OBJECTIVE: The goal was to examine pediatric hospitalist rounding practices and characteristics associated with programs conducting family-centered rounds (FCRs).
METHODS: The Pediatric Hospitalist Triennial Survey, sent to a subset of pediatric hospitalists on the Pediatric Research in Inpatient Settings listserv from the United States and Canada, consisted of 63 questions on sociodemographic characteristics, training, practice characteristics, and rounding practices.
RESULTS: Among 265 respondents (response rate: 70%), 78% practiced in academic hospitals and 22% in nonacademic hospitals. The prevalences of specific rounding categories were as follows: FCRs, 44%; sit-down, 24%; hallway, 21%; others, 11%. FCRs occurred significantly more often in academic (48%) than nonacademic (31%) hospitals (P = .04). FCRs can include pediatric residents, bedside nurses, charge nurses, case managers, pharmacists, and social workers. Academic settings and higher average daily patient censuses, but not FCRs, were significantly associated with prolonged rounding duration. The most commonly perceived FCR benefits included increased family involvement and understanding, trainee role modeling, and effective team communication. Physical constraints, trainees' apprehensions, and time were the main perceived FCR barriers. Greater perceived benefit/barrier ratios, FCR benefits, and family involvement in care were associated with a greater likelihood of conducting FCRs, whereas a greater number of perceived FCR barriers was associated with not conducting FCRs.
CONCLUSIONS: FCRs were the most-common rounding category among respondents. FCRs were not associated with a self-reported increase in rounding duration. Successful FCR implementation may require educating staff members and trainees about FCR benefits and addressing FCR barriers.
WHAT'S KNOWN ON THIS SUBJECT:
FCRs are inpatient, multidisciplinary rounds that involve parents' perspectives in decision-making. Many hospitals now conduct FCRs; however, little is known about current national FCR practices, characteristics of programs that conduct FCRs, and factors associated with conducting FCRs.
WHAT THIS STUDY ADDS:
FCRs were the most-common rounding category among those surveyed. Academic settings and higher patient censuses, but not FCRs, were associated with longer rounds. Successful FCR implementation may require educating staff members and trainees about FCR benefits and barriers.
Family-centered rounds (FCRs) are multidisciplinary rounds that occur inside patients' rooms, in the presence of patients and family members, and integrate patient and parent perspectives and preferences into clinical decision-making.1,2 Major national organizations, including the American Academy of Pediatrics (AAP), the Institute of Family-Centered Care, the Institute of Medicine, and the Accreditation Council of Graduate Medical Education, have published statements supporting family-centered care and its role in enhancing quality of care.1,3,–,5 In a policy statement, the AAP recommended that conducting attending rounds in patients' rooms with family members present should be standard hospital practice, and decisions on care plans for patients should be made only after such rounds, to incorporate family involvement in decision-making.1 As part of a national trend to enhance family-centered care, FCRs have gained substantial momentum throughout the nation, and many hospitals have instituted FCRs.2,6,–,9
Although many hospitals now conduct FCRs, little is known about national FCR practice, characteristics of programs conducting FCRs, and factors associated with conducting FCRs. Only 5 published studies (to our knowledge) have addressed pediatric FCRs, and their focus was limited to definition of FCRs, qualitative study of parental involvement on rounds, or investigation of the impact of FCRs on teamwork.2,6,–,9 The objectives of this study were to identify rounding practices among pediatric hospitalists, characteristics of programs conducting FCRs, and factors associated with conducting FCRs.
