Article
Using genograms to understand pediatric practices’ readiness for change to prevent abuse and neglect
Journal of Child Health Care 16(2) 153–165 ª The Author(s) 2012 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1367493511424888 chc.sagepub.com
Diane J Abatemarco Thomas Jefferson University, USA
Steven Kairys Jersey Shore University Medical Center, USA
Ruth S Gubernick RSG Consulting, USA
Tammy Hurley American Academy of Pediatrics, USA
Abstract A novel use of genograms in primary care practice is to identify processes and relationships among physicians and staff prior to implementing practice change. The authors hypothesized that the genogram would inform researchers and practice staff, participating in a child maltreatment prevention study, how practice members function in a practice. They describe the use of genograms and show how the genogram results are associated with intervention uptake. Researchers constructed genograms, collected baseline surveys, and conducted postintervention interviews with physicians. Data were analyzed to determine processes associated with intervention uptake. While survey results supported the relationships and conflicts observed in the genograms, the genogram provided more multilevel information that reflected practices’ abilities to implement change. By providing a snapshot of the relationship and organizational dynamics within a practice, genograms can assess culture for practice
Corresponding author: Diane J Abatemarco, School of Population Health, Thomas Jefferson University, 1015 Walnut Street, Curtis Bldg. Suite 115, Philadelphia, PA 19107, USA Email:
[email protected]
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change. Genograms describe organizational dynamics and are useful tools to use prior to initiating new programs. Keywords parenting, child abuse, crying, action research, practice change
Children in the United States younger than 4 years are at greatest risk for severe injury or death as a result of abuse and neglect (U.S. Federal Interagency Forum on Child and Family Statistics, 2010). In 1972, the term ‘‘new morbidities’’ was adopted by the American Academy of Pediatrics to describe persistent and increasing behavioral, developmental, and psychosocial problems, replacing infectious diseases as the most significant health issues of childhood (Hagan, 2001; Roghmann and Haggerty, 1972). Parents no longer have the benefits and supports of traditional extended families and cohesive communities; thus, they are now more isolated in their parenting. New parents receive little education and support to deal with the added stress of a newborn or their very young children. In the United States, primary care pediatric practices typically see children at least 12 times before age 3 (American Academy of Pediatrics, 2000). Parents identify pediatricians as one of their preferred primary sources for childrearing advice (Schuster et al., 2001). Practices generally fail to deliver consistent psychosocial screening and anticipatory guidance to parents (Margolis, 2004; Olson et al., 2004). Efforts to effect practice change to increase screening, anticipatory guidance, referral, and follow-up for complex issues such as psychosocial development related to abuse and neglect prevention have been disappointingly slow and only weakly effective (Bethell et al., 2004; Halfon et al., 2004; Randolph et al., 2005). Understanding practice culture may provide insight as to how to engage clinicians and staff in practice change to improve psychosocial development by preventing abuse and neglect. Operational dynamics and organization characteristics of clinical practices may relate to the quality of care that patients receive in practice settings. Components of practice functioning, such as staff and physician perceptions of relationships and organizational dynamics, may influence the extent to which practices can effectively implement interventions to deliver quality patient care. Physician offices vary in their clinical practice (Miller et al., 2001). Team-centered staffing arrangements in many clinical practices are potential sources of stress (Fried, 2006). Few studies have explicitly described the nature of these operational dynamics, especially within the context of pediatric practices (Randolph et al., 2005). Typically, staff surveys are used to gather information about perceptions of organizational functioning. Surveys may provide insight into the individuals’ perceptions but shed little light on the functioning of the practice as a whole. The implementation of practice change strategies in clinical settings to improve patient service delivery is a complex process that can be impeded by relational and organizational dynamics (Stroebel et al., 2005). Researchers invested in practice change efforts have traditionally overlooked the unique nature of practice environments and relationships, as well as the impact these dynamics have on program success, in favor of efficient and broad programs that can be implemented on a widespread scale (e.g. learning collaboratives or use of Plan-Do-Study-Act cycles; Stange, 1996). Failing to recognize these dynamics may result in limited long-term success of an intervention and failure to meet patient needs for improved patient–provider communication and service delivery (Solberg et al., 2000).
