Effects of Patient and Family-Centered Care on Quality of Care in Pediatric Patients: A Systematic Review

Abstract


Introduction
Children are hospitalized when there is a change in health conditions caused by having an acute or chronic disease that requires health care services (Witt et al., 2014).Young human children are more susceptible to disease because the body's defense system is generally in the growth process compared to adults (Simon et al., 2015).A study stated that children aged 0-3 years experienced 14 types of infections in their lives, of which 71% suffered from respiratory infections, and it was reported that the main cause of these infections came from the host (Vissing et al., 2018).Besides, research reported that a large proportion of mortality in hospitalized children occurs early during admission (Bohn et al., 2016).
During hospitalization, it is important to develop and implement an intervention that is feasible, acceptable, and positively impacts health outcomes (Geerligs et al., 2018).One of the most fundamental changes in pediatric health care is the recognition of the importance of patients' and families' involvement in health care (National Association of Pediatric Nurse Practitioners, 2013).Patient and Family-Centered Care (PFCC) is an approach that recognizes the role of the family in the patient's life and encourages mutually beneficial collaboration between patients, families, and health care professionals (Brown et al., 2008).

Research design
A systematic review was used as a method in this study.The researchers used PICO (Patient, Intervention, Comparison, and Outcomes) to determine the clinical questions (Table 1).PICO is a widely used framework for developing research questions on systematic review (Considine et al., 2017).The research question in this study was "How are the effectiveness of patient and family-centered care in improving the quality of care?"

Search methods
Literature searching was conducted using seven databases: ScienceDirect, Scopus, ProQuest, EBSCOhost, Sage Journal, Tailor and Francis, and PubMed within the year from 2011 to 2021.Determination of keywords was conducted by using the Boolean operators' technique, i.e.AND and OR to combine words when searching.In addition, the author also used quotations or quotation marks (") and also grouping on similar concepts symbolized by ( ).The keywords used: ("patient and family-centered care" OR "patient-centered care" OR "family-centered care") AND (intervention OR effect) AND ("usual care") AND ("quality of care" OR "clinical outcome") AND (newborn OR children OR adolescent OR teenager).

Inclusion and exclusion criteria
The inclusion criteria in this study were (1) studies that included pediatric patients aged 0-18 years and their families, (2) accredited international journal, (3) publication year of the journal from 2011 to 2021, (4) articles with experimental design such as quasi-experimental, true experimental, and Randomized Controlled Trials (RCTs), (5) articles are written in English.Meanwhile, the exclusion criteria were (1) articles written in the form of reviews, conference proceedings, protocols, case reports, surveys, and thesis/dissertation, and (2) articles that cannot be downloaded (not fully accessible).

Screening of articles
Screening articles were conducted by two reviewers (TS and DW).The screening was carried out through several stages, such as identifying keywords in seven available databases, selecting the appropriate title and abstract, and identifying the availability of the full text and its suitability with the existing inclusion criteria.In case of disagreement between TS and DW, a third reviewer (NN) would be involved.NN would reconcile the disagreement to identify and ensure that both reviewers have done the screening process correctly.Reconciliation can play a significant role in ensuring that abstract screeners make the right decision at each stage of the screening process (Polanin et al., 2019).

Data extraction
Fifteen selected articles were extracted by all reviewers using a grid synthesis format.This format contained some information, i.e., authors, year of publication, country, objective, design, hospital setting, intervention model, duration, results, and components of the patient and familycentered care.All reviewers identified all included articles based on the foregoing information and summarized them in a table (Table 2, Appendix 1).

Quality assessment of the selected article
The assessment of the quality of studies in this review used tools from the Joanna Briggs Institute (JBI), i.e., the critical appraisal checklist for quasi-experimental research through https://jbi.global/critical-appraisal-tools.JBI critical appraisal tools were created by the JBI and partners and were subsequently accepted by the JBI Scientific Committee after undergoing thorough peer assessment (Joanna Briggs Institute, 2020).Meanwhile, the quality of studies for RCT design was measured using the Critical Appraisal Skills Programme (CASP) through https://casp-uk.net/casp-tools-checklists/(Table 3, Appendix 2).The CASP RCT checklist was initially developed based on the Journal of the American Medical Association (JAMA) Users' Guides and piloted with medical professionals (Critical Appraisal Skills Programme, 2020).A critical appraisal of the article was conducted by TS and DW.If there was disagreement, NN would involve in reconciling the process based on guidelines from JBI and CASP.

