Patient and public involvement in Paediatric Intensive Care research: considerations, challenges and facilitating factors

Involvement of children and young people in the conduct of health research: A rapid umbrella review

BACKGROUND

Patient and public involvement and engagement (PPIE) have long been considered important to good research practice. There is growing, yet diverse, evidence in support of PPIE with children and young people (CYP). We must now understand the various approaches to involvement of CYP in research.

AIMS

This rapid umbrella review aimed to provide an overview of when, how and to what extent CYP are involved in the conduct of health research, as well as the reported benefits, challenges, and facilitators of involvement.

METHODS

We searched OVID Medline, Embase and PubMed. Published reviews were included if they reported meaningful involvement of CYP in the conduct of health research. Extracted data were synthesised using thematic analysis.

RESULTS

The 26 reviews included were predominately systematic and scoping reviews, published within the last decade, and originating from North America and the United Kingdom. CYPs were involved in all stages of research across the literature, most commonly during research design and data collection, and rarely during research funding or data sharing and access. Researchers mostly engaged CYP using focus groups, interviews, advisory panels, questionnaires, and to a lesser extent arts-based approaches such as photovoice and drawing. Visual and active creative methods were more commonly used with children ≤12 years. The evidence showed a shared understanding of the benefits, challenges, and facilitators for involvement of CYP, such as time and resource commitment and building partnership.

CONCLUSION

Overall, the review identified consistency in the range of methods and approaches used, and stages of research with which CYP are commonly involved. There is a need for more consistent reporting of PPIE in the literature, both in terminology and detail used. Furthermore, the impact of approaches to CYP involvement on research and community outcomes must be better evaluated.

PATIENT/PUBLIC CONTRIBUTION

This review forms part of broader research initiatives being led by the authors. Together, these projects aim to support embedding of child voices in research practice and to explore the desirability and suitability of Young Persons Advisory Groups within birth cohort studies. The findings from this review, alongside public and stakeholder consultation, will inform development of resources such as practice recommendations to guide future involvement of CYP in health research undertaken at the author's respective institutions.

Implementing early rehabilitation and mobilisation for children in UK paediatric intensive care units: the PERMIT feasibility study

Background

Early rehabilitation and mobilisation encompass patient-tailored interventions, delivered within intensive care, but there are few studies in children and young people within paediatric intensive care units.

Objectives

To explore how healthcare professionals currently practise early rehabilitation and mobilisation using qualitative and quantitative approaches; co-design the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual of early rehabilitation and mobilisation interventions, with primary and secondary patient-centred outcomes; explore feasibility and acceptability of implementing the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual within three paediatric intensive care units.

Design

Mixed-methods feasibility with five interlinked studies (scoping review, survey, observational study, codesign workshops, feasibility study) in three phases.

Setting

United Kingdom paediatric intensive care units.

Participants

Children and young people aged 0-16 years remaining within paediatric intensive care on day 3, their parents/guardians and healthcare professionals.

Interventions

In Phase 3, unit-wide implementation of manualised early rehabilitation and mobilisation.

Main outcome measures

Phase 1 observational study: prevalence of any early rehabilitation and mobilisation on day 3. Phase 3 feasibility study: acceptability of early rehabilitation and mobilisation intervention; adverse events; acceptability of study design; acceptability of outcome measures.

Data sources

Searched Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, MEDLINE, PEDro, Open grey and Cochrane CENTRAL databases.

Review methods

Narrative synthesis.

Results

In the scoping review we identified 36 full-text reports evaluating rehabilitation initiated within 7 days of paediatric intensive care unit admission, outlining non-mobility and mobility early rehabilitation and mobilisation interventions from 24 to 72 hours and delivered twice daily. With the survey, 124/191 (65%) responded from 26/29 (90%) United Kingdom paediatric intensive care units; the majority considered early rehabilitation and mobilisation a priority. The observational study followed 169 patients from 15 units; prevalence of any early rehabilitation and mobilisation on day 3 was 95.3%. We then developed a manualised early rehabilitation and mobilisation intervention informed by current evidence, experience and theory. All three sites implemented the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual successfully, recruited to target (30 patients recruited) and followed up the patients until day 30 or discharge; 21/30 parents consented to complete additional outcome measures.

Limitations

The findings represent the views of National Health Service staff but may not be generalisable. We were unable to conduct workshops and interviews with children, young people and parents to support the Paediatric Early Rehabilitation and Mobilisation during InTensive care manual development due to pandemic restrictions.

