Collaborative and Empathetic Communication as a Critical Tool to Build Rapport and Engage Families in Family-Centered Rounds

Family-centered rounds (FCR) have been widely adopted in inpatient pediatrics and are associated with improved family engagement, experience, and safety culture.1–3 Patient and Family-Centered I-PASS (PFC I-PASS) is a framework for FCR that involves family and nurse engagement on rounds, health literacy best principles, and structured verbal and written communication around the I-PASS format (Illness severity, Patient summary, Action items, Situation awareness and contingency planning, Synthesis by receiver).4 It was associated with a 38% reduction in harmful medical errors and improvements in aspects of family experience without prolonging rounds duration.5 While structured communication is an essential aspect of high-reliability communication during FCR, there are also important interpersonal aspects of communication on FCR that are often understudied. Additionally, FCR does not always effectively deliver patient- and family-centered communication or engage all caregivers equally. For instance, individuals identifying as Black or Latino(a/x) and those who use languages other than English (LOE) for care feel less comfortable and empowered speaking during FCR, likely because of individual and systemic factors (eg, past discrimination by physicians, lack of language accessibility via interpreters).6 Therefore, inpatient clinicians cannot assume that all patients and families will feel comfortable speaking during FCR if merely given the opportunity. Additionally, perspectives from pediatric patients and families from systematically excluded or disenfranchised backgrounds are not always centered in research evaluating the impact of FCR on patient and family outcomes.7 Studies on the communication impacts of FCR must center on the perspectives of patients from diverse populations to ensure equitable, patient-centered, and effective care.In this edition of Hospital Pediatrics, Dever et al8 aimed to address these gaps by studying communication practices using audio-recordings of a convenience sample of patients receiving PFC I-PASS FCR at one tertiary care center. They oversampled caregivers identifying as Black and Latino(a/x) and assessed caregiver-reported outcomes of comfort during rounds, understanding of the child’s admission diagnosis, and participation. They also assessed associations between observed clinician behaviors and observed caregiver participatory behaviors on rounds. Interestingly, Dever et al8 found that collaborative communication—with an emphasis on building strong patient-clinician partnerships—emerged as an important practice associated with positive caregiver outcomes. They note that active listening practices (eg, using reflection statements) by clinicians were associated with improved caregiver participation and comfort speaking during rounds. For example, although Black and Latino(a/x) caregivers participated less in FCR than white caregivers, when adjusting for race, ethnicity, age, and education level, clinician use of one reflection statement was associated with significantly increased caregiver participation. Additionally, Dever et al8 highlight the importance of breaking down the patient-clinician hierarchy through power-sharing as a powerful tool for building strong partnerships. Power-sharing is a central tenet in the practice of cultural humility.9 Breaking down the patient-clinician hierarchy involves a shift to a relationship-centered approach through shared decision-making, active listening, and acknowledging the caregiver’s lived experience as well as their expertise in their child’s care.9 Dever et al8 offer concrete strategies for partnership-building, like affirming patient and caregiver efforts to express their opinions, “We’re thinking he’s really ready for discharge today… What do you all think about that? How do you feel about it?”Respect was another important collaborative FCR practice that Dever et al8 identified. They define respect as taking caregivers seriously and treating them with dignity. Respect was assessed by the clinician’s manner of speaking and their recognition of the caregiver as knowledgeable about their child. Previous studies have shown that patients and families frequently experience disrespect in the hospital and that this impacts communication and patient experience.10 In a multicenter pediatric study, 1 in 14 patients and families reported feeling unheard during hospitalization, often manifested as experiencing disrespectful behavior from staff and having to escalate concerns to be heard.11 Other studies show that patients from systematically excluded or disenfranchised backgrounds often experience stigma, discrimination, and racism in health care settings.12,13 Although capturing experiences of disrespect during hospitalization has received some attention (eg, through patient experience surveys about courtesy and respect), health care systems do not routinely elicit patient and family experiences of disrespect. At the systems level, recognizing disrespect as a form of emotional harm—and addressing it with the same rigor applied to physical harms (ie, adverse events)—would advance both patient safety and equity, particularly for systematically excluded or disenfranchised populations. This study by Dever et al8 suggests that one