Data Source and Participants
The data source was the Pediatric Research in Inpatient Settings (PRIS) Network Pediatric Hospitalist Triennial Survey, a 2007 survey of the subset of pediatric hospitalists on the PRIS listserv. The PRIS network originated in 2002 from collaborative efforts of the Society of Hospitalist Medicine, the AAP, and the Academic Pediatric Association.10 The network consists of 377 hospitalists representing 45 US states, 2 Canadian provinces, and 80 medical centers. PRIS projects are reviewed by the steering committee, which consists of 7 national pediatric hospital medicine experts. Its mission is to improve the care of hospitalized children by developing an evidence base for inpatient care.10
Study Design and Survey
The PRIS survey included 63 yes/no or multiple-choice questions. Survey domains about participants included demographic features (age, gender, and race/ethnicity); training characteristics (medical school, residency, fellowship, and years since completion of residency); practice setting (academic or nonacademic); teaching, administrative, and research responsibilities; and rounding characteristics. An academic hospital was defined as any hospital in which residents and other trainees provide direct patient care and a community hospital as any hospital that was not a freestanding children's hospital or a children's hospital within a hospital. Rounding characteristics examined included rounding category (sit-down in a common room on the ward, hallway in the space immediately outside patients' rooms, family-centered in patients' rooms, or other [open-ended description]), personnel participating in rounds, estimated duration of rounds (<30 minutes, 30–60 minutes, 60–90 minutes, or >90 minutes), average daily patient census (<5 patients, 6–9 patients, 10–14 patients, or >15 patients), rounding team size (0–5 members, 6–9 members, or >10 members), perceived FCR barriers, and perceived FCR benefits. The latter 2 questions were asked of all participants, irrespective of their preferred rounding category.
Questionnaire items were chosen through consensus by the PRIS steering committee. The survey was administered electronically by using SurveyMonkey (SurveyMonkey, Menlo Park, CA) and was sent to all PRIS listserv members in June 2007.11,12 In August 2007, at the annual Society of Hospitalist Medicine pediatric meeting, an announcement was made by a member of the PRIS steering committee, requesting all PRIS members to participate in the survey. The announcement briefly described the survey and provided information on how to become a member of the PRIS listserv. A final SurveyMonkey wave was e-mailed to all nonrespondents at 2 weeks, 3 months, and 6 months after the initial survey mailing.
The main outcome measures were rounding category, estimated duration of rounds, staff members participating in rounds, and team size.
Data were coded and analyzed by using SAS 9.1 (SAS Institute, Cary, NC). Pearson's χ2 test was used to test for independence between categorical variables. The nonparametric Kruskal-Wallis test was used to compare continuous characteristics among different groups. P values of <.05 were considered significant.
Bivariate analyses were used to identify factors associated with conducting FCRs. Factors examined included academic environment; years since graduation from residency program; presence of medical students, pediatric residents, or fellows; time spent teaching by faculty members; years worked as a hospitalist; perceived barriers and benefits; total number of perceived benefits; total number of perceived barriers; and ratio of perceived benefits to barriers. Multivariate linear regression was used to identify factors associated with prolonged duration of rounds, after adjustment for relevant covariates. Variables hypothesized to affect rounding duration were an academic environment, average daily patient census, and rounding category.
Participant Sociodemographic Characteristics
Of 377 PRIS members contacted, 265 responded, for a response rate of 70%. The mean participant age was 41 years, and most participants were female and white (Table 1). Approximately two-thirds of participants were ≥5 years past residency and practiced in community hospitals, and approximately three-fourths practiced in academic settings. More than one-third of participants were directors of hospitalist services, 1 in 5 was a training director, and 17% were division chiefs or department chairs. Most participants were attending physicians on general pediatric wards, and many also provided care in other settings (Table 1).
Almost one-half of participants conducted FCRs, approximately one-fourth conducted sit-down rounds, 1 in 5 held hallway rounds, and a small proportion conducted a combination of rounds (Table 2). A significantly greater proportion of academic hospitals, compared with nonacademic hospitals, conducted FCRs (48% vs 31%; P = .04) (Table 2). Sit-down rounds occurred significantly more often in nonacademic hospitals, compared with academic hospitals (40% vs 20%; P < .01) (Table 2). There were no differences in the proportions of hospitals that conducted hallway rounds or other types of rounds.
Characteristics of Rounds
Bedside nurse participation was perceived to occur significantly more often on FCRs than on non-FCRs (83% vs 51%; P < .0001). No significant associations were found between any other staff category and rounding category, including FCRs versus non-FCRs, FCRs versus sit-down rounds, and FCRs versus hallway rounds (data not shown).
