BACKGROUND AND OBJECTIVE: Night teams of hospital providers have become more common in the wake of resident physician duty hour changes. We sought to examine relationships between nighttime communication and parents’ inpatient experience.
METHODS: We conducted a prospective cohort study of parents (n = 471) of pediatric inpatients (0–17 years) from May 2013 to October 2014. Parents rated their overall experience, understanding of the medical plan, quality of nighttime doctors’ and nurses’ communication with them, and quality of nighttime communication between doctors and nurses. We tested the reliability of each of these 5 constructs (Cronbach’s α for each >.8). Using logistic regression models, we examined rates and predictors of top-rated hospital experience.
RESULTS: Parents completed 398 surveys (84.5% response rate). A total of 42.5% of parents reported a top overall experience construct score. On multivariable analysis, top-rated overall experience scores were associated with higher scores for communication and experience with nighttime doctors (odds ratio [OR] 1.86; 95% confidence interval [CI], 1.12–3.08), for communication and experience with nighttime nurses (OR 6.47; 95% CI, 2.88–14.54), and for nighttime doctor–nurse interaction (OR 2.66; 95% CI, 1.26–5.64) (P < .05 for each). Parents provided the highest percentage of top ratings for the individual item pertaining to whether nurses listened to their concerns (70.5% strongly agreed) and the lowest such ratings for regular communication with nighttime doctors (31.4% excellent).
CONCLUSIONS: Parent communication with nighttime providers and parents’ perceptions of communication and teamwork between these providers may be important drivers of parent experience. As hospitals seek to improve the patient-centeredness of care, improving nighttime communication and teamwork will be valuable to explore.
- CCC —
- complex chronic condition
- CI —
- confidence interval
- OR —
- odds ratio
What’s Known on This Subject:
Communication between parents and providers is an important driver of parent experience of care. The impact of nighttime communication, which has become increasingly relevant after changes in resident physician duty hours, on parent experience is unknown.
What This Study Adds:
Parent communication with nighttime doctors and nurses, and parent perceptions of communication and teamwork between these providers, may be important drivers of parent experience. Efforts to improve nighttime communication, both with parents and between team members, may improve parent experience.
Patient and family experience is an important measure of the quality of inpatient care. Poor patient experience is associated with negative patient outcomes, including illness recovery and treatment adherence.1,2 Patient experience scores are also increasingly being linked to reimbursements and assessments of hospital performance.3,4
Parents’ communications with providers (doctors and nurses) are important predictors of their experience.5–9 However, parents’ communication with nighttime providers in particular has not been well studied. Communication at night may fundamentally differ from communication during the day. Staffing levels are typically lower,10,11 provider roles differ, and patients may be cared for by providers who know them less well (especially given recent reductions in consecutive resident physician duty hours).12–14 Communication may also be adversely affected by sleep deprivation and circadian misalignment15–18 as well as parental anxiety. Therefore, we sought to explore the relationships between nighttime communication and parent experience of care during hospitalization by analyzing rates and predictors of parent-reported “top-box” responses (defined as the most positive response option in a scale) to experience questions in a cohort of hospitalized children.
Data, Setting, and Study Population
We conducted a prospective cohort study of parents of a randomly selected subset of children (0–17 years) before anticipated discharge from 2 general pediatric units at Boston Children’s Hospital between May 2013 and October 2014. We included general pediatric, “short stay” (patients with straightforward illnesses), and subspecialty (eg, adolescent, immunology, hematology, rheumatology) patients. Research assistants administered written surveys to parents on weekday (Monday–Thursday) evenings. After explaining instructions and answering questions, research assistants left surveys with parents to complete. Research assistants checked in with families 2 to 3 times that evening, or the next morning if requested, to collect completed surveys. We obtained verbal consent from parents by using a study information sheet. We used hospital administrative data to obtain patient demographic and clinical characteristics. Our hospital institutional review board approved the study.
Given limited nighttime interpreter resources, we included only English-speaking parents. To ensure that parents had sufficient time to assess nighttime communication, we included only parents of patients who had spent ≥2 nights in the hospital. We excluded parents of patients “boarding” on the inpatient unit awaiting psychiatric placement, in state custody, or ≥18 years old.
