Parents' experiences of healthcare provider actions when their child dies: an integrative review of the literature

Development of the perceived miscommunication measure in the pediatric intensive care unit

PURPOSE

Miscommunication between parents and healthcare providers in the Pediatric Intensive Care Unit (PICU) can affect family-provider relationships and outcomes. This paper reports on the development and psychometric testing of a measure for parent perceived miscommunication, defined as the failure to communicate clearly as perceived by relevant stakeholders in the PICU.

DESIGN AND METHODS

Miscommunication items were identified through a review of the literature with interdisciplinary experts. In a cross-sectional quantitative survey, the scale was tested with 200 parents of children discharged from a PICU at a large Northeastern Level 1 Pediatric hospital. The psychometric properties of a 6-item miscommunication measure were assessed using exploratory factor analysis and internal consistency reliability.

RESULTS

Exploratory factor analysis yielded one factor explaining 66.09% of the variance. Internal consistency reliability in the PICU sample was α = 0.89. As hypothesized, there was a significant correlation between parental stress, trust, and perceived miscommunication in the PICU (p < .001). Confirmatory factor analysis supported good fit indices in testing the measurement model (χ2/df = 2.57, Goodness of Fit Index (GFI) = 0.979, Confirmatory Fit Index (CFI) =0.993 and Standardized Mean Residual (SMR) = 0.0136).

CONCLUSIONS

This new six-item miscommunication measure shows promising psychometric properties including content and construct validity, which can be further tested and refined in future studies of miscommunication and outcomes in PICU.

PRACTICE IMPLICATIONS

Awareness of perceived miscommunication in the PICU can benefit stakeholders within the clinical environment by recognizing the importance of clear and effective communication and how language affects the parent-child-provider relationship.

Understanding parent experiences of end-of-life care for children: A systematic review and qualitative evidence synthesis

BACKGROUND

An estimated 21 million children worldwide would benefit from palliative care input and over 7 million die each year. For parents of these children this is an intensely emotional and painful time through which they will need support. There is a lack of synthesised research about how parents experience the care delivered to their child at the end of life.

AIM

To systematically identify and synthesise qualitative research on parents' experiences of end-of-life care of their child.

DESIGN

A qualitative evidence synthesis was conducted. The review protocol was registered in PROSPERO (CRD42021242946).

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO and Web of Science databases were searched for qualitative studies published post-2000 to April 2020. Studies were appraised for methodological quality and data richness. Confidence in findings was assessed by GRADE-CERQual.

RESULTS

About 95 studies met the eligibility criteria. A purposive sample of 25 studies was taken, of good-quality papers with rich data describing the experience of over 470 parents. There were two overarching themes: parents of children receiving end-of-life care experienced a profound need to fulfil the parental role; and care of the parent. Subthemes included establishing their role, maintaining identity, ultimate responsibility, reconstructing the parental role, and continuing parenting after death.

CONCLUSIONS

Services delivering end-of-life care for children need to recognise the importance for parents of being able to fulfil their parental role and consider how they enable this. What the parental role consists of, and how it's expressed, differs for individuals. Guidance should acknowledge the need to enable parents to parent at their child's end of life.

L’expérience à long terme des parents endeuillés en oncologie pédiatrique : une étude rétrospective de 2 à 18 ans après le décès d’un enfant

Objectifs : Cette étude rétrospective et transversale vise à comprendre l’expérience à long terme des parents endeuillés en oncologie pédiatrique et les différences du deuil parental en fonction du genre.

Matériel et méthodes : Un questionnaire multisectionnel coconstruit avec des cliniciens et intervenants en suivi de deuil a été tenu en ligne en 2018 et 2019. Les participants au sondage étaient des parents dont l’enfant était décédé au service d’hématologie-oncologie du CHU Sainte-Justine 2 à 18 ans auparavant. Des sections spécifiques sur les réactions, les changements et les souvenirs ont fait l’objet d’analyses descriptives.

Résultats : Les réponses de 48 parents ont été analysées. Les résultats indiquent que les mères ont tendance à modifier certaines de leurs activités sociales, alors que les pères cherchent plutôt à retrouver leurs habitudes. Les réactions initialement fortes des parents s’atténuent au fil du temps sans disparaître, en particulier la tristesse et les troubles du sommeil. Les parents ont des souvenirs apaisants des interactions et des soins reçus des intervenants en milieux clinique et communautaire même plusieurs années après le décès de leur enfant.

Conclusion : L’offre de soutien psychosocial communautaire et professionnel à long terme est pertinente, de même aux besoins des couples et aux besoins individuels des parents en fonction du genre.

Family-centered care and pediatric death in the emergency department: A qualitative study using framework analysis

BACKGROUND

Family-centered care is an important concept underpinning care of children. Although much researched in some settings, little research has explored specialist settings, or areas where both children and adults are cared for, such as the emergency department.

METHODS

This study sought to explore how nurses employ family-centered care in delivering care to children and families when a child dies in the emergency department. Using a descriptive, qualitative approach, semi-structured interviews were conducted with 24 emergency nurses from six Australian states. Interviews were audio-recorded and transcribed verbatim. Framework analysis was applied to examine alignment with family-centered care principles.

FINDINGS

Nurses described providing support and education, and encouraged families to engage in care decisions, including about ceasing resuscitation efforts. Commonly, senior staff members were allocated during emergencies to support parents.