Conclusions

A randomised controlled trial is recommended to assess the effectiveness of the manualised early rehabilitation and mobilisation intervention.

Future work

A definitive cluster randomised trial of early rehabilitation and mobilisation in paediatric intensive care requires selection of outcome measure and health economic evaluation.

Study registration

The study is registered as PROSPERO CRD42019151050. The Phase 1 observational study is registered Clinicaltrials.gov NCT04110938 (Phase 1) (registered 1 October 2019) and the Phase 3 feasibility study is registered NCT04909762 (Phase 3) (registered 2 June 2021).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/21/06) and is published in full in Health Technology Assessment; Vol. 27, No. 27. See the NIHR Funding and Awards website for further award information.

A review of reviews exploring patient and public involvement in population health research and development of tools containing best practice guidance

INTRODUCTION

Patient and public involvement (PPI) is increasingly seen as something that is integral to research and of importance to research funders. There is general recognition that PPI is the right thing to do for both moral and practical reasons. The aim of this review of reviews is to examine how PPI can be done 'properly' by looking at the evidence that exists from published reviews and assessing it against the UK Standards for Public Involvement in Research, as well as examining the specific features of population health research that can make PPI more challenging.

METHODS

A review of reviews and development of best practice guidance was carried out following the 5-stage Framework Synthesis method.

RESULTS

In total 31 reviews were included. There is a lack of current research or clarity around Governance and Impact when findings are mapped against UK Standards for Public Involvement in Research. It was also clear that there is little knowledge around PPI with under-represented groups. There are gaps in knowledge about how to ensure key specific attributes of population health research are addressed for PPI team members - particularly around how to deal with complexity and the data-driven nature of the research. Four tools were produced for researchers and PPI members to further improve their PPI activity within population health research and health research more generally, including a framework of recommended actions to address PPI in population health research, and guidance on integrating PPI based on the UK Standards for Public Involvement in Research.

CONCLUSIONS

Facilitating PPI in population health research is challenging due to the nature of this type of research and there is far less evidence on how to do PPI well in this context. The tools can help researchers identify key aspects of PPI that can be integrated when designing PPI within projects. Findings also highlight specific areas where more research or discussion is needed.

Informing Simulation Design: A Qualitative Phenomenological Study of the Experiences of Bereaved Parents and Actors

INTRODUCTION

Simulations, which represent reality, are effective in pediatric healthcare communication skills education and training. Parents are increasingly engaged in simulation development, particularly for authentic character development, to help achieve greater psychological fidelity. For simulated encounters related to a child's end-of-life, involvement of bereaved parents would make sense. However, this is challenging because there is limited research to guide their inclusion and significant responsibility for any approach to be thoughtful and psychologically safe for participating parents. This study explores the impact and experiences of bereaved parents and actors who participated in simulation design.

METHODS

This qualitative phenomenological study involved five bereaved parents and two actors who participated in a full-day workshop to design and develop characters for use in a simulation. Individual semistructured interviews were conducted up to four weeks after the workshop. Data collected from these telephone interviews were analyzed using inductive content analysis.

RESULTS

Bereaved parents found the workshop emotionally challenging but positive, worthwhile, and beneficial. Similarly, actors found the workshop helpful in character development and, although it was an intense experience for them, it validated the importance of their work. Key elements of our research findings could inform future such activities.

CONCLUSIONS

Involving bereaved parents in simulation design can be psychologically safe and beneficial for both parents and actors. Ongoing involvement of bereaved parents may lead to higher-quality simulated experiences, allowing clinicians to practice skills to enhance care provided at a child's end-of-life.

Organisation of care in paediatric intensive care units during the first 18 months of the COVID-19 pandemic: a scoping review protocol

INTRODUCTION

The emergence of COVID-19 has had a significant impact on hospital services, particularly care delivered to those in intensive care units (ICUs) and paediatric ICUs (PICUs) across the world. Although much has been written about healthcare delivery and the healthcare setting since COVID-19 began, to the authors' knowledge, this is the first scoping review to investigate the organisation of care and changes implemented in PICUs during the COVID-19 pandemic. The aim is to conduct a scoping review of the literature to map out the existing studies about care delivery in PICUs during the COVID-19 pandemic and the changes made to the organisation of care in these units during the first 18 months of the pandemic. This review will also identify gaps in current knowledge in this area.

