Family-centered rounds (FCRs) are a cornerstone of inpatient pediatric care, exemplifying the principle that families are essential partners in their child’s health. Decades of research have linked FCR participation to improved communication, shared decision-making, satisfaction, and safety.1–3 At their best, FCRs model transparency, respect, and shared decision-making. Yet not all families experience bedside rounds, or the broader health care system, in the same way. Growing evidence demonstrates that prior experiences of discrimination can profoundly shape how families perceive and participate in clinical interactions.4,5In this issue of Hospital Pediatrics, Wein et al present a mixed-methods study examining how experiences of discrimination influence family engagement during FCRs.6 The authors audio-recorded and analyzed rounding encounters among families identifying as Black or Latinx and surveyed them regarding their lived experiences of discrimination, both within and beyond health care settings. Their findings are striking and highly relevant to pediatric hospitals: families who reported previous health care discrimination exhibited more participatory behaviors compared with those reporting past discrimination outside health care settings or no discrimination at all. These families experiencing previous health care discrimination asked more questions, offered more assertive statements, and demonstrated more behaviors characterized by advocacy and a drive to achieve medical understanding.Previous experiences of discrimination in health care can lead to heightened stress responses and can influence health behaviors,7 leading to inequitable health outcomes due to multiple factors, including the potential of decreased engagement and avoidance of care.8,9 Yet the findings from Wein et al’s study tell a different story—one of vigilance. Families who have experienced discrimination may feel a heightened need to ensure that their child’s care is equitable and that their concerns are heard. In this context, assertiveness may represent a form of protective advocacy rather than confrontation. The study’s findings challenge clinicians to recognize these patterns not as defiance but as adaptive responses.This study has several notable strengths. The authors triangulated data from multiple sources, including qualitative documentation of FCR behaviors, caregiver self-reported experiences using validated instruments, and clinical and demographic information extracted from the medical record. This multimethod approach provides a rich, multidimensional understanding of how prior lived experiences, including those outside health care settings, can shape interactions during clinical encounters.The authors also thoughtfully acknowledge the study’s limitations. Conducted at a single site and limited to English- and Spanish-language rounds, the findings may not fully capture the diversity of family experiences in other contexts. The investigators sought to minimize the Hawthorne effect by not disclosing specific communication behaviors being measured. However, nonverbal communication that was not captured in the audio recordings may have influenced caregiver or team behaviors in the moment. Naturally, the authors report that the associations and causal pathways between experiences and behaviors require additional study. Next steps include testing interventions designed to strengthen communication and partnership among families who have experienced prior health care discrimination. We look forward to the authors’ related randomized controlled trial evaluating clinician training in this area. Future work should continue to identify and address the systemic and structural factors that contribute to caregiver hypervigilance in health care settings, ensuring that family advocacy is met with curiosity and appreciation.The authors’ central finding, that prior experiences of discrimination correlate with more active participation, demands careful interpretation. On one hand, increased question-asking and assertive statements may reflect empowered communication, signaling families’ desire to partner in service of their child’s well-being. On the other hand, they may represent a hypervigilance born from necessity: families who have experienced bias may feel compelled to be more proactive to ensure their child’s needs are not overlooked. This hypervigilance may also be a trauma response to racism, leading individuals to exist in a constant state of “fight-or-flight” to prevent future harm.10 Both interpretations are likely true and not mutually exclusive. The behaviors observed are therefore likely expressions of trauma and/or adaptation within a context in which trust has previously been challenged. Regardless, what matters for clinicians is recognizing that these behaviors occur in a social context shaped by inequity.Without that awareness, engagement metrics risk misinterpretation. Active participation is often celebrated as a hallmark of successful FCRs, yet the meaning of such participation differs depending on a family’s experiences. A parent’s assertive question may be heard as collaboration or as a challenge, depending on the clinician’s perspective and implicit biases. Conversely, quieter families should not be assumed to be content with or well-informed about