DISCUSSION

Emergency nurses should be offered education on family-centered care, and research undertaken to explore families' experiences of their child dying in the emergency department.

PRACTICE IMPLICATION

Family-centered care should be a focus for the care of children and their families in the emergency department, regardless of the pressure from rapidly occurring events.

Factors associated with the decision to offer memory making in end-of-life: A survey of healthcare professionals in adult intensive care

AIM

Report experiences and behaviour influences with healthcare professionals' decision to and experiences of offering memory making during end-of-life care in the adult acute population.

BACKGROUND

Little is known about healthcare professionals' experiences offering memory making during adult acute end-of-life care.

DESIGN

Survey.

METHODS

Registered nurses, medical practitioners and social workers employed at a single tertiary referral adult intensive care, where memory making had been implemented nearly two years prior were invited to participate between June and August 2017. Reporting adheres to the STROBE checklist.

RESULTS

Ninety-six valid surveys (75% response rate: 75 registered nurses, 19 medical practitioners, and 2 social workers) were analysed with 67 participants reporting experience offering memory making. Highest overall agreement scores included believing families value memory making and the offer of memory making being beneficial. Enablers were described as organisational supports, personal qualities and good interpersonal relationships. Barriers identified included the intensive care environment, workload, inexperience offering/facilitating memory making, being afraid to offer, lack of resources and legality concerns. Compared with non-experienced participants, experienced participants reported higher level of confidence and comfort offering memory making, pride in their ability, ability to spend time supporting families and had observed colleagues offering memory making. Experienced participants were less likely to be afraid to offer, be limited by the family's behaviours, report lack of resources or be time limited to offer memory making.

CONCLUSION

Findings identify elements needed for the development and support for offering memory making to assist bereaved families in adult acute care including role modelling, support to reduce negative emotions, workload assistance and leadership/organisational support.

RELEVANCE TO CLINICAL PRACTICE

Discoveries have important implications in addressing evidence gaps regarding behaviour influences linked to the decision to offer memory making. Findings inform development and sustainability to integrate memory making as routine end-of-life care intervention in adult acute care.

What hinders and helps in the end-of-life decision-making process for children: Parents' and physicians' views

AIM

To investigate the main factors which facilitate or hinder end-of-life decision-making (EoLDM) in neonates and children.

METHODS

A qualitative inductive, thematic analysis was performed of interviews with a total of 73 parents and 71 physicians. The end-of-life decisions mainly concern decisions to withhold or withdraw life-sustaining treatment.

RESULTS

The importance of taking sufficient time and exchanging clear, neutral and relevant information was main facilitators expressed by both parents and physicians. Lack of time, uncertain information and changing doctors were seen as important barriers by both parties. Most facilitators and barriers could be seen as two sides of the same coin, but not always. For example, some parents and physicians considered the fact that parents hold strong opinions as a barrier while others considered this a facilitator. Furthermore, parents and physicians showed differences. Parents especially underlined the importance of physician-related facilitators, such as a personalised approach, empathy and trust. On the contrary, physicians underlined the importance of the child's visible deterioration and parents' awareness of the seriousness of their child's condition and prognosis as facilitators of EoLDM.

CONCLUSIONS

This study gained insight into what parents and physicians experience as the main barriers and facilitators in EoLDM for neonates and children.

Little time, lasting impact: Bereaved caregiver perceptions of legacy in perinatal and infant loss

BACKGROUND

Legacy interventions are standard in most children's hospital, but little is known about how bereaved parents understand and describe the concept of legacy that these interventions are designed to document. The aim of this qualitative study was to understand the legacy experiences and perceptions of parents who have experienced perinatal or early infant (less than three months of age) loss.

METHODS

Grounded in constructionist epistemology and phenomenological qualitative traditions, ten bereaved parents completed an in-depth phenomenological interview regarding their perceptions of and experiences with the legacy of their deceased child. Interviews were transcribed verbatim and analyzed using an open, inductive coding process to illuminate the essence of participants' experiences.

RESULTS

Three themes were identified: 1) legacies are composed of memories and experiences that have a lasting effect on others; 2) healthcare experiences both generate and participate in infants' legacies; and 3) parents' legacy perceptions are shaped by cultural conceptions, spiritual beliefs, and grief experiences. Parents described experiences and interactions with community members and healthcare providers that honored or challenged their perceptions of their child's unique legacy.

CONCLUSIONS

In the context of perinatal or early infant loss, bereaved parents describe legacy as enduring, unique to each child and family, and heavily influenced by healthcare experiences and staff relationships. Parent-led, legacy-oriented interventions are needed in maternal/fetal, labor/delivery, and neonatal intensive care settings to support parent coping with loss.

Metaphors that shape parents' perceptions of effective communication with healthcare practitioners following child death: a qualitative UK study

OBJECTIVES

To offer an interpretation of bereaved parents' evaluations of communication with healthcare practitioners (HCPs) surrounding the death of a child.

DESIGN

Interpretative qualitative study employing thematic and linguistic analyses of metaphor embedded in interview data.

SETTING

England and Scotland.

PARTICIPANTS

24 bereaved parents (21 women, 3 men).

METHODS

Participants were recruited through the True Colours Trust website and mailing list, similar UK charities and word of mouth. Following interviews in person or via video-conferencing platforms (Skype/Zoom), transcripts first underwent thematic and subsequently linguistic analyses supported by NVivo. A focused analysis of metaphors used by the parents was undertaken to allow in-depth interpretation of how they conceptualised their experiences.

