Students' Perceptions of Trigger Warnings in Medical Education

Twelve tips for implementing trigger or content warnings in healthcare professions education

Trigger warnings are statements offering prior notification of sensitive content, allowing recipients to prepare for and avoid ensuing distress. Students are increasingly reporting expectations for warnings in classrooms and learning contexts. Discussions regarding use of warnings have clear relevance to healthcare education, which regularly explores sensitive content. Their use has been positioned as a measure for inclusive education and as a means to enhance trauma awareness and empathy. Expectations for warnings need to be considered in the context of preparedness for professional practice. This Twelve Tips paper explores the evidence in relation to warnings and its applicability to social learning contexts. These tips highlight considerations and strategies for the use of warnings in the context of healthcare education, balancing issues of inclusivity, learner and educator wellbeing, and professional preparedness. These discussions are situated within the context of current classroom-based healthcare education.

Storylines of Trauma in Health Professions Education: A Critical Metanarrative Review

PHENOMENON

Learners in medical education are often exposed to content and situations that might be experienced as traumatic, which in turn has both professional and personal implications. The purpose of this study was to synthesize the literature on how trauma has been conceptualized and approached within medical education, and the implications thereof.

APPROACH

A metanarrative approach was adopted following the RAMESES guidelines. Searches of 7 databases conducted in January 2022 with no date limitations yielded 7,280 articles, of which 50 were identified for inclusion through purposive and theoretical sampling. An additional 5 articles were added from manual searches of reference lists. Iterative readings, interpretive and reflexive analysis, and research team discussions were performed to identify and refine metanarratives.

FINDINGS

Five metanarratives were identified, including the concept of trauma, the trauma event, the person with trauma, the impact of trauma, and addressing trauma, with each metanarrative encompassing multiple dimensions. A biomedical concept of trauma predominated, with lack of conceptual clarity. Theory was not integrated or developed in the majority of articles reviewed, and context was often ambiguous. Trauma was described in myriad ways among studies. Why certain events were experienced as trauma and the context in which they took place were not well characterized. The impact of trauma was largely concentrated on harmful effects, and manifestations beyond symptoms of post-traumatic stress were often not considered. Furthermore, the dominant focus was on the individual, yet often in a circumscribed way that did not seek to understand the individual experience. In addressing trauma, recommendations were often generic, and earlier research emphasized individually-focused interventions while more recent studies have considered systemic issues.

INSIGHTS

Multiple dimensions of trauma have been discussed in the medical education literature and from many conceptual standpoints, with biomedical, epidemiologic, and individualized perspectives predominating. Greater precision and clarity in defining and understanding trauma is needed to advance research and theory around trauma in medical education and the associated implications for practice. Exploring trauma from intersectional and collective experiences and impacts of trauma and adapting responses to individual needs offers ways to deepen our understanding of how to better support learners impacted by trauma.

Trigger warnings as tools for learning-theorising an evolving cultural concept

BACKGROUND

While definitions of trigger warnings vary, it is generally accepted that they caution about potential reactions arising from exposure to distressing material. Controversy surrounds use of warnings in education, with concerns noted regarding impacts on academic freedom, "coddling", thereby undermining resilience, reinforcement of traumatised identity and enablement of avoidance. Proponents of warnings position them as accommodations for those affected by trauma, enhancing inclusion, and suggest warnings empower choice and enable informed engagement in learning. A recent meta-analysis of warnings' efficacy demonstrated no effect on affective responses or comprehension. Findings regarding avoidance suggested warnings may increase engagement with material. Synthesis of heterogeneous results relating to context of warning application necessitates cautious interpretation of findings. Furthermore, controlled experimental designs do not reflect complex ecologies of social learning environments.

METHODS

Evidence relating to warnings in healthcare professions education remains limited. We undertake a narrative review and synthesis of evidence regarding the role and functions of trigger warnings from a range of disciplines, to inform healthcare education practice. We apply this evidence in considering how warnings may act within a range of theoretical frameworks for healthcare professionals educations including andragogy, self-directed learning and, ultimately, transformative learning. Tensions between exposure to emotionally stimulating learning episodes and the necessity of emotion for learning while simultaneously attending to learners' needs and fulfilling educators' responsibilities are explored. We probe gaps and contentions in existing theoretical frameworks for learning, and consider implications of recognised limitations with reference to warnings. We summarise by proposing a conceptual model for the role of warnings that considers wider salient factors for fostering effective learning.