Risk of bias
The risk of bias in individual studies for quasi-experiment design was determined with the following cutoffs: low risk of bias if 70% of answers scored yes, moderate risk if 50 to 69% of questions scored yes, and high risk of bias if yes scores were below 50% (Goplen et al., 2019).On the results of the risk assessment bias, it was found that of the nine articles reviewed, seven articles had a low risk of bias, two included a moderate risk, and none had a high risk of bias (Table 4).Meanwhile, assessment of the risk of bias in RCT studies was conducted using the Cochrane collaboration tool (Higgins et al., 2011).Of five articles on RCT design, one study used single-blind, two studies did not show clear blindness, and two were non-blind studies (Table 5).

Data analysis
The authors used synthesis without meta-analysis (SWiM) guidelines in analyzing the data (Campbell et al., 2020).The SWiM guidelines were used to synthesize quantitative data in the form of intervention effects and present it in nine reporting items.Item 1 was grouping the studies into several sections such as authors and year of publication, country, objective, design, hospital setting, intervention model, duration, results, and components of the patient and family-centered care.Items 2-6 were reviewing full-text articles that meet the inclusion criteria to answer the clinical review questions.The article analysis was carried out by reviewing the study design, intervention methods, assessment tools, and intervention effects.The findings are presented in the form of a summary table (item 7), and then the similarities and differences of the outcomes are reported in the form of a narrative (item 8).Furthermore, reporting on the limitations of this study was presented as the final stage of data analysis (item 9).

Characteristics of the selected studies
Fifteen articles were included in the review process.The researchers identified 29,780 articles from seven databases, and 28,473 articles were excluded according to limiters (year of publication, type of article, subject area, and open access).Fifty-three articles were selected for review after the remaining 1,307 papers were filtered based on their titles and abstracts.Finally, fifteen articles were included in this review after assessing their eligibility and adding articles from the reference list (Figure 1).
Five of the reviewed articles came from Iran, two from South Korea, and one from Columbia, China, Finland, India, Indonesia, Italy, North America, and Pakistan.All of the articles in this study were conducted in the hospital setting.There were eight studies implemented in the NICU room, two studies in the PICU room, four in the pediatric ward, and one in the pediatric nephrology office (see Table 2).Moreover, this review produced six outcomes related to the quality of care, including pediatric quality of life, length of stay, patient safety, parent satisfaction, parent psychological response, and parent involvement and partnership with staff.

Participants
The participants in this study were in the age range from 0 to 12 years.The majority (9 of 15 articles) of published studies involved newborn participants and their families in the intervention.The highest number of participants was 3106 children (1574 pre-intervention and 1532 postinterventions), and the number of parents was 2148 (Khan et al., 2018).In comparison, the lowest number of participants was 43 children (21 in the intervention group and 22 in the control group) (Sannino et al., 2016).

Quality of care outcomes
Of the 15 articles reviewed, six outcomes were obtained related to the quality of care, i.e., pediatric quality of life, length of stay, patient safety, parent satisfaction, parent psychological response, and parent involvement and partnership with staff (see Table 2).The outcome measurement of this review refers to the quality of care domain issued by WHO (2018), including effectiveness, safety, and people-centredness.Outcome indicators of effectiveness consist of hospital readmission rate, improvement in health status, and death prevention.Meanwhile, outcome indicators of patient safety may include treatment complications or incidence of hospital-acquired infections.Patient satisfaction, activities of daily living, and readiness to recommend the hospital are the outcome indicators of patient-centredness (European Observatory on Health Systems and Policies, 2019).

