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Journal for Specialists in Pediatric Nursing
ORIGINAL ARTICLE
Evaluating the feasibility of a parent-briefing intervention in a pediatric acute care setting Karen LeGrow, Ellen Hodnett, Robyn Stremler, and Eyal Cohen Karen LeGrow, RN, PhD, is Assistant Professor, Daphne Cockwell School of Nursing, Ryerson University; Ellen Hodnett, RN, PhD, is Professor; Robyn Stremler, RN, PhD, is Assistant Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto; Eyal Cohen, MD, MSc, FRCP(C), is Pediatrician & Director, Complex Care Service, The Hospital for Sick Children, and Associate Professor, Paediatrics, University of Toronto, Toronto, Ontario, Canada
Search terms Acute hospital care, children with complex healthcare needs, phase I study. Author contact [email protected], with a copy to the Editor: [email protected] Acknowledgement This research was funded by the Canadian Institutes of Health Research (CIHR) Allied Health Fellowship Award Research Fund. Conflicts of interest: The authors report no actual or potential conflicts of interest. First Received August 14, 2013; Final revision received January 29, 2014; Accepted for publication January 29, 2014.
Abstract Purpose. The purpose of this study was to test the feasibility of a parentbriefing intervention for parents of hospitalized children with complex healthcare needs. Design and Methods. A phase I, single-group, posttest study. There were 18 physicians, 25 nurses, and 31 parents who participated in the study. Participants were asked to sit while carrying out the briefings with parents. Parents and clinicians completed a feasibility questionnaire post briefings. Results. Sixty-eight briefings were carried out. Parents and nurses evaluated the briefings in a favorable manner, whereas physicians’ ratings were mixed. Practice Implications. Further inquiry is recommended to understand the effects of a structured communication intervention on parent– professional decision-making practices.
doi: 10.1111/jspn.12073
Recent advances in medical knowledge and improved technologies have resulted in longer life expectancies for many children with serious congenital or acquired complex chronic conditions. Consequently, the prevalence of children with complex chronic conditions who require frequent and lengthy hospitalizations is increasing (Burke & Alverson, 2010; Burns et al., 2010; Cohen et al., 2011; Goldson, Louch, Washington, & Scheu, 2006; Gordon et al., 2007; Newacheck & Halfon, 1998; Sieben-Hein & Steinmiller, 2005; van der Lee, Mokkink, Grootenhuis, Heymans, & Offringa, 2007). However, despite many North American hospitals’ adoptions of the tenets of familycentered care (FCC), the admission of these children to hospital is a highly emotional and stressful time for parents (Burke, Costello, & Handley-Derry, 1989; Burke, Kauffmann, Costello, & Dillon, 1991; Harrison, 2010; Kenney, Denboba, Journal for Specialists in Pediatric Nursing 19 (2014) 219–228 © 2014, Wiley Periodicals, Inc.
Strickland, & Newacheck, 2011; Knox & Hayes, 1983; Lotze, Bellin, & Oswald, 2010; Sieben-Hein & Steinmiller, 2005). Parents have consistently reported that relinquishing important aspects of their roles was the most stressful aspect of their children’s hospitalization (Brown & Ritchie, 1990; Callery & Smith, 1991; Carnevale, 1990; Curley & Wallace, 1992; Dudley & Carr, 2004; Goldfarb et al., 2010; Knox & Hayes, 1983; Macdonald, Liben, Carnevale, & Cohen, 2012; Ratcliffe, Harrigan, Haley, Tse, & Olson, 2002). Other stressors parents experienced during their children’s hospitalizations included receiving limited information regarding their children’s medical status and having little or no opportunity to participate in decisions regarding their care (Balling & McCubbin, 2001; Brown & Ritchie, 1990; Burke et al., 1991; Carnevale, 1990; Carnevale et al., 2007; Kerr, 2002; King, King, & Rosenbaum, 1996; Miceli & Clark, 219
Evaluating the Feasibility of a Parent-Briefing Intervention in a Pediatric Acute Care Setting
2005; Robinson, 1987; Starke & Moller, 2002; Stewart, Ritchie, McGrath, Thompson, & Bruce, 1994; Thorne & Robinson, 1988). As a result, communication problems and interpersonal conflict between parents and members of the healthcare team were the dominant themes that emerged from parents’ reports of their hospital experiences (Bain, Rosenbaum, & King, 1995; Brown & Ritchie, 1990; Burke et al., 1989, 1991; Callery & Smith, 1991; Coffey, 2006; Dodgson, Garwick, Blozis, & Patterson, 2000; Mello et al., 2004; Sieben-Hein & Steinmiller, 2005; Studdert, Burns, et al., 2003; Studdert, Mello, et al., 2003; Thorne & Robinson, 1989). Given the prevalence of parents’ dissatisfaction with communication and decision-making processes during their children’s acute care hospitalizations, despite the philosophy of FCC that was supposed to guide practice, we chose an alternative perspective to design an intervention intended to address these issues. Bourdieu’s, The Logic of Practice (Bourdieu, 1990, 1991; Swartz, 1997), provided the conceptual orientation for the intervention and the phase I study that followed. He posited that individuals’ predispositions for certain behaviors, beliefs, and attitudes are a result of the resources available to them in the social environments or fields in which they live and interact (Swartz, 1997). In an earlier article, we reported how Bourdieu’s key concepts—habitus, capital, and field—were used to frame the development of a briefing intervention for parents of children with complex healthcare needs who were hospitalized in a pediatric acute care setting (LeGrow, Hodnett, Stremler, McKeever, & Cohen, in press). The parent briefing was a process that structured time for the physician and nurse, together with the parents, to participate in important communication practices regarding the child’s health status and care needs. This article is a report of a phase I study of the intervention. STUDY OBJECTIVES
The aim of this study was to evaluate the feasibility and acceptability of the parent-briefing intervention from the points of view of the clinicians carrying out the briefings and the parents participating in them, specifically by determining (a) the percentage of eligible physicians, nurses, and parents who agreed to participate, (b) clinicians’ and parents’ compliance with the parent-briefing protocol, and (c) clinicians’ and parents’ evaluations of the parent briefings. 220
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METHOD Design
A phase I, single-group, posttest study of a parentbriefing intervention was conducted in a universityaffiliated pediatric hospital in a large metropolitan Canadian city over a 9-month period in 2010. Rationale for the study design is provided by the Medical Research Council (MRC) Framework for Development and Evaluations of randomized controlled trials (RCTs) for Complex Interventions to Improve Health. This framework provides a sequential series of phases of investigation in the evaluation of complex intervention (Campbell et al., 2000) Participants
Eligibility criteria for parents. Parents were eligible to participate in the intervention if their children (new-born to 18 years of age) had a nonelective admission to a large teaching metropolitan pediatric tertiary care center. Their children’s healthcare needs had to meet the following criteria: (a) health problem that affected at least two organ systems, (b) at least two medical subspecialists were involved in the children’s care, (c) at least two allied health professionals were involved in the children’s care, (d) the children had at least two of the following: chronic prescription medication(s), special diet requirement, or medical technology dependence, and (e) the children had at least two or more hospitalizations or 10 or more clinic visits in the prior year (Cohen, Friedman, Nicholas, Adams, & Rosenbaum, 2008; Gordon et al., 2007). The parent also had to be able to speak and read English, had to have been the primary parent who spent time with his or her child in the hospital, and had to be available to participate in the patient bedside rounds. Parents were excluded from participating in the intervention if their children were expected to be discharged from hospital within the next 48–72 hr, as assessed by the attending staff physician, or if their children were able to be involved in discussions about their care. The parent-briefing intervention was not designed to meet the complex and unique needs of including adolescents in decisions related to their health care. Eligibility criteria for nurses and physicians. Nurses with a minimum of 1 year of pediatric experience and physicians working within the pediatric medicine service were eligible for the study. Journal for Specialists in Pediatric Nursing 19 (2014) 219–228 © 2014, Wiley Periodicals, Inc.
