What Participants Think About FCRs
We have learned much from data regarding participants’ perceptions of FCRs. Most of this early data was collected as part of routine customer service and staff satisfaction surveys, but some has been developed through more formal focus groups.
Some brief highlights of what we have learned to date: Family satisfaction, particularly in regard to their perception of involvement in their children’s care, is very high.4 More recently, in regard to units that do not use FCRs routinely, we have received critical comments from families about the difference in the quality of communication. Nurses comment that the discharge planning process has been greatly enhanced by FCRs. Echoing some of our family feedback, nurses noticed a void in discharge planning when rounds did not include families.
In addition, nurses indicate nurse-to-nurse communication at change of shift is better when nurses are included in rounds. Resident feedback is generally positive, particularly in regard to the enhanced efficiency and communication of FCRs. A vocal minority make it clear that FCRs need to be “done right” to balance resident’s educational needs with patient care. Participating attendings are nearly unanimous in the opinion that FCRs provide better care.5 Most also feel FCRs provide new, important educational opportunities, allowing for daily direct observation of trainees’ interactions with families. Echoing residents, attendings acknowledge it takes time to learn how to do FCRs well.
Further, ongoing quality assurance and improvement work has demonstrated decreased length of stay and increased discharge timeliness on units where FCRs are used extensively.
Family-centered rounds can look a little different within various institutions, depending on the logistical issues on specific units or with specific resident teams.
Barriers to FCRs
Probably the biggest barrier at CCHMC has been and continues to be attending physician buy-in. As I see it, at the core of attending physician reluctance is concern with sharing uncertainty in front of the family. The uncertainty issue cuts to the core of what family-centered means: The patient or family is in control of the decision-making process—not the physician. In practice at CCHMC, this concern has not been substantiated among the attendings participating in FCRs.5
Nurse-physician collaboration has been an intermittent barrier. For FCRs to reach their full potential, nurse and physician both need to actively participate and take responsibility for the process. A care plan truly comes together and becomes maximally effective when family, nurse, and physician can listen to each other’s points-of-view.
Many of the logistical barriers likely vary among institutions around issues like private rooms, computerized order entry, resident and nurse staffing, communication with referring or consulting physicians, and so on. While seeking for standardization across units, FCRs do look a little different within our institution depending on the logistical issues on specific units or with specific resident teams.
Final Thoughts
I am no longer a skeptic. While I have much to learn about how to make FCRs better, most days I feel FCRs enable me to be the doctor I hope to be: Families are informed, active participants in their children’s care; nurses are informed and empowered to make care more effective and efficient; residents get “work” done on rounds; and I get to consistently observe and model history taking, physical exam, and communication skills with physician trainees.
Fundamentally, FCRs have changed my appreciation of how to develop and teach a medical plan. I deliver better care when families are at the center of the presentation of information, the discussion of options, and the choice of plan for their children. TH