Family member experiences with adult ICU multidisciplinary rounds: Transition from Observers to Participants
Tannis Sidloski, MN, RN, CNCC(C), Marie Edwards, PhD, RN, Donna Martin, PhD, RN, and Kendiss Olafson, MD, FRCPC, MPH
By Tannis Sidloski, MN, RN, CNCC(C), Marie Edwards, PhD, RN, Donna Martin, PhD, RN, and Kendiss Olafson, MD, FRCPC, MPH
Abstract
Background & Purpose: Family members’ participation in multidisciplinary rounds (MDR) is an accepted practice in neonatal and pediatric intensive care units (ICUs) with evidence this practice is occurring in adult ICUs. The purpose of this study was to explore family members’ experiences with participating in MDR in one Canadian adult ICU.
Methods: Using qualitative interpretive description, family members of critically ill patients were interviewed about their MDR experiences. Interviews were digitally recorded and transcribed verbatim. Impressions from interviews were logged in field notes. Transcripts were coded, with data explored for patterns, similarities and differences, and relationships across interviews.
Results: Seven family members agreed to participate. Three themes were identified: (i) finding your footing – learning how to participate in MDR; (ii) part of the team – feeling included and part of the team in MDR; and (iii) in the know – the benefits of sharing information in MDR. Participants spoke about their eagerness to participate, a need for support to understand how to participate, benefits of participation, and what they learned from and contributed to MDR.
Conclusion: Families valued the opportunity to participate in MDR. Participation may be enhanced with team education, formal orientation for families to ICU and MDR, and the use of checklists and daily goals sheets in MDR.
Keywords: multidisciplinary rounds, family, participation
Implications for Nursing
- Family members valued the opportunity to participate in multidisciplinary rounds in the ICU, but require support to understand how best to participate.
- Family members gained knowledge from participating in MDR and felt they contributed knowledge of the patient to the discussion.
- Family member participation would be enhanced through team education, formal orientation to MDR, and the use of checklists and daily goal sheets in MDR.
The intensive care unit (ICU) environment and experience can be overwhelming and incomprehensible for family members of critically ill patients. As the benefits of patient-centred and family-centred care are better understood, new and creative ways to include family members in care and care decisions are explored. In 2007, the American College of Critical Care Medicine Task Force (Davidson et al., 2007) clinical practice guidelines for family-centred care in ICUs recommended family participation in multidisciplinary rounds (MDR). Pediatric and neonatal ICU settings were early adopters of this practice, with evidence that parents desire to participate in MDR, express satisfaction with rounds participation, view rounds as a good source of information, feel respected at rounds, and value the opportunity to discuss care plans during rounds (Burns et al., 2017; Glick et al., 2020; Kuo et al., 2012; McPherson et al., 2011; Rappaport et al., 2012; Rea et al., 2018; Woldring et al., 2023). As studies are emerging from adult ICUs, family participation in rounds has been shown to increase family satisfaction, decrease anxiety for families, and improve communication between families and the healthcare team (Calderone et al., 2022; Kydonaki et al., 2021).
Despite evidence of the benefits of inclusion of families in MDR, an international survey of member countries of the World Federation of Societies of Intensive and Critical Care Medicine (n = 345 respondents from 40 countries) found that only 16% of respondents reported fully adopting family-centred rounds, with 28% indicating these rounds were “somewhat in place” and 56% indicating family-centred rounds were not in place (Kleinpell et al., 2018, p. 254). In an observational study across adult ICUs in seven hospitals in Canada, only 23% of families participated in rounds (Au et al., 2018). More research is needed to describe the experience of families participating in MDR in adult ICUs to understand better how to implement family-centred MDR effectively, including barriers and facilitators to family participation (Calderone et al., 2022).
In our experiences as clinicians and researchers with careers spanning decades, we have long recognized the value of family inclusion in patient care. We have witnessed the positive impact of family involvement on the health and well-being of the critically ill patient and on our ability to provide care consistent with patient values and beliefs. All patient-centred and family-centred interventions, however, must be grounded in the feedback and experience of patients and their families. The purpose of this study was to explore the experiences and perspectives of family members of critically ill patients on participating in MDR in an adult ICU.
