Pilot Testing of an Equity Focused and Trauma-informed Communication Intervention During Family-centered Rounds

Study Overview
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Brief Summary
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Development and pilot testing of a clinician coaching communication intervention to improve communication between medical teams and caregivers (parents, family members) of children in the hospital. Our team is specifically focused on improving partnership, respect, and collaboration with Black and Latinx caregivers of children in the hospital by incorporating elements from trauma-informed care and racial equity into a communication intervention. The investigators will explore the impact of this intervention on child and caregiver mental health both in the hospital and 90 days after discharge.

Detailed Description
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When admitted to the hospital, Black and Latino(a/x) children are at greater risk of medical errors, surgical complications, longer, more-costly hospital stays, and mortality compared to White children. Although many factors play a role, poor clinician communication likely contributes to these disparities in health outcomes. Across settings, including our preliminary work in the inpatient pediatric environment, Black and Latino(a/x) patients have been shown to experience worse communication quality as evidenced by less patient and family-centered, empathic, and respectful communication as compared to White patients. Poor communication can make the hospital stay more stressful for caregivers, with implications for caregiver and child health and recovery from illness. While prior experiences of discrimination and trauma can negatively affect clinician-caregiver communication, current best practices in clinician communication fail to incorporate equity and trauma-informed principles. In this study the investigators will test the feasibility, acceptability, and preliminary efficacy of a pilot randomized waitlist control trial of an equity focused and trauma-informed clinician coaching communication intervention that aims to teach clinicians skills to improve communication in areas where inequities are known to exist (i.e. respect, partnership) and incorporate principles of equity (i.e affirmation) and trauma-informed care. To do this, first the investigators will co-develop and refine a clinician coaching communication intervention with iterative feedback from Black and Latino(a/x) caregivers as well as clinicians of children in the hospital. Second, the investigators will examine the feasibility, acceptability and preliminary efficacy of the intervention. The investigators will randomize 10 clinicians to an intervention or waitlist group; clinicians in the intervention group will receive the intervention immediately, while clinicians in the waitlist group will initially serve as the control arm then receive the intervention to provide feasibility and acceptability data. The investigators will assess the feasibility of recruiting and collecting data as well as acceptability of the intervention by clinicians. The investigators will explore preliminary efficacy for the effect of the intervention on child adjustment to hospitalization and caregiver post-discharge stress. The investigators hypothesize that our intervention will reduce caregiver stress in the hospital leading to greater participation in hospital care as well as better child adjustment and caregiver mental health after discharge. The investigators will explore the effect of the intervention on child 30 and 90 day readmission.

Official Title
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Development and Pilot Testing of an Equity-focused and Trauma-informed Communication Intervention During Family-centered Rounds

Conditions
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Hospitalism in Children, Post Traumatic Stress Disorder

Intervention / Treatment
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* Behavioral: Equity Focused and Trauma-Informed Communication Intervention


