Application of a Framework to Implement Trauma-Informed Care Throughout a Pediatric Health Care Network

Implementation outcomes of a digital, trauma-informed care, educational intervention targeting health professionals in a paediatric burns setting: A mixed methods process evaluation

Trauma-informed care practices are associated with a culture of safety following traumatic experiences, including medical trauma. An interactive, web-based training package ('Responsive CARE') was developed for voluntary uptake by paediatric burns health professionals to increase staff knowledge about trauma-informed practice. This paper reports on a mixed methods process evaluation conducted alongside a preliminary effectiveness study of 'Responsive CARE'. The process evaluation was conducted using The Consolidated Framework for Implementation Research (CFIR) and a logic model, to examine feasibility of both the intervention and implementation strategy. Health practitioners (including senior managers) delivering care to children and caregivers attending an outpatient burns service were eligible to enrol in 'Responsive CARE'. Qualitative interview data and quantitative metadata were used to evaluate the implementation outcomes (adoption, acceptability, fidelity, feasibility and preliminary effectiveness). Children and caregivers attending an outpatient service for change of burn wound dressing or burn scar management during the 3-month control or 3-month intervention period were eligible to enrol in the effectiveness study. The impact on child pain and distress, as well as cost, was investigated using a pretest-posttest design. Thirteen (from anticipated 50 enrolled) health professionals (all female) with mean 10 years (SD=11) of experience with paediatric burns hospital-based outpatient care completed an average of 65% (range 36% to 88%) of available content. Twenty-five semi-structured interviews were completed with health practitioners (21 female) and with 14 caregivers (11 female). Four themes were identified as influencing feasibility and acceptability of the intervention: 1) Keeping a trauma-informed lens; 2) Ways of incorporating trauma-informed care; 3) Working within system constraints; and 4) Being trauma-informed. Preliminary effectiveness data included 177 participants (median age 2 years, and median total body surface area burn 1%). Causal assumptions within the logic model were unable to be fully tested, secondary to lower-than-expected adoption and fidelity. We found no significant difference for pain, distress and per-patient hospital care costs between groups (pre- and post-intervention). Future implementation strategies should include organizational support to keep a trauma-informed lens and to incorporate trauma-informed principles within a medical model of care. Despite efforts to co-design a staff education intervention and implementation approach focused on stakeholder engagement, adaptations are indicated to both the intervention and implementation strategies to promote uptake highlighting the complexity of changing clinician behaviours.

Improving attitudes toward trauma-informed care in the neonatal intensive care unit through comprehensive multi-disciplinary education

OBJECTIVE

This study measured staff understanding and integration of trauma-informed care following comprehensive education.

STUDY DESIGN

This mixed method design used the validated Attitudes Related to Trauma-Informed Care (ARTIC) scale and open-ended survey questions via REDCap optional surveys. Trauma-informed care education was made available to staff members in a level IV NICU. Pre- and post-intervention ARTIC scores were compared and post-intervention REDCap surveys were analyzed.

RESULT

There were 245 multi-disciplinary NICU team members who completed the ARTIC survey before and/or after the educational intervention; and 764 REDCap surveys were completed throughout the study time. ARTIC scores increased from pre- to post-training both for participants with data at both time points (0.5 SD mean increase) and among those with data at only one time point (0.4 SD mean increase). Content analysis of the REDCap survey corroborated the ARTIC results.

CONCLUSION

System-wide trauma-informed education can achieve measurable effect in a NICU setting.

Implementing Trauma-Informed Care-Settings, Definitions, Interventions, Measures, and Implementation across Settings: A Scoping Review

Traumatic experiences can have long-lasting negative effects on individuals, organizations, and societies. If trauma is not addressed, it can create unsafe cultures with constant arousal, untrusting relationships, and the use of coercive measures. Trauma-informed care (TIC) can play a central role in mitigating these negative consequences, but it is unknown how and in which way(s) TIC should be implemented. Our objective was to conduct a scoping review that systematically explored and mapped research conducted in this area and to identify existing knowledge about the implementation of TIC. The search was conducted on the CINAHL, Cochrane, Embase, ERIC, Medline, PsycINFO, and Web of Science databases, and more than 3000 empirical papers, published between 2000 and 2022, were identified. Following further screening, we included 157 papers in our review, which were mainly from the USA, Australia, New Zealand, and Canada, focusing on study settings, methodologies, and definitions of TIC, as well as the types of interventions and measures used. This review shows that TIC is a complex and multifaceted framework, with no overarching structure or clear theoretical underpinnings that can guide practical implementations. TIC has been defined and adapted in varied ways across different settings and populations, making it difficult to synthesize knowledge. A higher level of agreement on how to operationalize and implement TIC in international research could be important in order to better examine its impact and broaden the approach.

Evaluating the Effectiveness of Trauma-Informed Care Frameworks in Provider Education and the Care of Traumatized Patients

INTRODUCTION

Trauma-informed care (TIC) spans many different health care fields and is essential in promoting the well-being and recovery of traumatized individuals. This review aims to assess the efficacy of TIC frameworks in both educating providers and enhancing care for adult and pediatric patients.

METHODS

A literature search was conducted using PubMed, EMBASE, Proquest, Cochrane, and Google Scholar to identify relevant articles up to September 28, 2023. Studies implementing TIC frameworks in health care settings as a provider education tool or in patient care were included. Studies were further categorized based on adult or pediatric patient populations and relevant outcomes were extracted.

