The coronavirus disease 2019 pandemic has required modifications to family-centered rounds (FCR), although the specific changes and the effects on patients, families, and providers are not well known. In this study, we explore physician perspectives on changes made to FCR during the initial wave of the coronavirus disease 2019 pandemic and recommendations for the future.
Semistructured individual interviews were conducted with 20 pediatric attending and resident physicians who cared for hospitalized patients between March and May 2020 on pediatric hospital medicine and subspecialty services that typically perform FCR. Transcripts were reviewed by using principles of framework analysis to iteratively develop a codebook. Review of coded segments, with attention to code co-occurrences, was used to clarify themes in the data relating to the research objective and the conceptual framework.
The rounding format changed for all providers and varied on the basis of clinical service and phase of the pandemic. Themes highlighted specific areas of change: (1) the process of FCR, (2) reaching consensus with families, (3) collaboration with members of the medical team, and (4) resident education, modeling, and supervision. Participants offered recommendations, including standardization of rounds, intentional involvement of nursing staff, and inclusion of families through virtual or small-group bedside rounds.
The pandemic led to a variety of modifications to FCR, and these changes had varied effects on communication and education. These findings provide insight into the state of FCR during the pandemic and may frame future recommendations for the development of shared guidelines for circumstances requiring limited bedside rounding.
Family-centered rounds (FCR) have become standard practice on general pediatric inpatient services at academic institutions in recent years.1 Although the exact practices vary by institution and specific needs of each patient and family, FCR provide an opportunity for members of the treatment team to gather perspectives and achieve consensus with the patient and family regarding their medical conditions and involve them in medical decision-making.2–4 FCR also provide a setting for resident education and graduated autonomy.4 The benefits of FCR are well documented and include family participation in care, nurse engagement, trainee education, and the prevention of harmful medical errors.2,3,5
In response to the coronavirus disease 2019 (COVID-19) pandemic, many hospitals modified the structure and process for bedside rounds, including the suspension or modification of FCR within pediatrics.6–10 Since the widespread adoption of FCR, the COVID-19 pandemic was the first major event that required such an extensive and rapid change in FCR practices. Thus, recommendations for conducting FCR in these circumstances have not been well described.
The effect of pandemic-related modification of FCR on patient outcomes, families’ experiences, team communication, and teaching has not been well defined. Our aims for this study were to explore physician perspectives on the changes to FCR that were brought by the COVID-19 pandemic and to solicit recommendations to address novel challenges that arose.
Methods
This study was a qualitative study of physicians who provided direct patient care to hospitalized children at an academic children’s hospital during the first wave of the COVID-19 pandemic in New York, New York. This study received approval from the institutional review board.
Setting
At this institution, FCR are routinely performed on the hospital medicine and critical care services and by select faculty on the cardiology and gastroenterology services. Rounds include the patient and family, physician team and trainees, nursing staff, and other specific providers, such as clinical pharmacists and respiratory therapists. Second- and third-year residents act in a supervisory role, except in the ICU, where they serve as first-call providers. After a hospital-wide requirement to limit group sizes in March 2020, students were removed from inpatient services, and FCR were adapted to mitigate severe acute respiratory syndrome coronavirus 2exposure and preserve personal protective equipment (PPE). There was no hospital-wide standard, so many services modified FCR or suspended them altogether.
Participants
We used a purposive sample meant to better understand the impact of COVID-19 on FCR by capturing diversity around this phenomenon. Eligible participants included pediatric residents and faculty who provided direct patient care for at least 1 week during the first wave of the pandemic in New York City (March 9, 2020, to May 31, 2020) on a teaching service that typically performs FCR. The eligible pool of faculty was limited because few perform FCR on teaching services and service schedules during this time were focused to limit potential exposures. Thus, out of 10 possible faculty and 20 residents who met these criteria, we enrolled 8 and 12 participants, respectively. Interviews were conducted during June and July 2020.
Interview Guide
After a literature review revealed no pertinent studies, an open-ended semistructured interview guide was developed de novo by study investigators. By using principles of patient- and family-centered care as a guiding framework,2–4,11 a conceptual framework was developed to guide all facets of this study: development, data collection, coding and data analysis, and presentation of findings (Fig 1A). Prompts were focused on (1) changes to the FCR process, (2) communication with the patient and family and medical team during rounds, (3) teaching and learning during rounds, and (4) adaptations to pandemic-related challenges around communication and education during FCR (Supplemental Fig 2). The guide was piloted for content validity, clarity, and length with 2 faculty and 2 residents who were not eligible to participate as study subjects. Prompts were then adapted as necessary.
