to ensure that treatment recommendations are followed at home.

Orienting child- and family-centered care toward equity

Child- and family-centered care (CFCC) is being increasingly adopted internationally as a fundamental philosophical approach to the design, delivery, and evaluation of children's services in diverse primary and acute health care contexts. CFCC has yet to be explored in the context of families and children whose health and health care is likely to be compromised by multifaceted social and structural factors, including racialization, material deprivation, and historically entrenched power imbalances. To date, an equity orientation for CFCC has not been examined or developed. This is a critical area of inquiry, given the increasing evidence that children in families who face such inequities have poor health outcomes. This article examines dominant discourses on CFCC in the context of families and children who are at greater risk of health inequities in wealthy countries, drawing on Canada as a useful example. It outlines an evidence-based approach to equity-oriented care that the authors contend has the potential to orient CFCC toward equity and provide greater clarity in the conceptualization, implementation, measurement, and evaluation of CFCC in ways that can benefit all families and children including those who have typically been excluded from research.

The Healthcare Staffs' Perception of Parents' Participation in Critical Incidents at the PICU, a Qualitative Study

BACKGROUND

Internationally, there are very few guidelines regarding how near relations can be taken care of on a children's intensive care unit. Despite knowledge about the positive effects of parental presence, staff frequently reject parents out of insecurity. This study aimed to investigate health professionals' understanding of letting parents be present throughout critical situations. A qualitative method with semi-structured interviews was used to answer the aim of his study. Nine persons participated in the study, both physicians and nurses. The result showed that health professionals' main view is that parents' presence is positive. However, their presence often has lower priority than the medical focus of the child and the health professionals' concern of failure.

CONCLUSION

Health professionals have the power to decide if parents can be present in critical situations. Only when a parent demands to be present does that demand beat the decisions made by health professionals. Lack of resources within the team and fear of parents becoming a disturbance or a distraction are cited as the primary reasons not to let parents be present.

Familial experience of acute bacterial meningitis in children: a transversal qualitative study using interpretative phenomenological analysis

OBJECTIVES

To capture the subjective experience of close family ascendants of acute bacterial meningitis survivors and to explore how they give meaning to this specific experience.

DESIGN

A qualitative study of indepth interviews using interpretative phenomenological analysis.

PRIMARY OUTCOME

Main meaning-making processes of participants' experience.

SETTINGS

Participants were recruited through two associations of people affected by meningitis and their family ascendants.

PARTICIPANTS

Convenience sampling of 11 women whose children or grandchildren were between 0.2 and 20 years old at the time of their meningitis diagnosis (M=4.06, SD=7.3). On average, 9.39 (SD=5.4) years had passed between the onset of illness and the interview.

RESULTS

Six superordinate themes (meningitis disease; healthcare services and professionals; knowledge/ignorance; repercussions of the meningitis experience: 'life afterwards'; sick child attitudes/behaviour; and sibling attitudes/behaviour) and two main meaning-making processes in relation to participants' experience of meningitis were identified: (1) the sick child becoming a 'hero': comparison with other children; and (2) engaging action/attitude: finding the 'positive' of the traumatic experience and engaging action to improve the care system. These two processes underpin the psychological adjustment to meningitis and its consequences.

CONCLUSIONS

This study provides a unique insight into close family members' first-hand experience with acute bacterial meningitis. Findings highlighted factors characterising the disease experience, the psychological adjustment of meningitis survivors' families and their meaning-making processes. These findings are important for research and clinical practice, demonstrating the multidimensional impact of the disease on family ascendants, their need for professional psychological support and the importance of direct involvement of parents in identifying key aspects of care.

Development and feasibility testing of a play-based psychosocial intervention for reduced patient stress in a pediatric care setting: experiences from Pakistan

BACKGROUND

Hospitalization can be a source of great stress for children and their families. In high-income countries, there are specialized staff to help children cope using different techniques including play. However, it is a major challenge in low and middle-income countries (LMIC) due to financial constraints and untrained human resource. The objective of study was to develop and test the feasibility and acceptance of a psychology trainee-delivered model postulated on employing play as a means of enhancing child-parent interactions leading to reduced stress during hospitalization.