RESULTS

A total of 36 articles were included in this review, evaluating over 7843 providers and patients. When implemented as a provider education tool, TIC frameworks significantly improved provider knowledge, confidence, awareness, and attitudes toward TIC (P < 0.05 to P < 0.001). Trauma screenings and assessments also increased (P < 0.001). When these frameworks were applied in adult patient care, there were positive effects across a multitude of settings, including women's health, intimate partner violence, post-traumatic stress disorder, and inpatient mental health. Findings included reduced depression and anxiety (P < 0.05), increased trauma disclosures (5%-30%), and enhanced mental and physical health (P < 0.001).

CONCLUSIONS

This review underscores the multifaceted effectiveness of TIC frameworks, serving both as a valuable educational resource for providers and as a fundamental approach to patient care. Providers reported increased knowledge and comfort with core trauma principles. Patients were also found to derive benefits from these approaches in a variety of settings. These findings demonstrate the extensive applicability of TIC frameworks and highlight the need for a more comprehensive understanding of their applications and long-term effects.

Pediatric Medical Traumatic Stress and Trauma-Informed Care in Pediatric Chronic Illness: A Healthcare Provider Survey

OBJECTIVE

To inform approaches to pediatric medical traumatic stress (PMTS) by exploring providers' (1) perception of the impact of PMTS on the medical care of patients with pediatric-onset chronic illnesses, (2) self-reported competencies and practices of PMTS prevention, treatment, and counseling, and (3) perception of the barriers influencing the adoption of these practices.

STUDY DESIGN

A convenience sample of multidisciplinary healthcare providers was recruited through a multimodal recruitment strategy to participate in an electronic survey adapted from the Trauma-Informed Care Provider Survey.

RESULTS

Among participants (n = 304), 99% agreed that PMTS impacts patient health. Participants report altering medical care plans due to PMTS, including deferring or stopping treatments (n = 98 [32%]) and changing medication regimens (n = 88 [29%]). Sixty-eight percent (n = 208) report negative impact of PMTS on patient implementation of medical care plans, including medication nonadherence (n = 153 [50%]) and missed appointments (n = 119 [39%]). Although participants agreed it is their job to decrease patient stress (n = 292 [96%]) and perform PMTS assessments (n = 268 [88%]), few practiced PMTS-focused trauma informed care. Systems-level barriers to practice included insufficient training, absent clinical workflows, and lack of access to mental health experts.

CONCLUSIONS

Our findings have helped inform a conceptual framework for understanding the relationship between PMTS and health outcomes. Systems-level opportunities to optimize PMTS-focused trauma-informed care include (1) dissemination of provider training, (2) integrated workflows for PMTS mitigation, and (3) enhanced accessibility to mental health providers. Further work is required to determine if these interventions can improve health outcomes in patients with pediatric-onset chronic illnesses.

Trauma-Informed Care Curricula for the Health Professions: A Scoping Review of Best Practices for Design, Implementation, and Evaluation

PURPOSE

Trauma-exposed persons often experience difficulties accessing medical care, remaining engaged in treatment plans, and feeling psychologically safe when receiving care. Trauma-informed care (TIC) is an established framework for health care professionals, but best practices for TIC education remain unclear. To remedy this, the authors conducted a multidisciplinary scoping literature review to discern best practices for the design, implementation, and evaluation of TIC curricula for health care professionals.

METHOD

The research team searched Ovid MEDLINE, Cochrane Library, Elsevier's Scopus, Elsevier's Embase, Web of Science, and the PTSDpubs database from the database inception date until May 14, 2021. Worldwide English language studies on previously implemented TIC curricula for trainees or professionals in health care were included in this review.

RESULTS

Fifty-five studies met the inclusion criteria, with medicine being the most common discipline represented. The most prevalent learning objectives were cultivating skills in screening for trauma and responding to subsequent disclosures (41 studies [74.5%]), defining trauma (34 studies [61.8%]), and understanding trauma's impact on health (33 studies [60.0%]). Fifty-one of the studies included curricular evaluations, with the most common survey items being confidence in TIC skills (38 studies [74.5%]), training content knowledge assessment (25 studies [49.0%]), participant demographic characteristics (21 studies [41.2%]), and attitudes regarding the importance of TIC (19 studies [37.3%]).

CONCLUSIONS

Future curricula should be rooted in cultural humility and an understanding of the impacts of marginalization and oppression on individual and collective experiences of trauma. Moreover, curricula are needed for clinicians in more diverse specialties and across different cadres of care teams. Additional considerations include mandated reporting, medical record documentation, and vicarious trauma experienced by health care professionals.

Understanding the Conceptualization and Operationalization of Trauma-Informed Care Within and Across Systems: A Critical Interpretive Synthesis

Policy Points In order to achieve successful operationalization of trauma-informed care (TIC), TIC policies must include conceptual clarity regarding the definition of both trauma and TIC. Furthermore, TIC requires clear and cohesive policies that address operational factors such as clearly delineated roles of service providers, protocol for positive trauma screens, necessary financial infrastructure, and mechanisms of intersectoral collaboration. Additionally, policy procedures need to be considered for how TIC is provided at the program and service level as well as what TIC means at the organizational, system, and intersectoral level.

CONTEXT

Increased recognition of the epidemiology of trauma and its impact on individuals within and across human service delivery systems has contributed to the development of trauma-informed care (TIC). How TIC can be conceptualized and implemented, however, remains unclear. This study seeks to review and analyze the TIC literature from within and across systems of care and to generate a conceptual framework regarding TIC.