Pediatric quality of life
There were five (33.33%) published studies that reported quality of life as an outcome of PFCC intervention.The study by Minooei et al. (2016) claimed that there were significant differences in the mean score of the children's QoL, including physical and psychosocial domain, and the total QoL score in the intervention group before and after the training (p<0.05).In the physical domain, the percentage of normal visual orientation development in infants aged 40 weeks was higher (81%) in the intervention group compared to the control group (52.4%), and neurofunctional assessment at three months had normal scores of 66.6% of children compared to 47.6% of the control group (Sannino et al., 2016).Moreover, there was a significantly reduced respiratory support time, a significant positive weight gain, and a significant increase in breastfeeding for infants in the intervention compared with the control group (He et al., 2018;Verma et al., 2017).However, There was no difference in infants' weight between the intervention and control groups during the parent's participation program in the NICU setting (Heo & Oh, 2019).

Length of stay
Of 15 articles reviewed, four studies (26.67%) described length of stay as an outcome of this research.The results of 3 studies revealed that there was a significant decrease in the length of stay in children during hospitalization (Ladak et al., 2013;Nurhaeni et al., 2018;Bastani et al., 2015).Meanwhile, one article confirmed no significant difference between the intervention and control groups (Welch et al., 2013).

Patient safety
There were three (20%) published studies that proclaimed patient safety as a result of this study, including medical complications and nosocomial infection.There was an unchanged rate of medical errors, but harmful errors (preventable adverse events) went down after intervention significantly by p<0.01 (Khan et al., 2018).However, the other study stated no significant difference between groups in medical complications (Welch et al., 2013) and nosocomial infection (Verma et al., 2017).

Parent psychological response
There were two (13.33%)reviewed articles that presented the psychological responses of parents as a result of the intervention in this study.There was a significant decrease in mothers' anxiety with p<0.001 and increased parent self-efficacy with p<0.008 after the implementation of the partnership model between mothers and nurses (Uhm & Kim, 2019).Furthermore, mothers reported an emotional readiness in preparing to care for their infant on discharge from NICU to home (Peyrovi et al., 2015).

Parent involvement and partnership with staff
There were six (40%) published studies reported that parent involvement and partnership with health professionals as the result of the PFCC intervention.Parents reported that there was an increase in parental involvement (Khan et al., 2018;Ladak et al., 2013;Welch et al., 2013) and a significant raised in parent-staff partnership during child care in hospitals with p<0.001 (Heo & Oh, 2019;Uhm & Kim, 2019).This partnership is demonstrated through the support of doctors and nurses in helping them how to care for their infants (Sannino et al., 2016).