METHODS

This study was conducted in the paediatric ward of a tertiary care private hospital in Pakistan. Pre-intervention survey revealed that parental stress stemmed mainly from seeing their child irritable, distressed, or in pain. Using a theory of change model, a play-based psychosocial intervention was developed to address these factors. The intervention approach was informed by principles of Nurturing Care Framework and play therapy. Children between birth and 6 years admitted in the acute care ward were eligible. The intervention was delivered between March 2019 and December 2020 by psychology trainees who were supervised by a clinical psychologist. The play-based sessions were delivered at the bedside and ranged from 20 to 40 min. Parents receiving the intervention were later interviewed for their stress, child emotions, and feedback about the service using structured surveys administered by psychology graduates. The trainees delivering the intervention were requested to provide their feedback as a written qualitative open-ended narrative. These narratives were analyzed using an inductive approach.

RESULTS

The survey was conducted with 223 families with about half of the sample having children under 2 years of age. Forty-five percent of parents reported play intervention to be one of 3 key factors in improving their experience during hospital stay. Only 5% of parents reported feeling stressed about the child illness after the intervention. Ninety to 96% parents felt respected, listened to, and understood by the therapists. Thematic analysis of the feedback by trainees indicated the internship to be a useful experience and a new avenue for professional life whereas physicians appreciated the interventions.

CONCLUSIONS

The authors conclude that psychology trainees can feasibly deliver a play-based intervention under supervision for reduced stress in children and their parents during hospitalization with mutual benefits.

An Affective-Appraisal Approach for Parental Shared Decision Making in Children and Young People's Mental Health Settings: A Qualitative Study

Background: The majority of existing shared decision making (SDM) models are yet to explicitly account for emotion as an influencing factor to the SDM process. This study aimed to explore the role of parents' and carers' emotional experiences as a concept that has implications for SDM in children and young people's mental health (CYPMH) settings. Methods: A social constructivist grounded theory approach, analyzing data from focus groups (n = 4) and semi-structured interviews (n = 33) with parents and healthcare professionals, was undertaken. Participants were identified and selected at CYPMH sites and through social media platforms or in-person advertising as part of a larger feasibility trial. Interviews and focus groups were audio-recorded and transcribed verbatim. Thematic analysis moved from open to focused coding. Results: The majority of the sample consisted of mothers of adolescent girls. Healthcare professionals had an average of 7.54 (SD = 6.24) years of work experience in CYPMH outpatient capacities. Findings suggested that parents are "expected to, but not always able to" engage in SDM. Themes and subthemes described an affective-appraisal SDM process capturing: (1) views and experiences of SDM, (2) parents' emotional states, (3) the influence of emotions on SDM, and (4) key support systems accessed. The emerging affective-appraisal framework highlighted that negative emotional states hindered parents' active involvement in SDM, and positive emotions encouraged involvement in SDM. Conclusion: The current findings describe an SDM model specific to CYPMH. This new understanding contributes to addressing a possible theory to practice gap opening new challenges and opportunities for academic enquiry.

Evaluating abusive head trauma in children <5 years old: Risk factors and the importance of the social history

BACKGROUND

Abusive head trauma (AHT) is the leading cause traumatic death in children ≤5 years of age. AHT remains seriously under-surveilled, increasing the risk of subsequent injury and death. This study assesses the clinical and social risks associated with fatal and non-fatal AHT.

METHODS

A single-institution, retrospective review of suspected AHT patients ≤5 years of age between 2010 and 2016 using a prospective hospital forensic registry data yielded demographic, clinical, family, psycho-social and other follow-up information. Descriptive statistics were used to look for differences between patients with AHT and accidental head trauma. Logistic regression estimated the adjusted odds ratios (AOR) for AHT. A receiver operating characteristic (ROC) curve was created to calculate model sensitivity and specificity.

RESULTS

Forensic evaluations of 783 children age ≤5 years with head trauma met the inclusion criteria; 25 were fatal with median[IQR] age 23[4.5-39.0] months. Of 758 non-fatal patients, age was 7[3.0-11.0] months; 59.5% male; 435 patients (57.4%) presented with a skull fracture, 403 (53.2%) with intracranial hemorrhage. Ultimately 242 (31.9%) were adjudicated AHT, 335(44.2%) were accidental, 181 (23.9%) were undetermined. Clinical factors increasing the risk of AHT included multiple fractures (Exp(β) = 9.9[p = 0.001]), bruising (Expβ = 5.7[p < 0.001]), subdural blood (Exp(β) = 5.3[p = 0.001]), seizures (Exp(β) = 4.9[p = 0.02]), lethargy/unresponsiveness (Exp(β) = 2.24[p = 0.02]), loss of consciousness (Exp(β) = 4.69[p = 0.001]), and unknown mechanism of injury (Exp(β) = 3.9[p = 0.001]); skull fracture reduced the risk of AHT by half (Exp(β) = 0.5[p = 0.011]). Social risks factors included prior police involvement (Exp(β) = 5.9[p = 0.001]), substance abuse (Exp(β) = 5.7[p = .001]), unknown number of adults in the home (Exp(β) = 4.1[p = 0.001]) and intimate partner violence (Exp(β) = 2.3[p = 0.02]). ROC area under the curve (AUC) = 0.90([95% CI = 0.86-0.93] p = .001) provides 73% sensitivity; 91% specificity.