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Recruitment of parents
Following research ethics board approval, all children admitted to the unit and their parents were assessed daily for their eligibility by the principal investigator (PI), the clinical nurse manager, and members of the Complex Care Service team. Parents who indicated their interest were contacted by the PI, who reviewed the study in detail and obtained a signed consent form. Recruitment and training of clinicians
Nurses who were interested in participating attended one of many information sessions that provided a brief description of the study, the parent-briefing intervention, and expectations of nurse participants. Nurses who agreed to participate then attended a more detailed 4-hr education session, outside of their regularly scheduled shifts, to learn more about the study and how to carry out the parent-briefing intervention. A signed consent was obtained at that time. The educational sessions took place at the hospital during days when the nurses were not scheduled to work. Each nurse was given an educational folder that contained an outline for the session along with important information necessary for their involvement in the study. The study nurse training sessions involved the following information: (a) an overview of the study, (b) a summary of the evidence related to physician/ nurse–parent communication and the decisionmaking process, (c) a detailed description of the “parent-briefing” process, (d) the process for engaging parents, and (e) clinical application of the parent briefing in a practice setting. The training session involved didactic presentations, case studies, and small group discussions. In addition, each study nurse completed a modified objective structured clinical evaluation (OSCE) to demonstrate competency in the study intervention prior to the start of data collection. The OSCE process provided study nurses the time needed to acquire the necessary skills to carry out the “parentbriefing” process prior to the start of the study. All nurses demonstrated competence after completing the initial OSCE; therefore, a second OSCE was not required. Two focused sessions were conducted with physicians during regularly scheduled department meetings. The sessions were 45 min in length and involved: (a) an overview of the study, (b) a Journal for Specialists in Pediatric Nursing 19 (2014) 219–228 © 2014, Wiley Periodicals, Inc.
detailed description of the study intervention, and (c) an outline of what physicians were asked to do that was different from their present practice, (e.g., having both a parent and a nurse present during rounds discussion, following a brief template to guide briefing, and sitting down to conduct the parent briefing). The PI also met the attending physicians individually prior to their on-call duties to review the intervention, and obtain a signed consent.
Study intervention. The parent-briefing intervention was a communication process designed to provide clinicians with a template from which to guide a brief structured review for parents about their children’s health status and care needs. Drawing upon the guiding conceptual orientation for the study (Bourdieu, 1990, 1991), the goal of the parent-briefing intervention was to provide an opportunity for parents to attain medical and technological knowledge (cultural capital) and learn a linguistic style, (symbolic capital) through communication practices with physicians and nurses, that had the potential to enhance their social positioning within the inpatient unit (field) and enable them to gain an active role in decision-making practices (habitus) that related to their children’s care. The briefing included the following components to enhance parents’ cultural and symbolic capital: (a) a medical and nursing update regarding the child’s health status (i.e., medical and technological knowledge), (b) a review of the goals and plan of care for the next 12–24 hr (i.e., medical and technological knowledge), (c) a discussion about medical terminology, jargon, short forms, and acronyms used by physicians and nurses (i.e., linguistic style), and (d) an opportunity to listen to and answer/address parents’ questions and concerns (i.e., linguistic style). The participating physician/fellow/resident, the assigned study nurse, and the child’s parent participated in the parent briefing at the child’s bedside on the inpatient unit during the bedside rounds process. The physician, nurse, and parent were asked to sit to conduct the briefing, using chairs placed in the child’s room on enrollment in the study. The arrangement of the chairs for the briefings was at the discretion of the briefing participants. The intervention period began on Day 2 of the child’s admission. Each study family was to participate in a minimum of three briefings in the first week of the child’s admission. 221
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Data collection
The PI carried out all data collection for the study, which included (a) recording the number of physicians, nurses, and parents who participated in the study out of the total eligible, (b) monitoring participants’ compliance with the intervention protocol on a daily basis, using data entered on the parentbriefing checklist, and (c) collecting outcome data from parents and clinicians at various points in time. Parent-briefing checklist. The data were selfreported; briefings were not directly observed. Study nurses, who carried out the briefings in collaboration with the physicians, were required to complete a parent-briefing checklist for each briefing in which they participated during the data collection period. The checklist captured individuals present, the amount of time it took to conduct the briefing, whether chairs were used, and the key content areas discussed during the briefing. Feasibility questionnaire. Participating staff physicians, nurses, and parents were asked to complete a Parent-Briefing Feasibility Questionnaire designed to explore their perceptions of (a) the timing and duration of the intervention, (b) the clinical usefulness of the parent briefing to enhance communication and decision-making practices between physicians, nurses, and parents, and (c) their preferences for the future use of the briefing in clinical practice. Parents completed the questionnaire 1 day prior to transfer and/or discharge from the hospital, while physicians and nurses completed the questionnaire on 2 weeks postdata collection period. The questionnaire content was developed by clinical experts in relation to key themes identified in the literature relating to parents’ dissatisfaction with communication and decision-making practices for hospitalized children with complex healthcare needs and in relation to the goal of the parentbriefing intervention. Limitations
The feasibility questionnaire was specifically designed for this study and as such, the lack of reliability and validity data for this tool is a limitation of the study.
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tionnaire served as an initial organizing framework where data were grouped according to each question. Participants’ written responses were analyzed for units of meaning, that is, words, phrases, and sentences that described physicians’, nurses’, and parents’ experiences. Data considered representative of similar patterns and themes were arranged into categories, which then were identified to guide the coding of qualitative data (Sandelowski, 1995, 1996). RESULTS Descriptive statistics
Characteristics of the parents. The mean age for mothers was 37.4 years (SD = 6.9, Median [Mdn] = 36.0), ranging from 27 years to 47 years. Fathers’ mean age was 40.0 years (SD = 7.7, Mdn = 39.0), ranging from 27 years to 52 years. Educational levels tended to be high; 78.3% (n = 18/27) of mothers and 66.6% (n = 16/27) of fathers had a university or college degree. The majority of parents were married or living in a common law arrangement (92.5%, 25/27). Most parents had other children (85.2%, 23/27) in addition to the child admitted to hospital. Characteristics of the children. The mean age of the children enrolled was 5.1 years (SD = 5.6, Mdn = 2.3, interquartile range = 0.4, 8.3), with a minimum age of a few days to a maximum of 17 years. For the majority of children, it was not their first admission to hospital (54.8%), with length of stay ranging from 2 to 86 days. Characteristics of nurses. Twenty-nine nurses completed the education sessions and successfully completed the OSCE. Four nurses dropped out of the study for the following reasons: (a) one nurse resigned from the hospital, (b) one nurse took a leave of absence for 6 months, and (c) two nurses transferred to other units/programs within the hospital. Twenty-five nurses participated in the study. Twenty-two out of 29 nurses (75.9%) had completed their Bachelor of Nursing degree; 26 out of 29 nurses (89.7%) had less than or equal to 10 years of experience; of the latter, 12 had 1–3 years of experience.
Data analysis
Percentage of eligible physicians, nurses, and parents who agreed to participate
Data were analyzed using descriptive statistics such as frequencies and percentages. Items in the ques-
All of the 18 eligible physicians and 29 out of the 76 eligible nurses (38.1%) participated in the study.
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Reasons nurses stated for not participating included not being able to participate in the educational session and OSCE activity, working part-time, anticipating an extended leave (such as maternity leave), or generally not interested. Four nurses, however, dropped out of the study because of being transferred to another unit within the hospital (n = 3) and taking an extended leave (n = 1). Therefore, a total of 25 nurses participated in all aspects of the study. Thirty-one parents (62% of those eligible) consented to participate in the study. Eight out of the 19 eligible parents who did not participate stated that they were unable to be present during the rounds process to participate in the briefings. Reasons the other 11 eligible parents gave for not participating included the child being quite anxious during the admission, feeling that they already had a very good understanding of what was happening to their children, and feeling that they were already involved in a number of research studies at the hospital. Compliance of parents and clinicians with the parent-briefing protocol
Ninety-three briefings were expected to be carried out per study protocol, that is, a minimum of three briefings for each parent enrolled in the study. Sixty-eight of the expected briefings (73.1%) were conducted. Thirty-one parents participated in a minimum of one briefing to a maximum of five briefings during their children’s hospitalizations over a minimum length of stay of 4 days to a maximum of 88 days. Twelve of 31 parents (38.7%) participated in three or more briefings. Sixty-six out of 68 briefings (97.1%) were attended by a resident and/or fellow and 24 out of 68 briefings (35.3%) were attended by the attending physician most responsible for the child’s care. Chairs provided for the intervention were used in 47 out of 68 briefings (69.1%) and at least once for 27 of the 31(87%) parents. Key elements of the briefings’ content were carried out for all 68 briefings. Twenty-five of the expected 93 (26.9%) parent briefings were not completed per study protocol for various reasons. Table 1 provides a detailed description of compliance with the parent-briefing intervention. Parents’ and clinicians’ evaluations of the intervention
Twenty-seven of the 31 parents completed the parent-briefing feasibility questionnaire. Two Journal for Specialists in Pediatric Nursing 19 (2014) 219–228 © 2014, Wiley Periodicals, Inc.
