Pediatric Family-Centered Rounds and Humanism: A Systematic Review and Qualitative Meta-analysis Free

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to complete a systematic review and qualitative synthesis, to understand the relationships between FCRs and humanism.²⁸ 

We included (1) English-language (or translated) peer-reviewed literature published from journal inception to January 1, 2020, (2) literature addressing FCRs, and (3) literature specific to pediatrics. Literature that was focused primarily on nonhumanistic outcomes (eg, educational outcomes, efficiency, or FCC) or did not contain original data was excluded unless it also measured outcomes pertinent to this study.

We searched these databases: PubMed, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and Dissertation Abstracts, using the search terms noted in Supplemental Table 4. We included 3 additional studies after completion of a hand review of article bibliographies.^7,29,30  Since the coronavirus disease 2019 (COVID-19) pandemic began in 2020, there have been no additional studies that met our search criteria; however, the impact on FCRs has been felt,³¹  and authors of 1 published abstract offer a novel adaptation.³²  This will be discussed below.

After an initial database search that yielded 9319 titles, we removed duplicates, letters to the editor, and editorials (Fig 1). The remaining 6847 studies were prescreened by title, and studies that were unambiguously irrelevant to the study aims were removed. Next, 4 members of the research team conducted a “first pass” screen of the remaining 158 publications by abstract (Fig 1). The use of the Sisterhen et al¹⁴  definition of FCRs as a guide was critical to this stage, because the initial search identified many articles related to FCC. Sisterhen et al¹⁴  narrow the scope of FCR to exclude other elements of FCC that might occur after hospitalization. In keeping with the traditional “triad” of pediatric care (patient, parent, and physician) study abstracts were also included if they discussed the impact of FCRs from the perspective of any of these groups.³³  In a “second pass,” studies that were focused only on FCC or nonhumanistic outcomes, were theoretical, or were review articles without original content were excluded by 2 senior authors; this yielded 42 publications (Fig 1). Next, 4 senior members of the research team separately examined the full text (“third pass”) for appropriateness, relevance, strength of study design, and results. Reviewers then met to discuss and resolve discrepancies until consensus was reached. This careful iterative process, after excluding studies on the basis of the same criteria as the second pass, ultimately yielded 29 studies (Table 3) that met all eligibility criteria. (Fig 1).

We then used the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist for observational studies to assess the comprehensiveness of reporting for studies included in our review,^34,35  an approach similar to other systematic reviews of qualitative studies.^36,37  We reviewed the articles for each element of the STROBE checklist and discussed any disagreements to arrive at consensus. This allowed us to ascertain how explicit and complete the reporting was, using a widely accepted standard for observational studies (see Supplemental Table 6).³⁴ 

Four members of the research team then reread the 29 remaining studies with an analytic, intentional focus on humanistic ends and identified specific outcomes related to the core values of humanism. These outcomes were deductively coded through interactive team discussion and reflection and mapped to APGF’s 7 core values (Table 2). Through this process, 5 common humanistic outcomes were associated to at least 1 of the APGF’s 7 core values of humanism: empathy, enhanced communication, partnership, respect, and satisfaction and service. Three of these outcomes directly correlated to 1 of the 7 APGF’s definitional elements of humanism (service, respect, and empathy: see Table 2). Two (partnership, enhanced communication) are not 1 of the 7 core values but are integrally related to multiple values and can be evaluated by outcomes-based studies; they were later mapped to the APGF’s core values of humanism (Table 2). Using these 5 humanistic outcomes as a “code book,” we then reinvestigated the 29 studies by coding for the presence of any of the 5 humanistic outcomes and whether FCRs had a positive, negative, or no effect on that theme (Table 3).

