Neonatal Consultant, Oliver Rackham, shares his project, Parent-led Ward Rounds as an example of best practice for Neonatal Mental Health Awareness Week.
Why did we do this?
Family Integrated Care is a model which integrates families as partners in the neonatal unit team caring for their baby. This has been shown to improve outcomes and also prepares parents for the transition from hospital to home.
Feedback from parents shows that they want to be involved in all aspects of their babies’ care, with the support of healthcare staff. Where ward rounds are concerned, this is usually taken to mean parental presence, or perhaps “taking part” in ward rounds by being able to ask questions at the end.
Our view was that parents are actually ideally placed to “lead” the ward round, not just to observe. They are the constant throughout their baby’s stay, and have only their own baby or babies to focus on.
Parent feedback is always mixed on how best to conduct ward rounds. One key question is whether parents of other babies should stay in the room. Obviously this depends greatly on size and layout of facilities. In a spacious unit, it is easierer to maintain confidentiality with other parents present. With less space between cots, this can be hard. In these cases, some units will decide to ask other parents to leave, so that confidentiality is maintained and parents and staff are more able to discuss sensitive or emotional topics. While having an open visiting policy, our practice in Arrowe Park was to ask parents to leave when other babies were being discussed. This was done after surveying parents on their preferences; something we repeated a couple of years later, when the topic arose again. Other units has instituted other measures, such as headphones for other parents. Obviously, if parents were in the middle of, for example, feeding, expressing, skin-to-skin, etc then we would be sensitive to their needs. By discussing with the parents we could decide whether to change the order of the ward round, speak away from the cotside, or perhaps continue, being aware that some issues would need to be discussed again later.
Parents consistently fed back to us that hearing a list of “problems” every day could be distressing, particularly when many are no longer active. They also told us that it can be scary hearing about progress in clinical terms, especially in the earlier part of the stay. Parents also said that when the health professional talked they felt “left out and on the outside”. When they were asked if they had any questions, parents fed back that they “felt a bit thick” if they were asking for explanation of medical terms. Parents did value the ward round, though, and the opportunity to hear directly from the doctors.
How did we go about it?
To start running a “parent led ward round” needs no more preparation than telling parents, doctors and nurses what to expect. We did not alter the timing or pattern of the ward rounds. Parents continued to stay in for their own baby, but were asked to step outside while we discussed other babies. Obviously in other units, all parents will stay in the room.
We gave out information sheets to parents a few days in advance, which explained what it would mean. The introduction said:
I would really like to give you the opportunity to “present” your baby on the ward round this week.
This just means saying how old they are, what they weigh now, how they are doing with feeding, etc.
If you don’t want to, or don’t feel able to, don’t worry; we’ll just carry on as normal, and you can tell us or ask us anything at any time.”
We made it clear that it was entirely voluntary, and they could participate as much or as little as the wanted. We made it clear that it is not a “test” and that we would work out all the information between us all.
We gave them a brief outline to the kind of things we would normally talk about, in case they wanted to make any notes.
Gestation at birth, Days old today -> Corrected gestation
Birth weight -> Weight now
– Main issues at the moment
– Breathing support or help
– Head scans
– Eye screening
(and things like that)
– Plans for the next day or two
– Plans towards discharge
– Planned discharge date
We supplied pens and paper if they needed it.
How does it work?
As long as we give them the opportunity, all parents will “lead” a ward round, in the way that suits them.
Wait for parents to be there before starting.
Address the opening questions to them – open ended, so that they can say as much or as little as they want. Asking how they are, and then how their baby is.
And don’t ask the nurses and doctors anything until the parents have said or asked all they want to.
It means we get their key messages, and also address the things that matter to them.
As you know, that changes through the stay, and even day to day.
Some parents do not want to start the discussion, and are happy to chip in with comments and information. Others will wait until the end and then ask their questions then.
Some parents will just say something like, “she’s fine”, “he’s been OK on CPAP overnight”, “he’s off CPAP”, “his feeds were stooped again”, “we’ve taken his tube out”, and leave the doctors or nurses to carry on.
For others, they will want to give a bit more information about progress, changes or the questions they would like answering.
Often it evolves from “she’s OK” into a fairly comprehensive discussion, as they expand on what matters to them.
In the first few days of an intensive care admission, parents are generally not ready to “present” their baby, but will still let us know what is important to them.
Once a baby has been in the unit for longer, and especially as they move through their journey, either in terms of stability or in moving to high dependency or special care, parents are more likely to “present” their baby.
Most parents did this by discussing key changes in the last 24 hours; usually related to respiratory support or feeding. If the ward round started in this way, then once the doctor or nurse presented the rest of the baby’s information, the parents were more likely to contribute. They were also more likely to make suggestions regarding care when we started the ward round with them.
