CONTEXT: Family-centered rounding (FCR) is of increasing importance in pediatric medicine. Although researchers have begun to understand the effect of FCR on providers and systematic health care outcomes, we provide a systematic review of the literature regarding families’ experiences with FCR.
OBJECTIVE: To systematically review patient and family experiences with pediatric FCR.
DATA SOURCES: Our data sources included PubMed, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Scopus, and Embase.
STUDY SELECTION: Inclusion criteria included publication in a peer-reviewed journal between January 2007 and February 2017, written in the English language, pediatric population (patients 0–21 years), and specific measurement of a families' experience with FCR.
DATA EXRACTION Data extracted were sample size, participating medical unit, measures of family experience, and overall results of family experience.
RESULTS: Twenty-eight studies were included. It is unclear whether participation in FCR increases family satisfaction compared with standard rounds; however, families report a strong desire to participate in FCR. Family benefits of FCR included increased understanding of information and confidence in the medical team, as well as reduced parental anxiety.
LIMITATIONS: There were only 2 studies in which researchers examined pediatric patients’ experiences with FCR, and literature on the communication needs of non–English-speaking families was also limited.
CONCLUSIONS: Overall, it is suggested that families positively perceive their experience with FCR, although more research is needed to determine if satisfaction is greater in FCR versus standard rounds as well as to better understand different perspectives of adolescent patients and non–English-speaking families.
- CINAHL —
- Cumulative Index to Nursing and Allied Health Literature
- FCR —
- family-centered rounding
- PSS:NICU —
- Parental Stressor Scale: NICU
Emphasis on the importance of family-centered rounding (FCR) in pediatric medicine has increased over the past several decades. FCR involves multidisciplinary rounds at bedside in which the patient and family are involved in creating the plan and evaluating the rounding process.1 This includes a model for introducing team members as well as teaching and practicing communication with families.2 Many pediatric institutions have adopted FCR as standard care, resulting in shortened stays, earlier discharges, reduced costs, and improved provider satisfaction.3–7 Researchers suggest that FCR improves the medical team’s understanding of the care plan, physician comfort with clinical dilemmas, and collaboration between team members.8–14 Notably, FCR research to date is heavily focused on hospital- and provider-centered metrics, with little emphasis on patient- and family-reported experiences.
In the available literature, positive familial experiences with FCR appear to be demonstrated15–19; however, a systematic review is warranted to better understand these experiences. In the current systematic review, we sought to answer the following questions: (1) What are families’ overall experiences with the current model of FCR? (2) How do families perceive FCR? and (3) What benefits or disadvantages do families see in FCR? In answering these questions, the literature was critically reviewed. Study strengths and weaknesses, potential biases, sample size, and time of data collection were carefully considered when interpreting results.
Following Cochrane guidelines,20 an initial PubMed search strategy was developed in collaboration with an informationist by using the following core concepts: teaching rounds and families. After selecting relevant titles from the initial results, the team identified additional controlled vocabulary and keywords to further refine the search. The informationist revised the PubMed search strategy and translated it across the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO), PsycInfo (EBSCO), Scopus (Elsevier), and Embase (Elsevier). A full description of the search strategy is provided in Table 1. As outlined in the protocol, gray literature was not included in this review, and when available, appropriate filters were applied to the searches to eliminate irrelevant articles. The informationist exported the final set of citations into an EndNote X7 library to organize citations and remove duplicates.
Inclusion criteria were as follows: being published in a peer-reviewed journal between January 2007 and February 2017, being written in the English language, having a study population including pediatric patients (0–21 years), and having measurement of a specific outcome of a family’s experience with FCR (eg, psychosocial outcomes, understanding of plan and/or medical information, relationship with medical team, involvement in decision-making, prevention of adverse outcomes, length of stay). Studies were excluded if there was no outcome measure associated with family experience or if there was an FCR intervention. One author (K.E.R.) reviewed titles and abstracts of all results, and 2 authors (K.E.R. and P.R.) independently examined the full text of remaining articles for study inclusion and data extraction. Data that were extracted included sample size, participating medical unit, measures of family experience, and overall results. Evaluation of bias included use of a comparator, random assignment, blind outcome assessment, explanation of response rate and attrition, use of established measurements, and sample size (see Table 2). Analysis of bias revealed that most researchers used an investigator-designed parent satisfaction survey or qualitative interview rather than an established measure owing to the lack of established measurements assessing family satisfaction in FCR. A comparison group was used in a little less than half (n = 13) of the studies. Parent reports alone were used in most studies (n = 22), although adolescent perspectives (n = 2) or direct observations of FCR (n = 5) were also used in a few studies. Explicit inclusionary and exclusionary criteria were used in the majority of studies to explain data attrition and their sample, and a sample size of >30 was included in most studies (n = 18). A risk of bias rating was assigned to each study on the basis of the number of items endorsed during the analysis of risk (see Table 2: low = 1–2; moderate = 3–4; high = 5–6), and this rating is included in the summary of results table (see Table 3).