DISCUSSION AND CONCLUSIONS

Difficulties associated with deriving contextually-relevant evidence and conclusions relating to warnings as an evolving cultural concept are highlighted. We propose warnings as tools to enable critical reflection and emotional literacy, to curate effective learning environments and support humanistic healthcare professional identity formation, within wider trauma-informed pedagogies and educator practice.

How do veterinary students perceive and prepare for compulsory slaughterhouse visits?

BACKGROUND

Veterinary students in the UK must visit a slaughterhouse as part of their studies. There is currently limited evidence exploring how students perceive these visits or which activities have been implemented to support learning during a visit that may be emotionally challenging.

METHODS

Veterinary students at the Royal Veterinary College and the University of Glasgow were invited to complete an online survey and participate in follow-up focus groups.

RESULTS

Participants appreciated the important role that veterinarians play in the slaughterhouse. Most (69%) agreed that in-person visits are important and would choose to visit, with around half (49%) thinking it should be optional. Previous slaughterhouse experience improved students' views towards compulsory in-person visits. Teaching events covering the slaughter process, videos and discussion sessions were perceived as useful preparatory activities. Anxiety was the most common emotion associated with visits.

LIMITATIONS

The response rate was low, at 15.6%, and a small number of students participated in focus groups. Data on diets and gender were not collected.

CONCLUSION

Slaughterhouse visits are valued by students, although they can cause negative emotions. Managing expectations and increasing awareness of visitation requirements during the application process and subsequent studies may improve the educational and emotional experience of visits.

Pulling the Trigger: A Systematic Literature Review of Trigger Warnings as a Strategy for Reducing Traumatization in Higher Education

In the academic context, trigger warnings can be defined as explicit statements that alert a group of learners that certain content explored or discussed in a learning environment may contain potentially distressing material. Extant research highlights a relationship between traumatization and trigger warnings; however, the extent to which trigger warnings constitute a method of best practice for reducing traumatization in higher education has not been addressed. Thus, a systematic literature review was conducted to explore this relationship. A search conducted across academic databases to locate peer-reviewed articles published between November 2010 and November 2020, combined three areas of interest: (1) "trigger warnings," (2) "best practice," and (3) "higher education." Database searches and further manual searches yielded a total of 194 journal articles. Of these, 20 studies satisfied all inclusion criteria. Following the data extraction process, thematic analysis was employed to identify, analyze, and report patterns within data. The key themes identified through the review include trigger warnings as inclusive practice, as part of trauma-informed pedagogy, as ineffectual practice, and as harmful practice. The evidence suggests that when embedded as part of a broader, holistic, and trauma-informed approach, trigger warnings can be a valuable tool for assisting with the effective reduction of traumatization in the higher education context.

Measuring grit, self-efficacy, curiosity, and intolerance of uncertainty in first-generation college and first-generation osteopathic medical students

BACKGROUND

Medical school is a challenging time, with many medical students reporting symptoms of burnout, depression, anxiety, suicidal ideation, and psychological distress during pre-clinical and clinical years. First-generation college and first-generation medical students may be two groups of students at increased risk for the negative psychosocial effects of medical school. Importantly, grit, self-efficacy, and curiosity are protective factors against the negative psychosocial effects of medical school, whereas intolerance of uncertainty is a risk factor. Thus, research examining the associations among grit, self-efficacy, curiosity, and intolerance of uncertainty in first-generation college and first-generation medical students is needed.

METHODS

We conducted a cross-sectional, descriptive study to assess medical students' grit, self-efficacy, curiosity, and intolerance of uncertainty. We conducted independent samples t-tests and regression analyses using SPSS statistical software version 28.0.