Some parents “presented” their baby in a structured way, either with written notes or from memory. There are many reasons that they are perfectly placed to do this. As parents spend time in a neonatal unit, they become experts in the terminology and jargon. They know their own baby’s journey in great detail, and do not have to make sure they don’t mix up one baby’s information with another’s. They remember dates (due date, date of extubation, retinopathy screening, immunisations, etc) without needing to look them up. They remember when and in what order events happened.
We were lucky enough to have some parents who were even happy to be videoed presenting on the ward round. This showed how it can be done, and the value of it. It also showed how easy it is to do. And there is always learning for the health professionals involved to improve their interactions with parents and staff, which are enhanced by watching it back.
What problems did we encounter?
Obviously this is not for everyone, and it must be made clear to staff and parents that it is voluntary, and that we will carry on “as normal” if parents do not want to lead. Some parents will not want to, or feel able to do this at all, or perhaps not until they are making plans for home.
It is possible that, while addressing issues key to their parents, staff could miss or forget to address other issues.
However, the staff will still have all of the information in the patient record, and this does not replace a structured assessment of the baby and recording of that assessment by the healthcare team.
We did receive some comments that this could limit discussion between doctors and nurses. That is certainly a very important issue to discuss. But it seems to relate to parents being present on the ward round, rather than whether they “present” their baby’s information.
Different consultants will always lead ward rounds differently. That is the nature of and one of the strengths of good team working. However, that can lead to difficulties for parents if they do not know what time they will be seen, what order a ward round might take, or how much they will be involved in the discussion. This is not an insurmountable problem, but does need open discussion among the team to ensure that this is communicated to parents.
If parents are not there at the time of ward round, a decision has to be made whether to continue without them, and catch up later, or whether to wait for them. This will depend on where they are in their neonatal journey, and what they have expressed as important to them.
Many babies are transferred between units, for example for acuity of care needed, or capacity. Differences in practice between units often confuses or upsets parents. Their level of input on the ward round can also be different as they move between units, and can increase their distress. This does need to be discussed with parents whose baby is likely to move between units.
This issue is seen with many other aspects of care as well, and so should not be a barrier to implementing parent-led ward rounds.
What are the benefits?
Parents feel a part of the team. Including them as fully as possible fosters a strong relationship between the parent and child as well as with the healthcare team.
This makes open honest discussions more likely. Parents are therefore more likely to speak to us, the healthcare professionals, about concerns or issues they have, as well as about the questions they need to ask.
Parents presenting gives a great opportunity to check that their understanding of the situation is the same as that of the doctors and nurses.
An example was of feedback from a parent who was told that “the bleed on the brain is stable” when they hadn’t been told about it in the first place. It is too easy to assume that we have told parents things when we haven’t. Or that they have been able to take it in or understand it at the time / place we did tell them. If the parents had been leading the ward rounds, this would not have happened.
Parents have also fed back that what was most important to them was often not discussed. For example, a likely date of discharge is an important topic from very early on for some parents; it gives them hope. If we do not let parents lead the discussions, we may not achieve this.
With consent, we shared one video of a parent presenting in full on Twitter. This was very well received, with some excellent feedback and comments, as well as some questions and challenges. This was a great way to spread the idea, and receive ideas.
What could we have done differently?
Once a “proof of concept” test had been done, try to make every ward round run like this.
Get more objective feedback before and after implementation from parents and staff.
Video different ways of parents presenting, for reflection from staff and for education.
Trial different ways for parents to write down their comments, thoughts, questions (eg laminated cards for the cot, pre-printed ‘ward round cards’).
What has the feedback been?
Feedback has been good, with parents appreciating the opportunity to be an integral part of the team.
Some staff were wary at first, fearing that this would be taking something away from them. However, once they realised that it only adds to the content of the ward round, this fear seemed to resolve.
Parents commented that they need to “present” their child when they attend the GP, emergency department, assessment ward or clinic. So it was very useful to be doing that in the neonatal unit.
“I actually think it’s set me up well to still be really proactive with his ongoing stuff, I want to understand everything. I reckon I could still rattle off all the problems he had in the early days.”
“When I was there with xxx I was more involved in the ward rounds and it gave me a better sense of what was happening but when I have been on other units with my babies they never really let me get involved with the ward rounds.”
“We were asked how he was doing….and you listened to what we had to say. We felt well informed and knew what the plan was every day. You helped us to know every detail about our baby which gave us confidence and comfort. We had a guaranteed time everyday to ask questions, raise concerns or celebrate achievements.”
“The ability to comment on things and being asked questions by Drs such as ‘how do you think the swelling compares to yesterday?’ during ward round and the parents’ conversation at the end all made it a success in my opinion.”
“… when they’ve been in for a while and the consultant knows the baby well perhaps only run through the relevant history and problems!”
“This is a fantastic idea! We often forget that the parents are the ones who’re there consistently and know their baby the most.”
“Thank you for keeping us so well informed and involved in those first scary weeks.”
“For us it was easy to do (apart from being camera shy!!) because of us living this day in day out…. We were super proud to present for our son!”