Duration of Rounds
Bivariate analyses revealed that only sit-down rounds were significantly more likely to be ≤90 minutes in duration (Table 3). In addition, sit-down rounds were significantly more likely than FCRs to be ≤90 minutes, but the proportions of rounds that were ≤90 minutes for other rounding categories were not significantly different from that for FCRs. Multivariate linear regression analysis revealed that an academic environment and a higher average daily patient census were significantly associated with prolonged adjusted rounding duration (P < .001) (Table 4); however, rounding category was not associated with rounding duration, after adjustment. Relevant covariates adjusted for included academic environment, average daily patient census, and rounding category. Additional analyses to examine the consistency of answers within the same hospital revealed that respondents from the same hospitals had 80% agreement (28 of 35 respondents) with respect to rounding category and 71% agreement (25 of 35 respondents) with respect to rounding duration.
Average Daily Patient Census and Rounding Team Size
No significant associations were found between the average daily patient census size and rounding category, including non-FCRs, sit-down rounds, and hallway rounds (data not shown). Irrespective of rounding category, the team size varied from 6 to 10 members (61%) to >10 members (13%). No significant associations were found between rounding category and rounding team size (data not shown).
Perceived Benefits of and Barriers to FCRs
Increased patient/family involvement in care was the most commonly cited perceived FCR benefit, at 78% (Table 5). Approximately three-fourths of participants also reported that FCRs allowed physicians to be better role models for trainees, improved patient/family understanding of discharge goals, and resulted in effective team communication. Approximately one-half of participants reported that conducting FCRs resulted in both efficient discharge and unit workflow and efficient physician time management. Approximately one-fourth cited confidential patient care discussion-related FCR benefits. Small proportions of participants also reported that FCRs decreased medical errors, increased patient satisfaction, improved decision-making by involving the family, provided direct clinical observation of residents and students, improved nurse and physician collaboration and education, had risk-management benefits, and facilitated order-writing during rounds.
The most common perceived FCR barrier was that the rounding team size was prohibitive, which was cited by 44% of participants (Table 5). Approximately one-third of participants stated that FCR barriers included trainees' fear of loss of families' respect if the trainees did not seem knowledgeable in front of the family, small room size, prolonged duration of rounds because of more parent questions, inefficient rounds because of an inability to perform full examinations of all patients and the need to return later to complete full assessments, patient confidentiality, lack of interest of other medical staff members because of poor buy-in regarding FCRs by other physicians, and negative impact on physician or nursing/unit workflow. Less frequently cited barriers included lack of interest because of poor FCR buy-in by other hospital staff members, language barriers, physician fear of loss of control, family absence during rounds, patients in isolation, the need to truncate teaching, and nurses being too busy to attend FCRs.
Factors Associated With Conducting FCRs
Several factors were significantly associated with whether FCRs were conducted (Table 6). A greater perceived benefit/barrier ratio, more perceived FCR benefits, and perceived increased patient/family involvement in care were associated with a significantly greater likelihood of conducting FCRs. A greater number of perceived FCR barriers, negative FCR impact on physician workflow, and confidentiality as a perceived FCR barrier were associated with a significantly lower likelihood of conducting FCRs. No significant associations were found between any other perceived benefit or barrier and conducting FCRs or non-FCRs. In addition, years since residency graduation, academic environment, presence of pediatric residents or fellows on rounds, time spent on teaching by faculty members, and years worked as a hospitalist were not found to be significantly associated with rounding category (data not shown).
To our knowledge, this is the first national study of pediatric hospitalists to identify current rounding practices. The study showed that FCRs were the most common rounding category among respondents. A recent AAP policy statement recommended that providers conduct rounds in patients' rooms, with family members present.1 Growing consensus suggests that providing family-centered care improves parent satisfaction and outcomes.1,3 Therefore, it is not unexpected that pediatric hospitalists increasingly are conducting FCRs. It is essential, however, that hospitalists be aware of FCR barriers. For those not conducting FCRs, it is important to recognize potential FCR benefits, as identified in this study, including improved family involvement and understanding, enhanced team communication and trainee education, and improved workflow.