Research Approach and Methods
The qualitative research approach of interpretive description was used in this study. Developed by Thorne (2016), this approach focuses on studying human experiences in a way that links findings to clinical practice. Additional information about interpretive description is provided in the data analysis section.
Study Setting
The study unit is a 10-bed mixed medical-surgical ICU located in an urban acute care hospital (i.e., non-tertiary centre) in Western Canada. Family presence during rounds is endorsed by the local critical care program and was routine practice in this unit for a few years prior to the study. This practice became disrupted during visitor restrictions with the COVID-19 pandemic. As recruitment commenced, two essential care providers were permitted to visit if it was confirmed that the patient did not have COVID-19. Family members had the option to participate in MDR in person or virtually.
Recruitment and Interviews
Following review and approval from a University of Manitoba Research Ethics Board (HE2021-0127) and the hospital’s research access committee, recruitment posters with the first author’s contact information were placed in the study ICU’s family waiting room and handed out by members of the staff to family members participating in MDR. Interested family members either contacted, or agreed to be contacted by, the first author. After obtaining informed consent, an interview time was determined. All interviews occurred via telephone and were digitally recorded and transcribed verbatim. Collection of demographic data occurred at the beginning of the interviews. Interview questions created through a review of the literature were used to guide the semi-structured interviews (see Appendix A). Field notes were recorded after each interview to capture the first author’s impressions of the interview. Based on field note observations of confusion with one question, the question was altered to make it clearer for participants and to elicit their assessments better of what worked well and what could be improved with MDR.
Data Analysis
A goal of interpretive description, through sorting, organizing, and analyzing the data, is to identify “recurrent patterns, or shared realities, within [human] experiences” (Burdine et al., 2021, p. 336). Relationships between data sections within and across data sources are identified and then researchers consider “the manner in which these relationships play out (or don’t) across the … wider data set” (Thorne, 2016, p. 152). Thorne (2016) refers to this as “making sense of pattern” (p. 163).
Demographic data were analyzed by calculation of frequencies, means, and ranges. Data analysis for interview data followed the steps outlined by Thorne (2016). Data were sorted and organized, starting with line-by-line coding by the first and second authors with the recording of notes in the margins of the transcripts as words, phrases, or ideas stood out. The first and second authors met to discuss their independent coding of the first two transcripts, flagging data excerpts that appeared
“meaningful” (Thorne, 2016, p. 162) and attending to the similarities and differences in participants’ descriptions of their experiences with MDR. This discussion informed the coding for the remaining data. As the whole set of transcripts were reviewed and coded, and field notes reviewed, patterns and relationships in the data were identified, discussed, and explored and themes were agreed upon to represent these patterns.
Findings
Characteristics of the Sample
A convenience sample of seven participants, five women and two men, was recruited for this study over a period of 7 months. The mean participant age was 57.3 years (range 33–85 years). One participant had completed high school and six participants had completed a college or university diploma or degree. Participants were partners (n = 2), adult children (n = 3), and extended family members (n = 2) to the critically ill patient, and most attended MDR in person (n = 6), while one participated only virtually. Four additional family members were interested in study participation but, ultimately, declined, as they felt overwhelmed with the ICU experience and wanted to focus on their ill family member.
Themes
A recurring point of discussion before, during, and after the interviews, as noted in the field notes, was the significant stress or anxiety participants reported surrounding their family members’ illness and ICU stay. Participants described the experience of having a family member in the ICU as challenging, using words like “confusing”, “isolating”, and “overwhelming”. As one participant noted:
“The intensive care unit was like a black box that the patient would disappear into. You’d get to visit for short periods of time, but, you know, it was very confusing, a very alien environment. And you don’t really know what’s going on. And that itself is just very anxiety provoking.”(Participant 7)
All participants viewed MDR participation positively and reported that it decreased the anxiety, confusion, and uncertainty of the ICU stay. Three themes were identified through the
data analysis process: 1) finding your footing – learning how to participate in MDR; 2) part of the team – feeling included through participation in MDR; and 3) in the know – the benefits of sharing information in MDR. Each theme is described below. The authors developed an infographic to summarize and depict themes identified in this study (Figure 1).