Conceptual framework of FCR. A, Before the COVID-19 pandemic. B, The perceived impact of modified rounding structures during the pandemic. a Themes highlighted.
Conceptual framework of FCR. A, Before the COVID-19 pandemic. B, The perceived impact of modified rounding structures during the pandemic. a Themes highlighted.
Data Collection
Recruitment, enrollment, and data collection were performed by a medical student investigator (K.E.S.C.) to limit coercion or response bias. Interviews were conducted over Zoom videoconferencing software,12 audio recorded, and transcribed verbatim.
Data Analysis
Data were analyzed by using a thematic framework analysis method with an inductive approach, which enabled themes to be developed both from the conceptual framework and from participant narratives.13 Two study investigators independently reviewed transcripts and generated initial codes. Investigators met regularly to review codes and resolve differences. A preliminary analytical framework (codebook) was developed and revised until no additional codes were identified. Saturation was achieved within the sample. The framework was reviewed by an additional team member to resolve discrepancies via group discussion and ensure intercoder reliability. A final framework was applied to all transcripts, and data were charted into a framework matrix by using a qualitative data analysis program (Dedoose, Los Angeles, CA). The matrix was interpreted by using the constant comparative analysis method,13,14 with attention to code co-occurrence across the matrix. Credibility of data was achieved via triangulation with different data sources (residents and faculty from different services) by using coders with different clinical backgrounds and member-checking with participants. The study team was interdisciplinary in clinical role and possessed expertise with qualitative methods.
Results
Twenty physicians (12 residents and 8 faculty) were interviewed. Participants included residents from each year of training and faculty from 4 services (Table 1). Exploration of data revealed 4 themes regarding changes to FCR: (1) the process of FCR, (2) reaching consensus with family, (3) collaboration with members of the medical team, and (4) resident education, modeling, and supervision. The conceptual framework illustrates the relationship between these themes and the changes in the context of the framework (Fig 1B).
Participant Demographics (N = 20)
| Value | |
|---|---|
| Level of training, n (%) | |
| Resident physician | 12 (60) |
| Faculty | 8 (40) |
| Sex, n (%) | |
| Male | 7 (35) |
| Female | 13 (65) |
| Faculty years post residency, n (%) | |
| 0–4 y | 3 (38) |
| 5–9 y | 3 (38) |
| >10 y | 2 (25) |
| Resident year of training, n (%) | |
| PGY1 | 4 (33) |
| PGY2 | 3 (25) |
| PGY3 | 5 (42) |
| Faculty specialty, n (%) | |
| Pediatric hospital medicine | 4 (50) |
| Pediatric critical care | 2 (25) |
| Pediatric cardiology | 1 (13) |
| Pediatric gastroenterology | 1 (13) |
| Weeks on inpatient service, median (range) | |
| Faculty | 3.5 (2–8) |
| Resident | 4 (4–12) |
| Value | |
|---|---|
| Level of training, n (%) | |
| Resident physician | 12 (60) |
| Faculty | 8 (40) |
| Sex, n (%) | |
| Male | 7 (35) |
| Female | 13 (65) |
| Faculty years post residency, n (%) | |
| 0–4 y | 3 (38) |
| 5–9 y | 3 (38) |
| >10 y | 2 (25) |
| Resident year of training, n (%) | |
| PGY1 | 4 (33) |
| PGY2 | 3 (25) |
| PGY3 | 5 (42) |
| Faculty specialty, n (%) | |
| Pediatric hospital medicine | 4 (50) |
| Pediatric critical care | 2 (25) |
| Pediatric cardiology | 1 (13) |
| Pediatric gastroenterology | 1 (13) |
| Weeks on inpatient service, median (range) | |
| Faculty | 3.5 (2–8) |
| Resident | 4 (4–12) |
PGY, postgraduate year.
Process of FCR
Participants shared that changes in FCR were driven by physical distancing recommendations, PPE requirements and shortages, and general uncertainty regarding the transmissibility of the virus. Rounding procedures varied by specialty and by time point within the pandemic. In general, the hospital medicine service suspended FCR and adopted a model in which faculty and residents rounded in a conference room. Most patients were seen after rounds either by faculty alone or by a faculty–first-year resident dyad.