METHODS AND ANALYSIS

This study will be guided by the Joanna Briggs Institute's methodology for scoping reviews, using Arksey and O'Malley's six-stage scoping review framework: (1) identifying the research question; (2) identifying relevant studies; (3) selecting the studies; (4) data charting; (5) collating, summarising and reporting results; and (6) consulting with experts. A comprehensive search will be conducted using the following databases: CINAHL Complete; MEDLINE; PsycINFO; PsycARTICLES and EMBASE. A search strategy with predefined inclusion and exclusion criteria will be used to uncover relevant research in this area. This study will include quantitative, qualitative and mixed research methods studies published in English from 2019 to May 2021.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review. The results from this study will be disseminated through conferences and in peer-reviewed academic journals for those working in the healthcare arena.

Appropriate use criteria for endotracheal suction interventions in mechanically ventilated children: The RAND/UCLA development process

OBJECTIVES

Endotracheal suction is an invasive airway clearance technique used in mechanically ventilated children. This article outlines the methods used to develop appropriate use criteria for endotracheal suction interventions in mechanically ventilated paediatric patients.

METHODS

The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop paediatric appropriate use criteria. This included the following sequential phases of defining scope and key terms, a literature review and synthesis, expert multidisciplinary panel selection, case scenario development, and appropriateness ratings by an interdisciplinary expert panel over two rounds. The panel comprised experts in the fields of paediatric and neonatal intensive care, respiratory medicine, infectious diseases, critical care nursing, implementation science, retrieval medicine, and education. Case scenarios were developed iteratively by interdisciplinary experts and derived from common applications or anticipated intervention uses, as well as from current clinical practice guidelines and results of studies examining interventions efficacy and safety. Scenarios were rated on a scale of 1 (harm outweighs benefit) to 9 (benefit outweighs harm), to define appropriate use (median: 7 to 9), uncertain use (median: 4 to 6), and inappropriate use (median: 1 to 3) of endotracheal suction interventions. Scenarios were than classified as a level of appropriateness.

CONCLUSIONS

The RAND Corporation/University of California, Los Angeles Appropriateness Method provides a thorough and transparent method to inform development of the first appropriate use criteria for endotracheal suction interventions in paediatric patients.

Research Priorities for U.K. Pediatric Critical Care in 2019: Healthcare Professionals' and Parents' Perspectives

OBJECTIVES

The Paediatric Intensive Care Society Study Group conducted a research prioritization exercise with the aim to identify and agree research priorities in Pediatric Critical Care in the United Kingdom both from a healthcare professional and parent/caregiver perspective.

DESIGN

A modified three-round e-Delphi survey, followed by a survey of parents of the top 20 healthcare professional priorities.

SETTING

U.K. PICUs.

PATIENTS

U.K. PICU healthcare professionals who are members of the professional society and parents and family members of children, with experience of a U.K. PICU admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Forty-nine healthcare professional submitted topics in round 1, 98 participated in round 2, and 102 in round 3. These topics were categorized into eight broad domain areas, and within these, there were 73 specific topics in round 2. At round 3, 18 topics had a mean score less than 5.5 and were removed, leaving 55 topics for ranking in round 3. Ninety-five parents and family members completed the surveys from at least 17 U.K. PICUs. Both parents and healthcare professional prioritized research topics associated with the PICU workforce. Healthcare professional research priorities reflected issues that impacted on day-to-day management and practice. Parents' prioritized research addressing acute situations such as infection identification of and sepsis management or research addressing long-term outcomes for children and parents after critical illness. Parents prioritized research into longer term outcomes more than healthcare professional. Parental responses showed clear support for the concept of research in PICU, but few novel research questions were proposed.

CONCLUSIONS

This is the first research prioritization exercise within U.K. PICU setting to include parents' and families' perspectives and compare these with healthcare professional. Results will guide both funders and future researchers.

Perspectives of children and adolescents with cerebral palsy about involvement as research partners: a qualitative study

PURPOSE

Children and adolescents with cerebral palsy have diverse needs and often engage with healthcare services, including paediatric rehabilitation. Partnering with these children and adolescents on research projects to inform practice has the potential to ensure services continue to remain relevant and appropriate. This study aimed to identify what children and adolescents with cerebral palsy suggest are effective ways for researchers to involve them as partners in research.

MATERIALS AND METHODS

This qualitative study was guided by interpretive description. Children and adolescents with cerebral palsy between 8 and 18 years participated in semi-structured, activity-based focus groups or interviews. Verbatim transcripts were coded and analysed using thematic analysis. One member of the research team was a young woman with cerebral palsy.