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 460 studies were identified after removing duplicates (see Fig 1). The majority of excluded studies were not related to FCR, did not examine family experiences, or were not pediatric. The remaining 28 studies were reviewed, and data were extracted on the basis of our questions of interest. Highlighting the growing interest in FCR, 18 studies were published within the last 5 years. Researchers conducted studies to examine FCR in PICUs (n = 10), general inpatient units (n = 6), NICUs (n = 4), or other inpatient units (n = 5). Researchers also conducted studies to examine FCR within a pediatric hematology ICU (n = 1) and a medical and/or surgical ICU (n = 1). Most studies were conducted in the United States (n = 23), although studies were also completed in Canada (n = 3), Pakistan, (n = 1), and New Zealand (n = 1).
Overall Parent Experience
Parent Satisfaction and Desire to Participate
Results are summarized in Table 3. In 5 studies, researchers examined parent satisfaction without using a comparator and found that parental desire for and satisfaction regarding FCR was high. One study revealed that 90% of parents of children in the PICU wanted to be present during rounds.34 Consistent with the previous finding, in a sample of 98 families surveyed in the PICU, 97% expressed an interest in attending rounds and 98% enjoyed rounds.22 Eighty-nine percent of parents of infants in the NICU who attended FCR liked being present during rounds.18 Similarly, 81% of parents who participated in FCR stated that their involvement led to increased overall satisfaction with their child’s health care.26 Using semistructured interviewing, Latta et al31 found that all 18 parents who participated in rounds described their experience as positive. In summary, studies that were conducted to assess parent satisfaction and desire to participate in rounds without a comparator found that parents were highly satisfied with FCR.
FCR Versus Standard Rounds
In the 6 studies that were conducted to compare parental satisfaction with FCR versus a comparator standard rounding procedure (ie, rounding conducted outside the patients’ rooms and without families present), findings were mixed. In a study of 63 parents of infants in the NICU, 95.2% supported FCR compared with their experience with standard rounds with significantly higher satisfaction scores relating to knowledge and understanding.21 In a sample of 97 families admitted to general pediatric inpatient services, families who experienced FCR were significantly more likely to be satisfied with their care as compared with families who received standard rounding.17 Overall satisfaction of parents of infants in the NICU was not associated with FCR participation; however, satisfaction specifically regarding communication was significantly increased in parents attending FCR.10 A study with 27 parents who completed both FCR and standard rounds revealed that parents were significantly more satisfied during FCR as compared with standard rounds and highly preferred FCR.30 Other studies revealed no difference between FCR and standard rounding satisfaction. Among 82 parents of children in the PICU, no statistically significant difference was detected in overall parental satisfaction with their child’s health care before or after implementation of FCR.29 Similarly, there were no significant differences in satisfaction between FCR and standard rounding in a sample of 36 adolescent patients and parents in a general pediatric inpatient unit.8 Importantly, a standard rounds comparator was used in these studies, and findings are mixed in comparison with the previous studies in which satisfaction without a comparator was examined.
Families’ Perspectives on Continuing FCR
All 18 parents of children in an inpatient hematology-oncology unit said parental inclusion in rounds should continue.16 Similarly, a study of 100 parents of medical and/or surgical ICU patients revealed that parents who attended rounds were more likely to agree that families should be invited to rounds, whereas parents who did not attend rounds felt that it would sometimes be inappropriate for parents to participate.37 Parents who attended FCR stated that collaboration and respect promote continuation of FCR.39
Impact of FCR on Parent and Family Outcomes
Of the 6 studies conducted to examine parent knowledge in FCR, a comparator was used in only 2. In the studies with a comparator, parents in the NICU who participated in FCR had significantly higher self-reported knowledge and understanding compared with parents who did not.21 Likewise, parents reported bedside FCR was a greater source of information and opportunity to ask questions as compared with standard rounds.17 All parents who participated in FCR reported they were given the option to discuss the care plan, whereas only half of parents who experienced standard rounds reported discussing their child’s care plan.17 In 1 of the 4 studies conducted to examine parental knowledge without a comparator, 95% of family members of PICU patients believed they understood the care plan for their child.35 Similarly, 89% in a sample of 36 parents of children who participated in FCR in the PICU reported that engaging in rounds improved understanding of their child’s condition and treatment.26 In a study that was conducted to examine family-reported knowledge compared with actual knowledge, Subramony et al38 found that families who participated in FCR had an accurate understanding of the discharge treatment plan. The majority of parents who experienced FCR in a cardiac PICU felt their participation in rounds increased their understanding.25 In sum, parents who experience FCR report increased participation, resulting in greater understanding about their child’s condition and treatment plan, which is consistent across studies with and without a comparator.