In general, FCR were abbreviated and not at bedside. Generally, a smaller group of doctors would go and communicate with the family, not always face-to-face, sometimes it would be via a phone call.… Every part was a little shorter, especially because we aren’t doing any teaching or explaining to the family, and any interaction with the nurse or patient.
First-year resident (participant 16)
Similar to prepandemic FCR, ICU teams continued rounding outside patients’ rooms with faculty, a fellow, and the patient’s primary resident and nurse. The parent was included only if the patient was negative for severe acute respiratory syndrome coronavirus 2. Other members of the clinical team, such as the pharmacist and other residents, participated virtually via Health Insurance Portability and Accountability Act–compliant Zoom videoconferencing software on a mobile workstation, although virtual participation changed week by week (Table 2). Other subspecialties’ rounding processes similarly featured decreased team sizes by having some members join virtually, with faculty responsible for most of the communication with families.
Themes 1 and 2 With Associated Subthemes and Quotations
| Representative Quotes | |
|---|---|
| Theme 1: Process of FCR | |
| Variation in rounding procedure | “We rounded in one conference room, so parents were not involved. Most of the time nursing was also not involved and we just ran down the list. So the structure of rounds in terms of how the resident presented…but the language was not family friendly or oriented, much more academic.” (Faculty, hospital medicine, participant 18) |
| “When I started the ICU rotation at the end of March, they were trying to enforce social distancing for us, so having fewer people on rounds. One resident stayed at the work station to put in orders if nurses needed them. And if we were on rounds, they wanted us to maintain 6 feet distance…. I had 4 different attendings over 4 different weeks, so I probably went from most to least strict. And I think that was also just everyone’s comfort with masks and social distancing and how the world was working.” (Third-year resident, participant 10) | |
| Feelings of loss of control and confusion about rounding structure | “It was a very difficult time in general. It was the very beginning of the pandemic and so there was a lot of ‘what if.’ Everything was changing every day. At the start of the block, we talked about trying to preserve the integrity of rounds, and making sure to do teaching…and I felt like rounds were allowed to be a lot more interrupted because the interns were sitting around during rounds.” (Third-year resident, participant 19) |
| Theme 2: Reaching consensus with families | |
| Partnership with family | “I think such a big part of taking care of someone is communication with their family, so definitely not communicating with them in person or not meeting everyone during the day, that aspect was more difficult. But I think clinically, the children had good plans, but I think in caring for them in the communication sense, like involving them in the plan and making them feel heard, that definitely suffered.” (Third-year resident, participant 5) |
| Family providing context | “It’s hard to not have the family input…so it was harder to make the plan without the family in front of me because a lot of times a question about discharge or how long we would monitor a patient would be very dependent on the family…when you’re in the room, you can assess that type of thing. In the backroom, it was harder to do that.” (First-year resident, participant 16) |
| Information sharing and transparency of communication | “[In the pandemic] we would go to [the family] and say, ‘Oh we rounded and we said the plan would be x, y, z,’ and the family misses out, they don’t hear us talking about the lab results, and unless they knew to ask…. [Families] I think would have really benefited from family-centered rounds; from hearing our thought process instead of ‘this is what we talked about and this is what we are doing.’” (First-year resident, participant 13) |
| Representative Quotes | |
|---|---|
| Theme 1: Process of FCR | |
| Variation in rounding procedure | “We rounded in one conference room, so parents were not involved. Most of the time nursing was also not involved and we just ran down the list. So the structure of rounds in terms of how the resident presented…but the language was not family friendly or oriented, much more academic.” (Faculty, hospital medicine, participant 18) |
| “When I started the ICU rotation at the end of March, they were trying to enforce social distancing for us, so having fewer people on rounds. One resident stayed at the work station to put in orders if nurses needed them. And if we were on rounds, they wanted us to maintain 6 feet distance…. I had 4 different attendings over 4 different weeks, so I probably went from most to least strict. And I think that was also just everyone’s comfort with masks and social distancing and how the world was working.” (Third-year resident, participant 10) | |
| Feelings of loss of control and confusion about rounding structure | “It was a very difficult time in general. It was the very beginning of the pandemic and so there was a lot of ‘what if.’ Everything was changing every day. At the start of the block, we talked about trying to preserve the integrity of rounds, and making sure to do teaching…and I felt like rounds were allowed to be a lot more interrupted because the interns were sitting around during rounds.” (Third-year resident, participant 19) |