RESULTS

A total of 420 students participated in the study for a response rate of 51.5%. One-fifth of participants (21.2%, n = 89) identified as first-generation students, 38.6% (n = 162) participants reporting having a physician relative, and 16.2% (n = 68) reported having a physician parent. Grit, self-efficacy, and curiosity and exploration scores did not differ by first-generation college status, physician relative(s), or physician parent(s). However, total intolerance of uncertainty scores differed by physician relative(s) (t= -2.830, p = 0.005), but not by first-generation status, or physician parent(s). Further, subscale scores for prospective intolerance of uncertainty differed by physician relative(s) (t= -3.379, p = 0.001) and physician parent(s) (t= -2.077, p = 0.038), but not by first-generation college student status. In the hierarchical regression models, first-generation college student status and first-generation medical student status were not predictive of grit, self-efficacy, curiosity and exploration, or intolerance of uncertainty, although statistical trends were observed with students with physician relative(s) predicting lower intolerance of uncertainty scores (B= -2.171, t= -2138, p = 0.033) and lower prospective intolerance of uncertainty (B= -1.666, t= -2.689, p = 0.007).

CONCLUSIONS

These findings suggest that first-generation college students did not differ by grit, self-efficacy, curiosity, or intolerance of uncertainty. Similarly, first-generation medical students did not differ by grit, self-efficacy, or curiosity; however, first-generation medical students showed statistical trends in higher total intolerance of uncertainty and higher prospective intolerance of uncertainty. Additional research needs to confirm these findings in first-generation medical students.

Medical students' views on the value of trigger warnings in education: A qualitative study

BACKGROUND

Trigger warnings-advance notification of content so recipients may prepare for ensuing distress-feature in discussions in higher education. Students' expectations for warnings in some circumstances are recognised, and some educators and institutions have adopted use. Medical education necessitates engagement with potentially distressing topics. Little is known about medical students' expectations regarding warnings in education.

METHODS

All students from a 4-year graduate-entry UK medical degree programme were contacted via digital message outlining study details and were openly sampled. Qualitative methodology was chosen to explore participant expectations, experiences and meanings derived from experiences. Students participated in semi-structured interviews exploring perspectives on functions, benefits and drawbacks of trigger warnings in classroom-based medical education. We analysed interview transcripts using thematic analysis.

RESULTS

Thirteen semi-structured, qualitative interviews were undertaken. Themes in the following areas were identified: (1) students' experiences influence understanding of trauma and trigger warnings, (2) warnings as mediators of learning experiences, (3) professional responsibilities in learning, (4) exposure to content, (5) professional ethos in medical education and (6) how to issue trigger warnings. Students recognised the term 'trigger warning', and that warnings are an accommodation for those affected by trauma. Students' conceptualisation of warnings was influenced by personal experiences and peer interactions both within and outside education. Students expressed both support and concerns about use of warnings and their ability to influence learning, assuming of responsibility and professional development.

DISCUSSION

Diverse student opinions regarding warnings were identified. Most students suggested that warnings be used prior to topics concerning recognised traumas. Incremental exposure to distressing content was recommended. Students should be supported in managing own vulnerabilities and needs, while also experiencing sufficient formative exposure to develop resilience. Greater understanding of trauma prevalence and impacts and underpinnings of warnings amongst students and educators are recommended to optimise education environments and professional development.

Trauma-Informed Care in the Classroom: Our Experience with a Content Warning in a Medical School Course

Trauma is now recognized as a common human experience that has consequences, including adverse effects on learning outcomes. Principles of trauma-informed care include awareness of the impact of trauma and use of strategies to prevent retraumatization. While well-described in medical and mental health care, these principles have been inconsistently applied in the medical education classroom. Content warnings can be part of a trauma-informed classroom approach that notifies learners about potentially distressing topics, allows individuals to employ self-care, and seeks to resist retraumatization. This article describes our experience integrating a content warning about reproductive topics in a second-year medical school course.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-022-01559-0.

Medical educators' views and experiences of trigger warnings in teaching sensitive content

BACKGROUND

Trigger warnings-prior notification of topics so recipients may prepare for ensuing distress-are encountered widely in contemporary culture. Students at some universities have expressed expectations for trigger warnings. Medical education routinely exposes students to numerous potentially distressing topics. However, this topic remains understudied in medical education. Little is understood about educators' views or practice relating to warnings in the context of medical education.