Participation Criteria
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Eligibility Criteria
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Eligibility criteria for caregivers: Adults (18 years of age or older) Proficient in English or Spanish Capable of providing informed consent Identified as a primary caregiver (parent or guardian) of a hospitalized Black or Latino(a/x) child on the general pediatrics team. We will exclude caregivers of children undergoing evaluation for child abuse/neglect or other cases in which the medical team believes family-centered rounds are not appropriate. Eligibility criteria for clinicians: pediatric attending physicians who provide hospital care to children at Duke Children's Hospital. Capable of providing informed consent We will exclude clinicians who do not provide hospital care to children on the general pediatrics team.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Crossover Assignment
Interventional Model Description: The investigators will test the intervention in a randomized pilot with intervention and waitlist control arms. Half the clinical teams will receive the clinician communication intervention immediately upon enrollment and half will receive the intervention after 6 months. The investigators will assess recruitment, enrollment, and data collection feasibility as well as intervention fidelity to evaluate feasibility of implementation and skill uptake using audio-recordings of rounds. The investigators will develop a semi-structured interview and survey to assess acceptability as well as facilitators/barriers to implementation.
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Clinician Coaching Immediate Intervention Arm-- Caregivers<br>Clinicians who receive the intervention will participate for up to 12 months, which includes completion of didactics, 8 audio-recorded clinical encounters, 4 feedback sessions, and completion of a post-intervention brief interview and survey. After completing didactic training elements, clinicians will receive coaching and professional feedback on their communication with caregivers of children in the hospital. The investigators will provide clinicians with illustrative examples from their encounters to prompt discussion and self-reflection. Caregivers of hospitalized children will not know if their clinician has received the communication intervention. The investigators will recruit 40 caregivers in this arm. | Behavioral: Equity Focused and Trauma-Informed Communication Intervention<br>* Clinician communication intervention that includes didactic training and real-time feedback on communication behaviors during clinical encounters.<br>|
| Other: Clinician Coaching Wait-List Control Arm-- Caregivers<br>Clinicians in the wait-list control arm will initially serve as the control arm then receive the intervention to provide feasibility and acceptability data. The clinicians randomized the control arm will undergo didactics and feedback once their pre-intervention audio-recordings are complete. Caregivers of hospitalized children will not know if their clinician has yet received the communication intervention. The investigators will recruit 40 caregivers in this arm prior to clinicians receiving the intervention. | Behavioral: Equity Focused and Trauma-Informed Communication Intervention<br>* Clinician communication intervention that includes didactic training and real-time feedback on communication behaviors during clinical encounters.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Caregiver Post-Traumatic Stress Symptoms as measured by the Impact of Events Scale at 30 days | The investigators will use the Impact of Events Scale- Revised (IES-R) a 22-item questionnaire that assesses post-traumatic stress symptoms and is a widely used measure. The investigators will administer this in a telephone survey of caregivers 30 and 90 days after discharge. Scores range from 0 to 88 with anything above 24 raising a concern for Post-Traumatic Stress Disorder. The investigators hypothesize caregivers in the intervention arm to have a lower IES-R score. | 30 days after discharge | 
| Caregiver Post-Traumatic Stress Symptoms as measured by the Impact of Events Scale at 90 days | The investigators will use the Impact of Events Scale- Revised (IES-R) a 22-item questionnaire that assesses post-traumatic stress symptoms and is a widely used measure. The investigators will administer this in a telephone survey of caregivers 30 and 90 days after discharge. Scores range from 0 to 88 with anything above 24 raising a concern for Post-Traumatic Stress Disorder. The investigators hypothesize caregivers in the intervention arm to have a lower IES-R score. | 90 days after discharge | 
| Child Post-Traumatic Stress Symptoms as measured by the Behavioral Assessment System for Children at 30 days | The BASC is a comprehensive measure of both adaptive and problem behaviors that has previously been used to evaluate the impact of illness and hospitalization on children. The BASC measure is available in English and Spanish. The BASC measure comes with scoring software that provides a T-score and percentile in 5 domains with cutoff points for population norms. Higher scores indicate a child is at risk for developing behavioral, emotion, and social problems. | 30 days after discharge | 
| Child Post-Traumatic Stress Symptoms as measured by the Behavioral Assessment System for Children at 90 days | The BASC is a comprehensive measure of both adaptive and problem behaviors that has previously been used to evaluate the impact of illness and hospitalization on children. The BASC measure is available in English and Spanish. The BASC measure comes with scoring software that provides a T-score and percentile in 5 domains with cutoff points for population norms. Higher scores indicate a child is at risk for developing behavioral, emotion, and social problems. | 90 days after discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in caregiver Salivary Cortisol | The investigators will assess for reductions in caregiver salivary cortisol following interactions with clinical teams. The investigators will collect saliva samples from caregivers at two time points: 30-60 minutes before and 20-30 minutes after family-centered rounds (FCR). The investigators anticipate lower salivary cortisol levels in the intervention compared to control arm at 20-30 minutes following FCR. The investigators will also compare differences in the change in cortisol from before and after FCR for each caregiver; the investigators hypothesize caregivers in the intervention arm will have a smaller change from baseline following FCR. | 30-60 minutes before and 20-30 minutes after FCR | 
| Number of participants with Hospital Readmission at 30 days | Child unplanned hospital readmission | 30 days after discharge | 
| Number of participants with Hospital Readmission at 90 days | Child unplanned hospital readmission | 90 days after discharge | 
| Number of Caregiver Participatory Behaviors | The investigators will measure caregiver participation during clinical encounters by counting the number of times caregivers (1) ask a question, (2) state a preference and (3) express an emotion per clinician encounter. These three behaviors will be summed together and analyzed in aggregate as a count of caregiver participatory behaviors. | During hospitalization |