Belonging on Rounds: Translating Research Into Inclusive Practices for Families With Limited English Proficiency to Promote Safety, Equity, and Quality

Effective communication between families and clinicians during family-centered rounds (FCR) depends squarely on a family’s engagement and comfort in participating. In this issue of Hospital Pediatrics, Velez et al¹  describe the experiences of Spanish-speaking parents with FCR and identify factors that facilitate or impede engagement. This article, along with previous work in this area, offers strategies to improve bidirectional communication and overcome language barriers. In this commentary, we will expand on the recommendations in this article to provide inclusive FCR for Latinx families by creating an environment of belonging, where patients and families feel accepted, included, valued, and safe to be themselves.² 

Social acceptance or belonging during FCR has not been adequately explored but is critical for patient engagement. In addition to language barriers, families with limited English proficiency (LEP) may experience intersectional bias on the basis of skin color, class, sex, country of origin, immigration status, religion, or other identities.³  Encountering past or current discrimination, exclusionary practices, or implicit bias impedes belonging and reduces parent comfort in participating.⁴  Families interpret cues during FCR on the basis of observations, interactions, and past experiences to infer whether they belong and are welcome. Side conversations between team members, failing to interpret the entirety of rounds, closed body language, and other nonverbal cues can subtly signal a lack of belonging and impact parental engagement.

Providing fully interpreted rounds without side conversations or uninterpreted medical presentations in English is critical for belonging. In the study by Velez et al,¹  families reported variability in how rounds were conducted with an interpreter. Some teams would complete rounds in English inside or outside the room and then have the interpreter summarize the discussion to families; others interpreted the entire conversation. In the former approach, teams value efficiency, settling for less-comprehensive, lower-quality, and inequitable rounds for Spanish-speaking families.⁵  Incomplete interpretation of rounds may kindle uncertainty about belonging, contribute to mistrust, and impact parent comfort making medical decisions. Indeed, families in the study by Velez et al¹  report understanding medical information as essential for participating in medical decisions. Thus, in addition to being inequitable, limited or abbreviated FCR may not provide families sufficient comprehension of medical information to fully participate in medical decisions. Along with overcoming language barriers through complete interpretation of rounds, caring for Latinx families with LEP requires bilingual and bicultural care.⁶  In a study of Latinx families’ experience with well-child checks, clinician self-reported cultural “competency” was associated with higher-quality family-centered care (as reported by families), whereas language concordance was not.⁷ 

To be inclusive, clinicians must move beyond cultural competency alone, which can be prone to stereotypes, to cultural humility, a process of continuous self-reflection that uses empathy, perspective-taking, and active listening to align care delivery with patient values, culture, and beliefs.⁸  Family-centered care and rounds have largely centered on preferences and cultural norms for White and English-speaking families. Misinterpretation of cultural norms in our current health care system contribute to clinician bias and negatively impact care.⁹  Clinicians and hospitals must culturally tailor FCR to families from differing backgrounds and adapt to the needs of the patient or family in front of us.¹⁰  For instance, clinicians could offer to invite or include additional family members on rounds to join by telephone to help with shared decision making, recognizing the importance of “familismo” in many Latinx families.¹¹  Additionally, hospitals can reimagine the role and scope of medical interpreters, many of whom are bicultural and bilingual, as key members of the health care team who can also serve as cultural brokers helping to facilitate effective communication and belonging among families with LEP.¹² 

“Confianza” (trust) is a key cultural value in the Latinx community that is crucial for a patient–clinician relationship that fosters open and effective communication.¹¹  Trust and rapport with clinicians are essential for families to speak up and ask questions and share concerns. However, patients with LEP frequently experience decreased trust and rapport with their clinicians.¹³  This may be a reflection of clinicians often cutting corners in communicating with families with LEP by “getting by” without using interpreters, using ad hoc family member or staff interpreters, and rushing through conversations because of time constraints. These shortcuts deprioritize building rapport with families with LEP, prioritizing more technical communication as a more valuable use of time.¹⁴  In reality, trust and rapport are not just “feel good” aspects of patient care; trust and rapport impact psychological safety, which in turn impacts patient safety. Therefore, clinicians should not only focus on fostering effective communication via accurate and complete interpretations but also on building trust and rapport, which promote a sense of belonging and psychological safety.