CONCLUSIONS

To improve surveillance of AHT, interviews should include and consider social factors including caregiver/household substance abuse, intimate partner violence, prior police involvement and household size. An unknown number of adults in home is associated with an increased risk of AHT.

STUDY TYPE/LEVEL OF EVIDENCE

Prognostic, Level III.

Nursing Perspective of the Humanized Care of the Neonate and Family: A Systematic Review

This systematic review aims to determine the extent to which published research articles show the perspective of health professionals in neonatal intensive care units (NICU), as facilitators of family empowerment. Studies conducted between 2013 and 2020 were retrieved from five databases (PubMed, Cochrane, CINHAL, Scopus, and Google Scholar). The search was carried out from January to October 2020. A total of 40 articles were used, of which 13 studies (quantitative and qualitative) were included in this systematic review. Its methodological quality was assessed using the mixed methods assessment tool (MMAT). In these, the opinions and perspectives of professionals on the permanence and participation of parents were valued. In addition, the training, experiences, and educational needs of nursing within the NICU were determined. The crucial role of health professionals in the humanization of care and its effect on the neonate-family binomial was estimated. However, conceptual changes are needed within the neonatal intensive care units. To implement humanization in daily care, family participation should be encouraged in them. For this, it is necessary to modify hospital health policies to allow changes in the infrastructure that facilitate open doors 24 h a day in special services.

The Emergency Nurses Association: 50 Years of Advocacy and Advancement

To commemorate the 50th anniversary of the Emergency Nurses Association, this article describes the 3 most enduring and impactful policy initiatives in the organization's history. These initiatives were identified through a comprehensive review of the articles published in the Journal of Emergency Nursing as well as in other publications of the Emergency Nurses Association, including position statements and press releases. The top 3 policy issues throughout the Emergency Nurses Association's history were identified as provision of care for vulnerable populations, trauma and injury prevention, and patient quality and safety. The Emergency Nurses Association also worked hard to professionalize emergency nursing within the realms of nursing and emergency services during the first half of its history, and since then the Emergency Nurses Association has promoted issues related to the emergency nursing workforce and to ensuring a safe and sustainable environment in which nurses practice. This article includes critical constructs such as the professionalization of emergency nursing; advocating for vulnerable populations such as children, older adults, and people experiencing sexual violence or human trafficking; improvements in trauma care and injury prevention; promoting quality and safety through nursing certifications, efficient and accurate nurse triage, and disseminating best practices in evidence-based care; and supporting the nursing workforce by championing issues such as workplace violence, ED crowding, and healthy work environments.

Management of Procedural Pain in Children

In recent years, there has been increased interest in the study of pain in children and its treatment. It is known that when facing diagnostic and therapeutic procedures similar to those performed on adults, children either do not receive specific pain treatment or receive it on a significantly lower scale. However, recent research suggests a change in attitude and an improvement in the current treatment of children's pain. Although current knowledge demonstrates the falsity of many preconceived ideas about pain and its management, our results suggest that attitudinal change towards childhood pain remains slow and that real improvement in the training and practical application of the pediatrician who has to treat childhood pain is urgently needed. In this context, this manuscript has prepared standards and guidelines to improve pain management practices in a large number of national and international professional settings.

Development of an App to Facilitate Communication and Shared Decision-making With Parents of Febrile Infants ≤ 60 Days Old

OBJECTIVES

We aimed to develop and test a tool to engage parents of febrile infants ≤ 60 days of age evaluated in the emergency department (ED). The tool was designed to improve communication for all parents and to support shared decision-making (SDM) about whether to perform a lumbar puncture (LP) for infants 29 to 60 days of age.

METHODS

We conducted a multiphase development and testing process: 1) individual, semistructured interviews with parents and clinicians (pediatric and general emergency medicine [EM] physicians and pediatric EM nurses) to learn their preferences for a communication and SDM tool; 2) design of a "storyboard" of the tool with design impression testing; 3) development of a software application (i.e., app) prototype, called e-Care; and 4) usability testing of e-Care, using qualitative assessment and the system usability scale (SUS).