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Systems theory can be applied to primary care practices in order to understand the interconnected nature of individual actions and overall system operation (Begun et al., 2003). Complex adaptive systems view organizations within a framework that explains how agents within a ‘‘living’’ system, such as a primary care pediatric practice (Abatemarco et al., 2008), might alter their unique initial conditions to continually improve and ultimately transform the delivery of early childhood psychosocial care. Conceptualizing the pediatric practice as a complex adaptive system moves beyond traditional approaches of examining individual actions and events as targets of change. Complex adaptive system theory reframes the issue by searching for patterns, relationships, and interrelated processes that can inform program implementation (Abatemarco et al., 2008). Tools to simplify this conceptualization process and provide a visual representation of the connections between actors and events within a system may be useful to inform program development and improve outcomes of practice change initiatives. Genograms are assessment tools used to document familial relationships and histories and to look for patterns of family interaction (McGoldrick et al., 2008). Constructing family genograms involves the following: (a) visually mapping the structure of a family; (b) documenting demographic information, issues, and events related to the family structure; and (c) illustrating roles, connections, and relationships among individuals identified on the genogram (Mcllvain et al., 1998). The genogram is drawn to appear as an organizational chart on paper that includes symbols and lines to depict individual demographics and communication patterns (see Figure 1). Although the genogram has been used extensively in family counseling and general medicine (Crabtree et al., 2001; Like et al., 1988; Rodie et al., 1999), its application in a broader practice context has been minimal. Mcllvain et al. extended the scope of the genogram beyond the family to the organizational setting of primary family medicine practices and showed how genograms provided a better model for describing practice participants and relationships than do the use of traditional organizational charts (Mcllvain et al., 1998). The purpose of this paper is to describe the use of practice genograms to assist practices to look reflectively at themselves prior to making practice changes. Within the larger study, Practicing Safety (PS), an intervention designed to engage pediatric practices to adopt screening, anticipatory guidance, and referral resources for abuse and neglect prevention with parents of children who were newborn to 3 years old, we sought to explore whether genograms were useful tools to understand practice culture prior to implementing an intervention for practice change (Abatemarco et al., 2008). Genograms were also used by the study team as a qualitative method to understand pediatric practices as complex adaptive systems. We hypothesized that the use of practice genograms—describing and visually displaying relationships and processes in each pediatric practice—would generate more multilevel information and provide the practice and the research team with a comprehensive assessment of the practice environment in order to tailor the intervention to individual practice cultures, thus establishing a framework for action research, encouraging researchers and practitioners to work collaboratively (Simons and MacDonald, 2006). However, where action research is assessed to evaluate the research retrospectively (Beringer and Fletcher, 2011), the genogram provided prospective information to inform a tailored implementation. In this paper, we describe genograms for five practices, compare the genogram analyses with staff and physician survey results about the practice environment, and compare each to practice change efforts reported by interviews with the lead physician in each practice at the conclusion of the study.
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Figure 1. ‘‘Unsanitized’’ genogram. MD ¼ medical physician/doctor; NP ¼ nurse practitioner (master’s level trained); LPN ¼ licensed practical nurse (1 or 2 year college degree); BSN ¼ bachelor of science in nursing (4-year baccalaureate degree); RN ¼ registered nurse (Graduate of a nursing program or college and has been licensed to practice); RNC ¼ registered nurse certified in pediatrics; PT ¼ part time; CO ¼ a staff person who checks patients out after a visit; CI ¼ a staff person who checks patients in prior to a visit; Chart prep ¼ chart preparation prior to the office visit; MR ¼ medical records clerk; WC ¼ well child visits.