Table 1. Compliance with the Parent-Briefing Intervention Parent briefings not completed Reasons Organizational barriers Study nurse not working Patient was transferred or discharged Study nurse not assigned Unit too busy Communication barriers Physician was not available Physician did not page the nurse Parent was not available n
Number of briefings (%) 7 (28.0) 5 (20.0) 4 (16.0) 2 (8.0) 5 (20.0) 1 (4.0) 1 (4.0) 25 (26.9)
Parent briefings completed Parent briefing items Attendance Attending physician Resident/fellow Nurse Parent Sitting Key content Medical/nursing update Review plan of care Review medical jargon Parent’s questions Parent’s concerns Parents requested additional meetings Parents made a formal compliant n
Number of briefings (%) 24 (35.3) 66 (96.7) 68 (100.0) 68 (100.0) 47 (69.1) 68 (100.0) 68 (100.0) 68 (100.0) 38 (55.9) 29 (42.7) 5 (7.4) 0 (0.0) 68 (73.1)
parents changed their minds about completing the questionnaire at point of follow-up and did not provide further explanation for their decisions. In addition, two other children were discharged from the hospital unexpectedly; therefore, their parents did not receive the questionnaire to complete. The fact that 4 out of 31 parents did not complete the questionnaire is worth noting for future study. Anecdotal comments parents provided about their participation in the briefings were of a positive nature and included feeling that their input was important, that being present during the team discussions was helpful, that they were able to ask questions and state their concerns, and that they would have tests and procedures explained to them. No negative comments were recorded or provided. A summary of parents’ evaluations of the parentbriefing intervention is provided in Table 2. All 25 nurses who participated in the whole study completed the feasibility questionnaire. Similar to parents, nurses also rated all aspects of the parent 223
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Table 2. Parents’ Evaluations of the Parent-Briefing Intervention
Number of parents’ responses on a Likert scale (%)a Survey questions
5
4
3
2
1
Easy to participate in Helpful Recommend to parents Recommend its future use
21 (77.8) 19 (70.4) 16 (59.3) 19 (70.4)
4 (14.8) 3 (11.1) 7 (25.9) 4 (14.8)
2 (7.4) 3 (11.1) 3 (11.1) 3 (11.1)
0 (0.0) 1 (3.7) 0 (0.0) 0 (0.0)
0 (0.0) 1 (3.7) 1 (3.7) 1 (3.7)
Note: aA total of 27 parents completed the feasibility questionnaire.
briefing in a favorable manner; however, some challenges were identified. These included the challenges that they faced trying to attend to patient care while also being available to participate in the briefings (n = 7). In addition, they reported that they had to follow up with the physician/resident on more than one occasion to ensure the briefing was completed as per protocol (n = 5). Out of 18 participating physicians, 13 filled out the feasibility questionnaire. Out of those 13, only 8 completed questions related to their participation in the briefing. Contrary to parents’ and nurses’ positive responses, physicians’ ratings were mixed (see Tables 2 and 3).Only about one half of the physicians rated the following items favorably: the parent briefing was easy to carry out (n = 8), it enhanced parent– physician/nurse communication (n = 6), and they would recommend that briefings become part of usual clinical practice (n = 4). Anecdotal comments from physicians were brief; however, they are worth noting in light of the mentioned results. A minority of physicians stated that (a) having the registered nurse present during rounds was helpful and contributed to the nurses’ enhanced role in facilitating effective parent–team communication (n = 2), (b) the act of sitting down for the discussion changed the atmosphere of the interaction (n = 2), and (c) the briefing did not change their usual style of interacting with parents (n = 2). A detailed summary of nurses’ and physicians’ evaluations of the parentbriefing intervention is provided in Table 3.
DISCUSSION
We conducted a Bourdieusian interpretation of the study results to explore (a) the positioning of physicians, nurses, and parents within the inpatient unit, (b) compliance with the intervention, and (c) the linguistic practices of parents in a pediatric acute care setting. Positioning of physicians, nurses, and parents within the inpatient unit
Physicians’, nurses’, and parents’ engagement in the parent briefings and their evaluations of the intervention could be viewed as reflecting the disparity between their respective positions within the inpatient unit. Physicians. Physicians were included in the study as an acknowledgment of their position on the interprofessional team within the inpatient unit (Hawryluck, Espin, Garwood, Evans, & Lingard, 2002; Lingard, Espin, Evans, & Hawryluck, 2004). All eligible physicians agreed to participate in the intervention; however, they delegated the briefing to a junior staff member 63.2% (n = 43/68) of the time. Also, only 13 out of the 18 participants completed the feasibility questionnaire. This behavior may have many explanations, depending on the view of capital that the physician held. One possibility is that those physicians who consented to
Table 3. Nurses’ and Physicians’ Evaluations of the Parent-Briefing Intervention Number of nurses’ responses on a Likert scalea
Number of physicians’ responses on a Likert scaleb
Survey question
5
4
3
2
1
5
4
3
2
1
Easy to carry out Enhanced communication Helpful to my practice Time it took was reasonable Recommend its use in the future
9 15 6 11 9
14 10 16 11 14
1 0 3 3 2
1 0 0 0 0
0 0 0 0 0
4 1 1 1 2
4 5 2 2 2
0 0 3 5 3
0 1 2 0 1
0 1 0 0 0
Note: an = 25; bn = 8.
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participate in the study, but did not carry out the briefings, did not perceive them to be a direct threat to their position in the inpatient unit and, therefore, delegated the briefings to junior staff to complete. Another, not necessarily conflicting possibility, is that those physicians did not view the briefings as capital or as a valuable practice that would add to their position in the inpatient unit and, therefore, did not feel the need to personally conduct the briefing. An equally plausible explanation is that the briefing was perceived as a threat to those physicians; therefore, delegation to a junior staff member prevented loss of capital. Nurses. Nurses occupy a lower position in the inpatient unit relative to physicians, based upon the amount and type of capital that they have obtained through education and training experiences. Those with more pediatric experience will have had more opportunities to acquire capital and engage in linguistic practices with physicians to secure their higher positions in the nursing hierarchy. Nurses may have used the briefings as an opportunity to demonstrate their medical and technological knowledge to the physicians and the parents simultaneously, thereby enhancing their positioning with both the physicians and the parents. This perspective may explain some of the nurses’ favorable responses in their evaluation of the parent briefings. Parents. A majority of the parents (n = 27/31, 87%) who participated completed the questionnaire, which may indicate their interest in and support for the briefings. Their participation could be viewed as an attempt to gain important medical and technological knowledge from the physicians and nurses caring for their children so that they could become active participants in decisions related to their children’s care. This perspective could explain their favorable responses. However, of the 19 eligible parents who did not agree to participate, 8 could not attend the briefings as scheduled. It is not clear whether the remaining 11 parents wished to acquire the medical and technological knowledge being shared during the briefings. It may be that they were already knowledgeable about their children’s chronic conditions and did not perceive that the intervention would provide them with any new knowledge to facilitate their involvement in decisions related to their children’s care. Another plausible explanation could be that they preferred that the physicians make all medical decisions related to Journal for Specialists in Pediatric Nursing 19 (2014) 219–228 © 2014, Wiley Periodicals, Inc.
their children’s care; therefore, they did not perceive that the briefings would be helpful to them. Compliance with the parent-briefing intervention
For the 68 briefings that were conducted, a majority of the time, the physician participating in the briefing was a resident or fellow. Having such clinicians involved in the parent-briefing process could be seen as a natural extension of their education and training in an academic health sciences center. Physicians may have viewed expert knowledge and decision-making as capital rather than the act of sharing information with parents through communication practices. On all but one occasion, a parent was present for the planned briefing. Parents’ commitment to be in the hospital during the time of the briefing probably highlights the value they placed on receiving up-to-date information from members of the healthcare team. This behavior could be viewed as an attempt to gain important medical and technological knowledge to enhance their positions with physicians and nurses (Lahire, 2003; Marcoulatos, 2001; Swartz, 1997). The act of sitting down to engage in the briefing process was an integral component of the intervention (LeGrow et al., in press). Although physicians and nurses indicated their support for using the chairs, the fact that the chairs were not used by clinicians in 21 of the 68 briefings is noteworthy and necessitates further critical reflection. Physicians and nurses have been socialized into acquiring certain practices that have shaped their interactions with parents. Typically, healthcare providers stand while engaging in daily discussions with parents, possibly because this signifies the briefness of the encounter to the parent and allows the physician/ nurse to easily take leave of the conversation in an efficient manner. Therefore, the act of sitting to engage in the parent briefing would have required them to change those habitual ways. This may have been more difficult for some to do than they had originally anticipated and may have required more sustained interactions with parents over a longer period of time than the study protocol allowed. Although anecdotal comments from physicians who used the chairs during the parent briefings indicated that the physical act of sitting changed the dynamics of the interaction, further research is required to examine the manner and style of healthcare provider–parent communication practices and to determine if the sustained use of chairs can bring about change in clinicians’ practices. 225
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Linguistic practices: cultural and symbolic capital
The parent briefings were designed to incorporate Bourdieu’s concepts of cultural and symbolic capital (LeGrow et al., in press). Based on parentbriefing checklist data, physicians and nurses were 100% compliant with the content of the briefing; that is, they shared medical and nursing knowledge and reviewed the plan of care. Twenty-two parents asked questions during 38 briefings. This behavior may be viewed as parents taking advantage of an opportunity to engage in linguistic practices with physicians and nurses to receive important information and have their question(s) answered. Nine parents did not ask questions. They may have had no questions or the briefing may not have helped them feel comfortable in stating their questions at that specific time with the team members present. IMPLICATIONS FOR FUTURE RESEARCH
This study is the first of its kind to include parents in a briefing intervention in an acute care setting; however, observation of clinician–parent interactions was not possible during this study. Therefore, before a future phase II study can be conducted, a qualitative study is needed to further to examine the manner and style of healthcare provider– parent communication and decision-making practices, including additional research with the use of chairs. Future qualitative study could involve video-taping parent briefings and interviewing each participant post-briefing using Bourdieu’s key concepts, specifically—habitus, capital, and fields— as the framework for analysis of the interactions. This could provide insightful information about clinician and parent behaviors during communication and decision-making practices that could lead to refinement of the intervention for a possible future pilot RCT. Future quantitative research should address the issue of physician and resident engagement in the parent-briefing intervention. A systematic approach to engaging physicians and junior staff such as residents would need to be conducted as part of the preparation stage prior to the start of the study data collection period. This would promote a consistent approach to the study intervention and encourage compliance with the study protocol and intervention. In addition, a future study would need to reassess the number of nurses needed to carry out the study intervention per protocol. This would require 226
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a sufficient number of study nurses available to be assigned to parents enrolled in the study. In addition, employing creative strategies to encourage staff nurses to participate in the study such as incorporating their participation into the hospital-based nursing professional development program may enhance recruitment efforts.