RESULTS

We interviewed 27 parents and 23 clinicians. Interviews revealed several themes, including that a communication tool should augment but not replace verbal communication; a Web-based format was preferred; and information about infections and testing, including the rationales for specific tests, would be valuable. We then developed separate versions of e-Care for infants ≤ 28 days and 29 to 60 days of age, in both English and Spanish. The e-Care app includes four sections: 1) homepage; 2) why testing is done; 3) what tests are done; and 4) what happens after testing, including a table for parents of infants 29 to 60 days of age to compare the risks/benefits of LP in preparation for an SDM conversation. Parents and clinicians reported that e-Care was understandable and helpful. The mean SUS score was 90.3 (95% confidence interval = 84 to 96.6), representing "excellent" usability.

CONCLUSIONS

The e-Care app is a useable and understandable tool to support communication and SDM with parents of febrile infants ≤ 60 days of age in the ED.

Acute psychosocial care of families in paediatric resuscitation settings: Variables associated with parent emotional response

BACKGROUND

Family presence in paediatric resuscitation settings is now accepted practice. However, there is limited evidence to guide psychosocial care of these families. This study aimed to increase the understanding of family demographics and needs for psychosocial care at the Royal Children's Hospital, Melbourne, Australia and to identify the factors that impact on families at this time of emotional and social distress.

METHOD

A retrospective clinical data-mining methodology was utilised (n = 1123). Descriptive and inferential data analysis was undertaken using STATA software to identify population demographics, patterns in service usage and family experience, and to identify factors associated with parents' emotional responses.

FINDINGS

Four areas were identified that support evidence-informed psychosocial care for families in paediatric resuscitation contexts: 1) family and parent dynamics 2) families' experiences of distress in relation to patient diagnostic category 3) systemic nature of family response, and 4) the identification and analysis of family emotional support needs, which is central to the psychosocial response.

Describing healthcare providers' perceptions of relational practice with families in the emergency department: A qualitative study

Background

Emergency departments are regarded as stressful working environments, associated with staff shortages, increased patient numbers and long waiting times. Increased organisational demands for performance can compromise genuine interactions between families and healthcare providers working in emergency departments. A relational practice approach in caring for families can enhance the capability of healthcare providers to simultaneously overcome these difficulties and provide emergency healthcare of high quality.

Objectives

The purpose of the study was to describe healthcare providers’ perceptions of relational practice with families in three emergency departments in KwaZulu-Natal, South Africa.

Method

Using a qualitative descriptive approach data were collected through semi-structured interviews with healthcare providers working in emergency departments. The data were analysed and categorised using qualitative content analysis.

Results

Four categories emerged from data analysis: (1) families and healthcare providers connecting; (2) recognising the uniqueness of families; (3) caring interactions; and (4) taking charge when necessary.

Conclusion

The study elicited that healthcare providers working in emergency departments perceived that despite high patient volumes and resource constraints, collaborative relationships with families were important. However, these collaborative relationships cannot be willed into practice, instead training workshops are needed to develop relational skills of healthcare providers which can facilitate family and healthcare professional collaboration.

The care provided by the family to the premature newborn: analysis under Leininger's Transcultural Theory

OBJECTIVE

To analyze the care practices of family members of premature infants admitted to a Neonatal Intensive Care Unit in the light of Leininger's transcultural theory.

METHODS

Qualitative, descriptive and exploratory study. Participant observation and semi-structured interviews were conducted with 16 family members of newborns, admitted to the neonatal unit of a public maternity hospital, during the months of May and June 2019. The software called Interface de R pour analyses Multidimensionnelles de Textes et de Questionnaire ® and the Bardin Content Analysis technique.

RESULTS

Two thematic categories emerged: Family care in the neonatal unit; (in)effective support for shared care.

CONCLUSION

The participation of families in the care of babies is still unstable, but it must be an inseparable element of culturally congruent care, thus collaborating with the full recovery of the premature.

Children in Immigrant Families: Advocacy Within and Beyond the Pediatric Emergency Department

In the United States, 1 in 4 children lives in an immigrant family. State and national policies have historically precluded equitable access to health care among children in immigrant families. More recently, increasingly restrictive policies, political rhetoric, and xenophobic stances have made immigrant families less able to access health care and less comfortable in attempting to do so, thus increasing the likelihood that patients will present to the emergency department. Once in the emergency department, language, cultural, and health literacy barriers make providing high-quality care potentially challenging for some families. Emergency care professionals can therefore glean critical insight regarding inequities from clinical work to inform advocacy and policy changes at institutional, community, regional, and national levels.