RESULTS

The findings illuminate the ways parents experienced communication with HCPs surrounding the death of a child. Key findings from this study suggest that good communication with HCPs following the death of a child should acknowledge parental identity (and that of their child as an individual) and offer opportunities for them to enact this; taking account their emotional and physical experiences; and accommodate their altered experiences of time.

CONCLUSIONS

This study suggests that HCPs when communicating with bereaved parents need to recognise, and seek to comprehend, the ways in which the loss impacts on an individual's identity as a parent, the 'physical' nature of the emotions that can be unleashed and the ways in which the death of a child can alter their metaphorical conceptions of time.

Utilizing high-fidelity simulation to improve newly licensed pediatric intensive care unit nurses' experiences with end-of-life care

PURPOSE

New pediatric intensive care unit (PICU) nurses face distinct challenges in transitioning from the protected world of academia to postlicensure clinical practice; one of their greatest challenges is how to support children and their caregivers at the end-of-life (EOL). The purpose of this quality improvement project was to create, implement, and assess the efficacy of a high-fidelity EOL simulation, utilizing the "Debriefing with Good Judgment" debriefing model.

DESIGN AND METHODS

Participants were nurses with 4 years or less of PICU experience from a 404-bed quaternary care, free-standing children's hospital in the northeastern United States. Data were collected with the Simulation Effectiveness Tool-Modified (SET-M) and the PICU EOL Simulation Evaluation Survey.

RESULTS

Twenty-four nurses participated; the majority (54%) were 25-29 years of age. The SET-M results indicate that the EOL simulation was beneficial to their learning and increased nurse confidence in delivering EOL care. Responding to the EOL Simulation Survey, participants rated high levels of confidence with tasks such as utilizing unit and hospital-based supports, self-care, ability to listen and support families, and medicating their patients at the EOL.

PRACTICE IMPLICATIONS

This high-fidelity EOL simulation is a robust teaching tool that serves to support the unmet needs of the PICU nurses who care for dying children. Nurse participants had a unique opportunity to practice procedural and communication skills without risk for patient or family harm. Findings from this project can serve to guide curriculum changes at the undergraduate level as well as provide direction for new nurse orientation classes.

Educational Priorities for Providing End-of-Life Care: Parent Perspectives

OBJECTIVES

Partnership with parents is a tenet of pediatric medicine; however, initiatives to include parents in education and research have been limited. Through focus groups, we included parents at the beginning of curriculum development by asking them to identify the priorities, existing supports, and opportunities for improvement in their child's end-of-life (EOL) care.

METHODS

English and Spanish-speaking bereaved parents whose child had been cared for by the palliative care team and had died >18 months before the study initiation were invited to participate. In-person focus groups and a follow-up phone call were used to elicit opinions and capture a diversity of viewpoints. Themes were identified and clustered through an iterative analytic process.

RESULTS

Twenty-seven parents of 17 children participated, with the total sample size determined by thematic saturation. Four themes were identified as important to parents in their child's EOL care: (1) honoring the role of the parent, (2) having confidence in the care team, (3) receiving gestures of love and caring, and (4) navigating logistic challenges.

CONCLUSIONS

We asked parents to be partners in guiding priorities for health care education and professional development to improve pediatric EOL care. In addition to strengthening skills in communication, confidence in the team, and compassion, parents in this study identified a need for hospital staff to anticipate financial and social stressors and provide supportive resources more readily. Additionally, parents described clinical and nonclinical staff as providing support, suggesting that a multidisciplinary and interdisciplinary curriculum be developed to improve pediatric EOL care.

Keepsakes at the End of Life

CONTEXT

Keepsakes are a relatively unexplored form of bereavement support that is frequently provided as part of the 3 Wishes Project (3WP). The 3WP is a palliative care intervention in which individualized wishes are implemented in the adult intensive care unit for dying patients and their families.

OBJECTIVES

We aimed to characterize and enumerate the keepsakes that were created as part of the 3WP and to understand their value from the perspective of bereaved family members.

METHODS

We performed a secondary analysis of family interviews during a multicenter study on the 3WP and characterized all wishes that involved keepsakes. Sixty interviews with family members regarding the 3WP were reanalyzed using qualitative analysis to identify substantive themes related to keepsakes.

RESULTS

Of 730 patients, 345 (47%) received keepsakes as part of their participation in 3WP. Most keepsakes were either tangible items that served as reminders of the patient's presence (thumbprints and locks of hair) or technology-assisted items (photographs and word clouds). The median cost per keepsake wish was $8.50 (interquartile range $2.00-$25.00). Qualitative analysis revealed two major themes: keepsakes are tangible items that are highly valued by family members; and the creation of the keepsake with clinical staff is valued and viewed as a gesture of compassion.

CONCLUSION

Keepsakes are common wishes that clinicians in the intensive care unit are able to provide and sometimes cocreate with families when patients are dying. Both the offering to create the keepsake and receipt of the final product are perceived by family members as helpful.