RESULTS

Seventeen children and adolescents with cerebral palsy from NSW and Victoria (Australia) were involved. Participants were between 8 and 18 years (mean = 12 years), male (n = 11) and female (n = 6). Analysis identified four nested themes: "insider knowledge", "reasons for involvement", "roles in research" and "facilitating partnership".

CONCLUSION

This study identified perspectives of children and adolescents on their involvement as research partners, and considerations for researchers to facilitate involvement of children and adolescents with cerebral palsy as partners in research.IMPLICATIONS FOR REHABILITATIONThe commitment in healthcare to client-centred practice requires that consumers, including children and young people with cerebral palsy, have opportunities to influence the direction of research which impacts them.Children and young people with cerebral palsy are interested in research partnerships and motivated to be involved in various areas of research.Effective research partnerships with younger populations can be facilitated by researchers acknowledging a child or young person's expertise, and employing strategies relating to open communication, flexibility and support.

Patient and Family Member Experiences in Critical Care Research and Quality Improvement Projects

BACKGROUND

Public and patient involvement in healthcare research is increasing, but the effect of involvement on individuals, service delivery, and health outcomes-particularly in specialist population groups like critical care-remains unclear, as does the best way to involve people who have experienced critical illness.

OBJECTIVES

The aim of the study was to explore former patients' and family members' views and experiences of involvement in critical care research and/or quality improvement.

METHODS

Using a qualitative methodology, semistructured telephone interviews were conducted with seven former intensive care unit patients and three close family members across England. Data were analyzed using a standard process of inductive thematic analysis.

RESULTS

Four key themes were identified: making it happen, overcoming hurdles, it helps, and respect and value. Findings center on the need for flexibility, inclusivity, and transparency. They further highlight the particular challenges faced by critical illness survivors and their family members in relation to research involvement, the importance of individualized support and training, and the vital role that project leads have in making people feel valued and equal partners in the process.

DISCUSSION

This is the first study to explore patients' experiences of involvement in critical care research. Despite the small, homogenous sample, the study provides valuable and important data to guide future practice. It highlights the need to enable and support people to make informed choices at a time when they are ready to do so. It further highlights the importance of gatekeepers to avoid vulnerable people contributing before they are ready-a practice that could negatively affect their health status.

Simulation-Based Research: A Scoping Review

There is an increasing interest in using simulation in qualitative research outside evaluation of educational-based activities. To examine how data from simulation has been generated and used in qualitative research, we conducted a scoping review of research topics and data collection and analysis processes reported in qualitative research using simulation in the research method. Of the 665 articles that involved qualitative inquiry, 46 involved simulation in research independent from simulation-based education. Phenomena explored included communication and clinical decision-making during routine care and at highly sensitive times, such as the end of life, as well as the experiences when providing care in a variety of settings and patients, individually and within teams. Our findings highlight that simulation can be used for analysis of phenomena that are difficult for researchers to gain access to firsthand, and we discuss features for consideration when using simulation in qualitative health research.

Survived so what? Identifying priorities for research with children and families post-paediatric intensive care unit

The involvement of patients and the public in the development, implementation and evaluation of health care services and research is recognized to have tangible benefits in relation to effectiveness and credibility. However, despite >96% of children and young people surviving critical illness or injury, there is a paucity of published reports demonstrating their contribution to informing the priorities for aftercare services and outcomes research. We aimed to identify the service and research priorities for Paediatric Intensive Care Unit survivors with children and young people, their families and other stakeholders. We conducted a face-to-face, multiple-stakeholder consultation event, held in the Midlands (UK), to provide opportunities for experiences, views and priorities to be elicited. Data were gathered using write/draw and tell and focus group approaches. An inductive content analytical approach was used to categorize and conceptualize feedback. A total of 26 individuals attended the consultation exercise, including children and young people who were critical care survivors; their siblings; parents and carers; health professionals; academics; commissioners; and service managers. Consultation findings indicated that future services, interventions and research must be holistic and family-centred. Children and young people advisors reported priorities that focused on longer-term outcomes, whereas adult advisors identified priorities that mapped against the pathways of care. Specific priorities included developing and testing interventions that address unmet communication and information needs. Furthermore, initiatives to optimize the lives and longer-term functional and psycho-social outcomes of Paediatric Intensive Care Unit survivors were identified. This consultation exercise provides further evidence of the value of meaningful patient and public involvement in identifying the priorities for research and services for Paediatric Intensive Care Unit survivors and illuminates differences in proposed priorities between children, young people and adult advisors.