Many families with LEP settle for lower-quality communication and believe care would be better if they spoke English. As participants in the Velez et al study noted, families expressed a sense of embarrassment and shame about their language proficiency, feeling they deserved subpar care. Clinicians and hospitals can destigmatize language barriers by normalizing interpretation. For instance, they can insist on using interpreters in all interactions, not just FCR, and reassure families that interpretation is a right, not a luxury. When patients perceive their care as unequal, it has both short- and long-term consequences. Not only does unequal care contribute to a lack of belonging in the current encounter but patients who perceive discrimination in health care settings are also less likely to follow medical advice and delay needed future care.¹⁵ 

Medical teams should take ownership of inclusive communication because quality communication is bidirectional and reinforcing. For example, when clinicians provide more information, patients are more active participants, and patients are more active when clinicians say more partnership-building statements (eg, “you’re a partner in care,” “you know your child best,” or “tell us what you think”).¹⁶  Importantly, communication behaviors can be taught, refined, and modeled to build belonging across differences of race or ethnicity, culture, and power.¹⁷ 

Communication that demonstrates respect may be especially important in the health outcomes of patients of color.^15,18  Patients are good at perceiving the level of respect their physicians have toward them, which involves interpreting both verbal and nonverbal cues that demonstrate the value and autonomy of the patient or family and the validity of his/her/their concerns.¹⁷  Clinicians may make assumptions that patients or families with LEP have lower intelligence or education leading to further disrespect. However, respecting patients and families during FCR requires the belief that patients and families have equal intelligence and worth, regardless of language or education. On rounds, communication behaviors to demonstrate respect and promote belonging include making eye contact with patients and families (even when using an interpreter), inviting families to set the agenda and ask questions early on in FCR, valuing parents’ knowledge of and experience with their child’s illness, involving them in decisions, avoiding dominating the conversation (active listening and power sharing), and asking follow-up questions.^19,20 

Lastly, to foster belonging, FCR should flow between medical teams, patients, and families, without large blocks of medical jargon. Medical jargon should be limited as it largely supports communication between members of the health care team rather than between the team and the family. Large blocks of scripted technical information, such as an extensive normal physical examination (eg, “lungs clear to auscultation bilaterally”), exclude families from the conversation and prevent providers from responding in real time to patient or family cues and preferences for communication. Families should be invited to provide input during FCRs early and often. Engaging families is particularly important in promoting patient safety in patients with LEP given that patients with LEP experience poorer safety and other health outcomes. For instance, patients with LEP have increased adverse events, hospital-acquired conditions, readmissions, and length of stay.²¹  Evidence supports the need to engage families with LEP for patient safety; a subgroup analysis of an FCR intervention that promoted family engagement, health literacy, and bidirectional communication (Patient and Family Centered I-PASS),²²  suggested that patients with limited comfort with English appeared to have even greater reductions in adverse events than English-speaking patients after intervention implementation.²³ 

Beyond comprehensive bilingual communication, creating a culture of belonging is essential to engaging patients and families to participate in FCR. Fostering belonging may be particularly critical for Latinx patients given common, but not ubiquitous, cultural values of familismo, confianza, and collectivism, which highlight the importance of social relationships in decision making.¹¹  To achieve belonging, clinicians must use interpreters for each complete medical encounter on FCR and beyond. Clinicians must practice cultural humility, particularly empathetic curiosity, and power-sharing in all interactions, including on FCR. They must focus on building trust, rapport, and a sense of belonging in their patients. These are not just feel-good practices. These practices are essential for families with LEP to receive the safe, equitable, and high-quality care they are entitled to.