FCRs and Trainees
A crucial FCR barrier is trainees' fear of not appearing knowledgeable in front of the family. Although most parents prefer case discussions inside their rooms13 and request involvement in FCRs,6 both students and housestaff members feel more comfortable with discussions away from patients.13 Rounds generally have moved away from the bedside, with bedside teaching rates decreasing from 75% in the 1960s to 16% in the current decade.14,15 Most learners however believe that bedside presentations are important for learning, and those exposed to bedside presentations prefer them.15
Role modeling by attending physicians is another FCR benefit, providing a valuable mechanism for trainees to learn communication, compassion, and professionalism.14,16 Given that FCRs are a relatively novel approach, trainees may require additional education about conducting FCRs, FCR benefits and barriers, and orienting family members about the roles of team members.
FCRs and Duration of Rounds
Study findings revealed that, after adjustment, the reported FCR duration did not differ significantly from the duration of other rounding categories. This contradicts a previous study in which FCRs were found to prolong rounding duration but saved time later in the day and improved discharge timeliness.6 A study of an adolescent ward found that FCRs added 2.7 minutes per patient, compared with sit-down rounds, but improved staff satisfaction and parental involvement.9 FCR duration was estimated by respondents in our study and the estimates may not be accurate, which may be an important study limitation. The finding that FCRs are not associated with increased duration of rounds, however, can be used to enhance FCR buy-in by hospitals considering or initiating FCRs. Additional studies are needed to measure FCR duration objectively, compared with other rounding categories.
Academic hospital status and greater average daily patient census were associated with prolonged rounds, regardless of rounding category. Because academic hospital status is associated with both greater likelihood of FCRs and prolonged rounding duration, academic hospitals need to be especially aware of strategies for conducting efficient rounds, including starting and ending FCRs on time, keeping the team focused on FCRs, and balancing case discussion and teaching. FCRs are associated with improved discharge timeliness,6 and early discharges may decrease rounding duration by reducing the average daily census.
FCRs and Nurse Participation
The study findings reveal a significantly greater perception of bedside nurse participation on FCRs, compared with other rounding categories. Bedside nurses are crucial members of the multidisciplinary team, because they have the most up-to-date patient information, often are first responders to parents' questions, and work closely with housestaff members. Greater nurse participation on FCRs may provide opportunities to enhance physician-nurse collaboration, which has been shown to foster teamwork9 and to improve outcomes.17,18
Factors Associated With Conducting or Not Conducting FCRs
Whether FCRs are conducted often depends on the medical team's attitudes toward and perceptions of FCRs. A greater perceived benefit/barrier ratio, greater numbers of perceived FCR benefits, and perceived increased family involvement were associated with greater odds of conducting FCRs, whereas an increased total number of perceived barriers, perceptions that FCRs negatively affect workflow, and confidentiality as a perceived FCR barrier were associated with non-FCRs. Although it may seem to be self-evident that those who recognize FCR benefits are more likely to conduct FCRs, to our knowledge this has never been reported before.
Room constraints and large team sizes are major reported FCR barriers. Given the resurgence of FCRs, established hospitals may consider room size when allocating space for inpatient wards, and new or expanding facilities may need to be aware of small room size as a FCR barrier when designing future pediatric wards and children's hospitals. In addition, identifying key FCR personnel may help limit team sizes. Although this is an area for a future study, our limited FCR experience on a general pediatric ward indicates that participation by bedside nurses and case managers is crucial for FCRs. Misconceptions may exist about the need for a full physical examination of every patient on FCRs; in our experience, a problem-focused examination is more useful and practical than a complete physical examination of every patient.