We developed a survey to assess overall inpatient experience and parent experience regarding nighttime communication with and between providers. Our survey included 29 closed questions with a 5-point Likert scale to assess communication and experience. Questions covered 5 distinct constructs: (1) parent understanding of the medical plan, (2) parent communication and experience with nighttime doctors, (3) parent communication and experience with nighttime nurses, (4) parent perceptions of nighttime interaction between doctors and nurses, and (5) parent overall experience of care during hospitalization. We validated the reliability of each construct by calculating a Cronbach’s α (α >.8 for each).
We also included in the survey an open question asking whether parents had anything else to share about communication during the hospitalization and 10 parent demographic questions. We designed this survey with the input of family partners and a survey methodologist. We cognitively tested and piloted the instrument in the study units before data collection.
Our primary outcome was parent-reported “top-box” overall experience of care during hospitalization (a dichotomous outcome generated from Construct 5). The top-box refers to the most positive response to a survey question. In our survey, items within the overall experience construct included 6 questions that used an agreement scale (top-box = strongly agree) and one that used a quality scale (top-box = excellent). Responses were subsequently coded onto a 5-point scale for analysis (eg, excellent and strongly agree responses were assigned a score of 5). Parents were considered to have top-box overall experience if they had a score of 5 out of 5 for all items in this construct.
Predictors of Top-Box Overall Experience
We examined the relationship between mean scores for each construct (Constructs 1–4) and our dichotomous top-box overall experience outcome (Construct 5). We assessed which parent and patient characteristics were associated with overall top-box experience. We evaluated parent age, gender, race/ethnicity, education, income, and primary language based on parent survey responses. We evaluated patient age, insurance, length of stay, and complex chronic condition (CCC) count based on hospital administrative data. The CCC system uses International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify medically complex children. It uses these codes to capture “any medical condition that can be reasonably expected to last at least 12 months (unless death intervenes) and to involve either several different organ systems or 1 organ system severely enough to require specialty pediatric care and probably some period of hospitalization in a tertiary care center.”19 Mean construct scores, age, and length of stay were analyzed as continuous predictors; all other predictors were dichotomized.
We performed a descriptive analysis of parent and patient characteristics by using percentages for categorical variables and means (SDs) for continuous variables. For survey questions pertaining to parent-reported communication and experience, we calculated mean scores (SDs) for each of the 5 constructs and for the 29 individual items within these constructs. However, for the purposes of modeling relationships, given the large number of survey questions, we opted to examine aggregate constructs rather than individual items.
To identify factors associated with top-box overall experience (our primary outcome), we dichotomized the sample into a top-box overall experience group (a score of 5 out of 5 for all items within the overall experience construct [Construct 5]) and a non–top-box group.
For bivariate analysis, we assessed the association of categorical sociodemographic and clinical factors across the 2 groups by using the χ2 and Fisher’s exact tests where appropriate. We used the analysis of variance test to assess differences between the 2 groups in mean scores for Constructs 1–4 and the Wilcoxon–Mann–Whitney test to assess differences in nonparametric continuous variables (patient age, length of stay). Covariates with a P of <.20 in the bivariate analyses were added into the multivariable logistic regression model. A P of <.05 was considered statistically significant. We also performed a content analysis with clustering according to theme on text from the open-ended question asking whether parents had anything else to share about communication. We collected and managed study data by using REDCap (REDCap Consortium, Nashville, TN).20 We performed analyses by using SAS version 9.4 (SAS Institute, Inc, Cary, NC).
Among eligible parents, 471 (98.9%) consented to participate in the study, and 398 completed surveys (84.5% response rate). Parents were predominantly female (69.1%), white (52.0%), primarily English-speaking (83.4%), college-educated (66.6%), with a mean age of 36.8 years (SD 8.9); 44.0% reported an annual household income ≥$50 000. Patients were predominantly ≤5 years old (57.3%), white (53.0%), and non–publicly insured (61.5%), with no CCCs (73.6%) and a median length of stay of 2.6 days (interquartile range 1.9–4.1) (Table 1).
Top-Box Experience Scores by Construct and by Individual Item
Overall, 42.5% (n = 169) of parents reported top-box overall experience (a score of 5 out of 5 on all items in the overall experience construct [Construct 5]). Mean (SD) construct scores ranged from 4.05 (0.88) for the nighttime doctor experience and communication construct to 4.59 (0.51) for the overall experience construct (our outcome) (Table 2).