Theme 1: Finding Your Footing – Learning How to Participate in MDR
All participants identified that they were invited to attend MDR by at least one nurse or physician in the ICU. Three participants who had past experiences with ICU environments through employment in healthcare settings described having a general understanding of team members’ roles and expectations. Even with this knowledge, they reported emotional challenges being “on the other side” of the rounds table. The remaining four participants reported that the invitation to rounds was unexpected.
Figure 1
Transition from Observers to Participants
One participant described the invitation to attend as follows:
“On Monday morning I was there at 9 o’clock and I was sitting looking at [patient’s name] through the glass. And the nurse came over to me and said, ‘Would you like to come over and listen to the rounds?’” (Participant 5)
The four family members with no prior knowledge of MDR expressed initial uncertainty regarding attending rounds in terms of the process, their role, and expectations around what was appropriate to say or ask, but all agreed to attend. One participant stated the following:
“I was hesitant to agree to this [MDR attendance] just because it is a kind of traumatizing situation to begin with. And I didn’t know what it really meant when I was offered to be part of rounds…” (Participant 2).
Once at MDR, all participants indicated they were not introduced to the team members present.
“It would have been nice if they kind of, you know, let the person know who they are. The doctor definitely did, but no one else did.” (Participant 2).
The four participants without healthcare backgrounds were also unsure of how best to contribute to MDR and what questions to ask.
“[Y]ou never know what kinds of questions to ask, right. Like I am not a doctor, so I don’t know what kinds of questions to ask in relation to what was going on with my [family member].” (Participant 3)
“But – I just feel, you know, it’s an awkward situation. You are in front of a bunch of highly qualified people and you are like – you don’t want to interrupt or ask silly questions. And – along with being overwhelmed, so, you don’t really think of the questions until later.” (Participant 2)
Most participants reported that comfort with the rounds process increased after their first experience, and they learned MDR structure, process, and expectations. Participants offered suggestions for how to prepare family members for MDR and increase their comfort in participating.
Participants felt introductions to the ICU staff present at rounds, along with their roles, would be helpful for family members. They also suggested that written information in the form of a brochure with information on the MDR structure and process, effective participation, and question examples
would assist family members in finding their footing during MDR.
Theme 2: Part of the Team – Feeling Included Through Participation in MDR
All participants described how the invitation to, and the experience of listening and participating in MDR promoted feelings of inclusion and value. These actions communicated that families were an important part of the team. One participant identified that MDR participation made her feel “part of the loop, you know, you’re not isolated” (Participant 7). Another described feeling like “your opinion matters, and the fact that you have all the information matters to them” (Participant 4). A third participant described how sitting amongst the team members and listening to the discussion conveyed that they were “part of the team.” (Participant 6)
Participants felt welcomed and included in MDR when team members greeted them and made space for them at the rounds table.
“They are all standing in a circle around a table, and they just fit me in between whoever is there, and I stand with them, and everybody, you know, nods and says good morning.” (Participant 5)
They also felt included when the team members used understandable language. One participant with past healthcare experience was impressed with the team’s efforts to be “aware” of family members’ backgrounds and to vary the way they spoke to different members of the family, speaking to one member of the family “at a level that they would understand” and then talking to the participant at a different level given their healthcare background (Participant 6). Finally, participants felt included and valued at rounds when team members checked in with them to see if they had questions. One family member noted as follows:
“I just think you feel valued, and you feel like you would be able to be heard and ask questions. And yeah, it just makes sure you are well informed, and your questions are answered.” (Participant 4)
Participants did not have new suggestions for the rounds process to aid in family member inclusion, instead they reinforced their positive experiences that promoted feeling part of the team. As noted above, they appreciated an individual invitation and welcome to rounds, the use of understandable terminology, and having the opportunity to ask questions about the information discussed.
Theme 3: In the Know – The Benefits of Sharing Information in MDR
Participants valued a bi-directional sharing of information during MDR, where family members learned about their loved one’s health status, prognosis, and plan, and also had an opportunity
to share information about their loved one with the healthcare team.