CONCLUSION
Because this study is the first of its kind to include parents in a situational briefing process, there are no previously established benchmarks available to provide context for its findings. The evidence from this study suggests, however, that a parent-briefing intervention may have benefits for parents of children with complex healthcare needs, as well as for the physicians and nurses providing their care. While physicians, nurses, and parents perceived the briefings to be easy to participate in and/or carry out and felt they enhanced parent–physician/nurse communication, their respective positions in the hierarchical acute care setting may have influenced their ability to complete the briefings as expected, as well as their respective evaluations of the parentbriefing intervention. Further research is therefore required to explore the utility of the briefings in clinical practice from physicians’, nurses’, and parents’ perspectives. In addition, the use of chairs during structured communication practices warrants further study to determine if their use has an effect on clinicians’ attitudes and behaviors and on parents’ satisfaction and behaviors.
How might this information affect nursing practice?
The information from this phase I study has implications for nurses caring for families of children hospitalized for complex healthcare needs. The fact that nurses in this study reported positive effects and aspects of engaging in the parent-briefing intervention with physicians and parents is important to note. The parent-briefing intervention and the use of chairs required clinicians to interact with parents in a different manner and style then their usual practice. By providing clinicians and parents with a structured template from which to guide daily conversations and a means by which to engage in these discussions (i.e., using chairs) they were able to engage in important conversations
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that had a positive effect on parents’ and nurses’ communication and decision-making practices. Parents and nurses were able to engage in real-time face-to-face dialogue that was seen as important and helpful to nurses and parents alike. This finding from the study speaks to the integral nature of relational care practices as a core element of pediatric nursing practice. Physicians also reported positive aspects of the parent-briefing intervention; however, overall their reports were mixed. Further inquiry is recommended to understand the effects of a structured communication intervention, which involved sitting down, on parent– professional decision-making practices, especially from an interprofessional practice perspective.
References Bain, S., Rosenbaum, P., & King, S. (1995). Chronic childhood illness: What aspects of caregiving do parents value? Child: Care, Health and Development, 21, 292–304. Balling, K., & McCubbin, M. (2001). Hospitalized children with chronic illness: Parental care giving needs and valuing parental expertise. Journal of Pediatric Nursing, 16, 110–119. doi:10.1053/jpdn.2001.23157 Bourdieu, P. (1990). The logic of practice. Stanford, CA: Stanford University Press. Bourdieu, P. (1991). Language & symbolic power. Cambridge, MA: Harvard University Press. Brown, J., & Ritchie, J. A. (1990). Nurses’ perception of parent and nurse roles in caring for hospitalized children. Children’s Health Care, 19, 28–36. Burke, R. T., & Alverson, B. (2010). Impact of children with medically complex conditions. Pediatrics, 126, 789–790. doi:10.1542/peds.2010-1885 Burke, S. O., Costello, E. A., & Handley-Derry, M. H. (1989). Maternal stress and repeated hospitalizations of children who are physically disabled. Children’s Health Care, 18, 82–90. Burke, S. O., Kauffmann, E., Costello, E. A., & Dillon, M. C. (1991). Hazardous secrets and reluctantly taking charge: Parenting a child with repeated hospitalizations. Image–The Journal of Nursing Scholarship, 23, 39–45. Burns, K. H., Casey, P. H., Lyle, R. E., Bird, T. M., Fussell, J. J., & Robbins, J. M. (2010). Increasing prevalence of medically complex children in US hospitals. Pediatrics, 126, 638–646. doi:10.1542/peds.2009-1658 Callery, P., & Smith, L. (1991). A study of role negotiation between nurses and the parents of hospitalized children. Journal of Advanced Nursing, 16, 772–781. Campbell, M., Fitzpatrick, F., Haines, A., Kinmonth, A. L., Sandercock, P., Spiegelhalter, D., & Tyrer, P. (2000).
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Framework for design and evaluation of complex interventions to improve health. BMJ (Clinical Research Ed.), 321, 694–696. Carnevale, F. A. (1990). A description of stressors and coping strategies among parents of critically ill children: A preliminary study. Intensive Care Nursing, 6, 4–11. Carnevale, F. A., Canoui, P., Cremer, R., Farrell, C., Doussau, A., Seguin, M. J., . . . Lacroix, J. (2007). Parental involvement in treatment decisions regarding their critically ill child: A comparative study of France and Quebec. Pediatric Critical Care Medicine, 8, 337–342. Coffey, J. S. (2006). Parenting a child with chronic illness: A metasynthesis. Pediatric Nursing, 32, 51–59. Cohen, E., Friedman, J., Nicholas, D. B., Adams, S., & Rosenbaum, P. (2008). A home for medically complex children: The role of hospital programs. Journal for Healthcare Quality, May/June, 1–9. Cohen, E., Kuo, D. Z., Agrawal, R., Berry, J. G., Bhagat, S. K. M., Simon, T. D., & Srivastava, S. K. M. (2011). Children with medical complexity: An emerging population for clinical and research initiatives. Pediatrics, 127, 529–538. doi:10.1542/peds.2010-0910 Curley, M. Q. A., & Wallace, J. (1992). Effects of the nursing mutual participation model of care on parental stress in the pediatric intensive care unit: A replication. Journal of Pediatric Nursing, 7, 377–385. Dodgson, J. E., Garwick, A., Blozis, S. A., & Patterson, J. M. (2000). Uncertainty in childhood chronic conditions and family distress in families of young children. Journal of Family Nursing, 6, 252–266. Dudley, S. K., & Carr, J. M. (2004). Vigilance: The experience of parents staying at the bedside of hospitalized children. Journal of Pediatric Nursing, 19, 267–275. doi:10.1016/j.pedn.2004.05.008 Goldfarb, F. D., Devine, K., Yingling, J. T., Hill, A., Moss, J., Ogburn, E. S., & Roberts, R. J. (2010). Partnering with professionals: Family-centered care from the parent perspective. Journal of Family Social Work, 13, 91–99. doi:10.1080/10522150903487081 Goldson, E., Louch, G., Washington, K., & Scheu, H. (2006). Guidelines for the care of the child with special health care needs. Advances in Pediatrics, 53, 165–182. doi:10.1016/j.yapd.2006.04.012 Gordon, J. B., Colby, H. H., Bartelt, T., Jablonski, D., Krauthoefer, M. L., & Havens, P. (2007). A tertiary care-primary care partnership model for medically complex and fragile children and youth with special health care needs. Archives of Pediatrics & Adolescent Medicine, 161, 937–944. Harrison, T. M. (2010). Family-centered pediatric nursing care: State of the science. Journal of Pediatric Nursing, 25, 335–343. doi:10.1016/j.pedn.2009.01.006 Hawryluck, L. A., Espin, S. L., Garwood, K. C., Evans, C. A., & Lingard, L. A. (2002). Pulling together and pushing
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apart: Tides of tension in the ICU team. Academic Medicine, 77, S73–S76. Kenney, M. K., Denboba, D., Strickland, B., & Newacheck, P. (2011). Assessing family-provider partnerships and satisfaction with care among US children with special health care needs. Academic Pediatrics, 11, 144–151. Kerr, M. P. (2002). A qualitative study of shift handover practice and function from a socio-technical perspective. Journal of Advanced Nursing, 37, 125–134. King, G. A., King, S. M., & Rosenbaum, P. L. (1996). Interpersonal aspects of care-giving and client outcomes: A review of the literature. Ambulatory Child Health, 2, 151–160. Knox, J. E., & Hayes, V. E. (1983). Hospitalization of a chronically ill child: A stressful time for parents. Issues in Comprehensive Paediatric Nursing, 6, 217–226. Lahire, B. (2003). From the habitus to an individual heritage of dispositions. Towards a sociology at the level of the individual. Poetics, 31, 329–355. doi:10.1016/ j.poetic.2003.08.002 LeGrow, K., Hodnett, E., Stremler, R., McKeever, P., & Cohen, E. (in press). Bourdieu at the bedside: Briefing parents in a pediatric hospital. Nursing Inquiry. doi: 10.1111/nin.12063 Lingard, L., Espin, S., Evans, C., & Hawryluck, L. (2004). The rules of the game: Interprofessional collaboration on the intensive care unit team. Critical Care, 8, R403–R408. doi:10.1186/cc2958 Lotze, G. M., Bellin, M. H., & Oswald, D. P. (2010). Family-centered care for children with special health care needs: Are we moving forward? Journal of Family Social Work, 13, 100–113. doi:10.1080/ 10522150903487099 Macdonald, M. E., Liben, S., Carnevale, F. A., & Cohen, S. R. (2012). An office or a bedroom? Challenges for family-centered care in the pediatric intensive care unit. Journal of Child Health Care, 16, 237–249. doi:10.1177/ 1367493511430678 Marcoulatos, I. (2001). Merleau-Ponty and Bourdieu on embodied significance. Journal for the Theory of Social Behaviour, 31, 1–27. Mello, M. M., Burns, J. P., Truog, R. D., Studdert, D. M., Puopolo, A. L., & Brennan, T. A. (2004). Decision making and satisfaction with care in the pediatric intensive care unit: Findings from a controlled clinical trial. Pediatric Critical Care Medicine, 5, 40–47. Miceli, P. J., & Clark, P. A. (2005). Your patient—My child: Seven priorities for improving pediatric care from the parent’s perspective. Journal of Nursing Care Quality, 20, 43–53.