METHODS

Our study followed a critical interpretive synthesis methodology. We searched multiple databases (Campbell Collaboration, Econlit, Health Systems Evidence, Embase, ERIC, HealthSTAR, IPSA, JSTOR, Medline, PsychINFO, Social Sciences Abstracts, Sociological Abstracts and Web of Science),as well as relevant gray literature and information-rich websites. We used a coding tool, adapted to the TIC literature, for data extraction.

FINDINGS

Electronic database searches yielded 2,439 results and after inclusion/exclusion criteria were applied, a purposive sample of 98 information-rich articles was generated. Conceptual clarity and definitional understanding of TIC is lacking in the literature, which has led to poor operationalization of TIC. Additionally, infrastructural and ideological barriers, such as insufficient funding and service provider "buy-in," have hindered TIC implementation. The resulting conceptual framework defines trauma and depicts critical elements of vertical TIC, including the bidirectional relationship between the trauma-affected individual and the system, and horizontal TIC, which requires intersectoral collaboration, an established referral network, and standardized TIC language.

CONCLUSIONS

Successful operationalization of TIC requires policies that address current gaps in systems arrangements, such as the lack of funding structures for TIC, and political factors, such as the role of policy legacies. The emergent conceptual framework acknowledges critical factors affecting operationalization.

Ethical Care of the Traumatized: Conceptual Introduction to Trauma-Informed Care for Surgeons and Surgical Residents

Trauma-informed care (TIC) is a set of principles and practices designed to improve the ways professionals treat people who have been traumatized. This study reviews fundamental concepts of TIC and applies them to the work of surgeons. TIC is described in relation to fundamental medical ethical concepts, and evidence for TIC-based intervention is reviewed. Implementation of TIC in medical education is also described, and recommendations for practice changes are made.

Trauma Informed Ethics Consultation

We argue for the addition of trauma informed awareness, training, and skill in clinical ethics consultation by proposing a novel framework for Trauma Informed Ethics Consultation (TIEC). This approach expands on the American Society for Bioethics and Humanities (ASBH) framework for, and key insights from feminist approaches to, ethics consultation, and the literature on trauma informed care (TIC). TIEC keeps ethics consultation in line with the provision of TIC in other clinical settings. Most crucially, TIEC (like TIC) is systematically sensitive to culture, history, difference, power, social exclusion, oppression, and marginalization. By engaging a neonatal intensive care ethics consult example, we define our TIEC approach and illustrate its application. Through TIEC we argue it is the role of ethics consultants to not only hold open moral spaces, but to furnish them in morally habitable ways for all stakeholders involved in the ethics consultation process, including patients, surrogates, and practitioners.

Trauma-informed care and ethics consultation in the NICU

Trauma-informed care responds to our current understanding of the ways in which people's traumatic life experiences influence both their health and their interactions with the health care system. Many ethics consults arise because those past traumatic life experiences are not recognized and addressed. In this paper, we present a NICU case that led to an ethics consultation about end-of-life decisions for a dying baby. We illustrate the ways in which a trauma-informed approach helped doctors, nurses and ethics consultants to better understand and care for the mother and baby.

Child Adversity and Trauma-Informed Care Teaching Interventions: A Systematic Review

OBJECTIVES

Health professionals need training to provide trauma-informed care (TIC) for children with adverse childhood experiences (ACEs), which can affect short- and long-term health. We summarize and evaluate published curricula for health professionals on ACEs and TIC.

METHODS

We searched PubMed, Embase, Web of Science, CINAHL, Cochrane Central Register of Controlled Trials, PsychInfo, and MedEdPORTAL through January 2021. Studies meeting the following criteria were included: Described teaching interventions on ACEs, TIC, and child abuse and maltreatment; included health care providers or trainees as learners; were written in English; included an abstract; and described a curriculum and evaluation. We reviewed 2264 abstracts, abstracted data from 79 studies, and selected 51 studies for qualitative synthesis.

RESULTS

Studies focused on ACEs/TIC (27), child abuse (14), domestic/intimate partner violence (6), and child maltreatment/parental physical punishment (4). Among these 51 studies, 43 were published since 2010. Learners included a mix of health professionals (34) and students (17). Duration, content, and quality of the 51 curricula were highly variable. An analysis of 10 exemplar curricula on ACEs and/or TIC revealed high and very high quality for methods and moderate to very high quality for curriculum evaluation, suggesting that they may be good models for other educational programs. Four of the 10 exemplars used randomized controlled trials to evaluate efficacy. Studies were limited to English language and subject to publication bias.

CONCLUSIONS

ACEs and TIC are increasingly relevant to teaching health professionals, especially pediatricians, and related teaching curricula offer good examples for other programs.

Recognizing and Reducing the Impact of Trauma of Hospitalization: Considerations for Persons Who Use Drugs

Amidst the ongoing opioid crisis, the number of individuals with substance use disorders being hospitalized for acute medical illnesses has increased. There is now a growing recognition that these events may be psychologically traumatic, leading to the development of acute stress reactions, and post-traumatic stress disorder. Patients who use drugs may be particularly susceptible to being traumatized due to their underlying psychiatric comorbidities, prior trauma histories, inadequate treatment of the underlying substance use disorders, and stigmatization. Interventions such as early identification and screening, trauma-informed care, and specialized addiction services may help to mitigate the risks of trauma amongst this population. More research is needed to better guide hospitals to ensure people who use drugs receive optimal care.