Parent Involvement in Medical Decision-making and Care
Involvement in FCR provides parents the opportunity to influence medical decision-making and care. Parent involvement results are reported without a comparator group in the majority of studies, with results indicating that the majority of family members agreed attending rounds improved the care of their child.18,27 McPherson et al34 found 87% of parents believed their presence at rounds enhanced their ability to advocate and care for their child. In an observation of 22 parents and patients, input initiated by either parents or patients impacted the plan of care in 90% of FCR encounters.8 Other studies have revealed that the medical team often discovers new information from family members participating in FCR.22,26 By involving families in FCR, families and providers serve as resources to one another, as was found in a study in which 32% of observed FCR experiences in the PICU involved the medical team asking questions directly to the family and 28% involved family members asking questions to the medical team.35 Cameron et al26 found similar results, such that 31% of families who joined rounds asked the medical team at least 1 question, and the medical team asked questions to parents in 48% of rounding encounters. In an examination of FCR encounters, 38% contained at least 1 family-initiated dialogue regarding their child’s medication.7 In the only study conducted to examine parent involvement by using FCR groups versus standard rounding groups, parents experiencing FCR in the PICU reported significantly greater inclusion in discussion and decision-making.29 Overall, researchers examining family involvement in medical decision-making and care found that the majority of families report positive experiences, and in observational data, it is suggested that families volunteered or medical teams solicited information in many FCR encounters.
Impact of FCR on Parent Psychosocial Functioning
Of the 7 studies conducted to examine measures of family psychosocial functioning, a comparator was used in 5. Two of these studies revealed that measures of parent stress did not differ between parents in the NICU who participated in FCR and those who did not.10,21 Similarly, of 132 parents of infants in the NICU, parent stress decreased for parents participating in FCR; however, this was not statistically significant between parents engaging in FCR and parents who did not.28 In studies in which researchers used Likert-scale parent surveys regarding views of FCR, 84% of parents who attended rounds felt it eased their anxiety.18 This is compared with 19% of parents participating in PICU FCR who reported participation made them feel anxious and 11% who felt it was stressful.26 There were 2 studies of psychosocial functioning in which a comparator was not used for analysis. In 1 of these studies, 94% of parents of PICU patients did not find the discussion of their child upsetting.35 However, 23% of parents in the PICU expressed concern that they may not want to hear certain discussions during FCR.34 Overall, across studies with and without a comparator, it is suggested that FCR does not create significant additional stress for families.
Parent Relationships With Medical Teams
FCR allows families to interact with the medical team; thus, in many studies researchers sought to understand families’ perceptions of health care professionals. Across these studies, most researchers did not use a comparator group. In those without a comparison group, 92% of families in the PICU who engaged in FCR had confidence in the residents caring for their child, and 91% reported being present at rounds gave them more confidence in the medical team.22 Only 7% of parents in 1 study worried that attendance at rounds would undermine their confidence in the medical team.34 Attendance at rounds made parents feel included, and they did not feel intimidated by team size.15,16 Likewise, 88% of parents in the NICU felt attending rounds increased confidence in the medical team.18 In the 1 study in which a comparator was used, parents who experienced FCR reported feeling increased respect from the medical team.17 Overall, parents reported increased confidence in the health care team as a result of participation in FCR.
Pediatric Patients’ Experiences With FCR
Of the 28 identified studies, pediatric patients’ experiences were only examined in 2. Berkwitt and Grossman24 found adolescent’s preferences for FCR were varied, emphasizing the need to tailor FCR to the individual patient. Some patients felt a large team made them feel safe and cared for, whereas others felt a bigger team was anxiety-provoking and intrusive.24 Rosen et al8 surveyed patient and parent perspectives on FCR (n = 15) compared with standard rounding (n = 12) and found no differences in satisfaction between the 2 rounding experiences. However, the small sample sizes and mixed sample composition of both parents and patients may limit the generalizability of this study to all pediatric patients’ experiences.
