Discussion
We have demonstrated that the majority of parents surveyed had attended at least one ward round and had generally found it a positive experience. We feel our results are representative as only one of the consecutive parents who was approached declined to take part. A strength of our study was that the researcher was able to conduct in-depth interviews resulting in a wealth of responses. A survey of parents in a tertiary neonatal unit in Liverpool carried out in 20054 found that parents had mixed views on attending the ward rounds and the authors concluded parental communication with the clinical team was probably best conducted outside of the ward round itself. A more recent study5 allocated parents to attendance or non-attendance of ward rounds, followed by a cross over to the other arm of the trial after a washout period. Ninety-five per cent of parents who completed the trial believed that parents should be allowed to attend ward rounds. This corresponds to the results of our study with 18 (90%) of parents attending at least one ward round.
There might, however, be negative effects on parents due to the perceived stress of attending ward round. In one study, ‘stress’ was compared in parents of babies who had attended ward rounds to those who had not. Importantly, there was no significant difference in scores using the Parent Stressor Scale between the two groups.6 In a paediatric intensive care unit (PICU) setting,7 it was found that race, educational level, age of the family member, age of the child, whether the admission was expected and whether the family member was a medical professional had no association with whether the family member attended rounds. The only factor associated with a higher likelihood of attending rounds was a family’s stated preference for doing so (OR 3.4). We have identified multiple reasons why parents may not be able to attend and these need to be taken into account in any outcome measure.
In a paediatric inpatient unit, interviewing 18 sets of parents after their participation in ward rounds8 revealed their overall experience was positive. The important outcomes to parents included being able to communicate with the team, understanding the plan of care and participation in decision-making.8 A unit where parents were excluded from the ward rounds surveyed the strengths and weaknesses in parent–staff communication over the course of a year.9 They found parents were generally satisfied with the communication they had with both nurses and doctors. Some parents, however, commented that if their child was not very unwell, they did not talk to the doctors as much as they would have liked. They recognised the time pressure the medical team were under, but wanted acknowledgement that the admission of any baby to a neonatal unit, no matter how ‘well’, is extremely stressful for the family. In our study, we highlight parents found the nurses looking after their baby an important source of information.
Although we found that the majority of parents would like to attend the ward rounds, it cannot be assumed that all healthcare professionals (HCPs) want to be involved in family-centred rounds (FCRs). Stickney et al
10 investigated the differences between HCPs and parents regarding experiences and attitudes towards participation in morning rounds. A cross-sectional study was undertaken of 100 parents and 131 HCPs in a tertiary PICU setting. Similar to other studies, 92% of parents expressed a desire to attend the rounds, but only 54% of HCPs reported a preference for parental presence on ward rounds.10 Furthermore, only 30% of HCPs perceived that parents would understand the format, 73% of parents reported that they did. HCPs in a survey of HCPs in French neonatal units11 expressed concerns about parents attending ward rounds; they were worried about longer duration of ward rounds, fewer opportunities for teaching and increased stress for parents and HCPs. The more experienced respondents, however, were much less likely to consider these concerns a barrier to implementing parental presence on ward rounds. A study in a tertiary neonatal unit in Canada,12 however, found that nurses were more likely than medical trainees to support parental presence at rounds. Trainees had concerns regarding a decreased level of teaching when parents were present. In a PICU setting, trainees also reported feeling less comfortable being questioned at the bedside compared with in a conference room.13 Parents, however, rated the trainees taking part in the bedside case presentations as more competent than when the trainees presented separately in the conference room. Possible advantages for doctors in training expressed were the increased opportunities to observe senior doctors communicating with patients and families and also to have their own skills evaluated. Osorio et al
14 found FCRs provided an enhanced environment for the assessment of communication skills by seniors and also an opportunity for feedback from members of the multidisciplinary team. Prior to the introduction of FCR in their neonatal unit, Voos et al
15 surveyed parents and HCPs and repeated the surveys 6 months after the introduction of FCR. Parents’ satisfaction scores increased significantly (p<0.01) regarding communication, meeting with physicians and obtaining information about their infants. The main members of staff communicating with parents on their unit were neonatal nurse practitioners and fellows and they reported increased collaboration and satisfaction with care decisions.15 FCRs were introduced in one acute care unit in Cinncinati Children’s Hospital, but spread throughout the departments as teams saw the benefits conferred.16 The initial concerns of longer duration of ward rounds and less teaching were addressed. Efficient use of the ward round time counterbalanced the longer duration by having less paperwork and parental updates to do after the ward round was finished. Teaching style was adapted and the advantage of learning bedside communication skills was felt to be beneficial.
In conclusion, our study demonstrates that parents recognise the importance of the ward round within the context of receiving information about their baby. The majority of parents would like the opportunity to attend, but there are important limitations to their attending including travel time and other siblings. Furthermore, it is important that there is appropriate communication with parents regarding attendance at ward rounds. These need to be factored in when developing any criteria for standard of care.