Learning from the team in MDR. All participants identified that there were clear benefits to receiving information at MDR. As one participant noted, learning more about the patient’s health condition and the plan of care helped one to “be in the know” and took away “the mystery of what’s going on”
(Participant 3). For another participant, learning from the team was reassuring:
“Very reassuring to see that, you know, there’s so much detail going on. And that with each patient they take quite a long time, you know, with each patient. And you could see all the details. They were leaving no stone unturned. They talk about the number of IV lines. They talk about the fluid balance. You know… these sorts of things. So, it’s reassuring to know that there’s a level of detail in the care
of your sick family member.” (Participant 7)
Attendance at MDR provided participants with information about the health status of their family member and the goals of care for the day and created opportunities for them to ask the healthcare team questions. While most participants indicated they initially participated by listening to the MDR discussion, as their comfort increased they reported raising questions to clarify prognosis, details of the plan (e.g., specifics about timelines), the pros and cons of a possible treatment, or the outcome
of a specialist consult. Some participants identified that the interactions they had with the attending physician at the end of the rounds were particularly valuable for learning from the team, as the physician summarized the rounds discussion and goals for the day and checked in with family members to see if they had any questions.
Knowledge gained through attendance at MDR helped inform family members’ decision making and enabled them to update family members on the current situation and plan for the patient. As one participant explained:
“I think it is very important to be part of rounds, actually. I think as a family member…our family is huge… so, there was a lot of people involved. And I think having someone be there and then being able to relay the information… You know, 30 people cannot be sitting at rounds. But I think it
helps for them to know the plan and kind of feel a little bit more, I don’t want to say at peace, but at least accepting or knowing what the doctor and the team are doing for the day.” (Participant 6)
Sharing knowledge of the patient with the MDR team. All participants identified that the flow of information was not one way at MDR, as family members possessed knowledge of the patient’s life, health history, values, expressed wishes, and current health condition that may not be reflected in the medical record. By answering questions and sharing information about the patient with the healthcare team at rounds, participants were able to increase the team’s knowledge of the patient,
add additional context for decision making, and ensure patient wishes were made known. Participants were grateful for the opportunity to share their knowledge of the patient at MDR and felt good about their contribution when it informed care.
“Because that is – that is a very good feeling when there is a piece of information that they don’t know from the family history or the patient’s history. And you say, ‘Oh, this happened to him.’ And sometimes that will actually change their decision making. And knowing that they’re grateful. And you do feel like you actually have participated in their care.” (Participant 7)
One participant noted that inviting family members to MDR was a potential time saver, as all present at MDR heard the same information, decreasing the need for families to seek out a specific team member to get answers to their questions.
Discussion
Family participation in ICU MDR is recommended as an important component of family-centred care (Calderone et al., 2022; Davidson et al., 2007; Kydonaki et al., 2021; Woldring et al., 2023). Experience in adult ICUs, however, is currently limited and more information is required to optimize family participation in this setting. In this study, families valued the opportunity to participate in MDR and share information with the healthcare team and highlighted important factors that contributed to successful participation.
Participants articulated benefits of MDR participation: feeling included and valued by the healthcare team; gaining a better understanding of their critically ill relative’s health condition; and having opportunities to relay important information to the healthcare team. These findings align with other studies in both pediatric and adult ICU settings (Calderone et al., 2022; Kydonaki et al., 2021; Woldring et al., 2023). A systematic review of family experiences in pediatric family-centred rounds in ICUs concluded that parents who attended rounds felt respected by the healthcare team and had greater knowledge of the patient situation and plan of care compared to those who did not attend (Rea et al., 2018). An integrative literature review identified that family participation in adult ICU MDR improved families’ understanding of their sick relative’s clinical situation (Kydonaki et al., 2021). Cody et al. (2018), using interviews with 19 family members in two American medical adult ICUs, found that MDR attendance enabled family members to “make a connection” (p. 18) with the healthcare team. A qualitative Canadian adult ICU study involving 29 family members reported that, through attending rounds, family members had improved access to information, a greater understanding of the ICU stay, and a sense of inclusion (Roze de Ordons et al., 2020).
In this study, participants indicated that they did not always know how to participate effectively in MDR, which is consistent with prior published research (Au et al., 2017; Roze des Ordons et al., 2020). It has been recommended that families be provided information about MDR purpose and processes and the benefits of participating in them, and this information should be provided early and repeatedly after ICU admission (Au et al., 2021; Davidson, 2013; Seaman et al., 2017; Stickney
et al., 2014). Written information regarding MDR can be provided in a paper or electronic brochure (Au et al., 2021; Kynoch et al., 2016) and should include a definition and purpose of MDR, a list of the titles and roles of team members present at rounds (Au et al., 2021; Lane et al., 2013), an outline of the MDR process (Au et al., 2021; Lane et al., 2013), with details including rounds timing and virtual options. At the beginning of MDR, team member introductions should occur (Au et al., 2021; Cody et al., 2018; Davidson, 2013).