Patient- and Family-Centered Care in the Emergency Department for Children With Autism

BACKGROUND

Emergency department (ED) care processes and environments impose unique challenges for children with autism spectrum disorder (ASD). The implementation of patient- and family-centered care (PFCC) emerges as a priority for optimizing ED care. In this article, as part of a larger study, we explore PFCC in the context of ASD. Our aims were to examine how elements of PFCC were experienced and applied relative to ED care for children with ASD.

METHODS

Qualitative interviews were conducted with parents and ED service providers, drawing on a grounded theory approach. Interviews were audio recorded, transcribed verbatim, and analyzed by using established constant comparison methods. Data were reviewed to appraise the reported presence or absence of PFCC components.

RESULTS

Fifty-three stakeholders (31 parents of children with ASD and 22 ED service providers) participated in interviews. Results revealed the value of PFCC in autism-based ED care. Helpful attributes of care were a person-centered approach, staff knowledge about ASD, consultation with parents, and a child-focused environment. Conversely, a lack of staff knowledge and/or experience in ASD, inattention to parent expertise, insufficient communication, insufficient family orientation to the ED, an inaccessible environment, insufficient support, a lack of resources, and system rigidities were identified to impede the experience of care.

CONCLUSIONS

Findings amplify PFCC as integral to effectively serving children with ASD and their families in the ED. Resources that specifically nurture PFCC emerge as practice and program priorities.

A two-centre survey of caregiver perspectives on opioid use for children's acute pain management

Background

Given the current opioid crisis, caregivers have mounting fears regarding the use of opioid medication in their children. We aimed to determine caregivers' a) willingness to accept, b) reasons for refusing, and c) past experiences with opioids.

Methods

A novel electronic survey of caregivers of children aged 4 to 16 years who had an acute musculoskeletal injury and presented to two Canadian paediatric emergency departments (ED) (March to November 2017). Primary outcome was caregiver willingness to accept opioids for moderate pain for their children.

Results

Five hundred and seventeen caregivers participated; mean age was 40.9 (SD 7.1) years with 70.0% (362/517) mothers. Children included 62.2% (321/516) males with a mean age of 10.0 (SD 3.6) years. 49.6% of caregivers (254/512) reported willingness to accept opioids for ongoing moderate pain in the ED, while 37.1% (190/512) were 'unsure'; 33.2% (170/512) of caregivers would accept opioids for at-home use, but 45.5% (233/512) were 'unsure'. Caregivers' primary concerns were side effects, overdose, addiction, and masking of diagnosis. Caregiver fear of addiction (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.01 to 1.25) and side effects (OR 1.25, 95% CI 1.11 to 1.42) affected willingness to accept opioids in the emergency department; fears of addiction (OR 1.19, 95% CI 1.07 to 1.32), and overdose (OR 1.15, 95% CI 1.04 to 1.27) affected willingness to accept opioids for at-home use.

Conclusions

Only half of the caregivers would accept opioids for moderate pain, despite ongoing pain following nonopioid analgesics. Caregivers' fears of addiction, side effects, overdose, and masking diagnosis may have influenced their responses. These findings are a first step in understanding caregiver analgesic decision making.

Mental health presentations to the emergency department: A perspective on the involvement of social support networks

The involvement of families, carers and significant others (i.e. social support networks) has a positive corollary for a person experiencing mental health problems. Accordingly, in Australia involvement of social support networks within mental health services is endorsed in national health policy and service guidelines. Despite the endorsement, this is yet to be fully realised in all areas that provide mental health services, including emergency departments. Social support networks are integral in the provision of mental health consumers' care. Supporting the involvement of social support networks in the emergency department can provide healthcare services with opportunities for enhanced and cost-effective care, contributing to improved outcomes for consumers. An overview of some of the barriers and facilitators of social support network involvement is provided. The intention of this paper is to encourage reflection and dialogue on this important area of mental health service provision and support the evolution of a new paradigm of research into social support network involvement in the emergency department.

Emergency Department Care of Young Children at Risk for Traumatic Brain Injury: What Are We Doing and Do Parents Understand?

OBJECTIVES

The aims of the study were to describe emergency department (ED) management of young children with head injury and to assess parental comfort level and perceptions of ED care.