Association of Neighborhood Gun Violence With Mental Health-Related Pediatric Emergency Department Utilization

IMPORTANCE

Many children and adolescents in the United States are exposed to neighborhood gun violence. Associations between violence exposure and children's short-term mental health are not well understood.

OBJECTIVE

To examine the association between neighborhood gun violence and subsequent mental health-related pediatric emergency department (ED) utilization.

DESIGN, SETTING, AND PARTICIPANTS

This location-based cross-sectional study included 128 683 ED encounters for children aged 0 to 19 years living in 12 zip codes in Philadelphia, Pennsylvania, who presented to an urban academic pediatric ED from January 1, 2014, to December 31, 2018. Children were included if they (1) had 1 or more ED visits in the 60 days before or after a neighborhood shooting and (2) lived within a quarter-mile radius of the location where this shooting occurred. Analysis began August 2020 and ended May 2021.

EXPOSURE

Neighborhood violence exposure, as measured by whether a patient resided near 1 or more episodes of police-reported gun violence.

MAIN OUTCOMES AND MEASURES

ED encounters for a mental health-related chief complaint or primary diagnosis.

RESULTS

A total of 2629 people were shot in the study area between 2014 and 2018, and 54 341 children living nearby had 1 or more ED visits within 60 days of a shooting. The majority of these children were Black (45 946 [84.5%]) and were insured by Medicaid (42 480 [78.1%]). After adjusting for age, sex, race and ethnicity, median household income by zip code, and insurance, children residing within one-eighth of a mile (2-3 blocks) of a shooting had greater odds of mental health-related ED presentations in the subsequent 14 days (adjusted odds ratio, 1.86 [95% CI, 1.20-2.88]), 30 days (adjusted odds ratio, 1.49 [95% CI, 1.11-2.03]), and 60 days (adjusted odds ratio, 1.35 [95% CI, 1.06-1.72]).

CONCLUSIONS AND RELEVANCE

Exposure to neighborhood gun violence is associated with an increase in children's acute mental health symptoms. City health departments and pediatric health care systems should work together to provide community-based support for children and families exposed to violence and trauma-informed care for the subset of these children who subsequently present to the ED. Policies aimed at reducing children's exposure to neighborhood gun violence and mitigating the mental symptoms associated with gun violence exposure must be a public health priority.

Perceptions of females about trauma-informed services for survivors of sexual violence in south western Uganda- a qualitative study

Background

Sexual violence is a public health concern globally and locally, and trauma-informed services are put in place to mitigate its consequences. A few studies have evaluated the quality and uptake of these trauma-informed services for sexual violence. This study aimed at; i) assessing the knowledge of participants about trauma-informed services, ii) exploring the attitudes of females about trauma-informed services, and iii) assessing different factors associated with the utilization of trauma-informed services.

Methods

This study employed a descriptive cross-sectional qualitative design. The participants were females at Kyangyenyi health center III and Kigarama health center III in Sheema district, southwestern Uganda. We used a purposive sampling procedure for all participants and then a consecutive sampling of females. Data about; knowledge of trauma-informed services for sexual violence, attitudes towards trauma-informed services, and factors influencing the utilization of trauma-informed services were collected using an in-depth interview guide. Data were analyzed using thematic content analysis.

Results

We interviewed 32 participants. There was a high prevalence of sexual violence, and it was a big concern in the community. Many of the respondents were not sensitized about trauma-informed services. Most of them knew only about HIV treatment. Our study shows that a good section of females did not seek the services after being sexually violated due to the fear of the perpetrator, bribing of the family of the affected and authorities, or even fear of family breakup and stigmatization. There were a lot of bribery, poor road networks, and inadequate health care services. These hindered survivors of sexual violence from utilizing trauma-informed services.

Conclusions

There was a knowledge gap about trauma-informed services for survivors of sexual violence. There was sexual violence in the community. Sensitization needs to be done among the populations by respective authorities to iron out issues of ignorance about the services and health workers evaluated for competence in offering the trauma-informed services.

Addressing Adultification of Black Pediatric Patients in the Emergency Department: A Framework to Decrease Disparities

Systematic racism and structural discrimination in the United States are factors that have negatively affected the health of Black individuals and families. One form of racism that often goes unrecognized and yet has a profound negative impact on the health and safety of Black children is adultification. Adultification occurs when children are perceived, or treated, as being older than they are. We implemented the Racism as a Root Cause framework to identify ways health care providers and health care systems can work to dismantle inequities and address the adultification of Black children in the emergency department (ED). A shift to change policies, systems, and environments in the ED begins with recognition of blind spots through training, communication, and reflection. Utilizing methods to identify adultification and racism, such as the ICD-10-CM Diagnosis Code Z60.5 Target of (perceived) adverse discrimination and persecution, can assist providers in recognizing the prevalence of racism and discrimination. To reduce the harms of inequities, injustice, and impacts of racism on Black children in the ED, it is essential to use trauma-informed care in all interactions. It is crucial for all employees of the ED to understand that adultification is extremely prevalent, hard to recognize, and causes harm to the health of Black children and their families. Without conscious efforts to decrease the pervasiveness and detriment of adultification bias, the repercussions of such racism will continue to perpetuate medical mistrust and negative health care experiences for Black children and families.

Trauma-informed care as a rights-based "standard of care": A critical review

BACKGROUND

A growing body of literature on the concept of trauma-informed care (TIC) has emerged in response to greater recognition of the prevalence of childhood trauma. Currently, no review has examined the conceptualization of TIC in various child-serving systems, specifically TIC as a standard of care, the outcomes examined relevant to care, and whether child rights are part of the TIC discourse.