Workflow and patient confidentiality were reported as 2 reasons for not conducting FCRs. Although some hospitalists reported workflow as a FCR barrier, it also was reported among the top 5 FCR benefits. Workflow can be optimized by developing a structured FCR process that includes educating families and FCR teams about conducting FCRs; performing preround preparation that includes performing early discharges, having trainees assemble patient charts before rounds, and assigning specific roles to trainees to facilitate work on rounds; conducting daily FCRs in a timely, focused manner; and ensuring that orders are written during FCRs. Patient confidentiality can be ensured by conducting FCRs entirely inside patients' rooms, identifying sensitive, patient-related issues before rounds, minimizing others' access to hallway computer screens while teams are in patients' rooms, and positioning rounding carts with patients' charts facing hallway walls. The findings that hospital practice environment, age, and the presence of trainees were not associated with conducting FCRs suggest that FCRs are adaptable and well accepted across the spectrum of pediatric services.
Certain study limitations should be noted. It is not clear how representative the study sample is of the population of hospitalists in North America. On the basis of literature estimates of the pediatric hospitalist workforce, the study sample may account for up to 37% to 47% of US hospitalists.19 It is possible, however, that hospitalists who are not PRIS members are less aware of and likely to conduct FCRs; nonhospitalists also may conduct FCRs. The survey was based on individual responses, rather than institutional responses; therefore, it is possible that some programs are overrepresented in the prevalence proportions for rounding categories. Up to 39 responses regarding rounding category items were missing, among the 265 surveys returned. It is not clear why participants did not respond to these items. The average rounding duration was estimated by respondents, rather than measured objectively. Many unmeasured factors may affect FCR duration, including interruptions, emergencies, pages, the presence of interpreters, faculty member and trainee experience with FCRs, and the use of computers on FCRs; none of these factors was measured in this study. The reported benefits and barriers were respondents' personal perceptions, rather than measured outcomes. This study did not address language barriers and the presence of interpreters on rounds. How FCRs should be conducted in the presence of an interpreter and the impact on FCR duration require further study. Our study did not include surveying family members, trainees, and staff members. We are in the process of conducting focus groups involving families, multidisciplinary team members, residents, and attending physicians, to obtain more in-depth insight regarding FCR knowledge, attitudes, and beliefs.
FCRs were the most-commonly practiced rounding category among those surveyed, and academic hospitals were more likely to conduct FCRs. FCRs were not associated with a self-reported increase in rounding duration. The most-common perceived FCR benefits included improved patient involvement in care and understanding of discharge goals, role modeling for trainees, effective team communication, and enhanced workflow. The most-common perceived FCR barriers included physical constraints, trainees' apprehensions, and misconceptions about rounding duration. A greater perceived benefit/barrier ratio, greater numbers of perceived FCR benefits, and perceived increased family involvement in care were associated with greater likelihood of conducting FCRs, whereas a greater number of perceived FCR barriers, perceived negative impact on physician workflow, and confidentiality as a perceived FCR barrier were associated with not conducting FCRs.
Because hospitals are under increasing scrutiny in providing high-quality patient care and reporting performance measures,20 conducting FCRs may represent a powerful means of improving the quality of inpatient care. Successful FCR implementation requires educating staff members and trainees about FCR benefits, addressing FCR barriers, and allaying concerns about time constraints.
We are grateful to the PRIS steering committee for input on this study. We also thank the 3 anonymous reviewers for helpful comments on earlier drafts of this manuscript.
- Accepted March 10, 2010.
- Address correspondence to Vineeta S. Mittal, MD, University of Texas Southwestern Medical Center, Division of General Pediatrics, Department of Pediatrics, 5323 Harry Hines Blvd, Dallas, TX 75390-9063. E-mail:
This work was presented in part as a platform presentation at the annual meeting of the Pediatric Academic Societies; May 6, 2008; Honolulu, HI; and the annual meeting of the Society of Hospitalist Medicine; July 26, 2008; Denver, CO.
FINANCIAL DISCLOSURE: The authors have no financial relationships relevant to this article to disclose.
- FCR =
- family-centered round •
- PRIS =
- Pediatric Research in Inpatient Settings •
- AAP =
- American Academy of Pediatrics
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- Copyright © 2010 by the American Academy of Pediatrics