Discussion
This study aimed to describe and assess the effects of patient and family-centered care on the quality of care in the pediatric patients.There were six outcomes related to the quality of care, including pediatric quality of life, length of stay, patient safety, parent satisfaction, parent psychological response, and parent involvement and partnership with staff.The majority of the components of the PFCC in the articles reviewed used family participation as a research intervention.PFCC in nursing is about treating patients and their families as a partner in care with fostering their participation or collaboration (Seniwati et al., 2023).Family participation in taking care of hospitalized children is a mutual relationship between parents and nurses in providing children's health information and decisions making to improve the quality of care (Vasli & Salsali, 2014).Parental participation can be in the form of involvement in daily care during hospitalization (Melo et al., 2014).Feeding the child or preparing the food tray, changing their clothes, assisting in elimination and sleeping, bathing/wiping with a washcloth, and performing oral care are forms of parental participation in nursing care delivery (Abdelkader et al., 2016).
Improving children's quality of life is an outcome resulting from the PFCC intervention in this review.In the physical domain, PFCC interventions are reported to improve children's clinical outcomes by decreasing oxygen support time (He et al., 2018), promoting better motor, visual, and auditory development (Sannino et al., 2016), and increasing breastfeeding rates predischarge (Verma et al., 2017).Quality of life in children is associated with the role of the family in terms of parent-child interactions (Santos et al., 2015).During hospitalization, parents have an important role in child care by providing physical comfort, physiological needs, and psychosocial support and facilitating children to develop abilities in line with the stages of development (Suparto et al., 2020).
Regarding the impact of PFCC on parents, there was a significant increase in the level of parent satisfaction, parent involvement, and parent-staff partnership scores.Parental satisfaction is associated with the attitude of the professional staff, the treatment provided, information, and parental participation during the child's care (Cintra et al., 2022).Nurses as a team in implementing PFCC have a role in involving children and families in the nursing process to improve the quality of care ( Palokas et al., 2015;Uhl et al., 2013).A previous study reveals that involving parents in a child's care leads to enhancing their satisfaction in health care (Cimke & Mucuk, 2017).Furthermore, PFCC also has an impact on the psychological response of parents.According to Aljabari et al. (2022), parental involvement in childcare can reduce anxiety in parents.Parental involvement in care will provide opportunities for them to care for their children directly, receive information on their children's health conditions, and improve relationships with care providers (McCabe, 2014).
In addition, the results showed a decrease in length of stay, a negative parent's psychological response, and the incidence of side effects in children during hospitalization.The previous review using an adult sample also stated that the results obtained after the PFCC intervention included decreased length of stay, family satisfaction, and achievement of medical goals (Goldfarb et al., 2017).Likewise, increasing quality of life, reducing the length of the hospital stay, reducing anxiety in family members, and increasing family satisfaction and relationship with healthcare providers an outcomes of PFCC intervention in adult patients (Park et al., 2018).A study revealed that the positive impact of reducing the length of hospital stay in children is related to improved psychological well-being (Segers et al., 2019).Improved psychological conditions such as decreased anxiety, depression, and stress in children are due to the presence of families who accompany children during hospitalization (Adineh et al., 2016).The presence of the family is considered to bring comfort to the patient.It has also been demonstrated that being able to stay in the moment while a family member is in the hospital helps them deal better (McCabe, 2014).
The strength of this review is that the articles were selected using an experimental design, including quasi-experimental and RCT.The results of the risk assessment bias also show that 80% of the quasi-experimental design and about 71% in the RCT included the low risk of bias in the 15 reviewed articles in this study.A study categorized as low risk of bias indicates confidence on the part of the reviewer that the outcome shows the true treatment impact (study results are considered valid).The study informing is capable of judging that no major or minor sources of bias are likely to consequence results (Viswanathan et al., 2012).

Implications and limitations
The results of this study have implications for childcare delivery during hospitalization.This review has provided evidence that patient and family-centered care can be an appropriate approach for improving the quality of care for the patient, family, and health care professional.Nurses as a team in health care providers encourage families to be involved in child care, including planning, implementation, and evaluation based on partnerships.
The limitation of this research is generalizations in the research setting and not specific to a particular treatment room.In addition, the types of childhood diseases are also screened in general, and there are no criteria for certain conditions that are included in this review.However, the researcher included all possible interventions within the PFCC components and included RCTs and quasi-experimental designs to analyze the highest quality of evidence.Therefore, recommendations for future research to conduct PFCC reviews by equalizing the research setting and diagnosis of diseases in children.

Conclusion
This review conclude that patient and family-centered care intervention is effective in improving the quality of care.The results of this study found that there was an increase in the quality of care in terms of pediatric quality of life, parental satisfaction, parental involvement, and parent-staff partnership scores.Moreover, there was a decrease in the length of stay, the incidence of harmful errors, and a negative parent's psychological response during hospitalization.Family participation is the most component of the PFCC that was applied as an intervention in this study.

Figure 1 .
Figure 1.PRISMA flowchart articles were removed based on the abstract and title review with the following reasons: -Not experimental research nor RCT -Patient aged >18 years -Article review, proceeding, protocols, case report, survey, and thesis/dissertation -Not available in English Full-text articles assessed for eligibility (n = 13) Article added from reference list (n=5) 45 articles were excluded based on the full text for eligibility with the following reasons:-Not full text -Patient aged >18 years -Not available for patient and family-

Table 1 .
Description of PICO

Table 4 .
Risk of bias assessment for quasi experiment design

Table 5 .
Cochrane risk of bias tool for RCT Note: (+) indicates a low risk of bias, (-) indicates a high risk of bias, (?) shows unclear risk of bias

Table 6 .
Findings of the quality of care outcomes with PFCC intervention

Table 3 .
Critical appraisal for RCT with CASP Apart from the experimental intervention, did each study group receive the same level of care (that is, were they treated equally)?