Legacy Building in Pediatric End-of-Life Care through Innovative Use of a Digital Stethoscope

Background: Legacy making has been the focus of recent literature; however, few studies examine how legacy making affects bereaved parents. Objective: To better understand legacy making's effect on bereaved parents, this study examined (1) the presentation of legacy making to parents, (2) parent satisfaction, and (3) parent utilization of the project. Design: Eko CORE (Eko Devices, Inc., Berkeley, CA), a digital stethoscope that generates a phonocardiogram, a graphical representation of S1 and S2 heart sounds, was used to record children's heartbeats as they approached end of life. The heartbeat was then overlaid to a song or voice recording or kept as a stand-alone file. An artistic embellishment of the phonocardiogram was also created. Parents were surveyed about their experience with the Music Therapy Heart Sounds (MTHS) program. Twelve parents completed the survey. Setting/subjects: Tertiary care children's hospital. The subjects were bereaved parents. Measurements: Five-question survey. Institutional Review Board review exempt. Results: All respondents would recommend the MTHS program to other families experiencing end-of-life decision making. Forty-two percent (N = 5) heard about the program from pediatric palliative physicians, and 50% (N = 6) heard about it from therapists such as music or child life. The respondents varied in how often they utilized their child's heartbeat recordings: 25% (N = 3) viewed or listened monthly, 33% (N = 4) not at all, 17% (N = 2) almost weekly, 17% less than monthly, and 8% (N = 1) daily. Conclusion: The MTHS program is an easy-to-implement and cost-effective way to perform legacy making that bereaved parents recommend for other families.

When a Child Dies in the PICU: Practice Recommendations From a Qualitative Study of Bereaved Parents

OBJECTIVES

Around the world, the PICU is one of the most common sites for hospitalized children to die. Although ensuring the best possible care experience for these children and their families is important, clear recommendations for end-of-life and bereavement care, arising from the parents themselves, remain limited within current literature. This report aims to describe bereaved parents' recommendations for improvements in end-of-life care and bereavement follow-up when a child dies in intensive care.

DESIGN

Thematic analysis of incidental data from a larger grounded theory study.

SETTING

Four Australian PICUs.

SUBJECTS

Twenty-six bereaved parents participated in audio-recorded, semi-structured interviews in 2015-2016. Interviews explored their experiences of having a child die in intensive care and their experiences of end-of-life care and bereavement follow-up. Data pertaining to this report were analyzed via thematic analysis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Bereaved parents identified several areas for care delivery and improvement across three time periods: during hospitalization; during the dying phase; and during bereavement. During hospitalization, parents' recommendations focused on improved communication, changes to the physical environment, better self-care resources, and provision of family support. During the dying phase, parents suggested private, de-medicalized rooms, familiar staff members, and support to leave the hospital. Recommendations for care after death focused mainly on the provision of ongoing support from the hospital or local bereavement services, as well as improved information delivery.

CONCLUSIONS

Findings from this study offer many concrete recommendations for improvements in care both during and after a child's death. These recommendations range from simple practice changes to larger organizational modifications, offering many potential avenues for change and improvement both on an individual healthcare provider level and within individual PICUs.

End-of-life communication: a nationwide study of bereaved parents’ perceptions

Objective

To investigate bereaved parents’ perception of end-of-life communication with healthcare professionals after losing a child due to life-limiting diagnoses.

Methods

A national register identified the causes of death of 951 children aged 0–18 years during the period 2012–2014. A previously described classification of life-limiting diagnoses identified 402 children. A modified version of the self-administered questionnaire 'To Lose a Child' was distributed to the parents of these 402 children, capturing their perceptions of communication with the healthcare professionals throughout the child’s disease trajectory and imminent death.

Results

A total of 193 bereaved parents, representing 38% of the identified children, participated in the study. Overall, 98% of the parents expressed the view that physicians should immediately disclose when curatively intended treatment options were exhausted. Some 79% of parents reported that information about their child’s incurable illness was given in an appropriate manner; however, 42% said that information about the child's imminent death was given too late. Finally, 31% felt deprived of the option to say goodbye to their child in their preferred manner, and 56% said that their child’s death was “a shock”.

Conclusions

Parents request accurate and timely information. However, a substantial number of the parents surveyed reported that healthcare professionals communicated too late about palliative care and end-of-life issues. Even though healthcare professionals strive to communicate effectively with dying children and their parents, barriers were identified that may hinder even the best of intentions. National guidelines addressing communication issues and improved education of healthcare professionals should form part of any future agenda.

Supporting Muslim families before and after a death in neonatal and paediatric intensive care units

BACKGROUND

The death of a child is regarded as one of the most devastating events for a family. Families are reliant on nurses to not only provide end-of-life care but also to support and care for grieving families in a way that is sensitive to their cultural and religious needs and preferences.

AIMS

The aim of this study was to explore the perceived impact and influence of cultural diversity on how neonatal and paediatric intensive care nurses care for Muslim families before and after the death of infants/children.

DESIGN

A qualitative descriptive approach was used in this study, conducted in Saudi Arabia.

METHODS

Semi-structured interviews were used to gather data from a convenience sample of registered nurses working in neonatal and paediatric intensive care, with experience in providing end-of-life care. Interviews were conducted between July and November, 2018. Interviews were audio-recorded and transcribed for analysis.

RESULTS

Thirteen registered nurses participated; all were born overseas, identified with various faiths and spoke English in the workplace. A respect for diversity and care of the family was prioritized yet impacted by communication challenges. Caring and respect was demonstrated by facilitating important cultural and religious practices important in the Muslim faith. Self-care was identified as important, transcending the culturally diverse nature of the nursing workforce.