A variety of study methodology was included in the 29 reviewed studies (Table 3). Researchers in 3 used controlled trial methodology,^15,38,39  those in 7 used a pre- and posttest intervention design,^19,40–45  those in 3 used interview or focus group methodology,^30,46,47  and 1 was a systematic review in which researchers reported mixed methods.¹¹  Authors of the remaining 16 used survey methodology.^{7,8,20,26,29,48–56}  In 5 of the survey studies, researchers used other evaluation methodologies, including interview and focus group and/or observation tools.^20,51,53,56 

These studies varied in terms of the specific populations analyzed. In 11 studies (38%), researchers evaluated parents and/or families only^{26,30,38,40–42,45–48,57} ; in 6 (21%), researchers evaluated parents and/or families and health care providers^{20,38,44,49,51,53} ; and the rest evaluated a combination of parents and/or families, patients, trainees, and nurses.^{7,8,11,15,19,29,39,43,50,52,54–56} 

Empathy was identified in 9 studies. Researchers in 2 studies found no difference in empathy: those in one used semistructured parental interviews, and those in another used surveys administered to patients and members of the rounding team.^35,53  Researchers in the other 7 studies reported increased empathy.^{7,15,19,38,39,47,54}  In 2 studies of medical students’ experiences, researchers reported that students observed attending physicians modeling empathetic qualities and perceived this as a positive effect.^7,19  Authors of a Pakistani study found that parents perceived that their inclusion made the child feel more secure.³⁸  Lewis et al¹⁵  reported that parents’ perceptions of physician empathy increased with FCRs.

Enhanced communication was evaluated in 24 of 29 studies (83%). Communication improved in 21 of 24 studies (88%), including evaluation by patients, parents, health care team members, and/or trainees. The 3 studies not reporting enhanced communication had mixed findings. Lion et al⁴⁶  compared FCR use with limited English proficiency (LEP) families and English proficient (EP) families⁴⁶  and found that teams were more likely to summarize in plain language for LEP families but also more likely to have medical discussions without the family present. Cheston et al⁴¹  used interpreters within FCRs for LEP families and demonstrated improved communication and satisfaction with both LEP and EP families. Rappaport et al⁵³  found significant differences with FCRs in one small aspect of communication: families understanding the various team member roles. Khan et al⁵⁰  showed improvements in some elements of communication, but nighttime perceptions of communication by families did not improve postintervention, possibly because of the irregularity of nighttime rounding and lower staffing.

Partnership, defined here as an increased perception of respect through shared decision-making, was evaluated in 23 of 29 studies (79%). In all but 4 studies, there was an increased sense of “partnership” through the use of FCRs,^42,50,53,54  often demonstrated by increased involvement in decision-making. Latta et al³⁰  found an increase in inclusion after FCR implementation. Similar results were seen across multiple clinical settings, including neonatology (NICU), the PICU, and general pediatric inpatient service and oncology units, as well as in online and in-person surveys of health care providers from different disciplines and levels of training.^44,48,52,55  Mittal et al,⁸  in a cross-sectional online survey of 265 pediatric hospitalists, found 78% of respondents perceived a benefit to “increased patient/family involvement in care” with FCRs. In a prospective study, Kuo et al²⁶  compared 49 FCR and 48 non-FCR families, showing an increase in the domain of partnership, with parental perception of FCR-practicing doctors as more likely to explain things clearly, spend more time with the child, and make the parent feel like a partner.²⁶ 

Rea et al¹¹  conducted a systematic review of families’ experiences with pediatric FCRs (2007–2017). In their analysis, they demonstrated strong evidence of increased partnership. Parents’ desire to be included in FCRs was high, and parents perceived that partnering with the medical team led to improved care while allowing families and medical teams to serve as “resources to one another.” In the systematic review, they emphasized, as we do, the study by McPherson et al⁵¹ , in which 87% of parents surveyed believed that inclusion increased the ability to advocate for their child. However, Rosen et al⁵⁴  studied both parents and staff in all 5 humanistic thematic areas (Table 2). They observed an increase in empathy by health care providers and enhanced communication but did not report differences in partnership, respect, and service and satisfaction between FCR and non-FCR rounds. We speculate that this may be due to brevity of the study period, which compared PICU pre-FCR rounding (1 week) with post-FCR rounding (1 week).

Respect was evaluated in 16 of 29 studies (55%), and researchers all but 3 found an increase in the perception of respect between providers and families.^8,53,54  The Mittal et al⁸  survey yielded mixed results. Although there was a modest improvement in confidential patient care (22%), an outcome we included as “respect,” the researchers also reported trainees’ fears that they would be “less respected” or seem less knowledgeable by parents during FCRs. Still, Whelihan et al⁴⁵  surveyed families in the NICU before and after an FCR intervention and demonstrated increased perception of respect.⁴⁵  Additionally, in hospitalist and PICU patients of Latino families, Walker-Vischer et al⁵⁷  demonstrated increased perceptions care and respect. Jeglinsky et al,⁴⁹  in their Finnish study in neuropediatric wards, compared health care providers’ and parents’ attitudes toward FCRs. “Treating people respectfully” was highly rated by both groups. Landry et al³⁹  evaluated both parents and pediatric residents after FCR implementation. Parents felt that FCRs were associated with higher levels of respect for the child, more parental “confidentiality and intimacy,” and that the clinical problem was taken more seriously. In summary, the majority of studies found that FCRs increased patient and family perception of respect for families by the health care team.