individual-level strategy to address emotional harm could be to coach clinicians (eg, resident physicians) on respect-building skills using a clinician global rating to enforce positive behaviors and identify areas for improvement.Dever et al8 also found that clinician communication emphasizing emotional connection, like validating caregiver emotion, is important to increase FCR caregiver participation. Validating patient emotions by recognizing, accepting, and affirming their feelings is an evidence-based communication skill that has been shown to improve patient outcomes.14 Prior studies, primarily in adult populations, have shown that validating patient emotions can foster trust, increase treatment adherence, and improve patient satisfaction.15 A key addition to the literature Dever et al8 identify is that clinician warmth—rapport-building and expressions of genuine concern—is associated with increased caregiver understanding of the child’s diagnosis, possibly through the role of emotion in learning. Rapport-building involves not only verbal communication (asking about a patient’s family, summarizing concerns), but also nonverbal communication. Actions such as sitting at eye level with the patient and family, nodding, and using body language (avoiding crossing arms) can convey active listening and help build rapport. Inpatient clinicians face increasing barriers to effective nonverbal communication, such as limited seating in a crowded hospital room or using computers on wheels. Thus, clinicians must commit to practice rapport-building and nonverbal communication skills with intention. This can include a prerounds huddle that establishes roles for every team member, including a “rounds ambassador,” a designated team member who strives to build a genuine connection on rounds with the patient (eg, the primary resident). For example, where possible, the primary clinician responsible for presenting the patient case and interacting with the family should walk into the room first and identify a seating placement close to the patient and family, and engage in rapport-building talk while the remainder of the team trickles in. Another team member can be assigned the role of gathering data on the computer, helping with orders and documentation, and be introduced as having this role to the patient and family. For patients who use LOE, partnering with in-person medical interpreters, if available, is critical. Interpreters often serve as cultural navigators and help build rapport.16 Clinicians often undertake communication shortcuts for patients who use LOE, including engaging in less “small talk” or rapport-building out of time concerns.17 Dever et al’s study8 reinforces the importance of ensuring that clinicians make time for such rapport-building moments, especially for patients who use LOE. They suggest that rapport-building is time well spent with implications for patient outcomes.Interestingly, several clinician behaviors in this study by Dever et al8 found to be associated with positive caregiver-reported outcomes, such as caregiver understanding and participation, were used infrequently, sometimes only once during the FCR interaction. This included single instances of partnership-building, reflection, and supportive talk. As pediatric hospitals continue to see increasing volumes of patients in their wards, inpatient physicians may feel increasing competing demands and forego these important communication skills to be efficient. This study suggests that clinicians do not need to invest substantial time to impact caregiver-reported outcomes. Rather, even brief interactions can be meaningful when approached with genuine intention.Although this study by Dever et al8 was conducted in a single center and stratification of results based on sociodemographic factors (like Spanish language) was not possible, the study adds important insights into family engagement during FCR.Investigators make a call to action for increased communication training for trainees and faculty on verbal and nonverbal communication skills that convey partnership-building, rapport-building, and respect. Strategies to do so may include: Before rounds: Conduct a prerounds huddle that establishes roles for every team member, including a “rounds ambassador,” a designated team member who strives to build a genuine connection on rounds with the patient (eg, the primary resident).During rounds: focus on power-sharing and nonverbal communication that builds rapport (sitting at eye level, minimizing distractions).After rounds: follow up on concerns or questions families may have, continue genuine connection building.Authors emphasize the importance of engaging patients and caregivers, including those from systematically excluded or disenfranchised backgrounds, in research assessing the impacts of FCR. Future studies should focus on assessing interventions that promote communication practices of partnership-building, reflection, and supportive talk. In clinical practice, pediatric hospitalists should also strive to engage families of all backgrounds on rounds through the strategies suggested herein, but also develop mechanisms for patients and families to share feedback with the medical team and hospital leadership about FCR communication. This ensures there is a process for continuous learning and assessment as an important component of safe and equitable care for all.