Barriers to FCR
Awareness and Approachability of FCR
Although emphasis on FCR has increased over the last few decades, families still may not be aware of this practice. Parents of patients in the PICU on the first day of admission reported greater concerns and were less likely to understand the plan compared with parents who were further in their stay.22 These families may require additional care and attention during FCR. Additionally, when examining parents who did not attend rounds in the NICU, Grzyb et al18 found that 75% of parents indicated they did not know they could have attended rounds but would have if they knew. Of the parents who did not elect to participate in FCR, researchers sought to understand the barriers to their participation and found that feeling welcome to participate predicted parents’ attendance at rounds.37 Additionally, in qualitative interviews of 6 family members, themes emerged that suggested FCR is not meeting its original goals. Specifically, although FCR is designed to be informative for all, medical jargon often limits communication, and parent participation and collaboration with the medical team is not guaranteed.39 Importantly, parents endorsed barriers to understanding presented information. In focus groups of parents who experienced FCR, parents reported difficulty remembering and feeling overloaded, especially when health care professionals used medical jargon.23
Families With Limited English Proficiency
FCR is centered on communication; however, language barriers may arise. Among families with limited English proficiency, using an interpreter during rounds was associated with a decreased likelihood of correctly naming a diagnosis and less likelihood of understanding the medical plan after rounds compared with English-speaking families.33,41 English-speaking families were more likely to report knowing discharge goals and the discharge day as compared with Spanish-speaking families.38 Latino parents felt explanations in Spanish were essential for FCR40; however, some felt disempowered to request interpreter services.36,41 With this research, it is suggested that families with limited English proficiency require additional support in FCR to promote participation and collaboration.
Overall, parents who attended rounds reported high satisfaction with their experience,15,21,26 although studies conducted to compare satisfaction in FCR to standard rounds have mixed results, with no differences in family satisfaction between FCR and standard rounds indicated in some of these results.8,10,21 Despite these inconsistent results regarding family satisfaction, parents report a strong desire to participate in rounds.22,34 There were numerous reported benefits of family participation, including increased parental understanding of their child’s medical condition and care,21,26 greater information exchange between the medical team and the family,22,26 easing of parental anxiety,18 increased parental confidence in their child’s medical team,18,22 and heightened awareness of team member roles.15,22
Notably, of the 6 studies conducted to examine parent and patient satisfaction between FCR and a comparison group, findings were inconsistent. Some studies revealed no significant differences in parent satisfaction between those participating in FCR and those experiencing standard rounds, contradicting the extremely high satisfaction found in studies without a comparator. Findings within these 6 studies vary between study settings and samples. For example, parents in the PICU showed no statistically significant differences in parent satisfaction between FCR and standard rounds29; however, in a similar study of families admitted to general inpatient services, they were significantly more likely to report satisfaction with their care when receiving FCR versus standard rounding.17 Previous research has revealed that families in the PICU have greater stress than families in a general inpatient unit.42 Differing levels of parental stress and the severity of a patient’s condition may impact satisfaction with FCR because of more complicated medical information, greater fluctuation in their child’s health status, and the presence of more consulting services. Moreover, the study by Ladak et al29 was conducted in Pakistan, whereas the other studies we reviewed were conducted in the United States. Thus, cultural differences may also account for variable findings. In addition, sample composition varied across each of these studies. Rosen et al8 assessed both parents and adolescent patients in their study and found no significant differences in satisfaction when comparing FCR and standard rounding. Yet this was the only study in which researchers combined measures of parent and patient satisfaction, limiting the generalizability to either population. On the basis of these results, we believe it is unclear whether FCR has an impact on satisfaction compared with standard rounds. It will be essential for researchers of future studies to use the results of this review to determine the ways satisfaction may differ between samples and settings as well as further examine the effects of FCR versus standard rounds.
It is important to consider the quality of studies informing our understanding of satisfaction between FCR and standard rounding. In each study, a comparator was included as a reference but with unique methodology. Researchers evaluated periods of FCR compared with standard rounding,8,10,29 concurrent experiences on an FCR team versus a non-FCR team,17 or within-participant completions of both FCR and standard rounding.21,30 Despite inclusion of a comparator, the quality of these studies is variable. Researchers in four of the studies included thorough and explicit inclusion criteria (eg, expected length of stay, consistent medical team, and parent presence) and exclusion criteria (eg, developmental delay, readmission).8,17,29,30 However, Voos et al’s 10 inclusion criteria were only parent age (>18 years) and at least 1 week in NICU. On the basis of this review, it is recommended that future researchers use comparators and explicit inclusion and exclusion criteria more rigorously to compare FCR to standard rounding and determine if FCR has an impact on family satisfaction.