In 16 of the 29 studies, researchers evaluated satisfaction (55%). Of these, all but 3 revealed a significant increase in satisfaction.^38,53,54  For example, Rea et al¹¹  noted 5 FCR studies in which researchers that did not use a direct comparison (non-FCR control), and all found increased parental and/or family satisfaction. Bogue and Mohr⁴⁰  showed that even in the PICU and cardiac ICU, pre- and post-FCR intervention surveys revealed improved overall satisfaction. By contrast, Ladak et al,³⁸  in their PICU study in Pakistan, showed no difference between the traditional rounding group and the FCR group. Rosen et al⁵⁴  showed high satisfaction with both conventional rounds and FCRs and, therefore, no statistical difference. Although Rappaport et al⁵³  showed no improvement in parental satisfaction, authors of an earlier study⁴³  by the same author reported increased family satisfaction after FCRs.

In our systematic review and thematic analysis, we demonstrated that FCRs did improve 5 humanistic outcomes: enhanced communication, partnership, respect, satisfaction and service, and empathy. These improvements occurred across a variety of different hospital-based settings, with diverse study populations, and were particularly notable among LEP families and children with special health care needs. In this review, we demonstrate that humanistic outcomes are actually demonstrated in many studies but are not framed as such and are “embedded,” therefore requiring “extraction” to be highlighted. Our study also serves as a “needs assessment” for greater refinement and measurement of the humanistic benefits of FCRs and fills a gap in the literature. Explicitly framing the benefits of FCRs in this and future studies through a humanistic lens provides an ethical impetus for their implementation. Our discussion will focus on (1) barriers to FCR implementation and how solutions may further enhance humanism, (2) integrity, and (3) the impact of COVID-19 on FCRs.

Despite the positive effects of pediatric FCRs, many families remain unaware of their existence or how to use them.^8,11  Other barriers include provider attitudes (eg, FCRs will harm professional identity or education),^21,58  family concerns, cultural obstacles, and organizational barriers such as cost-containment.¹⁶  Rea et al¹¹  note in their review that various studies reveal that families’ cognitive and health literacy limitations may also present a barrier to FCR efficacy, because families can feel “overwhelmed.”

Provider attitudes can be a potential obstacle to using FCRs effectively. For example, Cox et al¹⁹  discovered that although medical students’ attitudes toward FCRs improved over time, a number still expressed “frequent concerns” about FCRs (eg, anxiety about presenting publicly, teaching), and students did not endorse FCRs over bedside rounds. McPherson et al⁵¹  showed that although 90% of parents wanted to be included in rounds, 90% of providers in the PICU expressed concerns about the harm of parental inclusion. Cameron et al²⁰  found that 32% of the 375 attending physicians and residents surveyed felt that FCRs limited discussion on prognoses and social issues with families, leading to negative educational and ethical impacts in the PICU. Future researchers might focus on mitigating these barriers through educational interventions targeting trainees and providers, focusing on humanistic or ethical benefits, improving the organization of rounds (eg, teaching both at “table rounds” and the bedside), and enhancing communication strategies.^2,59  Some institutions have recently piloted successful “FCR checklists” and coproduced (with parents and providers) FCR protocols to aid in standardization and best practice follow-through.^42,56  Medical educators might address the specific concerns of trainees through simulation, in which trainees can experience FCRs in a safe learning environment. Despite these challenges, researchers in the majority of studies suggest that FCRs can enhance communication between physician, parent, and patient while also improving a sense of partnership and promoting respect (Table 3).