METHODS

Twenty medical educators from a medical degree programme in the UK participated in a semi-structured qualitative interview study, exploring medical educators' views and experiences of managing distressing situations and, specifically, their use of warnings. We analysed interview transcripts by thematic coding and identified themes.

RESULTS

Analysis identified themes relating to educators' conceptualisation of trigger warnings and rationale for use, concerns about the use of warnings and the critical purpose of medical school in ensuring preparedness for clinical practice. Participants shared that warnings were given to empower students in approaching distressing topics and to enable engagement with learning. Warnings acknowledged that some experiences would be distressing and normalised and signalled acceptability of emotional responses. Decisions to use warnings were influenced by the nature of content and, reactively, in response to experiences of student distress. Terminology regarding trigger warnings was interpreted varyingly by participants. A broad variety of topics were identified as potentially sensitive. A number of concerns were noted regarding the use of warnings.

DISCUSSION

Warnings alone did not fulfil educators' responsibility in supporting students' professional development, but may be a useful adjunct, signalling that self-care is valued and should be prioritised. Despite frequent use of warnings, individual educator practice was shaped by varying rationale. A framework that addresses competing tensions of preventing distress and supporting professional development is needed as part of a trauma-informed approach to medical education.

On Triggering and Being Triggered: Civil Society and Building Brave Spaces in Medical Education

IssueHow educators should respond to student reports of intense emotional reactions to curricular content-i.e., being triggered-invites intense debate. There are claims of insensitivity on one side and calls to "toughen up" on the other. These polemics aside, such instances sometimes represent a true dilemma, particularly within medical education where engaging highly sensitive content is essential to future patient care and where managing one's own emotions is a core competency. Parsing this convoluted and emotional debate into these domains illustrates how medical educators can simultaneously legitimize the lived experiences of students, engage in honest dialogue, and maintain a shared commitment to education. Evidence: While substantial energy has been spent debating the legitimacy of students' emotional reactions, the discourse lacks a clear conceptual framework and we often end up talking past each other. The concept of brave spaces offers an important alternative where sensitive subject matter can be engaged with civility. Implications: This paper offers a model for building brave spaces within medical education by clarifying the rights and responsibilities of both teachers and learners in each of three intersecting domains: intrapersonal, interpersonal, and civic. This model is exemplified in a case where students reported being triggered by course content. By parsing this case across the three domains, we can clarify how responses are multifaceted and we can simultaneously avoid indictment of another's lived experiences while preserving the pedagogical integrity of the curriculum.

Recorded Mental Health Recovery Narratives as a Resource for People Affected by Mental Health Problems: Development of the Narrative Experiences Online (NEON) Intervention

BACKGROUND

The internet enables sharing of narratives about health concerns on a substantial scale, and some digital health narratives have been integrated into digital health interventions. Narratives describing recovery from health problems are a focus of research, including those presented in recorded (eg, invariant) form. No clinical trial has been conducted on a web-based intervention providing access to a collection of Recorded Recovery Narratives (RRNs).

OBJECTIVE

This study presents knowledge produced through the development of the Narrative Experiences Online (NEON) Intervention, a web-based intervention incorporating the algorithmic recommendation of RRNs.

METHODS

Knowledge was gathered through knowledge integration (KI) activities. KI1 synthesized previous studies to produce the NEON Impact Model describing how accessing RRNs produces health-related outcomes. KI2 developed curation principles for the NEON Collection of RRNs through consultation with the NEON Lived Experience Advisory Panel and the curation of a preliminary collection. KI3 identified harm minimization strategies for the NEON Intervention through consultation with the NEON International Advisory Board and Lived Experience Advisory Panel. The NEON Intervention was finalized through 2 research studies (RS). In RS1, mental health service users (N=40) rated the immediate impact of randomly presented narratives to validate narrative feedback questions used to inform the recommendation algorithm. In RS2, mental health service users (n=25) were interviewed about their immediate response to a prototype of the NEON Intervention and trial procedures and then were interviewed again after 1 month of use. The usability and acceptability of the prototype and trial procedures were evaluated and refinements were made.