| Theme 2: Reaching consensus with families | |
| Partnership with family | “I think such a big part of taking care of someone is communication with their family, so definitely not communicating with them in person or not meeting everyone during the day, that aspect was more difficult. But I think clinically, the children had good plans, but I think in caring for them in the communication sense, like involving them in the plan and making them feel heard, that definitely suffered.” (Third-year resident, participant 5) |
| Family providing context | “It’s hard to not have the family input…so it was harder to make the plan without the family in front of me because a lot of times a question about discharge or how long we would monitor a patient would be very dependent on the family…when you’re in the room, you can assess that type of thing. In the backroom, it was harder to do that.” (First-year resident, participant 16) |
| Information sharing and transparency of communication | “[In the pandemic] we would go to [the family] and say, ‘Oh we rounded and we said the plan would be x, y, z,’ and the family misses out, they don’t hear us talking about the lab results, and unless they knew to ask…. [Families] I think would have really benefited from family-centered rounds; from hearing our thought process instead of ‘this is what we talked about and this is what we are doing.’” (First-year resident, participant 13) |
Both faculty and residents reported uncertainty about rounding procedures and rapidly evolving policies, which added to the overall sense of loss of control during this time.
I would say I think there was a change over the course of my time on service…I think as the pandemic was unfolding, a lot of mental and emotional attention was put to how do we keep us and our families and our patients safe, how do we get to the hospital, do we have the right clothes, etc…so much attention was paid to those elements of simply doing the job that there was less room for anything else.
Faculty, hospital medicine (participant 17)
Although participants perceived changes to FCR, they did not believe that patient care suffered as a consequence.
Reaching Consensus With Families
Participants described the importance of arriving at consensus with families during FCR and noted challenges when families were not included in rounds. Three subthemes were identified: (1) partnership with the family, (2) the family providing context, and (3) transparency and accuracy of communication with the family. Participants reported fewer opportunities to build partnership with families due to lack of bedside rounds, fewer interactions throughout the day, and the constraints of PPE.
When you actually go and see the parents, they would say, “Oh I haven’t really seen a doctor today, except for that one person that came earlier,” and that added another level of anxiety to the families because they feel abandoned and not really heard, which was true.
First-year resident (participant 9)
Participants were also unable to devise tailored plans when family members were not present to provide additional information or background regarding their child. As this participant states, most felt that communication with patients and families lacked clarity and timeliness because it was often done later in the day and lacked the clinical reasoning discussion that would have taken place during FCR:
Whenever we went into the room, it was less drawing them into the care plan and more like, “This is our plan, we came up with it in the hallway, this is what we are going to do unless you say that you don’t agree.” And I think we spent less time in each room throughout the day.
Faculty, hospital medicine (participant 6)
Miscommunications were exacerbated by fragmented communication by individual providers, frequent changes to plans once the family was involved, and inability to provide a unified message during FCR (Table 2). In the ICU setting, where families remained involved, providers described less difficulty creating partnership, although they endorsed challenges due to physical barriers of PPE.
Collaboration With Members of the Medical Team
Residents and faculty identified FCR as a designated time for collaboration among many parts of the medical team. Two subthemes were identified: (1) the nursing role in devising plans and (2) a shared group mental model. Perspectives were mixed on whether the role of the nurse changed. On services in which nurses were unable to join rounds, most participants noted the loss of their perspective and familiarity with daily plans.
I felt like we just didn’t have the benefit of hearing [the nurse’s] impression…they often know the patient best, so you are rounding with incomplete information until you find the nurse.
Faculty, hospital medicine (participant 18)
Outside rounds, many participants felt the nurse’s role globally increased to include more family communication and reporting of clinical information because they were inside rooms more frequently to fulfill patients’ clinical needs.
Many participants viewed FCR as an opportunity to adopt a shared group mental model about patients’ conditions and plans among the primary team and consulting services. Faculty perceived no change in ability to discuss patients within the primary team, whereas residents expressed difficulty contributing if they were not physically present (Table 3). In terms of communication with other subspecialties, many residents reported difficulty contacting other services and shared concerns that virtual consultations were inferior.