Mean (SD) construct scores for parents who reported top-box overall experience as compared with parents who did not report top-box overall experience were 4.69 (0.50) vs 4.19 (0.64) for understanding of the medical plan (Construct 1), 4.55 (0.68) vs 3.68 (0.83) for communication and experience with nighttime doctors (Construct 2), 4.85 (0.30) vs 4.31 (0.59) for communication and experience with nighttime nurses (Construct 3), and 4.87 (0.37) vs 4.19 (0.71) for interaction between nighttime doctors and nurses (Construct 4) (P < .001 for all).
Individual items for which parents provided highest ratings included feeling that nurses listened to their concerns (70.5% strongly agreed), having the same understanding of the medical plan as nighttime nurses (70.3% always), and feeling that nurses thought of them as an important part of the health care team (69.2% strongly agreed). Items for which parents reported lowest ratings included regular communication with nighttime doctors (31.4% strongly agreed), being updated about what changes to look out for overnight (41.0% strongly agreed), quality of communication with nighttime doctors (43.7% excellent), and coordination between daytime and nighttime doctors (43.9% excellent).
More than 80% of parents who reported top-box overall experience provided top ratings for coordination between daytime and nighttime nurses and for teamwork between nighttime doctors and nurses, as compared with <40% of parents who did not report top-box overall experience (P < .05 for both) (Fig 1).
Bivariate predictors of top-box overall experience included patient age and increased scores for Constructs 1–4: parent understanding of the medical plan, communication and experience with nighttime doctors, communication and experience with nighttime nurses, and interaction between nighttime doctors and nurses (P < .05 for all) (Table 3).
Multivariable predictors (odds ratio [OR] and 95% confidence interval [CI]) of top-box overall experience included increased patient age (OR 1.06; 95% CI, 1.01–1.11) and higher mean scores for Constructs 2–4: communication and experience with nighttime doctors (OR 1.86; 95% CI, 1.12–3.08), communication and experience with nighttime nurses (OR 6.47; 95% CI, 2.88–14.54), and perception of nighttime doctor–nurse interaction (OR 2.66; 95% CI, 1.26–5.64) (Table 3).
Narrative comments (n = 109) provided by parents in response to the open-ended item asking whether they had anything else to share about communication covered a number of themes (see Table 4 for illustrative quotes for each). The majority of parents relayed positive comments (n = 64) that ranged from general to detailed comments about respectfulness, clarity of communication, experience with staff, teamwork, attentiveness, patient and family involvement, and thoroughness. However, some expressed concerns about communication with their doctors and nurses (n = 36). These included concerns related to completeness and quality of information, physical absence of nighttime doctors, delays in communication, receiving conflicting information, frustration at needing to repeat information, feeling dismissed, and interpersonal concerns. In addition, several parents (n = 9) provided suggestions for improving communication. These included tools to help identify staff and requests to provide regular nighttime updates, provide written summaries, and generally increase communication.
We found that parents who experienced suboptimal communication and teamwork at night were much more likely to rate their overall hospital experience poorly. More than 80% of parents who reported top-box overall experience provided top scores for teamwork among nighttime doctors and nurses, as compared with <40% of parents who did not report top-box overall experience. On multivariable analyses, parents’ ratings of their direct communications with doctors and nurses, and their observations of teamwork and communication between doctors and nurses, were significant predictors of top-box overall experience. These findings suggest that improving nighttime communication could be an important, largely underrecognized means by which hospitals could achieve improvements in patient experience.
Parents’ communication with providers is known to affect their ratings of inpatient experience.6,7 Previous studies have not focused on differences between communication during the day and night, however. Over the past decade, hospitals have increasingly moved toward care models in which different teams of providers care for patients by day and by night. Parent communications with nighttime providers, who may be responsible for more than half of care provided in hospitals, may differ from communications with daytime providers given different provider roles and responsibilities at night.
Interestingly, we found that parent experience seemed predicated not only on parent communications at night with physicians and nurses but also on parent perceptions of nighttime communication and teamwork between nurses and physicians. Our study suggests that parents may perceive, to a greater extent than providers realize, problems in interprofessional teamwork and communication that in turn may affect their experience. Thus, our data suggest that in addition to interventions to improve communications between health care providers and parents, initiatives to improve interprofessional (eg, physician–nurse) and intraprofessional (eg, daytime physician–nighttime physician or daytime nurse–nighttime nurse) communication and teamwork may be associated with improved parent experience of care.