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Newacheck, P. W., & Halfon, N. (1998). Prevalence and impact of disabling chronic conditions in childhood. American Journal of Public Health, 88, 610–617. Ratcliffe, C. E., Harrigan, R. C., Haley, J., Tse, A., & Olson, T. (2002). Stress in families with medically fragile children. Issues in Comprehensive Pediatric Nursing, 25, 167–188. doi:10.1080/014608602900 42558 Robinson, C. A. (1987). Roadblocks to family centered care when a chronically ill child is hospitalized. Maternal-Child Nursing Journal, 16, 181–193. Sandelowski, M. (1995). Qualitative analysis: What it is and how to begin. Research in Nursing & Health, 18, 371–375. Sandelowski, M. (1996). Using qualitative methods in intervention studies. Research in Nursing & Health, 19, 359–364. Sieben-Hein, D., & Steinmiller, E. A. (2005). Working with complex care patients. Journal of Pediatric Nursing, 20, 389–395. doi:10.1016/j.pedn.2005.06.011 Starke, M., & Moller, A. (2002). Parents’ needs for knowledge concerning the medical diagnosis of their children. Journal of Child Health Care, 6, 245–257. Stewart, M. J., Ritchie, J. A., McGrath, P., Thompson, D., & Bruce, B. (1994). Mothers of children with chronic conditions: Supportive and stressful interactions with partners and professionals regarding caregiving burdens. Canadian Journal of Nursing Research, 26, 61–82. Studdert, D. M., Burns, J. P., Mello, M. M., Puopolo, A. L., Truog, R. D., & Brennan, T. A. (2003). Nature of conflict in the care of pediatric intensive care patients with prolonged stay. Pediatrics, 112, 553–558. Studdert, D. M., Mello, M. M., Burns, J. P., Puopolo, A. L., Galper, B. Z., Truog, R. D., & Brennan, T. A. (2003). Conflict in the care of patients with prolonged stay in the ICU: Types, sources, and predictors. Intensive Care Medicine, 29, 1489–1497. doi:10.1007/s00134-003 -1853-5 Swartz, D. (1997). Culture & place: The sociology of Pierre Bourdieu. Chicago, IL: The University of Chicago Press. Thorne, S. E., & Robinson, C. A. (1988). Health care relationships: The chronic illness perspective. Research in Nursing & Health, 11, 293–300. Thorne, S. E., & Robinson, C. A. (1989). Guarded alliance: Health care relationships in chronic illness. Image–The Journal of Nursing Scholarship, 12, 153–157. van der Lee, J. H., Mokkink, L. B., Grootenhuis, M. A., Heymans, H. S., & Offringa, M. (2007). Definitions and measurement of chronic health conditions in childhood: A systematic review. Journal of the American Medical Association, 297, 2741–2751. doi:10.1001/jama.297 .24.2741
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Journal for Specialists in Pediatric Nursing
ORIGINAL ARTICLE
Evaluating the feasibility of a parent-briefing intervention in a pediatric acute care setting Karen LeGrow, Ellen Hodnett, Robyn Stremler, and Eyal Cohen Karen LeGrow, RN, PhD, is Assistant Professor, Daphne Cockwell School of Nursing, Ryerson University; Ellen Hodnett, RN, PhD, is Professor; Robyn Stremler, RN, PhD, is Assistant Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto; Eyal Cohen, MD, MSc, FRCP(C), is Pediatrician & Director, Complex Care Service, The Hospital for Sick Children, and Associate Professor, Paediatrics, University of Toronto, Toronto, Ontario, Canada
Search terms Acute hospital care, children with complex healthcare needs, phase I study. Author contact [email protected], with a copy to the Editor: [email protected] Acknowledgement This research was funded by the Canadian Institutes of Health Research (CIHR) Allied Health Fellowship Award Research Fund. Conflicts of interest: The authors report no actual or potential conflicts of interest. First Received August 14, 2013; Final revision received January 29, 2014; Accepted for publication January 29, 2014.
Abstract Purpose. The purpose of this study was to test the feasibility of a parentbriefing intervention for parents of hospitalized children with complex healthcare needs. Design and Methods. A phase I, single-group, posttest study. There were 18 physicians, 25 nurses, and 31 parents who participated in the study. Participants were asked to sit while carrying out the briefings with parents. Parents and clinicians completed a feasibility questionnaire post briefings. Results. Sixty-eight briefings were carried out. Parents and nurses evaluated the briefings in a favorable manner, whereas physicians’ ratings were mixed. Practice Implications. Further inquiry is recommended to understand the effects of a structured communication intervention on parent– professional decision-making practices.
doi: 10.1111/jspn.12073
Recent advances in medical knowledge and improved technologies have resulted in longer life expectancies for many children with serious congenital or acquired complex chronic conditions. Consequently, the prevalence of children with complex chronic conditions who require frequent and lengthy hospitalizations is increasing (Burke & Alverson, 2010; Burns et al., 2010; Cohen et al., 2011; Goldson, Louch, Washington, & Scheu, 2006; Gordon et al., 2007; Newacheck & Halfon, 1998; Sieben-Hein & Steinmiller, 2005; van der Lee, Mokkink, Grootenhuis, Heymans, & Offringa, 2007). However, despite many North American hospitals’ adoptions of the tenets of familycentered care (FCC), the admission of these children to hospital is a highly emotional and stressful time for parents (Burke, Costello, & Handley-Derry, 1989; Burke, Kauffmann, Costello, & Dillon, 1991; Harrison, 2010; Kenney, Denboba, Journal for Specialists in Pediatric Nursing 19 (2014) 219–228 © 2014, Wiley Periodicals, Inc.
