Recentering Family-Centered Rounds to Address Racial and Ethnic Disparities Free

Family-centered rounds (FCRs) are intended to improve family understanding of medical conditions, promote open communication, and encourage patient and family participation in shared decision-making.¹  Pediatric FCRs have been shown to promote the core values of humanism in pediatric medicine, including increased communication, partnership, respect, empathy, and service.²  However, literature supporting FCRs as beneficial to patient and family satisfaction, patient safety, interdisciplinary communication, and bedside teaching has not always examined ethnic and racial disparities.^3,4 

In this issue of Pediatrics, Parente et al⁵  offer a seldom-available direct glimpse into family communication with medical teams that highlights the barriers that caregivers from racial and ethnic minority groups face when participating in FCRs. This observational study of FCRs used audio recordings and caregiver surveys to assess communication quality, medical team behaviors, and caregiver participation. They report that Black and Latinx caregivers participated less, and providers demonstrated less respect and partnership with Black and Spanish-speaking caregivers.

Through rigorously analyzed recordings, Parente et al⁵  provide valuable insight into the current reality of FCRs. They found that FCRs were brief, ranging from 7 to 21 minutes, which is consistent with prior studies.^6–8  Additionally, regardless of caregiver race, providers infrequently elicited questions, used open-ended questions, made reflections, or offered empathetic statements—using these behaviors once or less on average per encounter.

Although FCRs were brief for all caregivers, Parente et al⁵  found that barriers to participation for Spanish-speaking caregivers were even greater because time spent in a caregiver’s preferred language was minimal (ranging from 10% to 48%). Previous research has demonstrated that parents with limited English proficiency (LEP) are uncomfortable requesting an interpreter and feel embarrassed when FCRs accentuate their limited English.⁹  Interpreters are essential to providing quality care to families with LEP.¹⁰  However, optimizing interpreter involvement in FCRs and maximizing time spent in a caregiver’s preferred language may be challenging. For example, Parente et al⁵  note variability in the use of interpreters, with some teams incorporating interpreters throughout and others summarizing rounds in Spanish at the end, which may hinder caregivers’ perception of open communication.¹¹  These findings underscore the need to critically examine the use of interpreters and portions of FCRs that are not interpreted to determine how rounds can be reconfigured to ensure equitable best practices of FCRs.

Lower participation among Spanish-speaking caregivers may also be due to a lack of empowerment. Congruent with previous literature^9,12  Parente et al⁵  found Spanish-speaking caregivers endorsed less comfort participating in rounds, inadequate time to ask questions, and fear of asking questions. Recording also revealed medical teams asked Spanish-speaking caregivers fewer questions, made fewer reflective statements, and demonstrated less respect, which may facilitate a lack of empowerment.

These findings are consistent with prior literature demonstrating that caregivers of racial and ethnic minority groups feel less comfortable participating in and less valued during FCRs.¹³  Racial and ethnic differences in participatory behaviors may indicate that FCRs are not linguistically or culturally centered around the needs of many families. The provider–caregiver interaction is a complex interplay of multifaceted components, including patient age and cognitive development, patient versus caregivers’ preferred languages (including when 1 caregiver prefers English), caregiver education, and culture, among many other facets that may affect a caregiver’s participation. This complex dynamic poses a challenge in defining culturally centered FCRs. A promising approach may be for providers to elicit families’ preferences, individual needs, and expectations analogous to delivering bad news,¹⁴  particularly for families in ethnic and racial minority groups whose communication preferences may not always be well understood by providers.¹⁵ 

One of the principles of FCRs is honoring racial, ethnic, and cultural diversity¹ ; however, evidence from Parente et al⁵  and other studies suggest that interventions are needed to move toward linguistically and culturally appropriate FCRs.¹⁶  To guide interventions, studies of the intersection of health literacy, LEP, and socioeconomic group and FCRs are needed, as are critical examinations of how these factors are associated with a safe climate for health care delivery.^17,18  To address concerns previously described by Spanish-speaking caregivers, care should be taken to explain the structure and intent of FCRs and allow families to decide who should participate.⁹  Medical jargon limits communication¹⁹  and should be avoided, particularly among LEP caregivers given low health literacy among this population.²⁰  Quality improvement initiatives may be needed to ensure consistent interpreter use,¹⁰  particularly because Spanish-speaking caregivers have underscored the importance of interpreters in FCRs.¹⁶  We also recommend increased provider education on implicit biases, microaggressions, and cultural competency as countermeasures to mitigate reported disparities in family communication. Importantly, provider–caregiver language and racial and ethnic concordance have been shown to improve patient outcomes, medical understanding, and patient satisfaction.^11,21–24  Efforts to diversify the pediatric workforce through increasing recruitment and retention of providers who identify as underrepresented in medicine,²⁵  dismantling systemic bias in recruitment, evaluating multilingual skills, and developing inclusive work climates can support a multicultural multilingual workforce necessary to fully implement the principles of inclusive, culturally centered FCRs.²⁶ 

FCRs

family-centered rounds

LEP

limited English proficiency