A lot of consults were done virtually during that time, and that was a unique challenge…they got the important information…I just do wonder, sometimes the consult was virtual so there was no physical exam and just the video and getting what they can…it makes sense from risk and benefits, but it’s not the same exam.
Second-year resident (participant 14)
Themes 3 and 4 With Associated Subthemes and Quotations
| Representative Quotes | |
|---|---|
| Theme 3: Collaboration with members of the medical team | |
| Nursing role in patient care and plans | “I think the biggest [change] was the nurse, because it’s nice to have that face-time in the morning so you can see their face of whose taking care of your patient and make sure that they are on the same page.… I think that some interns were really good about texting the nurses after rounds to say, ‘This is what’s going on and this is the plan,’ but I think sometimes they got busy and would forget to do that. So the nurses would see an order going in and be like, ‘Why are we doing this?’” (Third-year resident, participant 5) |
| Shared group mental model among care team | “It wasn’t as easy to know the other patients that you weren’t directly caring for. So on rounds, like I mentioned, it was just the resident specific to that patient and then the other resident on call, so the other residents that would eventually be on call another night, you weren’t seeing the day by day details of these patients, so you knew their story a bit less granularly. And that made being on call harder.” (Third-year resident, participant 11) |
| “There were some services that were…less quick to come to bedside unless there was a strong reason.… On the one hand, that was suboptimal because there was less in-person interaction, which is valuable, but I almost feel like a culture of easy access developed, people became much more accustomed to calling and texting than before.” (Faculty, hospital medicine, participant 17) | |
| Theme 4: Resident education, modeling, and supervision | |
| Balance of teaching | “My sense of that is that [modified rounding] didn’t necessarily change the amount of teaching, but the way that it was done was very different…I think that opportunity to learn about interactions with families or how to have potentially difficult conversations with families, I think that part was lost, because we just weren’t doing that as a team.” (Faculty, hospital medicine, participant 1) |
| Roles on team and provider autonomy | “When I came on service, I was told by others that everyone was sit-rounding and mostly seeing patients independently or with the interns…if there is a dynamic [clinically evolving] child or a child that one of the team members is worried about, then we would see them together, but my default was to see them alone to minimize everyone’s exposures.” (Faculty, hospital medicine, participant 17) |
| “I think that without being able to see the patient as the senior resident…I think on family-centered rounds, depending on the attending, usually the senior resident would be in charge of saying, ‘I agree with you’ or ‘Here’s how I would change the plan,’ and not being able to see the kid, I mean I can give a generic plan, but…it was hard to do concrete plans. And then sometimes for those kids, you just let the attending make the plan because they would go and see them and then I would just find out afterwards.” (Third-year resident, participant 5) |
| Representative Quotes | |
|---|---|
| Theme 3: Collaboration with members of the medical team | |
| Nursing role in patient care and plans | “I think the biggest [change] was the nurse, because it’s nice to have that face-time in the morning so you can see their face of whose taking care of your patient and make sure that they are on the same page.… I think that some interns were really good about texting the nurses after rounds to say, ‘This is what’s going on and this is the plan,’ but I think sometimes they got busy and would forget to do that. So the nurses would see an order going in and be like, ‘Why are we doing this?’” (Third-year resident, participant 5) |
| Shared group mental model among care team | “It wasn’t as easy to know the other patients that you weren’t directly caring for. So on rounds, like I mentioned, it was just the resident specific to that patient and then the other resident on call, so the other residents that would eventually be on call another night, you weren’t seeing the day by day details of these patients, so you knew their story a bit less granularly. And that made being on call harder.” (Third-year resident, participant 11) |
| “There were some services that were…less quick to come to bedside unless there was a strong reason.… On the one hand, that was suboptimal because there was less in-person interaction, which is valuable, but I almost feel like a culture of easy access developed, people became much more accustomed to calling and texting than before.” (Faculty, hospital medicine, participant 17) | |
| Theme 4: Resident education, modeling, and supervision | |
| Balance of teaching | “My sense of that is that [modified rounding] didn’t necessarily change the amount of teaching, but the way that it was done was very different…I think that opportunity to learn about interactions with families or how to have potentially difficult conversations with families, I think that part was lost, because we just weren’t doing that as a team.” (Faculty, hospital medicine, participant 1) |
| Roles on team and provider autonomy | “When I came on service, I was told by others that everyone was sit-rounding and mostly seeing patients independently or with the interns…if there is a dynamic [clinically evolving] child or a child that one of the team members is worried about, then we would see them together, but my default was to see them alone to minimize everyone’s exposures.” (Faculty, hospital medicine, participant 17) |
| “I think that without being able to see the patient as the senior resident…I think on family-centered rounds, depending on the attending, usually the senior resident would be in charge of saying, ‘I agree with you’ or ‘Here’s how I would change the plan,’ and not being able to see the kid, I mean I can give a generic plan, but…it was hard to do concrete plans. And then sometimes for those kids, you just let the attending make the plan because they would go and see them and then I would just find out afterwards.” (Third-year resident, participant 5) |
However, some faculty reported that mobile technology facilitated consultant communication and/or inclusion in rounds (Table 3).