CONCLUSIONS

Significant challenges exist for a culturally diverse nursing workforce in providing care to a Saudi Muslim population of infants/children and families, before and after a death. Their overriding commitment to respect for others, and an openness to cultural diversity and difference, aided in overcoming the inherent challenges in providing culturally sensitive end-of-life care that meets the needs of Muslim families. These findings provide valuable insights for intensive care clinicians in other countries to address challenges associated with cultural diversity.

Pediatric End-of-life Simulation: Preparing the Future Nurse to Care for the Needs of the Child and Family

PURPOSE

Preparing a future nurse to respond to the complex and sensitive needs of a child and family during the end-of-life requires more than didactic content in a classroom. During clinical experiences, students may care for children diagnosed with a terminal illness however; it is less likely that a student will have a clinical opportunity to care for a child and their family at the end-of-life. Without having an experience, it is challenging to teach students how to care for the dying child and family including how to appreciate the emotions, thoughts, and expectations when faced with a pediatric death (Lindsay, 2010).

DESIGN AND METHODS

The instructional model integrates an end-of-life simulation into an undergraduate pediatric nursing course allowing students to practice caring for a child and their family while developing an understanding of the unique needs of a dying pediatric patient.

RESULTS

Post simulation, students participating in guided reflection, identified several themes impacting their experience with end-of-life care, including symptom management, emotional care and "what to say".

CONCLUSIONS

The structured simulated experience provided knowledge, skill and awareness to the role of the nurse when providing care at the end-of-life.

PRACTICE IMPLICATIONS

Nurses' behaviors and responses when caring for a child can have a significant impact on the family's experience and memory of their child's death. Unintended actions may result in the family experiencing negative impressions, causing further distress to the grieving family (Butler, Hall, Willetts, & Copnell, 2015).

Bereaved parents' experiences of research participation

Background

As understandings of the impacts of end-of-life experiences on parents’ grief and bereavement increase, so too does the inclusion of bereaved parents into research studies exploring these experiences. However, designing and obtaining approval for these studies can be difficult, as guidance derived from bereaved parents’ experiences of the research process are limited within the current literature.

Methods

We aimed to explore bereaved parents’ experiences of research participation in a larger grounded theory study exploring experiences of the death of a child in the paediatric intensive care unit. Data were obtained during follow-up phone calls made to 19 bereaved parents, five of whom provided data from their spouse, 1 week after their participation in the study. Participants were asked to reflect on their experiences of research participation, with a focus on recruitment methods, timing of research contact, and the location of their interview. Parents’ responses were analysed using descriptive content analysis.

Results

Our findings demonstrate that despite being emotionally difficult, parents’ overall experiences of research participation were positive. Parents preferred to be contacted initially via a letter, with an opt in approach viewed most favourably. Most commonly, participants preferred that research contact occurred within 12–24 months after their child’s death, with some suggesting contact after 6 months was also appropriate. Parents also preferred research interviews conducted in their own homes, though flexibility and parental choice was crucial.

Conclusions

Findings from this study offer further insight to researchers and research review committees, to help ensure that future studies are conducted in a way that best meets the unique needs of bereaved parents participating in research.

Healthcare Users' Experiences of Communicating with Healthcare Professionals About Children Who Have Life-Limiting Conditions: A Qualitative Systematic Review

BACKGROUND

Globally, an estimated eight million children could benefit from palliative care each year. Effective communication about children with life-limiting conditions is well recognized as a critical component of high-quality pediatric palliative care.

OBJECTIVE

To synthesize existing qualitative research exploring healthcare users' experiences of communicating with healthcare professionals about children with life-limiting conditions.

DESIGN

The results of a systematic literature search were screened independently by two reviewers. Raw data and analytic claims were extracted from included studies and were synthesized using thematic analysis methods for systematic reviews.

DATA SOURCES

MEDLINE, PubMed, CINAHL, Embase, PsycINFO, Scopus, Web of Science, ProQuest, and ScienceDirect were searched for articles published in English between 1990 and May 2017.

RESULTS

This review included 29 studies conducted across 11 countries and involving at least 979 healthcare users (adults [n = 914], patients [n = 25], and siblings [n = 40]). The four domains of communication experience identified through thematic synthesis are: Information, Emotion, Collaboration, and Relationship. Although included studies were from a range of settings and diverse populations, further research is needed to explore whether and how domains of communication experience differ across settings and populations. In particular, further research about children's palliative care experiences is needed.

CONCLUSIONS

Healthcare users typically value communication with healthcare professionals: that (1) is open and honest, (2) acknowledges emotion, (3) actively involves healthcare users, and (4) occurs within established and trusting relationships.

Critical care nurses' experiences of caring for a dying child: A qualitative evidence synthesis

AIM

To synthesize qualitative research examining the experience of critical care nurses caring for a dying child.

BACKGROUND

Caring for a dying child remains one of the most difficult aspects of nursing, potentially leading to personal and professional distress. A thorough understanding of this experience for critical care nurses allows for improved delivery of care and support for the nurse.

DESIGN

A qualitative evidence synthesis was undertaken, informed by Thomas and Harden's thematic synthesis methodology.

DATA SOURCES

Studies were retrieved from CINAHL Plus, Scopus, OVID Medline, and Embase, alongside hand-searching reference lists in February 2016.

REVIEW METHODS

Two reviewers independently assessed each study using a multistep screening process and performed critical appraisal of each included study. Data were extracted onto a predeveloped tool and analysed using thematic analysis.