METHODS

This was a prospective observational study of children younger than 5 years who presented to a pediatric ED after head injury. Children were eligible if clinical observation was an appropriate ED management option per the Pediatric Emergency Care Academic Research Network's neuroimaging clinical decision rule. Demographics, injury variables, and ED clinician surveys explaining the care provided were collected at time of study enrollment. Parents were subsequently contacted to assess understanding of ED management and comfort with care.

RESULTS

One hundred four children were enrolled with a mean (standard deviation) age of 1.19 (1.34) years. Thirty (29%) had emergent neuroimaging and 59 (57%) were placed into a period of observation per clinician report. A total of 37 children received a head computed tomography, of which 21 (57%) were normal. Eighty-four parents (81%) completed the phone follow-up. Of these children, there was a significant difference between whether parents and clinicians reported that the child had been clinically observed in the ED (P < 0.0001). Parents of children who did not receive a head CT were more likely to be uncomfortable with the decision to obtain neuroimaging compared with those who did receive a head CT (P = 0.003).

CONCLUSIONS

Parents are not always comfortable with the medical care practices provided and are often unaware of clinical observation when it does occur. Better parent-clinician communication could improve parental understanding and reduce overall discomfort.

[Impact of a strategy to improve the quality of care and risk management in a paediatric emergency department]

INTRODUCTION

Emergency departments are a high risk area for the occurrence of adverse events. The aim of this study is to analyse the impact of a strategy to improve the quality assurance and risk management in the notification of incidents in our Unit, and describe the improvement actions developed from the reported incidents.

MATERIAL AND METHODS

A retrospective observational study was developed during one year, divided into two periods: P1 (Start: training session and implementation of the risk management process), and P2 (Start: feed-back session of incidents reported in P1 and improvement actions developed). In each period, the number of reported incidents in relation to the number of emergencies attended (‰) and the descriptive data of each incident were recorded. The improvement actions developed from the incidents reported in P1 were described.

RESULTS

The number of notifications from P1 (4.1‰; 95%CI 3.2-5.0‰) increased in P2 (10.9‰; 95%CI 9.8-10.2‰, P<.001). The most frequent incidents in P1 were medication (33.3%), and identification errors (25.9%): both were significantly reduced in P2 (16.9%, P=.001 and 9.3%, P<.001, respectively). In P2, prescription errors of the P1 were reduced (35.9% vs 62.9%, P=.02). The factors of "Knowledge and training" (23.5%) were the most frequent in P1, decreasing in P2 (7.4%, P<.001).

CONCLUSION

It is considered that the implementation of a risk management process, and the promotion of a safety culture, through training and feed-back sessions to all professionals, contributed to increase the volume of notifications in our Unit. The voluntary and anonymous reporting of incidents is useful to identify risks, and plan corrective measures, contributing to improve quality assurance and patient safety.

Cultural sensitivity in paediatric nursing care: a concept analysis using the Hybrid method

BACKGROUND

Cultural sensitivity is a core concept to establish awareness and knowledge about various ethnicities, cultures, genders and additional diversity characteristics to understand individual's requests and respond appropriately to them. A need for further development of the concept is warranted, especially in the context of paediatric nursing.

AIMS

The purpose of this paper was to determine the main elements of cultural sensitivity in the context of paediatric nursing in Iran.

METHODS

The Hybrid method was implemented consisting of three phases: theoretical, fieldwork and final analysis. In the theoretical phase, articles from 2007 to 2017 were reviewed for relevance. In the phase of fieldwork, 25 nurses and nine parents were interviewed to explore the aspects of cultural sensitivity in paediatric nursing. The interviews were transcribed, and content analysis was conducted. In the final phase, an overall analysis of the two previous phases was performed.

RESULTS

In the theoretical phase, the following attributes were determined: cultural encounter and awareness, acceptance of cultural diversity and designing programmes in accordance with family culture. The fieldwork phase explored three themes of intercultural encounters, intercultural communication and adapting the care plan with family culture. The final synthesis yielded that sensitivity to family requests and beliefs, effective intercultural communication and integration of family culture with the care plan are the main elements of cultural sensitivity in Iranian paediatric nursing.

CONCLUSION

With a deeper understanding of the term cultural sensitivity, nurses will have a foundation to improve paediatric nursing care and align the care plan with the patient's culture to provide trust, child/parent participation, secure care, effective communication and satisfaction. Since the concepts are the building blocks that underpin theory, the present concepts identified can help to serve as the foundation for the development of a theoretical model.