Methods
The toolkit we present here is informed by a large program of research, some of which has been reported elsewhere 9,10, and some which we report here for the first time.
Ethnographic study: Our research program began with an observational study of family participation in ICU care team rounds10. We conducted ethnographic observations of rounds, employing both structured (documentation of pre-specified processes) and unstructured (note-taking to characterize interactions and context) data collection techniques to directly observe and describe family member attendance in ICU rounds in seven medical-surgical ICUs located in seven hospitals in three Canadian cites in the province of Alberta.
Interviews and focus groups: Interviews and focus groups with family and healthcare providers were conducted in four urban tertiary care medical-surgical ICUs within a large city, and in five additional ICUs across Alberta, one of which was an urban tertiary care centre and the others which serve a rural patient population 9. These in-depth interviews and focus groups explored facilitators, barriers, and suggestions for improvement from the perspectives of participants in ICU family rounds. Our research program culminated in a full-day toolkit development workshop.
Workshop: A diverse group of family members and healthcare providers from 14 adult ICUs were invited to attend a one-day, 8-hour workshop to deliberate upon and collaboratively develop a toolkit to guide patient and family centered rounds. The key facilitators identified through our qualitative observations and interviews9,10 were incorporated into an electronic survey with a 5-point Likert scale for rating the importance of each facilitator, along with 2 open-ended questions for respondents to write additional facilitators and site-specific contextual factors (see Appendix 1). The survey was distributed to family members and providers one week before the workshop to identify the highest priority elements of patient- and family-centered rounds. Family members and providers were provided with a summary of key findings from the research to date, and were asked to come to the workshop prepared to discuss ideas on how key processes involved in patient-and family-centered rounds could be developed into a practical toolkit for use in the clinical setting.
The workshop was held on November 5th, 2018 and divided into morning and afternoon sessions. The day commenced with a review of existing literature, findings from previous research, and objectives for the workshop, which were to 1) consolidate components of the toolkit including structures, processes, and existing tools, 2) refine toolkit components to optimize communication with all stakeholders, and 3) prioritize further tool development. Participants were divided into six groups. Groups rotated through 12 stations representing structures, processes and tools to guide implementation of the 6 highest priority elements of patient- and family-centered rounds identified in the pre-workshop survey. Groups were asked to generate ideas on the structures, processes and tools, and vote on the importance and relevance of the tools. At the end of the morning and afternoon sessions, large group discussions were held to review and discuss the ideas generated at each workshop station and establish consensus on which elements to include in the final toolkit.
The collaborative worksheets from each activity station were retained for subsequent analysis and to support toolkit development. Three research team members independently took memos during the group discussion portions of the workshop, which were also audio-recorded and transcribed verbatim. The three sets of notes were compiled and collated to create a record of the discussions; the researchers reviewed the collated notes and transcripts for fidelity. From the notes and transcripts, the researchers assembled a consensus list of toolkit items that had been agreed upon and discussed by workshop participants, including numerous suggestions and examples of their application. This consensus list formed the basis for the final toolkit components reported below.