Beyond having an impact on parent experience, teamwork and communication interventions may affect patient outcomes. The quality of provider–patient communication predicts treatment adherence.21–24 Physician–nurse interactions are associated with patient mortality and readmissions.25,26 Teamwork has been correlated with patient outcomes27 and quality of care.28,29
An important secondary finding of our study was the absence of nighttime doctors at the bedside. The nighttime doctor construct had the lowest mean score (4.0) of all 5 constructs, and of all individual survey items, parents reported the lowest score for regular communication with nighttime doctors (only 31% strongly agreed). Although parents who reported suboptimal experience had significantly lower scores than their counterparts for all survey items, these differences were particularly marked for items relating to communication with nighttime doctors. For instance, 70% of parents who reported top-box overall experience rated quality of communication with nighttime doctors as excellent, compared with only 24% of parents who did not report top-box overall experience. These results may reflect, in part, night physicians engaging in behind-the-scenes care coordination and communication, of which parents are unaware. Regardless, parent perceptions of physician presence appear to be associated with overall experience.
The narrative comments from parents in our study enable a richer understanding of these findings. For instance, 1 parent remarked that the role of the nighttime doctors seemed merely to ensure that the plan established by the day doctors went smoothly. Although resident physicians in the studied residency program are taught through the I-PASS program that responsibility is fully transferred to them when they assume care at night,30 the realities of discontinuity in coverage, decreased staffing, and increased workload appear to have a continued impact at night. Hospitals seeking to address this challenge will need to contend with cultural change and consider changes in staff logistics and resources.
In contrast, parents seemed to report particularly high scores for experience with nighttime nurses. The nighttime nurse experience construct had a mean score of 4.5, and parents’ highest-rated single item was whether they thought nurses listened to their concerns (71% strongly agreed). Experience with nighttime nurses was also our strongest predictor of overall experience. We found more than a sixfold increase in the odds of having a top-box overall experience for every 1-point increase in the mean nighttime nurse communication and experience construct score. Our study was not designed to directly compare the relative importance of physician, nurse, and physician–nurse factors in informing parent experience, and CIs for these 3 domains overlap. However, our results did preliminarily suggest a particularly important role of the nighttime nurse in shaping overall care experience. This finding is consistent with previous literature31 and may reflect in part the large amount of time nurses often spend at the bedside.
Our study has a number of possible implications warranting additional exploration for how hospitals and providers might improve nighttime communication and thereby improve parent experience. However, rigorously designed intervention studies are needed to determine their effectiveness, ensure feasibility, and avoid unintended negative consequences. Possible interventions warranting future study include targeted initiatives to increase the amount of time spent at the bedside by nighttime physicians earlier in the evening (while parents are awake) and initiatives to allow parents to more clearly identify their daytime and nighttime care teams (eg, through white boards or photo information face sheets32,33). Additional interventions, as suggested by parents in our study, include providing written documentation with updates about the care plan. Also, although a great deal of emphasis has been placed on improving communication at change of shift between daytime and nighttime physicians,30,34–36 our study suggests that efforts to improve interdisciplinary communication, such as teamwork training,37,38 multidisciplinary handoffs34,39 that involve parents,40,41 huddles,42–44 and bedside shift reports,45 may provide additional value. In addition, technology may be leveraged to improve real-time communication between members of the care team, including parents, nurses, and physicians. For instance, secure text messaging46 may be an efficient way to improve communication, even when staffing is low and workload is high. In addition to more studies to ensure their feasibility and effectiveness, many of these interventions require culture change, as well as practical, logistical, and financial support.
We recognize that night is a difficult time for physicians, nurses, and families alike given different roles and priorities compared with daytime care (eg, dealing with emergencies in a larger cohort of patients; provider, patient, and parent sleep). Nevertheless, these data suggest that the limited time available to night providers is greatly valued by patients as the communication parents have with their night providers and the perceived teamwork between night doctors and nurses may have an important effect on parents’ overall experience. However, any efforts to improve communication at night between patients and providers will need to be sensitive to provider workflow, parent and patient sleep, and parent preferences.