METHOD

A systematic search of 12 health and non-health databases, reviewed for relevance to children and youth specifically, was conducted to form a critical review of the literature.

RESULTS

Forty-nine documents were selected, which included articles from child welfare (n = 16), education (n = 15), juvenile justice (n = 8), health (n = 7), and multiple sectors (n = 3). A common theme across all sectors was a lack of clear understanding regarding what is TIC and how to implement it. While trauma symptoms are seemingly a good-fit outcome and reflective of a right to rehabilitative health, validated assessment tools were not commonly used. Few studies explicitly included a child rights perspective within TIC.

CONCLUSION

Emerging evidence encourages systematic inquiry into the operationalization of TIC to better assess whether it is an established model with consistent measurement. Empirical studies need to embrace established intervention methodology (e.g., improvement from baseline, control groups). From this expanded rigor, the issue as to whether TIC can evolve to a rights-based standard of care can be addressed.

A need for trauma informed care curriculum: Experiences from Pakistan

Trauma is a major global health problem. Currently a trauma curriculum, from a psychological perspective, has not been uniformly incorporated in medical education. Nonetheless, professionals from various medical disciplines have an integral role in providing trauma care to survivors. The current COVID-19 pandemic only underscores the relevance and urgent need of this training, as studies show an uptick in mental health disorders due to this trauma. This article will present a discussion on the need for trauma curriculum for health care professionals, using information gained through trauma informed care workshops for healthcare personnel at Aga Khan University Hospital Pakistan.

A Systematic Review and Synthesis of Trauma-Informed Care Within Outpatient and Counseling Health Settings for Young People

There is growing consensus that outpatient health services for young people (aged 12-25 years) need to deliver trauma-informed care to ameliorate the effects of trauma, offer safe treatments, and avoid retraumatization. Trauma-informed care has become a familiar term for many professionals; however, its operating definition lacks clarity. MEDLINE, Embase, and PsycINFO were systematically searched to clarify what trauma-informed care is, and what it should achieve in these settings. We reviewed 3,381 unique records, of which 13 met criteria for inclusion. Content analysis identified 10 components of trauma-informed care as it has been operationalized in practice: seven of these occurred at the system-level (interagency collaboration; service provider training; safety; leadership, governance and agency processes; youth and family/carer choice in care; cultural and gender sensitivity; youth and family/carer participation), and three involved trauma-specific clinical practices (screening and assessment; psychoeducation; therapeutic interventions). There is a need for greater consensus regarding an operating definition of trauma-informed care and further research into outcomes for young people and their families/carers.

A patient-oriented research approach to assessing patients' and primary care physicians' opinions on trauma-informed care

OBJECTIVE

To gather patients' and primary care physicians' (PCP) opinions on trauma-informed Care (TIC) and to investigate the acceptability of recommendations developed by patient, family, and physician advisors.

DESIGN

Cross-sectional research survey design and patient engagement.

SETTING

Canada, 2017 to 2019.

PARTICIPANTS

English-speaking adults and licensed PCPs residing in Canada.

MAIN OUTCOME MEASURES

Participants were given a series of questionnaires including a list of physician actions and a list of recommendations consistent with TIC.

RESULTS

Patients and PCPs viewed TIC as important. Both patients and PCPs rated the following recommendations as helpful and likely to positively impact patient care: physician training, online trauma resource centres, information pamphlets, the ability to extend appointment times, and clinical pathways for responding to trauma. PCPs' responses were significantly more positive than patients' responses.

CONCLUSION

TIC is important to patients and PCPs. Patients and PCPs believe changes to physician training, patient engagement, and systemic factors would be helpful and likely to positively impact patient care. Future research needs to be conducted to investigate whether these recommendations improve patient care.

A concept analysis of trauma-informed care

AIM

This concept analysis aims to provide an in-depth analysis of the concept of trauma-informed care and explore the use of this concept in nursing, using Walker and Avant's method.

BACKGROUND

Trauma-informed care is a priority for nurses caring for patients with previous trauma. Many forms of trauma exist. Various types of trauma may not be apparent without appropriate assessment. Therefore, nurses must approach all patients with the components of trauma-informed care.

DESIGN

Concept analysis.

DATA SOURCE

PubMed, Cumulative Index of Nursing and Allied Health Literature, and PsycINFO databases were searched for articles in English. The final sample consisted of 23 documents published from 2015 to 2020.

REVIEW METHODS

Concept analyzed using Walker and Avant's eight-step method.

RESULTS

Four defining attributes of trauma-informed care were identified as recognition, knowledge, concern, and respect. Definitions, the use of the concept of trauma-informed care, antecedents, consequences, and empirical referents are described. Model, borderline, and contrary cases are discussed.

CONCLUSION

Many forms of trauma exist. Various types of trauma may not be apparent without appropriate assessment. Therefore, establishing an operational definition of trauma-informed care has implications and significance in victim identification and the provision of trauma-informed care, advocacy, and nursing and interdisciplinary research.

Training Hospital Personnel in Trauma-Informed Care: Assessing an Interprofessional Workshop With Patients as Teachers

OBJECTIVE

Trauma-informed care (TIC) and violence intervention programs (VIPs) facilitate psychosocial healing and reduce injury recidivism for children and families affected by community violence. To integrate a VIP into 2 Level 1 Pediatric Trauma Centers, an educational initiative was developed and co-taught by pediatricians and former patients. The primary aim was to increase provider-driven patient referrals to the VIP. A secondary aim was to improve all participants' comfort levels in 5 areas of TIC.