the plan; silence may equally reflect alienation or fear of judgment or avoidance, which can also be a trauma reaction.11This study extends prior work that has primarily focused on the experiences of Black patients and families by also including the perspectives of Latinx caregivers, who may be further marginalized by language differences.12,13 Notably, fewer Latinx participants reported past experiences of discrimination compared with their Black counterparts, whose responses were consistent with national data reported in 2020. As reports of discrimination rise among minoritized groups,14,15 these differences underscore that experiences of discrimination are shaped by a complex interplay of familial, interpersonal, community, and sociopolitical factors. Central to understanding these findings is intersectionality, that individuals hold multiple overlapping identities, and different facets of identity may influence behaviors and interactions in distinct contexts.The study also raises deeper questions about what equity means in family-centered care. FCRs were developed to flatten hierarchies between families and medical teams, yet it occurs within institutions shaped by structural inequities. This study underscores that for some families, equity in FCRs is still aspirational rather than achieved. It reminds us that participation is not solely a function of communication skills or clinician facilitation—it is also a reflection of trust, belonging, and prior encounters with systems that may or may not have affirmed one’s dignity. When those with histories of discrimination must advocate more strongly to be heard, the responsibility lies not with them to temper their voices but with the health care team to build systems of listening and trust.Clinicians should therefore interpret advocacy behaviors as evidence of engagement and courage. The very behaviors that may challenge team hierarchies often reflect families’ deep commitment to their child’s care. Recognizing this reframes assertiveness as an opportunity to connect and improve care, rather than a threat to authority.This study points toward several practical implications for both clinicians and hospitals:Welcome advocacy as partnership. When families ask probing or insistent questions, clinicians can respond with gratitude rather than defensiveness: “Thank you for raising that; it helps us care for your child better.”Practice cultural humility. Cultural humility involves a lifelong commitment to learning through humble curiosity and flattening of hierarchies.16 In practice, this can involve having “pause moments” in which one becomes curious about a patient’s or family’s reaction and seeks to respond with genuine humility and curiosity rather than judgment or defensiveness.Use universal trauma precautions. Consider using trauma-informed practices with all families.17 These involve demonstrating safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment (“voice and choice”), and considering cultural, historical, and gender factors.18Acknowledge prior harm. Even providing brief acknowledgment of negative experiences caregivers have disclosed, either during the hospitalization or during prior health care experiences, can validate experiences and reduce tension.19Create structured opportunities for the family’s voice. Offering a predictable time for questions during rounds and explicitly inviting input (“What are your questions and priorities for today?”) communicates that advocacy is welcome and expected.20Reflect after rounds. Post-round debriefings, both with clinicians and later with caregivers, can help teams examine whether families were heard equitably and how team behavior may have facilitated or inhibited inclusion.21Train teams in equity-centered and trauma-informed communication. Programs addressing implicit bias, trauma-informed care, and shared decision-making can help teams recognize how discrimination manifests in clinical settings.22Co-design FCRs with family partners. Include family and community advisors with diverse lived experiences in quality improvement initiatives focused on FCRs.23Gather data to drive improvement. Collect and review feedback from families regarding their rounding experiences to identify inequities and narrow the gaps.Optimize rounds and incentive structures. Develop equitable rounding models that provide adequate time for teams to listen, engage with families in preferred languages, and foster curiosity.This study also reminds us that equity is not achieved by inviting families to speak—it is realized when their voices are respected, believed, and acted upon. Families who have experienced discrimination often understandably carry that history into every medical encounter. Their engagement during rounds is not only about clarifying care plans but about seeking assurance that their child’s and family’s needs will be fairly met.Wein et al offer an important contribution by reframing family engagement through the lens of social experiences. Their findings call on clinicians to listen not just to what families say but to the history that gives rise to it. As we strive toward more equitable care in hospitals, this study challenges us to listen more closely to caregiver experiences and let them reshape how we round.
Banker et al. (Mon,) studied this question.