In this study, participants recommended information be provided regarding the types of questions to ask at rounds. The healthcare team can encourage family members to think about and write down their questions before they attend rounds (Au et al., 2021), while examples of common questions
could be included in the information brochure. In one American pediatric ICU initiative, families’ concerns and questions were identified at the start of rounds, which allowed the questions to be incorporated into the round’s discussion immediately, thereby ensuring that family needs and concerns were addressed (Gal et al., 2024).
Participants valued being provided an understandable MDR summary that included patient plans and goals for the day. Daily goals sheet implementation is associated with improved team communication (Kim et al., 2010), improved team understanding of the care plan (Justice et al., 2016), and consistency in information sharing between team members. Although not discussed by the participants in this study, prior research recommended that a clear and consistent structure to MDR may enhance the MDR experience for all involved (Holodinsky et al., 2015). Process checklist utilization can enhance consistent communication, support continuity of care, and support family
inclusion in MDR (Boydston, 2018; Lane et al., 2013), while decreasing fear and anxieties of family members and supporting MDR quality improvement (Davidson, 2013; Holodinsky et al., 2015).
Essential to any change in culture or clinical practices related to MDR is healthcare team awareness of family members’ needs and the benefits of family participation in MDR. Staff input on how to effectively involve and support families in MDR is important (Jacobowski et al., 2010). Small continuous quality improvements through Plan-Do-Study-Act (PDSA) cycles can enhance communication and family participation in MDR (Gardner et al., 2022). Research related to family members’ virtual participation in rounds in ICUs is emerging now and this is another area that requires exploration (Fiest et al., 2022; Ramirez et al., 2024).
The study’s strengths include the rich data generated from the semi-structured interviews. To minimize the impact of preconceived perspectives of the research team on study findings, we utilized a standard set of questions developed from a review of the literature within this interview format. Limitations to this study include the small sample size, the high education level in the sample, and the single research site. COVID-19 disrupted usual ICU practices with visitor restrictions that impacted recruitment to this study. Using the findings from this and other studies, a future cross-sectional survey could be designed and implemented to describe family members’ experiences of MDR from multiple adult ICUs across Canada.
Conclusion
Although knowledge and experience are limited, family participation in MDR is recommended as an element of family-centred care in the ICU (Calderone et al., 2022; Davidson et al., 2007; Kydonaki et al., 2021). This study provides important information regarding family experiences and perspectives of participation in MDR in acute care adult ICUs. Although gaps in orientation to ICU and MDR processes led participants initially to feel apprehensive regarding their role in MDR participation, they ultimately felt welcomed, found benefit, and valued participation in MDR. MDR provided
families with a forum to gain and share knowledge and participants provided important suggestions to facilitate their transition from observers to participants. Understanding how to enhance active family participation in MDR in all ICU settings is an essential part of providing high-quality patient- and family-centred care that will ultimately benefit the patient, family, and healthcare team.
Author notes
Tannis Sidloski, MN, RN, CNCC(C), Manager Health Services – Intensive Care Medicine Surgery, St. Boniface Hospital
Marie Edwards, PhD, RN, Senior Scholar, College of Nursing, University of Manitoba
Donna Martin, PhD, RN, Professor, College of Nursing, University of Manitoba
Kendiss Olafson, MD, FRCPC, MPH, Assistant Professor, Max Rady College of Medicine, Internal Medicine, Section on Critical Care, University of Manitoba
Corresponding author: Tannis Sidloski, MN, RN, CNCC(C), Manager Health Services – Intensive Care Medicine Surgery, St. Boniface Hospital, tsidloski@sbgh.mb.ca, 204-794-4749
Acknowledgements
The authors thank the family members who participated in this study and the hospital staff members who assisted with recruitment.
Funding and Conflicts of Interest
This study was supported by the College of Nursing Endowment Fund Graduate Student Research Grant at the University of Manitoba. The authors declare no conflicts of interest.
References – Link the Reference PDF
Appendix A – Link Appendix A