RESULTS

There is a blurred line between the role of the nurse as a person or a professional while caring for the child and family throughout hospitalization and during and after the death. Each stage of care involves tasks and emotions that highlight the changing dominance of the nurse as either a person or professional.

CONCLUSION

Personal, interpersonal, and contextual factors affect delivery of care and impact of the death of the child on the critical care nurse. Reviewing individual and institutional practices could improve provision of care, interprofessional collaboration, and support provided to staff involved.

Becoming a Team: The Nature of the Parent-Healthcare Provider Relationship when a Child is Dying in the Pediatric Intensive Care Unit

PURPOSE

To explore bereaved parents' perspectives of parent and staff roles in the pediatric intensive care unit when their child was dying, and their relationships with healthcare staff during this time.

DESIGN AND METHODS

Constructivist grounded theory was used to undertake this study. Semi-structured interviewers were conducted with 26 bereaved parents recruited from four Australian pediatric intensive care units. The constant comparative method, coupled with open, focused, and theoretical coding were used for data analysis.

RESULTS

Becoming a team explores the changes that occurred to the parent-healthcare provider relationship when parents realized their child was dying and attempted to become part of their child's care team. When the focus of care changed from 'life-saving' to 'end-of-life', parents' perspectives and desires of their and the healthcare providers' roles changed. Parents' attempted to reconstruct their roles to match their changing perspectives, which may or may not have been successful, depending on their ability to successfully negotiate these roles with healthcare providers.

CONCLUSIONS

Findings offer insights into parental understandings of both the parental and healthcare provider roles for parents of dying children in intensive care, and the ways in which the parent-healthcare provider relationships can influence and be influenced by changes to these roles.

PRACTICE IMPLICATIONS

Successful parent-healthcare provider relationships require an understanding of the parental and healthcare provider role from the parents' perspective. The meanings of the parental and healthcare provider roles should be explored with parents of dying children, and supported as much as possible to enable the development of a collaborative relationship.

Bereaved parents' experiences of the police in the paediatric intensive care unit

BACKGROUND

A child's death in the intensive care unit is often sudden and unexpected, requiring the involvement of the state coroner to investigate both the cause and the circumstances surrounding the death. This process often involves the police, who arrive in intensive care to identify the body and collect statements from the parents. At present, very little is known about parents' experiences of this process.

OBJECTIVES

To explore bereaved parents' experiences of police presence in intensive care, as part of routine coronial investigations. The findings arose from a larger study on bereaved parents' experiences of the death of a child in the intensive care unit.

METHODS

Secondary analysis of incidental data from a larger grounded theory study. Nine bereaved parents from two paediatric intensive care units (PICUs) mentioned police presence in the PICU during their original audio-recorded, semistructured interviews. These data were extracted, and thematic analysis techniques were used to identify key themes.

RESULTS

Three main concepts were identified with the parents' experiences: (i) timing of police interviews; (ii) the impacts of police presence; and (iii) the demeanour of the officers. Overall, the parents' experiences of police presence were negative. They felt that police arrived too soon after their child's death and took too long taking their statements, hindering their ability to say goodbye. The presence of police officers also made parents feel as though they were being accused of involvement in their child's death. Finally, several participants also experienced inappropriate or unsympathetic attitudes from the police officers attending their child's death.

CONCLUSIONS

Findings from our study indicate that parents' experiences of police presence in the PICU as part of a coronial investigation may be negative, leaving lasting impressions on their experiences of their child's death. These findings provide areas for improvements in care delivery and the treatment of newly bereaved parents during the early phases of a coronial investigation.

Healthcare users' experiences of communicating with healthcare professionals about children who have life-limiting conditions: a qualitative systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to identify and synthesize the best international qualitative evidence on healthcare users' experiences of communication with healthcare professionals about children who have life-limiting conditions. For the purposes of this review, "healthcare users" will be taken to include children who have life-limiting conditions and their families. The question to be addressed is:What are healthcare users' experiences of communicating with healthcare professionals about children who have life-limiting conditions?