Strickland, & Newacheck, 2011; Knox & Hayes, 1983; Lotze, Bellin, & Oswald, 2010; Sieben-Hein & Steinmiller, 2005). Parents have consistently reported that relinquishing important aspects of their roles was the most stressful aspect of their children’s hospitalization (Brown & Ritchie, 1990; Callery & Smith, 1991; Carnevale, 1990; Curley & Wallace, 1992; Dudley & Carr, 2004; Goldfarb et al., 2010; Knox & Hayes, 1983; Macdonald, Liben, Carnevale, & Cohen, 2012; Ratcliffe, Harrigan, Haley, Tse, & Olson, 2002). Other stressors parents experienced during their children’s hospitalizations included receiving limited information regarding their children’s medical status and having little or no opportunity to participate in decisions regarding their care (Balling & McCubbin, 2001; Brown & Ritchie, 1990; Burke et al., 1991; Carnevale, 1990; Carnevale et al., 2007; Kerr, 2002; King, King, & Rosenbaum, 1996; Miceli & Clark, 219
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2005; Robinson, 1987; Starke & Moller, 2002; Stewart, Ritchie, McGrath, Thompson, & Bruce, 1994; Thorne & Robinson, 1988). As a result, communication problems and interpersonal conflict between parents and members of the healthcare team were the dominant themes that emerged from parents’ reports of their hospital experiences (Bain, Rosenbaum, & King, 1995; Brown & Ritchie, 1990; Burke et al., 1989, 1991; Callery & Smith, 1991; Coffey, 2006; Dodgson, Garwick, Blozis, & Patterson, 2000; Mello et al., 2004; Sieben-Hein & Steinmiller, 2005; Studdert, Burns, et al., 2003; Studdert, Mello, et al., 2003; Thorne & Robinson, 1989). Given the prevalence of parents’ dissatisfaction with communication and decision-making processes during their children’s acute care hospitalizations, despite the philosophy of FCC that was supposed to guide practice, we chose an alternative perspective to design an intervention intended to address these issues. Bourdieu’s, The Logic of Practice (Bourdieu, 1990, 1991; Swartz, 1997), provided the conceptual orientation for the intervention and the phase I study that followed. He posited that individuals’ predispositions for certain behaviors, beliefs, and attitudes are a result of the resources available to them in the social environments or fields in which they live and interact (Swartz, 1997). In an earlier article, we reported how Bourdieu’s key concepts—habitus, capital, and field—were used to frame the development of a briefing intervention for parents of children with complex healthcare needs who were hospitalized in a pediatric acute care setting (LeGrow, Hodnett, Stremler, McKeever, & Cohen, in press). The parent briefing was a process that structured time for the physician and nurse, together with the parents, to participate in important communication practices regarding the child’s health status and care needs. This article is a report of a phase I study of the intervention. STUDY OBJECTIVES
The aim of this study was to evaluate the feasibility and acceptability of the parent-briefing intervention from the points of view of the clinicians carrying out the briefings and the parents participating in them, specifically by determining (a) the percentage of eligible physicians, nurses, and parents who agreed to participate, (b) clinicians’ and parents’ compliance with the parent-briefing protocol, and (c) clinicians’ and parents’ evaluations of the parent briefings. 220
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METHOD Design
A phase I, single-group, posttest study of a parentbriefing intervention was conducted in a universityaffiliated pediatric hospital in a large metropolitan Canadian city over a 9-month period in 2010. Rationale for the study design is provided by the Medical Research Council (MRC) Framework for Development and Evaluations of randomized controlled trials (RCTs) for Complex Interventions to Improve Health. This framework provides a sequential series of phases of investigation in the evaluation of complex intervention (Campbell et al., 2000) Participants
Eligibility criteria for parents. Parents were eligible to participate in the intervention if their children (new-born to 18 years of age) had a nonelective admission to a large teaching metropolitan pediatric tertiary care center. Their children’s healthcare needs had to meet the following criteria: (a) health problem that affected at least two organ systems, (b) at least two medical subspecialists were involved in the children’s care, (c) at least two allied health professionals were involved in the children’s care, (d) the children had at least two of the following: chronic prescription medication(s), special diet requirement, or medical technology dependence, and (e) the children had at least two or more hospitalizations or 10 or more clinic visits in the prior year (Cohen, Friedman, Nicholas, Adams, & Rosenbaum, 2008; Gordon et al., 2007). The parent also had to be able to speak and read English, had to have been the primary parent who spent time with his or her child in the hospital, and had to be available to participate in the patient bedside rounds. Parents were excluded from participating in the intervention if their children were expected to be discharged from hospital within the next 48–72 hr, as assessed by the attending staff physician, or if their children were able to be involved in discussions about their care. The parent-briefing intervention was not designed to meet the complex and unique needs of including adolescents in decisions related to their health care. Eligibility criteria for nurses and physicians. Nurses with a minimum of 1 year of pediatric experience and physicians working within the pediatric medicine service were eligible for the study. Journal for Specialists in Pediatric Nursing 19 (2014) 219–228 © 2014, Wiley Periodicals, Inc.
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Recruitment of parents
Following research ethics board approval, all children admitted to the unit and their parents were assessed daily for their eligibility by the principal investigator (PI), the clinical nurse manager, and members of the Complex Care Service team. Parents who indicated their interest were contacted by the PI, who reviewed the study in detail and obtained a signed consent form. Recruitment and training of clinicians
Nurses who were interested in participating attended one of many information sessions that provided a brief description of the study, the parent-briefing intervention, and expectations of nurse participants. Nurses who agreed to participate then attended a more detailed 4-hr education session, outside of their regularly scheduled shifts, to learn more about the study and how to carry out the parent-briefing intervention. A signed consent was obtained at that time. The educational sessions took place at the hospital during days when the nurses were not scheduled to work. Each nurse was given an educational folder that contained an outline for the session along with important information necessary for their involvement in the study. The study nurse training sessions involved the following information: (a) an overview of the study, (b) a summary of the evidence related to physician/ nurse–parent communication and the decisionmaking process, (c) a detailed description of the “parent-briefing” process, (d) the process for engaging parents, and (e) clinical application of the parent briefing in a practice setting. The training session involved didactic presentations, case studies, and small group discussions. In addition, each study nurse completed a modified objective structured clinical evaluation (OSCE) to demonstrate competency in the study intervention prior to the start of data collection. The OSCE process provided study nurses the time needed to acquire the necessary skills to carry out the “parentbriefing” process prior to the start of the study. All nurses demonstrated competence after completing the initial OSCE; therefore, a second OSCE was not required. Two focused sessions were conducted with physicians during regularly scheduled department meetings. The sessions were 45 min in length and involved: (a) an overview of the study, (b) a Journal for Specialists in Pediatric Nursing 19 (2014) 219–228 © 2014, Wiley Periodicals, Inc.
detailed description of the study intervention, and (c) an outline of what physicians were asked to do that was different from their present practice, (e.g., having both a parent and a nurse present during rounds discussion, following a brief template to guide briefing, and sitting down to conduct the parent briefing). The PI also met the attending physicians individually prior to their on-call duties to review the intervention, and obtain a signed consent.
Study intervention. The parent-briefing intervention was a communication process designed to provide clinicians with a template from which to guide a brief structured review for parents about their children’s health status and care needs. Drawing upon the guiding conceptual orientation for the study (Bourdieu, 1990, 1991), the goal of the parent-briefing intervention was to provide an opportunity for parents to attain medical and technological knowledge (cultural capital) and learn a linguistic style, (symbolic capital) through communication practices with physicians and nurses, that had the potential to enhance their social positioning within the inpatient unit (field) and enable them to gain an active role in decision-making practices (habitus) that related to their children’s care. The briefing included the following components to enhance parents’ cultural and symbolic capital: (a) a medical and nursing update regarding the child’s health status (i.e., medical and technological knowledge), (b) a review of the goals and plan of care for the next 12–24 hr (i.e., medical and technological knowledge), (c) a discussion about medical terminology, jargon, short forms, and acronyms used by physicians and nurses (i.e., linguistic style), and (d) an opportunity to listen to and answer/address parents’ questions and concerns (i.e., linguistic style). The participating physician/fellow/resident, the assigned study nurse, and the child’s parent participated in the parent briefing at the child’s bedside on the inpatient unit during the bedside rounds process. The physician, nurse, and parent were asked to sit to conduct the briefing, using chairs placed in the child’s room on enrollment in the study. The arrangement of the chairs for the briefings was at the discretion of the briefing participants. The intervention period began on Day 2 of the child’s admission. Each study family was to participate in a minimum of three briefings in the first week of the child’s admission. 221
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Data collection
The PI carried out all data collection for the study, which included (a) recording the number of physicians, nurses, and parents who participated in the study out of the total eligible, (b) monitoring participants’ compliance with the intervention protocol on a daily basis, using data entered on the parentbriefing checklist, and (c) collecting outcome data from parents and clinicians at various points in time. Parent-briefing checklist. The data were selfreported; briefings were not directly observed. Study nurses, who carried out the briefings in collaboration with the physicians, were required to complete a parent-briefing checklist for each briefing in which they participated during the data collection period. The checklist captured individuals present, the amount of time it took to conduct the briefing, whether chairs were used, and the key content areas discussed during the briefing. Feasibility questionnaire. Participating staff physicians, nurses, and parents were asked to complete a Parent-Briefing Feasibility Questionnaire designed to explore their perceptions of (a) the timing and duration of the intervention, (b) the clinical usefulness of the parent briefing to enhance communication and decision-making practices between physicians, nurses, and parents, and (c) their preferences for the future use of the briefing in clinical practice. Parents completed the questionnaire 1 day prior to transfer and/or discharge from the hospital, while physicians and nurses completed the questionnaire on 2 weeks postdata collection period. The questionnaire content was developed by clinical experts in relation to key themes identified in the literature relating to parents’ dissatisfaction with communication and decision-making practices for hospitalized children with complex healthcare needs and in relation to the goal of the parentbriefing intervention. Limitations
The feasibility questionnaire was specifically designed for this study and as such, the lack of reliability and validity data for this tool is a limitation of the study.