METHODS

Referrals to the VIP from 2014 to 2018 were tracked and analyzed. A curriculum based on Five Points of TIC was developed and offered to interprofessional groups of hospital employees. Pediatricians and former patients recovering from violent injury facilitated the workshops. Twenty-two workshops were attended by 318 providers and hospital staff members from 2015 to 2018. Pre- and postworkshop surveys asked participants to rate their comfort levels with 5 areas of TIC.

RESULTS

Provider-driven patient identification increased from 34.8% to 86.8% over the study period. For the entire cohort, participants' self-assessment of comfort levels with TIC improved by 21% (P < .001), with medical students' scores improving the most (24%). Residents were less likely to complete the workshop than fellows or attendings (P = .03).

CONCLUSIONS

This novel curriculum was associated with a change in practice patterns, as well as a closer relationship between the VIP and pediatric hospital systems. All professional groups experienced an improvement in comfort levels with the Five Points of TIC. Future study on information retention and other patient care-related outcomes is needed.

Interactive Case-Based Childhood Adversity and Trauma-Informed Care Electronic Modules for Pediatric Primary Care

INTRODUCTION

Training health professionals for the skills and capacity to respond adequately to children and adults who have been exposed to adverse childhood experiences is recognized as an essential need in health care. Accessible opportunities to educate physicians and physician-trainees are limited.

METHODS

Four computer-based e-modules were created focusing on addressing childhood adversity and implementing trauma-informed care in the pediatric primary care setting. These childhood adversity and trauma-informed care (CA-TIC) e-modules were designed as an individualized, self-directed experience to allow for distance learning with flexibility to be embedded into existing coursework. To foster an engaging learning environment, we narrated the modules, prioritized images, and included the opportunity for participant interaction via multiple-choice and short-answer questions. Twenty-eight pediatric residents, two medical students, four attending physicians, and one fellow at Children's National Hospital completed the e-modules.

RESULTS

Overall, participants rated the CA-TIC e-modules 4.6 (SD = 0.5) out of 5 for design and quality. Using paired t tests and Wilcoxon signed rank tests, we found statistically significant score increases from presession to postsession for participants' knowledge, attitudes, practice, and confidence related to CA-TIC. The most commonly cited learning points and practice changes included asking about trauma in practice and the seven C's of resilience.

DISCUSSION

A trauma-informed, strengths-based approach to care can assist health care providers in mitigating the link between adversity and related poor health outcomes. The CA-TIC e-modules provide an opportunity to train health professionals using an innovative, self-directed, and low-resource mechanism.

Systematic Review of Evaluations of Trauma-Informed Organizational Interventions That Include Staff Trainings

Enthusiasm for trauma-informed practice has increased dramatically. Organizational interventions that train staff about trauma-informed practice are frequently used to promote trauma-informed systems change, but evidence about these interventions' effects has not been integrated. A systematic review was conducted of studies that evaluated the effects of organizational interventions that included a "trauma-informed" staff training component. A search was conducted in July 2017 and studies were identified in PubMed, PsycINFO, and the Published International Literature on Traumatic Stress database, limited to articles published in English after 2000. Six hundred and thirty-two articles were screened and 23 met inclusion criteria. Seventeen studies used a single group pretest/posttest design, five used a randomized controlled design, and one used a quasi-experimental design with a nonrandomized control group. The duration of trauma-informed trainings ranged from 1 hr to multiple days. Staff knowledge, attitudes, and behaviors related to trauma-informed practice improved significantly pre-/posttraining in 12 studies and 7 studies found that these improvements were retained at ≥1month follow-up. Eight studies assessed the effects of a trauma-informed organizational intervention on client outcomes, five of which found statistically significantly improvements. The strength of evidence about trauma-informed organization intervention effects is limited by an abundance of single group, pretest/posttest designs with short follow-up periods, unsophisticated analytic approaches, and inconsistent use of assessment instruments. In addition to addressing these methodological limitations, priorities for future research include understanding intervention effects on clients' perceptions of care and the mechanisms through which changes in staff knowledge and attitudes about trauma-informed practice influence client outcomes.

A web-based educational intervention to implement trauma-informed care in a paediatric healthcare setting: protocol for a feasibility study using pre-post mixed methods design

Background

Adoption of responsive trauma-informed practices by staff in hospital-based paediatric care may help mitigate downstream costs associated with treatment delivery due to reduced pain and distress for children and care providers, improved health-related quality of life and increased satisfaction with care. A web-based education intervention (termed Responsive CARE) was developed to build self-efficacy of staff in a paediatric medical setting. This protocol paper describes a feasibility study (including preliminary effectiveness) of the implementation of Responsive CARE in a tertiary, outpatient burn clinical setting.

Methods

A pre-post, mixed methods design will be employed. Children and caregivers attending hospital for change of burn wound dressings or burn scar management during the 3-month control or 3-month intervention period will be eligible, with follow-up to 6-months post-baseline. All children and caregiver/s will receive “standard care” including burn interventions focused on wound healing, scar management, itch management (both pharmacological and non-pharmacological), counselling, age-appropriate procedural support and burn rehabilitation. Health professional participants will be those involved in the management of children with burns during the study period or their senior managers. Health professional participants who attend a weekly educational clinical meeting will be invited to complete the intervention during a 1-month timeframe between the control and intervention period (or upon their commencement in burn outpatients during the intervention period) using an individualised log-in process. A purposive sample of caregivers and health professionals will be sought for participation in semi-structured interviews. Qualitative data will be analysed using Framework analysis. Feasibility will be evaluated via interviews, digital records of intervention usage and technical assistance logs. The primary outcome measures of effectiveness (pain, itch and distress) will be measured using self-report or behavioural observation. Quantitative data will primarily be analysed descriptively and using generalised linear models.

