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Objective: The purpose of this study was to explore how moral accountability is navigated when clinicians talk about parental behaviors to support the health of the hospitalized child., Methods: We conducted a secondary data analysis of 74 conversations during daily rounds video recorded as part of a randomized controlled trial of an intervention to advance family-centered rounds in one children's hospital. Conversations involving children under the age 18 who were cared for by a pediatric hospitalist service, pulmonary service, or hematology/oncology service were recorded. We used conversation analysis to analyze sequences in which physicians engaged in talk that had implications for parent behavior., Results: Two phenomena were apparent in how physicians and parents navigated moral accountability. First, physicians avoided or delayed parental agency in their references to parent behaviors. Second, parents demonstrated and clinicians reassured parental competence of parents caring for their children., Conclusion: Physicians appeared to be oriented toward the potential moral implications of asking about parental behavior., Practice Implications: Avoiding attributions of agency and moral accountability as well as providing reassurance for the parents' competence may be useful for clinicians to maintain a good relationship with the parents of children in their care in the hospital setting., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Elizabeth Cox reports financial support was provided by the Agency for Healthcare Research and Quality, National Patient Safety Foundation, Arthur Vining Davis Foundation, and National Center for Advancing Translational Sciences. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: The American Diabetes Association recommends a family-centered approach that addresses each family's specific type 1 diabetes self-management barriers., Objective: To assess an intervention that tailored delivery of self-management resources to families' specific self-management barriers., Subjects: At two sites, 214 children 8-16 years old with type 1 diabetes and their parent(s) were randomized to receive tailored self-management resources (intervention, n = 106) or usual care (n = 108)., Methods: Our intervention (1) identified families' self-management barriers with a validated survey, (2) tailored self-management resources to identified barriers, and (3) delivered the resources as four group sessions coordinated with diabetes visits. Mixed effects models with repeated measures were fit to A1c as well as parent and child QOL during the intervention and 1 year thereafter., Results: Participants were 44% youth (8-12 years) and 56% teens (13-16 years). No intervention effect on A1c or QOL was shown, combining data from sites and age groups. Analyzing results by site and age group, post-intervention A1c for teens at one site declined by 0.06 more per month for intervention teens compared to usual care (P < 0.05). In this group, post-intervention A1c declined significantly when baseline A1c was >8.5 (-0.08, P < 0.05), with an even larger decline when baseline A1c was >10 (-0.19, P < 0.05). In addition, for these teens, the significant improvements in A1c resulted from addressing barriers related to motivation to self-manage. Also at this site, mean QOL increased by 0.61 points per month more during the intervention for parents of intervention youth than for usual care youth (P < 0.05)., Conclusions: Tailored self-management resources may improve outcomes among specific populations, suggesting the need to consider families' self-management barriers and patient characteristics before implementing self-management resources., (© 2019 The Authors. Pediatric Diabetes published by John Wiley & Sons Ltd.)

