A Seat at the Table Requires an Invitation: Language-Based Inequities in Family Participation

Family-centered rounds (FCRs) are a cornerstone of inpatient pediatric care. In this issue of Hospital Pediatrics, findings from Kurtz et al highlight disparities in access to FCR for families speaking languages other than English (LOE).1 In this single-institution study capturing more than 7500 pediatric rounding encounters at a quaternary care teaching hospital, LOE-preferring families participated in rounds 30% less frequently than English-speaking families on average despite the availability of both interpreting resources and support staff assigned to invite family participation in rounds. The authors ask the critical question of how this disparity has developed. They strikingly show that more than 80% of cases in which families did not participate in LOE encounters were due to the families not being invited to join. These results underscore how even in resource-rich environments with protocols designed to promote appropriate care, variation in practice can drive inequities.Families of hospitalized children are not just visitors; they are valued and active members of the care team whose unique insights and observations contribute meaningfully to patient safety and quality of care. The centering of families during rounds enhances understanding, reduces anxiety, improves detection of medical errors, and provides essential context that supports shared decision-making.2,3 Further, recognizing and incorporating caregiver input demonstrates respect, an essential component of quality care, which has been associated with improved patient outcomes and satisfaction.4,5 Respect both includes the belief that patients and their families have value and requires behaviors in accordance with this belief.6 Not inviting families to participate in rounds insinuates disrespect, implying that their contributions are insignificant or not worth the time spent interpreting the conversation. Importantly, bioethicists argue that respect is owed to all patients regardless of personal characteristics, including the language they use for health care interactions.Fewer invitations to participate on rounds contribute to disparities in caregiver empowerment. Families that use LOE are less likely to feel comfortable speaking up and questioning decision-making than English-speaking families and incur greater levels of medical harm.7–9 In qualitative interviews of families, medical team communication and nonverbal cues such as body language are the strongest drivers of family comfort with participating on rounds.10 Although omitting a direct invitation to join rounds may seem minor, especially when updates can be given later, these subtle signals can convey to the family that their input is not valued or that interpretation is burdensome, decreasing future empowerment. Therefore, medical teams have a unique opportunity and responsibility on FCR to LOE-speaking groups to improve communication gaps. Moreover, when FCR is the primary communication touchpoint in the hospital, there may be even higher risk of failures to communicate updates outside of FCR due to lack of scheduled time to do so, leading to cumulative negative impacts on communication quality and care.Prior work exploring differences in caregiver participation has shown that the makeup of the rounding team can influence how often LOE-preferring families participate and that non-Spanish LOE-preferring families may face different limits on caregiver participation in FCR.11,12 The data presented by Kurtz et al lend further evidence of how both of these factors are associated with substantial variability in LOE caregiver participation. They find that senior resident-only teams more consistently had participation from LOE-preferring caregivers compared with senior-intern teams, and they observe a wide range of participation rates for non-Spanish LOE encounters. These patterns illuminate how individual practices of team members and team structural factors may drive deviations from standards of care.Moreover, the authors also show significant temporal variation in caregiver participation. For more than a quarter of the time periods used in the study, LOE caregiver participation was less than 40% and as low as 27%. In contrast, participation rates for families using English never dropped below 80%. Although drawn from a small sample size, these findings nevertheless emphasize how when teams deviate from the standard practices, it is far more likely to affect LOE-preferring patients and caregivers. Within a hospital system, both individual and team-level variability in practice may contribute to inequities, and standardized expectations and processes could decrease gaps in care.Kurtz et al describe their findings in the setting of a larger study to improve use of FCR at their institution and note they plan a follow-up evaluation to elucidate the factors driving differences in participation among the different provider teams in their study. This approach is critical as a recent secondary analysis of a different study to improve FCR practices across multiple institutions showed significant, persistent disparities in communication for families using LOE.12 In contrast, other efforts focusing on a checklist-based method have demonstrated success in improved FCR participation with no significant differences in rates between English- and LOE-preferring families,13 highlighting the impact standardization protocols may have.Language barriers can impact every interaction a patient and family have during the course of their hospitalization. Translation of written materials is not always available and can be prone to error;14,15 the majority of pediatric hospitalists report updating English-speaking families more often than those using LOE;14 and many conversations throughout the day may occur without a certified medical interpreter either just by speaking in English or using ad hoc interpreters such as family members.16,17 At many institutions, FCR represents a time when the most effective communication of patient and family concerns and medical decision-making takes place. When families are not even invited to participate, vital exchanges of information between families and the medical team fail to take place, contributing to risks for medical error and suboptimal care. It is imperative that institutions develop systems that not only provide access to language services nominally but also establish checklists or protocols that ensure every family is at least invited to participate.