BACKGROUND

The prospect of the death of a child from an incurable medical condition is harrowing, yet finding a way to discuss this prospect is crucial to maximize the quality of life for such children and their families. High-quality communication is well recognized as a core skill health care professionals need to maximize the quality of care they provide. This skill is valued by service users, who consistently rate it as one of the highest priorities for the care they receive. Evidence suggests, however, that healthcare professionals can feel ill-equipped or uncomfortable communicating with and about such children. Therefore, it is important to understand what represents high-quality communication and what is involved in accomplishing this within pediatric palliative care.In recent decades there has been an increased focus on providing palliative care for children who have life-limiting conditions. These are conditions for which no cure is available and for which the probable outcome is premature death. Palliative care may also be appropriate for children who have life-threatening conditions; these are conditions where there is not only a high probability of premature death but also a chance of long-term survival into adulthood Although pediatric palliative care is underpinned by the same philosophy as adult palliative care, children who have life-limiting conditions and their families have particular needs that distinguish them from users of adult palliative care. For example, at a physical level children are more likely than adults to have non-malignant conditions that follow trajectories in which children oscillate between feeling relatively well and acutely unwell. The social dynamic of their care is also radically different, particularly given the role of parents or guardians in making surrogate decisions about their child's care. Such factors warrant considering pediatric palliative care as distinct from palliative care more generally.Although the particular circumstances of children who have life-limiting conditions have led to development of pediatric palliative care, the particular provisions of this care differs among countries. One aspect of variation is the age range of patients. Pediatric palliative care is usually provided to neonates, infants, children, adolescents and young adults, but international variations in the definitions of these age ranges, particularly for adolescents and young adults, means pediatric palliative care is provided to different age groups in different countries. This review therefore adopts a pragmatic rather than an age-based definition of a pediatric palliative care, considering all studies relating to service users who are being cared for by pediatric rather than adult healthcare services.In catering for the unique needs of children who have life-limiting conditions and their families, pediatric palliative care aims to achieve pain and symptom management, enhanced dignity and quality of life, and psychosocial and spiritual care. It also seeks to incorporate care for patients' broader families and facilitating access to appropriate services and support. High-quality communication is crucial for achieving these aims. It enables healthcare users and providers to make decisions that underpin the care that is provided and the quality of the life that is possible for patients and their families.Although both users and providers recognize the value of high-quality communication with and about children who have life-limiting conditions, this does not mean that these stakeholders necessarily share the same perspective of what constitutes high-quality communication and the best way of accomplishing this. Focusing on healthcare users' experiences of communication with healthcare professionals about children who have life-limiting conditions, the present review will explore the subjective impact of professionals' communication on the people for whom they provide care.It may be necessary to consider a range of contextual factors to understand healthcare users' experiences of communicating with healthcare professionals about children who have life-limiting conditions. For instance, age, developmental stage, cognitive capacity, emotional and social strengths, and family dynamics can influence a child's level of involvement in discussions about their condition and care. Although there are factors that appear more consistent across the range of pediatric palliative care users, such as parents' preferences for being treated by healthcare professionals as partners in making decisions about the care of their child, there is not always such consistency. Nor is it clear whether such findings can be generalized across different cultural contexts. In appraising existing research, this systematic review will therefore consider the relationship between the context of individual studies and their reported findings.The primary aim of this review is to identify, appraise and synthesize existing qualitative evidence of healthcare users' experiences of communicating with healthcare professionals about children who have life-limiting conditions. The review will consider relevant details of these findings, particularly whether factors like age are relevant for understanding particular experiences of communication. An outcome of this review will be the identification of best available qualitative evidence that can be used to inform professional practice, as well as an identification of priorities for future research in pediatric palliative care.A preliminary search in MEDLINE and CINAHL found primary studies exploring healthcare users' experiences of aspects of communicating with healthcare professionals about children who have life-limiting conditions. A search was also conducted for existing systematic reviews in PubMed, CINAHL, EMBASE, PsycINFO, the Cochrane Database of Systematic Reviews, the JBI Database of Systematic Reviews and Implementation Reports, and PROSPERO. No systematic reviews on this topic were found.

"Some were certainly better than others" - Bereaved parents' judgements of healthcare providers in the paediatric intensive care unit: A grounded theory study

OBJECTIVE

To explore bereaved parents' judgements of healthcare providers, as part of a larger study examining their perceptions of the death of a child in the paediatric intensive care unit.

RESEARCH METHODOLOGY

Constructivist grounded theory.

SETTING

Four Australian paediatric intensive care units.

MAIN OUTCOME MEASURES

Semi-structured, audio recorded interviews were undertaken with 26 bereaved parents 6-48 months after their child's death. Data were transcribed verbatim and analysed using open, focused and theoretical coding and the constant comparative method.

FINDINGS

Bereaved parents judged healthcare providers as 'good' or 'poor' based on behaviours they exhibit. 'Good' behaviours were further subdivided by parents into four categories: 'Better than others', 'good', 'very good', and 'fantastic'. Common behaviours identified as 'good' included provision of practical assistance, facilitation of parental presence, and sharing of information. In contrast, the concept of 'poor' had no subdivision: all identified behaviours, including diminishing parental concern, mishandling hope, adopting an unprofessional demeanour, judging the child's worth, and mishandling communication, were equally detrimental.

CONCLUSIONS

Findings demonstrate that bereaved parents have clear opinions on what constitutes 'good' and 'poor' behaviours when their child is dying. These judgements provide clear examples for healthcare providers who provide end-of-life care, ensuring they provide high quality care.

Welcoming expertise: Bereaved parents' perceptions of the parent-healthcare provider relationship when a critically ill child is admitted to the paediatric intensive care unit

BACKGROUND

Entering the paediatric intensive care unit with a critically ill child is a stressful experience for parents. In addition to fearing for their child's well-being, parents must navigate both a challenging environment and numerous new relationships with healthcare staff. How parents form relationships with staff and how they perceive both their own and the healthcare providers' roles in this early stage of their paediatric intensive care journey is currently unknown.

PURPOSE

This paper explores bereaved parents' perceptions of their role and their relationships with healthcare providers when their child is admitted to the intensive care unit, as part of a larger study exploring their experiences when their child dies in intensive care.

METHODS

A constructivist grounded theory approach was utilised to recruit 26 bereaved parents from 4 Australian intensive care units. Parents participated in audio-recorded, semi-structured interviews lasting 90-150min. All data were analysed using the constant comparative analysis processes, supported by theoretical memos.

RESULTS

Upon admission, parents viewed healthcare providers as experts, both of their child's medical care and of the hospital system. This expertise was welcomed, with the parent-healthcare provider relationship developing around the child's need for medical care. Parents engaged in 2 key behaviours in their relationships with staff: prioritising survival, and learning 'the system'. Within each of these behaviours are several subcategories, including 'Stepping back', 'Accepting restrictions' and 'Deferring to medical advice'.