Background and Objectives: Family-centered rounds (FCRs) have become standard of care, despite the limited evaluation of FCRs' benefits or interventions to support high-quality FCR delivery. This work examines the impact of the FCR checklist intervention, a checklist and associated provider training, on performance of FCR elements, family engagement, and patient safety., Methods: This cluster randomized trial involved 298 families. Two hospital services were randomized to use the checklist; 2 others delivered usual care. We evaluated the performance of 8 FCR checklist elements and family engagement from 673 pre- and postintervention FCR videos and assessed the safety climate with the Children's Hospital Safety Climate Questionnaire. Random effects regression models were used to assess intervention impact., Results: The intervention significantly increased the number of FCR checklist elements performed (β = 1.2, P < .001). Intervention rounds were significantly more likely to include asking the family (odds ratio [OR] = 2.43, P < .05) or health care team (OR = 4.28, P = .002) for questions and reading back orders (OR = 12.43, P < .001). Intervention families' engagement and reports of safety climate were no different from usual care. However, performance of specific checklist elements was associated with changes in these outcomes. For example, order read-back was associated with significantly more family engagement. Asking families for questions was associated with significantly better ratings of staff's communication openness and safety of handoffs and transitions., Conclusions: The performance of FCR checklist elements was enhanced by checklist implementation and associated with changes in family engagement and more positive perceptions of safety climate. Implementing the checklist improves delivery of FCRs, impacting quality and safety of care., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Adults with sickle cell disease (SCD) report problems in relationship building and information exchange during clinic visits. To explore the origin of these communication challenges, we compare communication in pediatric SCD, diabetes, and asthma visits. We collected visit videos and parent surveys from 78 children ages 9-16 years with SCD, asthma, or diabetes. Coders assessed child, parent, and physician utterances reflecting relationship building, information giving, and information gathering. Associations of engagement with type of chronic disease visit were performed with negative binomial regression. Compared to SCD visits, children in diabetes visits spoke 53% more relationship-building utterances (p < .05) and physicians in asthma visits spoke 48% fewer relationship building utterances to the child (p < .01). In diabetes visits, physicians gave almost twice as much information to children and gave 48% less information to parents (both p < .01) compared to SCD visits. Compared to SCD visits, physicians spoke fewer information-gathering utterances to parents in diabetes and asthma visits (85% and 72% respectively, both p < .001). SCD visits reflect less engagement of the children and greater physician effort to gather information from parents. These differences highlight opportunities to enhance engagement as a mechanism for ultimately improving SCD care.

Background and Objective: Experts suggest family engagement in care can improve safety for hospitalized children. Family-centered rounds (FCRs) can offer families the opportunity to participate in error recovery related to children's medications. The objective of this study was to describe family-initiated dialogue about medications and health care team responses to this dialogue during FCR to understand the potential for FCR to foster safe medication use., Methods: FCR were video-recorded daily for 150 hospitalized children. Coders sorted family-initiated medication dialogue into mutually exclusive categories, reflecting place of administration, therapeutic class, topic, and health care team responses. Health care team responses were coded to reflect intent, actions taken by the team, and appropriateness of any changes., Results: Eighty-three (55%) of the 150 families raised 318 medication topics during 347 FCR. Most family-initiated dialogue focused on inpatient medications (65%), with home medications comprising 35%. Anti-infectives (31%), analgesics (14%), and corticosteroids (11%) were the most commonly discussed medications. The most common medication topics raised by families were scheduling (24%) and adverse drug reactions (11%). Although most health care team responses were provision of information (74%), appropriate changes to the child's medications occurred in response to 8% of family-initiated dialogue, with most changes preventing or addressing adverse drug reactions or scheduling issues., Conclusions: Most families initiated dialogue regarding medications during FCRs, including both inpatient and home medications. They raised topics that altered treatment and were important for medication safety, adherence, and satisfaction. Study findings suggest specific medication topics that health care teams can anticipate addressing during FCR., (Copyright © 2015 by the American Academy of Pediatrics.)

Human factors and ergonomics methods are needed to redesign healthcare processes and support patient-centered care, in particular for vulnerable patients such as hospitalized children. We implemented and evaluated a stimulated recall methodology for collective confrontation in the context of family-centered rounds. Five parents and five healthcare team members reviewed video records of their bedside rounds, and were then interviewed using the stimulated recall methodology to identify work system barriers and facilitators in family-centered rounds. The evaluation of the methodology was based on a survey of the participants, and a qualitative analysis of interview data in light of the work system model of Smith and Carayon (1989, 2001). Positive survey feedback from the participants was received. The stimulated recall methodology identified barriers and facilitators in all work system elements. Participatory ergonomics methods such as the stimulated recall methodology allow a range of participants, including parents and children, to participate in healthcare process improvement., (Copyright © 2014 Elsevier Ltd and The Ergonomics Society. All rights reserved.)