Discussion

This study will provide insights into factors that impact upon the feasibility of a web-based trauma-informed care education intervention in a clinical practice setting. This knowledge may support other education approaches within healthcare settings related to improving and supporting patients to reduce the risk of healthcare interactions that result in paediatric medical traumatic stress.

Long-Term Posttraumatic Stress Following Accidental Injury in Children and Adolescents: Results of a 2-4-Year Follow-Up Study

In this study, we determined the long-term prevalence of posttraumatic stress disorder (PTSD) in children and adolescents after accidental injury and gained insight into factors that may be associated with the occurrence of PTSD. In a prospective longitudinal study, we assessed diagnosed PTSD and clinically significant self-reported posttraumatic stress symptoms (PTSS) in 90 children (11–22 years of age, 60% boys), 2–4 years after their accident (mean number of months 32.9, SD 6.6). The outcome was compared to the first assessment 3 months after the accident in 147 children, 8–18 years of age. The prevalence of PTSD was 11.6% at first assessment and 11.4% at follow-up. Children with PTSD or PTSS reported significantly more permanent physical impairment than children without. Children who completed psychotherapy had no symptoms or low levels of symptoms at follow-up. Given the long-term prevalence of PTSD in children following accidents, we recommend systematic monitoring of injured children. The role of possible associated factors in long-term PTSS needs further study.

The Association Between Acute Pain and Posttraumatic Stress Symptoms in Children and Adolescents 3 Months After Accidental Injury

Previous research suggests that acute pain is a risk factor for later posttraumatic stress symptoms (PTSS). In a prospective cohort study, we examined the association between acute pain from accidental injury and PTSS in children and adolescents, taking into account factors potentially related to pain or posttraumatic stress. Participants were 135 children and adolescents, 8-18 years old. We measured the worst experienced pain since the accident took place with a visual analogue scale. Three months after the accident, posttraumatic stress was assessed with a self-report measure. We found a positive association between acute pain and posttraumatic stress. The amount of pain was negatively associated with injury severity in girls and positively associated with the presence of an extremity fracture in boys. In children who reported severe pain, this pain was significantly associated with PTSS and may account for around 10% of the variance in the severity of PTSS. Although the experience of pain is subjective, our study indicates that severe pain is associated with the severity of later PTSS. Timely management of pain according to acute pain protocols in all phases and disciplines after accidental injury is therefore recommended.

Systems Measures of a Trauma-Informed Approach: A Systematic Review

Interest in trauma-informed approaches has grown substantially. These approaches are characterized by integrating understanding of trauma throughout a program, organization, or system to enhance the quality, effectiveness, and delivery of services provided to individuals and groups. However, variation in definitions of trauma-informed approaches, coupled with underdeveloped research on measurement, poses challenges for evaluating the effectiveness of models designed to support a trauma-informed approach. This systematic review of peer-reviewed and gray literature identified 49 systems-based measures that were created to assess the extent to which relational, organizational, and community/system practices were trauma-informed. Measures were included if they assessed at least one component of a trauma-informed approach, were not screening or diagnostic instruments, were standardized, were relevant to practices addressing the psychological impacts of trauma, were printed in English, and were published between 1988 and 2018. Most (77.6%) measures assessed organizational-level staff and climate characteristics. There remain several challenges to this emerging field, including inconsistently reported psychometric data, redundancy across measures, insufficient evidence of a link to stakeholder outcomes, and limited information about measurement development processes. We discuss these opportunities and challenges and their implications for future research and practice.

Early life stress: update on neurophysiologic effects and treatment

PURPOSE OF REVIEW

Recent research on childhood trauma has focused on the effects of in-utero and early life stress (ELS) as well as improving access to care. This review includes the previous year's clinically relevant research with attention to gaps that require further research that should improve patient care.

RECENT FINDINGS

The current article focuses on the latest understanding of ELS effects on the neuroendocrine, inflammatory, immune, and neurologic systems, as well as epigenetic effects with a focus on research examining sex-specific differences. Resilience and innovative treatment delivery models are reviewed with emphasis on integrated care models and technology-based treatments.

SUMMARY

The findings reviewed point toward clinically relevant research avenues. The call for more and better treatment options can only be realized with a better understanding of ELS effects. There is a specific need for more in depth exploration and application of sex-specific differences as well as an examination of the effects of age of onset and chronicity of stressors. New developments in the delivery of interventions and treatment allow the potential to provide broader early access to care.

Opportunities for nurses to support recovery after pediatric injury: Relationships among posttraumatic stress, hope, and quality of life

PURPOSE

Nurses are at the forefront of children's postinjury recovery; this unique role provides an opportunity for nurses to recognize and screen for symptoms that may interfere with children's quality of life (QOL). As such, aims of the present investigation were to explore selected variables (e.g., posttraumatic stress symptoms [PTSS], hope) that have the potential to impact QOL after pediatric injury, with a larger goal of contributing to recommendations for nursing practice to support children's full (physical and emotional) recovery during the peritrauma period following injury.

DESIGN AND METHODS

Sixty children (aged 7-13) completed measures of PTSS, hope, and QOL while receiving injury treatment.