Family concerns regarding communication within FCRs may be an obstacle to reaching the full humanistic potential of FCRs. Parents, according to Cameron et al,²⁰  felt that FCRs might increase confusion and anxiety (47%), although far less than conventional rounds (88%). In qualitative interviews, parents indicated that anxiety might be due to medical language or jargon during rounds. With our review, we suggest that the use of principles of health literacy (in particular “lay language”) within FCRs improves quality and effectiveness and should be considered standard practice.¹⁰  One study revealed that explicit attention to the use of simpler, accessible language with LEP families had a clearly positive impact in their perception of inclusion.⁴⁷  Two international studies revealed that the use of simple language improves the quality of FCRs.^38,49  Walker-Vischer et al⁵⁷  showed that in 14 Latino families, the use of FCRs led to enhanced communication and perception that expectations were met and that their presence was valued. Developing educational interventions training providers in the importance and use of lay language during FCRs should be expanded. The Patient and Family-Centered I-PASS Research Study could be a model for such efforts.⁶⁰  The importance of the humanistic benefits of FCRs must also address health care provider concerns about teaching needs, efficiency, privacy, and burdens on the family. We agree with others that such barriers can be overcome.⁵⁹  Cameron et al²⁰  propose practical changes, including offering families the option to participate in FCRs, reminding parents of FCR’s educational purpose, returning later if concerns cannot be addressed within rounding time lines, and emphasizing the value of parental input.²⁰  Patient and family encounters should shift paradigmatically from “knowledge transfer” to a strategy of increasing self-efficacy and authentic partnership.⁶¹ 

Of the APGF’s core values of humanism, there was only 1 component, integrity, that no study of FCRs measured and that did not relate to any other identified theme (Tables 1 and 2). We acknowledge the crucial importance of integrity in medicine, and also that there are long-standing conceptual difficulties with measuring such complex values, requiring longer observation and tracking than the short clinical encounters typical of FCRs.⁶²  Future studies addressing this gap might, for example, incorporate perceptions of “ethical leadership” by patients and families as a surrogate for integrity.⁶³ 

Since we began our work on this review, the impact of COVID-19 has been felt worldwide; although challenging decisions are being made with respect to limits on family visitation, the humanistic benefits of FCRs should be underscored.³¹  In a recent report, Rogers et al highlighted the innovations already occurring because of the pandemic, using telemedicine for FCRs; researchers integrated a resident-led, in-person, in-room encounter, with an electronic tablet to facilitate live interaction between the patient, family, and other team members. They concluded that approaches such as this still preserved family engagement, trainee autonomy, and efficiency: core components of traditional FCRs.³²  Although this novel intervention needs additional data, it did reveal in a small cohort that, even with COVID-19 modifications, families appreciated FCRs strengths in “making the [hospital] experience feel more personal, the ability to see familiar faces and assess body language, and the opportunity for residents to present directly to families.”³² 

Our systematic review had several limitations. First, because precise definitions of “humanism” and “FCRs” are rarely given, we recognize subjective connections of humanistic themes to some portion of individual studies’ designs or outcomes must be made. We also equated for our purposes the terms “service” with “satisfaction.” Although satisfaction and service are not identical, reported satisfaction was often the result of the perception of service, although we acknowledge the multifactorial nature of satisfaction. Second, although there is publication bias in our review, it should be noted that some studies had mixed results as to the positive humanistic benefit of FCRs, and no researchers showed improvement in all 5 humanistic themes. Finally, as previously mentioned, the APGF’s core value of integrity, which no study of FCRs measured, will need addressing in future studies evaluating humanism.

In this systematic review, we demonstrate the association between pediatric FCRs and improved humanistic outcomes, adding significant credibility to FCRs representing the standard of care. Researchers in the majority of pediatric FCR studies highlight positive impacts on the humanistic domains of communication, partnership, respect, and service, whereas empathy was improved in one-fourth of studies. Positive effects are seen across diverse clinical settings including inpatient, PICU, NICU, hematology-oncology service, and complex-care subspecialties.

Future research should focus on overcoming barriers to FCRs achieving the humanistic outcomes they promise through education and training, addressing family concerns through empathetic communication skills and greater transparency, implementing FCRs within specialized populations requiring more complex care, and adapting and assessing FCRs in times of medical and social upheaval (such as COVID-19) to enhance its strengths of accessibility, partnership, and respect.

We are grateful for the financial support of the Arnold P. Gold Foundation’s Research Institute and for the editorial contributions of Alex Kemper, MD, Division Chief, Primary Care, Nationwide Children’s Hospital.