Background: Family-centered rounds (FCR) are recommended as standard practice in the pediatric inpatient setting; however, limited data exist on best practices promoting family engagement during rounds., Objective: To identify strategies to enhance family engagement during FCR using a recognized systems engineering approach., Methods: In this qualitative study, stimulated recall interviews using video-recorded rounding sessions were conducted with participants representing the various stakeholders on rounds (15 parents/children and 22 healthcare team [HCT] members) from 4 inpatient services at a children's hospital in Wisconsin. On video review, participants were asked to provide strategies that would increase family engagement on FCR. Qualitative content analysis of interview transcripts was performed in an iterative process., Results: We identified 21 categories of strategies corresponding to 2 themes related to the structure and process of FCR. Strategies related to the structure of FCR were associated with all five recognized work system elements: people (HCT composition), tasks (HCT roles), organization (scheduling of rounds and HCT training), environment (location of rounds and HCT positioning), and tools and technologies (computer use). Strategies related to the FCR process were associated with three rounding phases: before (HCT and family preparation), during (eg, introductions, presentation content, communication style), and after (follow-up) FCR., Conclusions: We identified a range of strategies to enhance family engagement during FCR. These strategies both confirm prior work on the importance of the content and style of communication on rounds and highlight other factors within the hospital work system, like scheduling and computer use, which may affect family engagement in care., (Copyright © 2013 Society of Hospital Medicine.)

Purpose: Factors that support self-efficacy in family-centered care (FCC) must be understood in order to foster FCC in trainees. Using social cognitive theory, the authors examined (1) how three supportive experiences (observing role models, practicing for mastery, and receiving feedback) influence self-efficacy with FCC during rounds and (2) whether the influence of these supportive experiences was mediated by self-efficacy with three key FCC tasks (relationship building, information exchange, and decision making)., Method: Researchers surveyed third-year students during pediatric clerkship rotations during the 2008-2011 academic years. Surveys assessed supportive experiences and students' self-efficacy both with FCC during rounds and with key FCC tasks. Researchers constructed measurement models via exploratory and confirmatory factor analyses. Composite indicator structural equation models evaluated whether supportive experiences influenced self-efficacy with FCC during rounds and whether self-efficacy with key FCC tasks mediated any such influences., Results: Of 184 eligible students, 172 (93%) completed preclerkship surveys. Observing role models and practicing for mastery supported self-efficacy with FCC during rounds (each P < .01), whereas receiving feedback did not. Self-efficacy with two specific FCC tasks-relationship building and decision making (each P < .05)-mediated the effects of these two supportive experiences on self-efficacy with FCC during rounds., Conclusions: Both observing role models and practicing for mastery foster students' self-efficacy with FCC during rounds, operating through self-efficacy with key FCC tasks. Results suggest the importance both of helping students gain self-efficacy in key FCC tasks before rounds and of helping educators implement supportive experiences during rounds.

Objective: To understand the association of race/ethnicity with engagement in pediatric primary care and examine how any racial/ethnic disparities are influenced by socioeconomic status., Methods: Visit videos and parent surveys were obtained for 405 children who visited for respiratory infections. Family and physician engagement in key visit tasks (relationship building, information exchange, and decision making) were coded. Two parallel regression models adjusting for covariates and clustering by physician were constructed: (1) race/ethnicity only and (2) race/ethnicity with SES (education and income)., Results: With and without adjustment for SES, physicians seeing Asian families spoke 24% fewer relationship building utterances, compared to physicians seeing White, non-Latino families (p<0.05). Latino families gathered 24% less information than White, non-Latino families (p<0.05), but accounting for SES mitigates this association. Similarly, African American families were significantly less likely to be actively engaged in decision making (OR=0.32; p<0.05), compared to White, non-Latino families, but adjusting for SES mitigated this association., Conclusion: While engagement during pediatric visits differed by the family's race/ethnicity, many of these differences were eliminated by accounting for socioeconomic status., Practice Implications: Effective targeting and evaluation of interventions to reduce health disparities through improving engagement must extend beyond race/ethnicity to consider socioeconomic status more broadly., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Over 8% of children have a chronic disease and many are unable to adhere to treatment. Satisfaction with chronic disease care can impact adherence. We examine how visit satisfaction is associated with physician communication style and ongoing physician-family relationships. We collected surveys and visit videos for 75 children ages 9-16 years visiting for asthma, diabetes, or sickle cell disease management. Raters assessed physician communication style (friendliness, interest, responsiveness, and dominance) from visit videos. Quality of the ongoing relationship was measured with four survey items (parent-physician relationship, child-physician relationship, comfort asking questions, and trust in the physician), while a single item assessed satisfaction. Correlations and chi square were used to assess association of satisfaction with communication style or quality of the ongoing relationship. Satisfaction was positively associated with physician to parent (p < 0.05) friendliness. Satisfaction was also associated with the quality of the ongoing parent-physician (p < 0.001) and child-physician relationships (p < 0.05), comfort asking questions (p < 0.001), and trust (p < 0.01). This shows that both the communication style and the quality of the ongoing relationship contribute to pediatric chronic disease visit satisfaction.