Our study had several limitations. It was conducted at a single, tertiary care children’s hospital among English-speaking, predominantly female, well-educated parents of patients admitted for ≥2 nights, all of which limit generalizability. The experience of parents of patients admitted for less time or in other contexts may vary. Additionally, unlike most parent experience surveys, which are typically mailed to families after discharge, we conducted our survey before discharge, while parents were still in the hospital with their children. Therefore, we were not able to capture the association between the discharge process and parent experience of inpatient hospitalization. This limitation may have biased our study toward higher experience scores. However, our response rates were high. In addition, parents do not have the opportunity to observe all communication between physicians and nurses, so their perceptions may reflect only a portion of such communication or may capture other elements of care. Finally, we were not able to determine causality in this study, and there are probably complex connections between the types of communication captured in our survey constructs that we could not fully explore here. Additional study is needed to examine these relationships in greater detail.
In an era of increasing reliance on night teams of residents, our study helps fill gaps in the literature about nighttime care in hospitals. It suggests that nighttime communication may be an important driver of parent experience of care and may be an underrecognized area of improvement for providers and hospitals. Targeted interventions that focus on improving teamwork and communication at night have the potential to improve patient experience and other important indicators of care quality.
The authors thank Thomas W. Mangione, PhD, for his assistance with reviewing the survey instrument, parent partners Brenda Allair and Katie Litterer for providing valuable parent perspectives, and all the families and research assistants who participated in this study.
- Accepted August 27, 2015.
- Address correspondence to Alisa Khan, MD, MPH, Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, 21 Autumn St, Rm 200.2, Boston, MA 02215. E-mail:
Dr Khan conceptualized and designed the study, obtained funding, acquired data, performed statistical analyses, analyzed and interpreted data, and drafted the initial manuscript; Ms Rogers provided intellectual advice and guidance for the study and obtained funding; Ms Melvin performed statistical analyses and analyzed and interpreted data; Ms Furtak participated in study design, tabulated articles, helped perform the literature review, and provided administrative support; Ms Faboyede participated in study design, acquired data, and helped perform the literature review; Dr Schuster provided intellectual advice and methodological guidance for the study; Dr Landrigan supervised the study, obtained funding, conceptualized and designed the study, analyzed and interpreted data, and drafted the manuscript; and all authors critically reviewed and revised the manuscript for important intellectual content and approved the final manuscript as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Support for this work was provided by an Agency for Healthcare Research & Quality NRSA T32 HS000063 grant, an Agency for Healthcare Research & Quality K12HS022986 grant, an internal Boston Children’s Hospital Program for Patient Safety and Quality grant, and a Taking on Tomorrow Innovation Award in Community/Patient Empowerment. The views expressed herein are those of the authors and do not necessarily represent those of the funding sources.
POTENTIAL CONFLICT OF INTEREST: Dr Landrigan has served as a paid consultant to Virgin Pulse to help develop a Sleep and Health Program. He is supported in part by the Children’s Hospital Association for his work as an executive council member of the Pediatric Research in Inpatient Settings (PRIS) network. In addition, Dr Landrigan has received monetary awards, honoraria, and travel reimbursement from multiple academic and professional organizations for teaching and consulting on sleep deprivation, physician performance, handoffs, and safety and has served as an expert witness in cases regarding patient safety and sleep deprivation. The other authors have indicated they have no potential conflicts of interest to disclose.
- ↵Centers for Medicare & Medicaid Services. HCAHPS: patients’ perspectives of care survey. September 2014. Available at: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html. Accessed June 26, 2015
- ↵Hospital Compare. Survey of patients’ experiences (HCAHPS). Available at: www.medicare.gov/hospitalcompare/Data/Overview.html. Accessed May 29, 2015
- Co JPT,
- Ferris TG,
- Marino BL,
- Homer CJ,
- Perrin JM
- Miller AD,
- Piro CC,
- Rudisill CN,
- Bookstaver PB,
- Bair JD,
- Bennett CL
- Feudtner C,
- Christakis DA,
- Connell FA
- Wheelan SA,
- Burchill CN,
- Tilin F
- J Alharbi TS,
- Olsson LE,
- Ekman I,
- Carlström E
- Starmer AJ,
- O’Toole JK,
- Rosenbluth G,
- et al.,
- I-PASS Study Education Executive Committee
- Starmer AJ,
- Spector ND,
- Srivastava R,
- Allen AD,
- Landrigan CP,
- Sectish TC,
- I-PASS Study Group
- Abraham J,
- Kannampallil T,
- Patel VL
- Clancy CM,
- Tornberg DN
- King HB,
- Battles J,
- Baker DP,
- et al
- Gosdin CH,
- Vaughn L
- Dingley C,
- Daugherty K,
- Derieg M,
- Persing R
- Copyright © 2015 by the American Academy of Pediatrics