RESULTS

KI1 produced the NEON Impact Model, which identifies moderators (recipient and context), mechanisms of connection (reflection, comparison, learning, and empathy), processes (identification of change from narrative structure or content and internalization of observed change), and outcomes (helpful and unhelpful). KI2 identified 22 curation principles, including a mission to build a large, heterogeneous collection to maximize opportunities for connection. KI3 identified seven harm minimization strategies, including content warnings, proactive and reactive blocking of narratives, and providing resources for the self-management of emotional distress. RS1 found variation in the impact of narratives on different participants, indicating that participant-level feedback on individual narratives is needed to inform a recommender system. The order of presentation did not predict narrative feedback. RS2 identified amendments to web-based trial procedures and the NEON Intervention. Participants accessed some narratives multiple times, use reduced over the 4-week period, and narrative feedback was provided for 31.8% (105/330) of narrative accesses.

CONCLUSIONS

RRNs can be integrated into web-based interventions. Evaluating the NEON Intervention in a clinical trial is feasible. The mixed methods design for developing the NEON Intervention can guide its extension to other clinical populations, the design of other web-based mental health interventions, and the development of narrative-based interventions in mental health.

Student reactions to traumatic material in literature: Implications for trigger warnings

INTRODUCTION

While trigger warnings have garnered significant debate, few studies have investigated how students typically respond to potentially triggering material.

METHOD

In this study, three hundred and fifty-five undergraduate students from four universities read a passage describing incidences of both physical and sexual assault. Longitudinal measures of subjective distress, PTSD symptoms, and emotional reactivity were taken.

RESULTS

Greater than 96% of participants read the triggering passage even when given a non-triggering alternative to read. Of those who read the triggering passage, those with triggering traumas did not report more distress although those with higher PTSD scores did. Two weeks later, those with trigger traumas and/or PTSD did not report an increase in trauma symptoms as a result of reading the triggering passage.

CONCLUSIONS

Students with relevant traumas do not avoid triggering material and the effects appear to be brief. Students with PTSD do not report an exacerbation of symptoms two weeks later as a function of reading the passage.

A qualitative study of expectations and experiences of women using a social media support group when exclusively expressing breastmilk to feed their infant

BACKGROUND

Global recommendations are that mothers exclusively breastfeed their infants for the first six months of life to achieve optimal growth, development, and health outcomes. When infants are unable to feed at the breast, giving expressed breastmilk is the preferred alternative. Mothers who exclusively express breastmilk are poorly supported in mainstream healthcare, and are increasingly using social media groups for assistance.

AIM

To understand the expectations and experiences of women who access social media groups when exclusively expressing breastmilk.

METHODS

A qualitative descriptive approach was used. Participants were recruited online using purposive sampling. The data was collected using semi-structured in-depth interviews with ten women. Audio data were transcribed and subjected to a thematic analysis.

FINDINGS

The first theme was expecting and experiencing emotional support; sub-themes include: coping with grief through emotional support and shared experiences; providing emotional support in the absence of in-person social support; providing emotional support through being non-judgemental; and the ability to access emotional support and engagement 24/7. The second theme was receiving information to manage exclusive expressing; sub-themes include: expression schedules and the let-down reflex; managing exclusive expression; and resolving lactation and breast-related issues.

DISCUSSION

Ajzen's 'Theory of Planned Behaviour' is used to better understand the women's expectations and experiences of belonging to an online peer support group while exclusive expressing.

CONCLUSION

The study highlights the importance of both antenatal and postnatal education and support, the need for reliable information, and the impact of the inability to breastfeed on mothers' emotional health.

Several Ways Generation Z May Shape the Medical School Landscape

Just as medical colleges have adapted to the Millennial generation of students, a new generation is poised to enter as matriculants. Learner attributes of this generation, Generation Z, are in stark contrast to previous ones, but more than that, they provide new challenges that undergraduate universities are already facing. This article aims to highlight some of these challenges, including those relating to student counseling services, volunteering activities, learning environments, and learner perspectives. These challenges are framed and discussed within the context of medical education.