RESULTS

PTSS significantly predicted concurrent QOL, β = -0.42, p = 0.001. Exploratory results demonstrated that specific PTSS clusters (re-experiencing [ β = -0.39; p = 0.003), avoidance [ β = -0.35; p = 0.009], arousal [ β = -0.34; p = .012]) all significantly predicted QOL. Specific PTSS were explored. Hope (overall, domains of pathways, general agency, goal setting) did not significantly predict concurrent QOL.

PRACTICE IMPLICATIONS

While this study is exploratory and more research is needed, current results suggest that nurses' awareness of PTSS (including symptoms of re-experiencing, avoidance, arousal) may help medical teams in identifying children that are at risk for impaired functional recovery (e.g., QOL) during the peritrauma period. Nurses may want to consider advocating for the integration of PTSS screeners into standard medical care. In addition, nurses have the opportunity to serve as key medical professionals in the delivery of trauma-informed medical care (which aims to minimize further trauma or re-traumatization). Nursing leadership may want to consider offering training in how nurses can identify and respond to children who have experienced an injury (such as trauma-informed care).

Trauma-Informed Care for Violently Injured Patients in the Emergency Department

Violent traumatic injury remains a common condition treated by emergency physicians. The medical management of these patients is well described and remains an area of focus for providers. However, violently injured patients disproportionately carry a history of physical and psychological trauma that frequently affects clinical care in the emergency department. The alteration of our clinical approach, taking into consideration how a patient's previous experiences influence how he or she may perceive and react to medical care, is a concept referred to as trauma-informed care. This approach is based on 4 pillars: knowledge of the effect of trauma, recognition of the signs and symptoms of trauma, avoidance of retraumatization, and the development of appropriate policies and procedures. Using this framework, we provide practical considerations for emergency physicians in the delivery of trauma-informed care for violently injured patients.

Trauma Providers' Knowledge, Views, and Practice of Trauma-Informed Care

Trauma-informed interventions have been implemented in various settings, but trauma-informed care (TIC) has not been widely incorporated into the treatment of adult patients with traumatic injuries. The purpose of this study was to examine health care provider knowledge, attitudes, practices, competence, and perceived barriers to implementation of TIC. This cross-sectional study used an anonymous web-based survey to assess attitudes, knowledge, perceived competence, and practice of TIC among trauma providers from an urban academic medical center with a regional resource trauma center. Providers (nurses, physicians, therapists [physical, occupational, respiratory]) working in trauma resuscitation, trauma critical care, and trauma care units were recruited. Descriptive statistics summarized knowledge, attitudes, practice, competence, and perceived barriers to TIC and logistic regression analyses examined factors predicting the use of TIC in practice. Of 147 participants, the majority were nurses (65%), followed by therapists (18%) and physicians (17%), with a median 3 years of experience; 75% answered the knowledge items correctly and 89% held favorable opinions about TIC. Nineteen percent rated themselves as less than "somewhat competent." All participants rated the following as significant barriers to providing basic TIC: time constraints, need of training, confusing information about TIC, and worry about retraumatizing patients. Self-rated competence was the most consistent predictor of providers' reported use of specific TIC practices. Despite some variability, providers were generally knowledgeable and held favorable views toward incorporating TIC into their practice. TIC training for trauma providers is needed and should aim to build providers' perceived competence in providing TIC.

Association of adverse childhood experiences and health risk behaviors among young adults visiting a regional primary healthcare center, Federation of Bosnia and Herzegovina

Background

Many studies have linked adverse childhood experiences (ACEs) to long-term health outcomes, as well as health risk behaviors. In the post-war period in Bosnia and Herzegovina, many young people grew up in an environment of deteriorated living standards due to high unemployment and economic insecurity. The objectives of the study were to: 1) describe the health risk behaviors of young adults accessing primary healthcare; and 2) examine associations of these risk factors with adverse childhood experiences in this context.

Methods

This was a cross-sectional survey, conducted from April to October 2014. Participants were recruited from the Primary Healthcare Center Zenica. Patients between the ages of 18 and 24 were eligible for inclusion. The informed consent and self-administered questionnaire were offered to patients during clinic intake. The questionnaire contained questions on sexual and reproductive health, use of alcohol and drugs, dating violence, and adverse childhood experiences.

Results

During the study period 520 questionnaires were distributed, and 400 complete surveys were returned, for a response rate of 76.9%. Among the 400 respondents, 166 were males (41.5%) and 234 were females (58.5%). Our study showed that 48.7% of respondents had experienced some form of childhood adversity. Emotional neglect was the most common type of adverse childhood experience (25.6%) and was significantly more prevalent among females. Our study indicated that more than 15% of respondents had witnessed domestic violence. Overall, ACEs were associated with increased odds of early sex initiation, alcohol use, drug use, and dating violence, although some of these associations did not reach statistical significance. Emotional neglect was the exception, and reporting emotional neglect was associated with a significantly elevated odds ratio for all four of the health risk behaviors. Emotional abuse was associated with an increased odds of drug abuse (OR = 2.78; 95% CI = 1.31–5.90) and dating violence (OR = 2.31; 95% CI = 1.10–4.89). Sexual abuse was marginally associated with increased early sex initiation (OR = 3.2; 95% CI 0.93–10.8). Parental divorce was significantly associated with alcohol abuse.

Conclusion

The results of this study demonstrated associations between adverse experiences in childhood and the probability of engaging in health risk behavior which has implications for health outcomes in the long-term.