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tionnaire served as an initial organizing framework where data were grouped according to each question. Participants’ written responses were analyzed for units of meaning, that is, words, phrases, and sentences that described physicians’, nurses’, and parents’ experiences. Data considered representative of similar patterns and themes were arranged into categories, which then were identified to guide the coding of qualitative data (Sandelowski, 1995, 1996). RESULTS Descriptive statistics
Characteristics of the parents. The mean age for mothers was 37.4 years (SD = 6.9, Median [Mdn] = 36.0), ranging from 27 years to 47 years. Fathers’ mean age was 40.0 years (SD = 7.7, Mdn = 39.0), ranging from 27 years to 52 years. Educational levels tended to be high; 78.3% (n = 18/27) of mothers and 66.6% (n = 16/27) of fathers had a university or college degree. The majority of parents were married or living in a common law arrangement (92.5%, 25/27). Most parents had other children (85.2%, 23/27) in addition to the child admitted to hospital. Characteristics of the children. The mean age of the children enrolled was 5.1 years (SD = 5.6, Mdn = 2.3, interquartile range = 0.4, 8.3), with a minimum age of a few days to a maximum of 17 years. For the majority of children, it was not their first admission to hospital (54.8%), with length of stay ranging from 2 to 86 days. Characteristics of nurses. Twenty-nine nurses completed the education sessions and successfully completed the OSCE. Four nurses dropped out of the study for the following reasons: (a) one nurse resigned from the hospital, (b) one nurse took a leave of absence for 6 months, and (c) two nurses transferred to other units/programs within the hospital. Twenty-five nurses participated in the study. Twenty-two out of 29 nurses (75.9%) had completed their Bachelor of Nursing degree; 26 out of 29 nurses (89.7%) had less than or equal to 10 years of experience; of the latter, 12 had 1–3 years of experience.
Data analysis
Percentage of eligible physicians, nurses, and parents who agreed to participate
Data were analyzed using descriptive statistics such as frequencies and percentages. Items in the ques-
All of the 18 eligible physicians and 29 out of the 76 eligible nurses (38.1%) participated in the study.
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Reasons nurses stated for not participating included not being able to participate in the educational session and OSCE activity, working part-time, anticipating an extended leave (such as maternity leave), or generally not interested. Four nurses, however, dropped out of the study because of being transferred to another unit within the hospital (n = 3) and taking an extended leave (n = 1). Therefore, a total of 25 nurses participated in all aspects of the study. Thirty-one parents (62% of those eligible) consented to participate in the study. Eight out of the 19 eligible parents who did not participate stated that they were unable to be present during the rounds process to participate in the briefings. Reasons the other 11 eligible parents gave for not participating included the child being quite anxious during the admission, feeling that they already had a very good understanding of what was happening to their children, and feeling that they were already involved in a number of research studies at the hospital. Compliance of parents and clinicians with the parent-briefing protocol
Ninety-three briefings were expected to be carried out per study protocol, that is, a minimum of three briefings for each parent enrolled in the study. Sixty-eight of the expected briefings (73.1%) were conducted. Thirty-one parents participated in a minimum of one briefing to a maximum of five briefings during their children’s hospitalizations over a minimum length of stay of 4 days to a maximum of 88 days. Twelve of 31 parents (38.7%) participated in three or more briefings. Sixty-six out of 68 briefings (97.1%) were attended by a resident and/or fellow and 24 out of 68 briefings (35.3%) were attended by the attending physician most responsible for the child’s care. Chairs provided for the intervention were used in 47 out of 68 briefings (69.1%) and at least once for 27 of the 31(87%) parents. Key elements of the briefings’ content were carried out for all 68 briefings. Twenty-five of the expected 93 (26.9%) parent briefings were not completed per study protocol for various reasons. Table 1 provides a detailed description of compliance with the parent-briefing intervention. Parents’ and clinicians’ evaluations of the intervention
Twenty-seven of the 31 parents completed the parent-briefing feasibility questionnaire. Two Journal for Specialists in Pediatric Nursing 19 (2014) 219–228 © 2014, Wiley Periodicals, Inc.
Table 1. Compliance with the Parent-Briefing Intervention Parent briefings not completed Reasons Organizational barriers Study nurse not working Patient was transferred or discharged Study nurse not assigned Unit too busy Communication barriers Physician was not available Physician did not page the nurse Parent was not available n
Number of briefings (%) 7 (28.0) 5 (20.0) 4 (16.0) 2 (8.0) 5 (20.0) 1 (4.0) 1 (4.0) 25 (26.9)
Parent briefings completed Parent briefing items Attendance Attending physician Resident/fellow Nurse Parent Sitting Key content Medical/nursing update Review plan of care Review medical jargon Parent’s questions Parent’s concerns Parents requested additional meetings Parents made a formal compliant n
Number of briefings (%) 24 (35.3) 66 (96.7) 68 (100.0) 68 (100.0) 47 (69.1) 68 (100.0) 68 (100.0) 68 (100.0) 38 (55.9) 29 (42.7) 5 (7.4) 0 (0.0) 68 (73.1)
parents changed their minds about completing the questionnaire at point of follow-up and did not provide further explanation for their decisions. In addition, two other children were discharged from the hospital unexpectedly; therefore, their parents did not receive the questionnaire to complete. The fact that 4 out of 31 parents did not complete the questionnaire is worth noting for future study. Anecdotal comments parents provided about their participation in the briefings were of a positive nature and included feeling that their input was important, that being present during the team discussions was helpful, that they were able to ask questions and state their concerns, and that they would have tests and procedures explained to them. No negative comments were recorded or provided. A summary of parents’ evaluations of the parentbriefing intervention is provided in Table 2. All 25 nurses who participated in the whole study completed the feasibility questionnaire. Similar to parents, nurses also rated all aspects of the parent 223
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Table 2. Parents’ Evaluations of the Parent-Briefing Intervention
Number of parents’ responses on a Likert scale (%)a Survey questions
5
4
3
2
1
Easy to participate in Helpful Recommend to parents Recommend its future use
21 (77.8) 19 (70.4) 16 (59.3) 19 (70.4)
4 (14.8) 3 (11.1) 7 (25.9) 4 (14.8)
2 (7.4) 3 (11.1) 3 (11.1) 3 (11.1)
0 (0.0) 1 (3.7) 0 (0.0) 0 (0.0)
0 (0.0) 1 (3.7) 1 (3.7) 1 (3.7)
Note: aA total of 27 parents completed the feasibility questionnaire.
briefing in a favorable manner; however, some challenges were identified. These included the challenges that they faced trying to attend to patient care while also being available to participate in the briefings (n = 7). In addition, they reported that they had to follow up with the physician/resident on more than one occasion to ensure the briefing was completed as per protocol (n = 5). Out of 18 participating physicians, 13 filled out the feasibility questionnaire. Out of those 13, only 8 completed questions related to their participation in the briefing. Contrary to parents’ and nurses’ positive responses, physicians’ ratings were mixed (see Tables 2 and 3).Only about one half of the physicians rated the following items favorably: the parent briefing was easy to carry out (n = 8), it enhanced parent– physician/nurse communication (n = 6), and they would recommend that briefings become part of usual clinical practice (n = 4). Anecdotal comments from physicians were brief; however, they are worth noting in light of the mentioned results. A minority of physicians stated that (a) having the registered nurse present during rounds was helpful and contributed to the nurses’ enhanced role in facilitating effective parent–team communication (n = 2), (b) the act of sitting down for the discussion changed the atmosphere of the interaction (n = 2), and (c) the briefing did not change their usual style of interacting with parents (n = 2). A detailed summary of nurses’ and physicians’ evaluations of the parentbriefing intervention is provided in Table 3.
