The Effect of Sitting Versus Standing on Family Perceptions of Family-Centered Rounds

We conducted a prospective, randomized study comparing the effect of the rounding team sitting versus standing on time spent on PFCRs and family perceptions of time spent on PFCRs. Our secondary outcome was overall family experience with PFCRs assessed by using a 5-item Likert survey.

Between February 2017 and November 2017, all English-speaking children (with a parent or guardian present during rounds) admitted to a general pediatric unit at our tertiary-care academic center to the hospital medicine inpatient service were potentially eligible to be included in the study. We limited the enrollment of patients to 1 hospital unit with almost entirely short-stay general admissions to limit variability in experience related to disease complexity. Data collection timing was driven by availability of the study team on any given week, and every eligible patient was only included once throughout the study period even if they were hospitalized on other data collection days.

All members of the medical team, including hospitalist attending physicians, rotate for 1 to 2 weeks at a time. All participate in PFCRs with a shared process. Medical teams consist of 1 intern, 1 senior resident, 1 to 2 medical students, and an attending physician. Teams generally care for an average census of 7 to 10 patients. Pharmacy residents and the patient’s nurse typically join the team for bedside rounds. Our institutional PFCR guidelines recommend sharing of complete medical information at the patient’s bedside unless the family expresses a different preference. The intern or medical student recaps the pertinent history and leads the discussion of the assessment and plan. Before discussing the assessment, nurses are asked for concerns and input. The senior resident engages the patient and/or family in making introductions, encouraging questions, and assessing understanding of plans.

Before each rounding experience, a study team member used a random number generator to dictate whether the rounding team would sit (even numbers) or stand (odd numbers) for each individual rounding encounter; thus, in a given day, the team would both sit and stand for encounters on rounds. Each member of the rounding team was given a folding stool to use if rounds were to be seated. A member of the rounding team, typically a student, timed each patient’s rounds in minutes (rounding to the half-minute) and provided the times to our study team. Later the same day, a study team member approached the family to obtain consent and administer an electronic survey, developed by using our institutional Qualtrics Software. In this survey, we asked families to estimate the number of minutes the team spent during PFCRs using a slider graphic and also to offer their opinions of the PFCR experience using 5 Likert scale questions. The survey was completed on a tablet device without the input of the survey team, and only 1 caregiver participated. Electronic medical records were reviewed to gather demographic data, including patient age, sex, race, ethnicity, and insurance status.

We compared both actual time and perceived time spent on PFCRs in the sitting group to the standing group. We powered our study to detect a difference of 2 minutes between the 2 groups, with a calculated sample size of 50 in each group. We compared time as a continuous variable using a 2-sided t test for analysis. To address the change in presenter experience that occurs in July with new intern arrivals, we also compared a subset of times (from May–June 2017 to July–August 2017) with a 2-sided t test. For the secondary outcome, Likert scale questions were analyzed by percent of top-box answers (strongly agree) for each question by using a χ² test. All statistical analysis was completed in Microsoft Excel. This study was granted an exemption by our institutional review board.

A total of 103 rounding encounters were observed in our study; 49 were randomly assigned to the sitting group, and 54 were randomly assigned to the standing group. Three families declined to complete the survey in the standing group, and 1 family declined participation in the sitting group, leaving 99 rounding encounters that were eventually included in our final analysis. Patient characteristics are shown in Table 1, with a significantly higher proportion of toddlers noted in the standing group.

Time data, both actual and perceived, are shown in Table 2. The average time of rounds was 14.2 minutes in the sitting group and 12.7 minutes in the standing group (P = .23). In general, families perceived rounds to be slightly longer than actual time in both groups, with family estimate of time as 15.8 minutes in the sitting group compared with 14.7 minutes in the standing group (P = .45). The difference in actual rounding time compared to perceived rounding time between the 2 groups was not significant (P = .95). Average rounding time at the end of the intern year was 12.3 minutes compared with 13.5 minutes at the beginning of the intern year (P = .6).

Analysis of the Likert scale questions regarding family experience on rounds is shown in Table 3. There were no statistical differences between percentage of top box in any single domain, comparing sitting rounds to standing rounds. The largest absolute difference in top-box response was seen in response to “I felt comfortable asking questions,” in which 60% of families in the sitting group strongly agreed compared with 45% in the standing group (P = .18). The overall percentage of top box for the sitting group was 62% compared with 55% in the standing group (P = .12).

This prospective, randomized trial revealed no statistical difference in either actual time spent on PFCRs, or family perception of time spent, on the basis of whether the medical team was sitting or standing. These findings contrast with previous work revealing a positive impact on the patient’s perception of time spent when physicians sit in the inpatient setting. In these previous studies, researchers evaluated interactions with a single physician that took place over a much shorter period of time, and our actual rounding times were much longer.^5–8  If sitting serves as a way to reveal physician patience in the interaction, there is likely a diminished effect of sitting when rounds last upwards of 15 minutes.

Although not significant, we did note overall improved top-box scores in the sitting group. It is possible that enlarging our sample size with additional encounters could have revealed a significant improvement of sitting over standing, and we were likely underpowered to detect this difference. An alternative explanation, however, could be the higher number of toddler-aged children in the standing group. The real stress of managing fear and discomfort in a hospitalized toddler, compared with a young infant, may have affected the families’ experience on rounds. More subsequent day encounters occurred in the standing group, although the difference was not statistically significant. Both time and family experience can be affected by whether the encounter was an initial historical and physical versus a progress note presentation. The data presented are often much shorter in the latter and often more streamlined. Subsequent days can have variable effects on the family experience, however. Although, as children improve, families may feel more positively overall, frustration can also build in long hospitalizations, and families may interpret long rounding encounters as challenging. The increase in H and P presentations in the sitting group may also serve to explain the slightly longer rounding time in that group.

Our study had a number of limitations. Most notably, we did not calculate sample size to power our study for differences in top-box response, which in hindsight was potentially a lost opportunity. We also had a long data collection period, with different attending and resident physicians on service. We relied on random assignment to control for different physician styles, but with relatively small groups for both intervention and control, there may have been a stylistic effect from individual physician behavior on the experience for families. We also did not collect demographic data on the respondent to the survey and, without these data, cannot eliminate the possibility that differences in these characteristics affected survey responses or the experience and timing of rounds.

Many physicians who participated in the intervention informally reported to study team members that they felt more connected to rounds and enjoyed sitting, and, notably, sitting did not take longer. We did not examine the provider experience with the intervention, but it is interesting that several providers expressed this perspective, particularly given the added operational difficulty of carrying a stool from room to room. Although there are barriers to consider in using a sitting approach long-term (infection prevention concerns as an example), if further studies reveal that physicians and patients alike enjoy the experience, these barriers could be overcome.