Method We adapted Mcllvain et al.’s practice genogram as part of our initial assessment of each individual practice’s culture. Data were collected by researcher observations, field notes, surveys, and interviews with practice staff and physicians. The genograms were constructed with these data and included the following: (a) visually mapping the organizational structure of the practice; (b) documentation of demographic information, issues, and events related to the practice’s physician and staff structure; and (c) illustration of roles, connections, and relationships among individuals identified on the genogram (McGoldrick et al., 1985). Thus, as shown in Figure 1, the genogram shows that there are physicians, nurses, and staff in the organization, and it shows the individual’s demographics, staff turnover, and position vacancies. In addition, it shows the lines and strength of communication and negative and positive communication between individuals. The practices selected represented various sizes (small, medium, and large), geographic areas (urban, suburban, and rural), and practice types (private practice vs. community health centers). Potential study practices were purposefully selected from lists supplied by the American Academy of Pediatrics state chapter’s executive leadership. Practice participants (clinicians and staff) at the selected sites provided written consent to participate in the study. The study began in 2003, and the
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evaluation follow-up was collected in 2009. This study was approved by the Institutional Review Boards at the University of Medicine and Dentistry of New Jersey, the University of Pittsburgh, and the American Academy of Pediatrics. A project facilitator spent approximately 3–5 days at each practice to collect ethnographic data (i.e. observations, notes of the physical environment, interviews with physicians and staff, and surveys) of each practice. The facilitators then used the ethnographic data to construct genograms that identified roles, provided visual representations of relationships between practice participants, and highlighted important events impacting the organizational processes of each practice. The genogram was shared with staff and clinicians in a meeting at each practice to elicit feedback regarding its accurateness in describing the practice and to stimulate discussion about the practice culture and how to implement change within the practice. Baseline surveys of staff and clinicians in each practice were conducted to assess perceptions of practice environment. All staff members within each practice were recruited to participate in the study and thus to fill out a survey. The structured surveys were adapted by the research team from previous research with family physicians (Crabtree, 1997). Respondents were asked to describe their level of agreement with each statement on a 5-point Likert scale (strongly agree, agree, neutral, disagree, and strongly disagree). The questions were categorized as either practice environmental strengths or barriers. We used descriptive statistics of survey data to illustrate staff and clinician perceptions of their practice settings and environments. Survey questions asked about stress, chaos, tension, staff input, constructive work relationships, and teamwork. Next, we compared the survey results to the individual practice genograms to determine concordance or differences and to determine whether surveys or the genograms more accurately identified relational dynamics perceived by staff and clinicians in the practices. The second question posed in the study was to understand whether the practice aggregate perceptions (i.e. survey data) or the visually depicted genograms were more associated with a practice’s efforts to adopt practice change. In order to evaluate the feasibility, effectiveness, and long-term sustainability of PS, in-depth interviews were conducted with lead pediatricians in each participating practice at the conclusion of the project. We used a guided interview process with questions that were developed from the qualitative data collected at baseline to gain an understanding of perceptions and practical experiences with the intervention. Telephone interviews were conducted and recorded by the primary researcher while a research assistant took notes. Notes were used to clarify and enhance transcriptions. Data generated from the interviews were iteratively analyzed to generate themes and included five steps—describing, organizing, connecting, corroborating/legitimating, and representing the data (Crabtree and Miller, 1999). The themes and subthemes were then examined across practices to determine practice change based on the fidelity to the intervention. This paper describes a triangulation of three sources of qualitative and quantitative data to explore factors associated with practice change. The data are derived from physician and staff surveys, practice genograms, and postintervention in-depth interviews with lead physicians from each practice.
Results The practices were unique in structure and represented different practice sizes and geographic settings. Our sample included both private practices and public health centers. The five practices employed from 10 to 33 physicians and staff. Table 1 describes the staff and physician demographic variables by each practice.
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8 (80%) 25 (100%)
29 (88%) 20 (100%)
13 (72%)
Practice
A B
C D
E
Note: M ¼ male; F ¼ female.
Response rate (%)
21–64 (43)
25–70 (44) 20–53 (36)
31–61 (47) 20–57 (38)
Age range (M)
12 Fs and 1 Ms
25 Fs and 4 Ms 18 Fs and2 Ms
5 Fs and 3 Ms 23 Fs and 2 Ms
Gender (M/F) 1 Asian and 7 Caucasians 4 Asians, 7 Blacks, 5 Caucasians, 8 Latinos, and 1 Other 23 Caucasians and 6 Latinos 5 Blacks, 9 Caucasians, 5 Latinos, and 1 missing 1 Asian, 11 Caucasians, and 1 Latino
Race/ethnicity
2/11; medium
5/24; large 8/12; large
4/4; small 7/18; large
Physician to staff ratio and practice size