DISCUSSION
We conducted a Bourdieusian interpretation of the study results to explore (a) the positioning of physicians, nurses, and parents within the inpatient unit, (b) compliance with the intervention, and (c) the linguistic practices of parents in a pediatric acute care setting. Positioning of physicians, nurses, and parents within the inpatient unit
Physicians’, nurses’, and parents’ engagement in the parent briefings and their evaluations of the intervention could be viewed as reflecting the disparity between their respective positions within the inpatient unit. Physicians. Physicians were included in the study as an acknowledgment of their position on the interprofessional team within the inpatient unit (Hawryluck, Espin, Garwood, Evans, & Lingard, 2002; Lingard, Espin, Evans, & Hawryluck, 2004). All eligible physicians agreed to participate in the intervention; however, they delegated the briefing to a junior staff member 63.2% (n = 43/68) of the time. Also, only 13 out of the 18 participants completed the feasibility questionnaire. This behavior may have many explanations, depending on the view of capital that the physician held. One possibility is that those physicians who consented to
Table 3. Nurses’ and Physicians’ Evaluations of the Parent-Briefing Intervention Number of nurses’ responses on a Likert scalea
Number of physicians’ responses on a Likert scaleb
Survey question
5
4
3
2
1
5
4
3
2
1
Easy to carry out Enhanced communication Helpful to my practice Time it took was reasonable Recommend its use in the future
9 15 6 11 9
14 10 16 11 14
1 0 3 3 2
1 0 0 0 0
0 0 0 0 0
4 1 1 1 2
4 5 2 2 2
0 0 3 5 3
0 1 2 0 1
0 1 0 0 0
Note: an = 25; bn = 8.
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participate in the study, but did not carry out the briefings, did not perceive them to be a direct threat to their position in the inpatient unit and, therefore, delegated the briefings to junior staff to complete. Another, not necessarily conflicting possibility, is that those physicians did not view the briefings as capital or as a valuable practice that would add to their position in the inpatient unit and, therefore, did not feel the need to personally conduct the briefing. An equally plausible explanation is that the briefing was perceived as a threat to those physicians; therefore, delegation to a junior staff member prevented loss of capital. Nurses. Nurses occupy a lower position in the inpatient unit relative to physicians, based upon the amount and type of capital that they have obtained through education and training experiences. Those with more pediatric experience will have had more opportunities to acquire capital and engage in linguistic practices with physicians to secure their higher positions in the nursing hierarchy. Nurses may have used the briefings as an opportunity to demonstrate their medical and technological knowledge to the physicians and the parents simultaneously, thereby enhancing their positioning with both the physicians and the parents. This perspective may explain some of the nurses’ favorable responses in their evaluation of the parent briefings. Parents. A majority of the parents (n = 27/31, 87%) who participated completed the questionnaire, which may indicate their interest in and support for the briefings. Their participation could be viewed as an attempt to gain important medical and technological knowledge from the physicians and nurses caring for their children so that they could become active participants in decisions related to their children’s care. This perspective could explain their favorable responses. However, of the 19 eligible parents who did not agree to participate, 8 could not attend the briefings as scheduled. It is not clear whether the remaining 11 parents wished to acquire the medical and technological knowledge being shared during the briefings. It may be that they were already knowledgeable about their children’s chronic conditions and did not perceive that the intervention would provide them with any new knowledge to facilitate their involvement in decisions related to their children’s care. Another plausible explanation could be that they preferred that the physicians make all medical decisions related to Journal for Specialists in Pediatric Nursing 19 (2014) 219–228 © 2014, Wiley Periodicals, Inc.
their children’s care; therefore, they did not perceive that the briefings would be helpful to them. Compliance with the parent-briefing intervention
For the 68 briefings that were conducted, a majority of the time, the physician participating in the briefing was a resident or fellow. Having such clinicians involved in the parent-briefing process could be seen as a natural extension of their education and training in an academic health sciences center. Physicians may have viewed expert knowledge and decision-making as capital rather than the act of sharing information with parents through communication practices. On all but one occasion, a parent was present for the planned briefing. Parents’ commitment to be in the hospital during the time of the briefing probably highlights the value they placed on receiving up-to-date information from members of the healthcare team. This behavior could be viewed as an attempt to gain important medical and technological knowledge to enhance their positions with physicians and nurses (Lahire, 2003; Marcoulatos, 2001; Swartz, 1997). The act of sitting down to engage in the briefing process was an integral component of the intervention (LeGrow et al., in press). Although physicians and nurses indicated their support for using the chairs, the fact that the chairs were not used by clinicians in 21 of the 68 briefings is noteworthy and necessitates further critical reflection. Physicians and nurses have been socialized into acquiring certain practices that have shaped their interactions with parents. Typically, healthcare providers stand while engaging in daily discussions with parents, possibly because this signifies the briefness of the encounter to the parent and allows the physician/ nurse to easily take leave of the conversation in an efficient manner. Therefore, the act of sitting to engage in the parent briefing would have required them to change those habitual ways. This may have been more difficult for some to do than they had originally anticipated and may have required more sustained interactions with parents over a longer period of time than the study protocol allowed. Although anecdotal comments from physicians who used the chairs during the parent briefings indicated that the physical act of sitting changed the dynamics of the interaction, further research is required to examine the manner and style of healthcare provider–parent communication practices and to determine if the sustained use of chairs can bring about change in clinicians’ practices. 225
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Linguistic practices: cultural and symbolic capital
The parent briefings were designed to incorporate Bourdieu’s concepts of cultural and symbolic capital (LeGrow et al., in press). Based on parentbriefing checklist data, physicians and nurses were 100% compliant with the content of the briefing; that is, they shared medical and nursing knowledge and reviewed the plan of care. Twenty-two parents asked questions during 38 briefings. This behavior may be viewed as parents taking advantage of an opportunity to engage in linguistic practices with physicians and nurses to receive important information and have their question(s) answered. Nine parents did not ask questions. They may have had no questions or the briefing may not have helped them feel comfortable in stating their questions at that specific time with the team members present. IMPLICATIONS FOR FUTURE RESEARCH
This study is the first of its kind to include parents in a briefing intervention in an acute care setting; however, observation of clinician–parent interactions was not possible during this study. Therefore, before a future phase II study can be conducted, a qualitative study is needed to further to examine the manner and style of healthcare provider– parent communication and decision-making practices, including additional research with the use of chairs. Future qualitative study could involve video-taping parent briefings and interviewing each participant post-briefing using Bourdieu’s key concepts, specifically—habitus, capital, and fields— as the framework for analysis of the interactions. This could provide insightful information about clinician and parent behaviors during communication and decision-making practices that could lead to refinement of the intervention for a possible future pilot RCT. Future quantitative research should address the issue of physician and resident engagement in the parent-briefing intervention. A systematic approach to engaging physicians and junior staff such as residents would need to be conducted as part of the preparation stage prior to the start of the study data collection period. This would promote a consistent approach to the study intervention and encourage compliance with the study protocol and intervention. In addition, a future study would need to reassess the number of nurses needed to carry out the study intervention per protocol. This would require 226
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a sufficient number of study nurses available to be assigned to parents enrolled in the study. In addition, employing creative strategies to encourage staff nurses to participate in the study such as incorporating their participation into the hospital-based nursing professional development program may enhance recruitment efforts.
CONCLUSION
Because this study is the first of its kind to include parents in a situational briefing process, there are no previously established benchmarks available to provide context for its findings. The evidence from this study suggests, however, that a parent-briefing intervention may have benefits for parents of children with complex healthcare needs, as well as for the physicians and nurses providing their care. While physicians, nurses, and parents perceived the briefings to be easy to participate in and/or carry out and felt they enhanced parent–physician/nurse communication, their respective positions in the hierarchical acute care setting may have influenced their ability to complete the briefings as expected, as well as their respective evaluations of the parentbriefing intervention. Further research is therefore required to explore the utility of the briefings in clinical practice from physicians’, nurses’, and parents’ perspectives. In addition, the use of chairs during structured communication practices warrants further study to determine if their use has an effect on clinicians’ attitudes and behaviors and on parents’ satisfaction and behaviors.
How might this information affect nursing practice?
The information from this phase I study has implications for nurses caring for families of children hospitalized for complex healthcare needs. The fact that nurses in this study reported positive effects and aspects of engaging in the parent-briefing intervention with physicians and parents is important to note. The parent-briefing intervention and the use of chairs required clinicians to interact with parents in a different manner and style then their usual practice. By providing clinicians and parents with a structured template from which to guide daily conversations and a means by which to engage in these discussions (i.e., using chairs) they were able to engage in important conversations
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that had a positive effect on parents’ and nurses’ communication and decision-making practices. Parents and nurses were able to engage in real-time face-to-face dialogue that was seen as important and helpful to nurses and parents alike. This finding from the study speaks to the integral nature of relational care practices as a core element of pediatric nursing practice. Physicians also reported positive aspects of the parent-briefing intervention; however, overall their reports were mixed. Further inquiry is recommended to understand the effects of a structured communication intervention, which involved sitting down, on parent– professional decision-making practices, especially from an interprofessional practice perspective.
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