Resident Education, Modeling, and Supervision
Participants noted changes in opportunities for resident education, modeling, and supervision during FCR. Two subthemes were identified: (1) balance of teaching and (2) roles on team and provider autonomy. Participants reported mixed effects on resident education. Participants reported continued opportunities for teaching during rounds, although the content was more theoretical in nature rather than bedside or case based. There was more use of medical language and learning about new disease processes (eg, multisystem inflammatory syndrome in children) and less modeling of family-centered conversations and physical examinations.
I think everyone was functioning in a crisis mode, so our priorities shifted appropriately. So I think we learned a lot about functioning in those conditions and new systems and about COVID and [caring for] adults and just very different things than we are used to…I think there was less bedside teaching. We still had the teaching about differentials and meds and things like that.
Second-year resident (participant 14)
Participants also noted changes in team roles, especially around communication and resident autonomy. Faculty had the responsibility of determining round structure, which often changed on the basis of evolving guidance. As part of this, some faculty described a desire to mitigate resident COVID-19 exposure and thus saw many patients independently, although residents often did not agree with this strategy.
I think going with the attending together, it felt like it preserved resident autonomy of “this is my patient” because other weeks when the attending would go by themselves, I lost a lot of my autonomy. And I get it, they wanted to limit our exposure and conserve PPE, but I just think there was a way to preserve autonomy and patient care, and if everyone took the resident together, it would have solved a lot of problems.
First-year resident (participant 13)
Faculty reported taking on more responsibilities that usually fall to residents, such as communicating plans to families. Faculty also stated they were more likely to dictate care plans rather than allowing space for residents to propose plans, which they attributed to a higher cognitive load from balancing team leadership and autonomy during an uncertain time.
[Communicating plans] happened during rounds…or would happen when I went to see the family in the morning, I would talk to them then. I mean the residents still had some communication with the family…but as far as the big plan, it was me…more fell to the attending.
Faculty, critical care (participant 12)
Participants agreed that roles on the team and autonomy had changed, although the changes and drawbacks varied by role (Table 3).
Participant Recommendations for FCR During the COVID-19 Pandemic
Participants shared several recommendations for rounding during pandemics and lessons learned for typical FCR as the pandemic abates. First, standardizing rounding plans by service was commonly cited as a mechanism to provide clarity to changes in FCR. This was universally recommended by faculty to eliminate pressure they faced to determine policies and by residents to reduce week-to-week variation. Second, participants recommended prioritizing nurse participation by rounding in order of nursing assignments and by calling nurses to participate over the phone. Third, participants emphasized the importance of virtual family participation in rounds. During the study period, handheld mobile devices were donated to enhance communication with isolated patients, yet these were only used intermittently for virtual consultations. If virtual rounds were not possible, many suggested that the faculty and first-year resident go to the bedside together after rounds for an abbreviated FCR in an effort to achieve a shared mental model, reach consensus, and preserve resident autonomy. Many faculty also noted that these recommendations would lead to more high-quality FCR even when pandemic-related restrictions are not necessary, specifically standardization of FCR processes and creation of models and/or schedules that prioritize nurse and family involvement despite competing priorities.
Discussion
The COVID-19 pandemic disrupted the typical FCR communication workflows and consequently led to changes in collaboration between families and the care team. Despite emerging literature describing hospitals’ pandemic responses, most studies are focused on the implementation of technological adaptations for patient care and not on the impact of rounding modifications.6–8,15–19 This study documents previously unreported physician perspectives on FCR changes. Many recommendations reported here have been implemented at our and other institutions and may continue to be relevant during the remainder of this pandemic, during future pandemics, and in situations in which a family member is unable to be physically present or a patient has a highly communicable agent, such as measles.