In multiple studies, researchers examined psychosocial functioning among families as an outcome of FCR with mixed results. Researchers in half of the studies assessed parent stress via the validated Parental Stressor Scale: NICU (PSS:NICU) measure. Studies in which researchers used the PSS:NICU revealed that stress did not differ between those who participated in FCR and those who did not.10,21,28 On the contrary, an investigator-developed parent survey revealed that the majority of parents who attended rounds in the NICU felt it eased their anxieties.18 It is possible that this contrast arises from differences in measurement, as the study-developed tool highlighted multiple aspects of parents’ experiences with FCR (eg, parent-perceived enjoyment, helpfulness, and preferences regarding FCR), not just perceived stress or anxiety. More research is needed to understand how FCR impacts parent psychosocial functioning. Specifically, the use of illness-specific measures and assessments of family functioning would help clarify the potential impact of FCR on psychosocial outcomes.
The modern implementation of FCR is not without flaws, and results from these studies reveal areas for improvement. It has been indicated in studies that the use of medical jargon negatively impacts families’ experiences with FCR, and providers should avoid its use.23,39 In addition, families may not be aware of their ability to be involved in FCR. Hospitals should take steps to make certain families understand the purpose and practice of FCR. For example, parents have benefited from being given a brochure along with a verbal explanation of FCR.25 Hospitals may also include a magnet outside of rooms used to indicate family and patient preference for participating in rounds, which has been successfully implemented in other hospital interventions.43
It is also important to better understand the role and preferences of pediatric patients. Previous research has revealed that adolescent patients are most dissatisfied with the lack of information provided to them and their lack of involvement in health care communication.44,45 In the current literature, there was a surprising dearth of research concerning pediatric patients and their experiences with FCR. Researchers in only 2 studies involved adolescent patients, and researchers in only 1 study solicited specific comments from adolescent patients exclusively. With respect to FCR, adolescent patients reported a wide variety of preferences for their care.24 Some preferred a high degree of involvement in FCR, whereas others preferred that all communication occur outside their room. Implementing tools designed to assess communication preferences of pediatric patients, such as the My CHATT tool, are essential for meeting the needs of pediatric patients.45 Future researchers should examine the efficacy of implementing patient-centered communication and rounding preferences tools.
In the results of this literature review, we also highlighted families with limited English proficiency as a population requiring special attention. These families may receive medical information through an interpreter, which can result in decreased understanding of their child’s care.33,38 Latino families reported more positive experiences when a Spanish-speaking provider was present and explanations were given in Spanish; however, these were not always available, and families did not feel empowered to ask for interpretation services.36,40 Hospital systems should work to standardize identification of families with limited English proficiency on admission.41 Improving communication between families and health care providers can only be achieved if the language barrier is minimized.
The importance of understanding families’ and patients’ perspectives of FCR is crucial for providing quality care. The strengths of the literature, including the variety of outcomes measured and use of objective FCR observations, must be considered in light of the weaknesses. There is not a standardized measure for assessing FCR outcomes. As a result, many researchers created their own surveys or conducted focus groups or interviews, making it difficult to compare results across studies. In addition, <50 participants were included in nearly half of the reviewed studies. Small samples limit power for detecting statistical differences. The settings of these studies were also highly variable, spanning multiple units and medical populations. This limits the generalizability of findings. Given the nature of FCR, it is unclear who was conducting rounds. Some training hospitals may have rounds conducted by trainees, whereas others include attending physicians whose years of practice, provider specialty training, and personal styles may influence rounding episodes. Finally, researchers in less than half (n = 13) of the included studies used a comparator group to examine the effects of FCR compared with standard rounding.
It is important to note limitations of this review. It is possible that relevant studies were not identified through our comprehensive search methodology despite using variations of terminology across multiple databases. In addition, our specific inclusion criteria may have limited the use of studies in which family outcomes regarding FCR were not specifically measured. Finally, the inherent publication bias toward studies in which significant results were achieved may limit generalizability of findings to actual practice.
This systematic review has critical implications for hospitals and health care professionals. To better serve pediatric patients and families, we must understand the experience of families in our care. Overall, families report high satisfaction with FCR, although it is unclear whether this is greater than standard rounds. Families report a desire to participate in FCR, citing many benefits to their involvement, including increased knowledge, involvement in medical decision-making, and increased confidence in the medical team. Authors of future studies should expand on the results of this review and address limitations of this research. An important focus should be determining whether satisfaction is improved during FCR as compared with standard rounds. Additionally, studies of pediatric patients’ experiences and communication with families with limited English proficiency will be vital to improve implementation of FCR.
- Accepted December 12, 2017.
- Address correspondence to Melissa K. Cousino, PhD, Department of Pediatrics, Michigan Medicine, 1500 E Medical Center Dr, Ann Arbor, MI 48109. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Funded by a University of Michigan Clinical Simulation Center research grant.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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