Objective: Family-centered bedside rounds (FCBRs) are recommended to improve trainee education, patient outcomes, and family satisfaction. However, bedside teaching has waned in recent years, potentially leading to less teaching and more concern for trainees. We examined medical students' concerns, teaching evaluations, and attitudes after experiencing FCBRs during the pediatric clerkship., Methods: Data are both cross-sectional and pre-clerkship and post-clerkship surveys for 113 (89%) of 127 students. Students reported frequencies of post-clerkship concerns (14 items) and teaching experiences (17 items), with 5 response options (1 = never, 2 = rarely, 3 = occasionally, 4 = usually, 5 = always, dichotomized with "frequent" being usually or occasionally). Students reported pre-clerkship and post-clerkship attitudes for 4 items on a 7-point scale (1 = strongly disagree, 7 = strongly agree). Analyses included adjusted means or proportions., Results: The most commonly endorsed concern was presenting information in a way that was understandable to patients and families, with 34.5% of students having this concern frequently. The majority of students frequently experienced 12 of 17 teaching items. Effective teaching of physical exam skills was the teaching item least often experienced frequently by students (20.3%). Student attitudes about the benefits of FCBRs for families were significantly more positive post-clerkship (mean change, 0.37 points; P < .001), but they remained neutral in their preference for FCBRs over traditional rounds without the family present (mean change, -0.14 points; P > .05)., Conclusions: Although students demonstrate positive attitudes toward FCBRs and report frequent occurrence of inpatient teaching elements, findings suggest opportunities for easing student concerns and for using this venue to teach exam skills., (Copyright © 2011 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Objective: The physician-caregiver relationship affects patients' health outcomes, but measures of this important relationship are lacking. We develop and validate the physician-caregiver relationship scales (PCRS), incorporating three relationship domains (liking, understanding, dominance)., Methods: Videotapes of 100 children's visits were coded for verbal and nonverbal communication. Roter interaction analysis system utterance categories (personal remarks, laughter, agreements, approvals, concerns, reassurances, back channels and empathy) and summary measures (physician proportion of total talk and of number of questions) along with nonverbal measures (touch initiations, upright postures and leaning toward a participant) were used as indicators. Model fit was evaluated with confirmatory factor analysis (CFA). Validity was evaluated by associations of the PCRS with visit characteristics and global affect ratings., Results: PCRS domains incorporating verbal and nonverbal indicators demonstrated good model fit (RMSEA<0.05; SRMR<0.12; TLI and CFI>0.95). Construct and predictive validity were demonstrated with PCRS domains relating to visit characteristics and affect ratings as predicted., Conclusions: CFA supported the multi-dimensional PCRS with three domains-liking, understanding and dominance. Such measures are valuable tools for investigations of physician-caregiver relationships., Practice Implications: Models suggest specific indicators of the physician-caregiver relationship and inform interventions to improve these relationships.