CONCLUSIONS

The relationships between parents and staff shift and change across the child's admission and subsequent death in the paediatric intensive care unit. However, upon admission, this relationship centres around the child's potential survival and their need for medical care, and the parent's recognition of the healthcare staff as experts of both the child's care and the hospital system.

Affording opportunities to discuss deterioration in paediatric palliative care consultations: a conversation analytic study

Objective

Discussing the potential deterioration of a child who has a life-limiting condition has recognised benefits for future care, but can be challenging in a clinical context where uncertain illness trajectories are common. Existing research is restricted to indirect forms of evidence such as self-report data from clinicians and families. This study directly explores how discussions about deterioration are managed within actual paediatric palliative care consultations.

Methods

9 consultations were video recorded in an Australian paediatric palliative care service. Each consultation involved the same paediatric palliative care specialist. Conversation analysis was used to identify and explore recurrent ways in which discussions about deterioration came to be realised.

Findings

The study identified two communicative practices used by a paediatric palliative care specialist that afforded opportunities to discuss deterioration: (1) soliciting the family's agenda for the consultation; (2) initiating and maintaining topics where discussing deterioration is a relevant possibility. Across these different practices, a common feature was indirect initiation of discussions about deterioration. This approach made such discussions possible, but without mandating or even suggesting that such discussion must occur.

Conclusions

These communicative practices balance the benefit of discussing deterioration against a recognised importance of allowing discussions to be directed by a child's family. This was achieved by creating opportunities for discussing deterioration, without making such discussions necessary.

A Synthesis of Coping Experiences After Infant Death

The purpose of this article was to synthesize qualitative research data that examine parental coping strategies following infant death. This qualitative synthesis found that parents who effectively cope with the death of their infant would continue the bond with the deceased child, have differences in the way they manage their emotions about the loss, and have intergenerational support in the form of family being present, acknowledging the death, performing immediate tasks, and providing helpful information. Nurses should be vigilant to ensure parents receive "memories" of their infant after an in-hospital death. Knowledge of the coping process can assist nurses and clinicians to better care and support parents following an infant death and, in turn, facilitate the healing process.

'Something normal in a very, very abnormal environment'--Nursing work to honour the life of dying infants and children in neonatal and paediatric intensive care in Australia

The majority of deaths of children and infants occur in paediatric and neonatal intensive care settings. For nurses, managing an infant/child's deterioration and death can be very challenging. Nurses play a vital role in how the death occurs, how families are supported leading up to and after the infant/child's death. This paper describes the nurses' endeavours to create normality amidst the sadness and grief of the death of a child in paediatric and neonatal ICU. Focus groups and individual interviews with registered nurses from NICU and PICU settings gathered data on how neonatal and paediatric intensive care nurses care for families when a child dies and how they perceived their ability and preparedness to provide family care. Four themes emerged from thematic analysis: (1) respecting the child as a person; (2) creating opportunities for family involvement/connection; (3) collecting mementos; and (4) planning for death. Many of the activities described in this study empowered parents to participate in the care of their child as death approached. Further work is required to ensure these principles are translated into practice.

Family Experience and PICU Death: A Meta-Synthesis

BACKGROUND AND OBJECTIVES

The PICU is the most common site for inpatient pediatric deaths worldwide. The impact of this clinical context on family experiences of their child's death is unclear. The objective of the study was to review and synthesize the best available evidence exploring the family experience of the death of their child in the PICU.

METHODS

Studies were retrieved from CINAHL Plus, OVID Medline, Scopus, PsycINFO, and Embase. Gray literature was retrieved from greylit.com, opengrey.edu, Trove, Worldcat, and Google scholar. Study selection was undertaken by 4 reviewers by using a multistep screening process, based on a previously developed protocol (International Prospective Register of Systematic Reviews 2015:CRD42015017463). Data was extracted as first-order constructs (direct quotes) or second-order constructs (author interpretations) onto a predeveloped extraction tool. Data were analyzed by thematic synthesis.

RESULTS

One main theme and 3 subthemes emerged. "Reclaiming parenthood" encompasses the ways in which the parental role is threatened when a child is dying in the PICU, with the subthemes "Being a parent in the PICU," "Being supported," and "Parenting after death" elucidating the ways parents work to reclaim this role. The review is limited by a language bias, and by the limitations of the primary studies.

CONCLUSIONS

When a child dies in a PICU, many aspects of the technology, environment, and staff actions present a threat to the parental role both during and after the child's death. Reclaiming this role requires support from health care providers and the wider community.

[Parent-child-interaction in infancy (author's transl)]

On the basis of many experimental studies it is demonstrated that not only mother-child-relationship in infancy but also father-child-relationship is important for child development. Different patterns of mother-child-interaction as well as father-child-interaction during the first weeks after birth are reported and intervening variables are discussed. Kind and degree of interactions of both parents with the newborn and infant influence the emotional, social, and cognitive development of the child. On the other hand the birth of child and the behavior of the newborn determine personal development of father and mother, too. The growth of the family is to be regarded as a process which is based on the differentiated net work of conditions. The concentration of research on mother-child-contacts has to be rejected in the light of these new findings and has to be regarded as hostile against the family as a whole.