Communication and partnership with families was hindered by lack of consistent family inclusion during FCR, use of additional PPE, and decreased overall in-person interaction. Teams that included families through “hallway rounds” or virtual adaptations felt better able to involve families, share information, and address their concerns. Participants recommended bringing families to rounds virtually, which has been described elsewhere.17–22 “Tele-rounds” have been received positively by both families who feel included and able to have time with providers7 and by clinicians who report family appreciation and decreased in-person exposure.17 Parents of children with medical complexity also recommend safely maintaining communication by virtual rounding, especially during this time marked by anxiety and isolation.20 Family participation through technology and/or other novel approaches should be standardized to maintain this core principle of FCR.
Perspectives were mixed regarding communication with members of the care team. Participants felt that bedside nurses were less involved in decision-making when they were not included in rounds. Still, they were expected to relay and reinforce care plans with families because of their bedside role and often played a heightened role in relaying clinical information to providers who saw the patient less frequently. This matches nurses’ own descriptions of increased reliance on their clinical observations and expansion of their role to include delivering bad news to families.21,23 Because of smaller in-person teams, residents reported gaps in the group’s shared mental model when denied the opportunity to enter the patient room or be present for rounds on patients whom they were not managing but would later cover while on call. Most participants reported difficulty communicating with consultants due to decreased physical presence, although some faculty reported a favorable culture change around texting and/or telephonic communication and virtual rounds with consultants. Virtual team rounds have been described in adult and pediatric settings7,8,15–17,24 ; virtual rounds with a standardized rounding script led to decreased faculty variation and better inclusion of nurses and physicians.25 Achieving a shared mental model with the care team is a key FCR principle that may be sustained through technological approaches ranging from telephone calls and messaging to videoconferencing.
Opportunities to model family and team communication workflows to trainees were also diminished because of FCR modifications. Although many teams seized opportunities for didactic teaching, typical FCR skills, including using family-friendly language, distilling complex medicine, and dealing with conflict, and the opportunity to provide feedback in these areas were missing. Team roles also shifted toward increased faculty ownership of clinical tasks, including direct family communication and clinical decision-making. Team members had different views about balancing exposure risk and trainee-patient interaction (trainees generally sought more involvement, consistent with findings at another institution26 ). A growing body of literature describes novel techniques for teaching during the COVID-19 pandemic, although few studies specifically address challenges with teaching, modeling, and supervising communication and soft skills during rounds.9,25,27–29 Virtual FCR may present opportunities to model effective family and medical team communication but notably lack patient physical examination and may have decreased time for teaching within the structured format.25 Those providing teaching services may wish to consider other means of modeling and evaluating communication (eg, simulation) in the absence of typical in-person opportunities afforded during FCR.
This study has several limitations. This study was a single-center study in a city that experienced an early first wave of the pandemic, which may not reflect the experiences at hospitals at other time points. However, the themes discussed here are core to FCR, and therefore broad themes, if not details, may be transferrable to other institutions. Similarly, recommendations described here should be adapted on the basis of site-specific details, such as structure of rounds and availability of technology. Importantly, in this study, we focused on physician perspectives and did not explore experiences of other stakeholders, such as families and nurses. This population was selected because of their capacity to discuss the concepts of interest. Future studies that explore other stakeholders’ perspectives would add to the overall understanding of FCR during the COVID-19 pandemic.
Conclusions
Physicians providing care to hospitalized children during the COVID-19 pandemic had varied experiences and perspectives with modified FCR, which likely reflects the overall uncertainty in the early phase of the pandemic. The absence of key stakeholders directly influenced established communication workflows and led to negative provider experiences. In concert with perspectives from additional stakeholders, findings from this study and application of the proposed conceptual framework may guide future efforts to strengthen patient- and family-centered care during the pandemic and beyond.
FUNDING: No external funding.
Ms Craddock conceptualized and designed the study, performed the interviews, participated in data interpretation and analysis, and drafted the manuscript; Dr Grilo participated in data interpretation and analysis; Drs McCann and Catallozzi participated in data interpretation and analysis and critically reviewed the manuscript; Dr Banker conceptualized and designed the study, participated in data interpretation and analysis, and critically reviewed the manuscript; and all authors approved the final manuscript as submitted.
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