Trauma-informed care: recognizing and resisting re-traumatization in health care

Impact of adverse childhood experiences on analgesia-related outcomes: a systematic review

BACKGROUND

There is well-established evidence linking adverse childhood experiences (ACEs) and chronic pain in adulthood. It is less clear how ACE exposure might influence the response to chronic pain treatment. In this systematic review, we synthesise the literature assessing the impact of ACE exposure on outcomes relating to the use, benefits, and harms of analgesic medications (analgesia-related outcomes).

METHODS

We searched seven databases from inception to September 26, 2023, for studies investigating adverse events in childhood (<18 yr) and any analgesia-related outcome during adulthood (≥18 yr). Title/abstract screening, full-text review, data extraction, and risk of bias assessment were performed independently by two authors. Given the high degree of study heterogeneity, a narrative synthesis was performed.

RESULTS

From 7531 records, 66 studies met inclusion criteria, involving 137 395 participants. Analgesia-related outcomes were classed into six categories: use of analgesics (n=12), analgesic side-effects (n=4), substance misuse (n=45), lifetime drug overdose (n=2), endogenous pain signalling (n=4), and other outcomes (n=2). No studies assessed the effect of ACE exposure on the potential benefits of analgesics. ACE exposure was associated with greater use of analgesic medication, higher incidence of analgesic medication side-effects, greater risk and severity of substance misuse, greater risk of drug overdose, and greater risk of attempted suicide in opioid dependency.

CONCLUSIONS

Adverse childhood experience exposure is associated with poor analgesia-related outcomes, so individual assessment adverse childhood experiences is important when considering the treatment of chronic pain. However, significant gaps in the literature remain, especially relating to the use and harms of non opioid analgesics.

SYSTEMATIC REVIEW PROTOCOL

CRD42023389870 (PROSPERO).

Trauma Connect Clinic: Continuing the trauma case management model for patients affected by traumatic injuries: A quality improvement initiative

BACKGROUND

A case-management model of care is frequently used in acute-care settings for patients with major traumatic injuries; however, its application to trauma follow-up care after hospital discharge remains unclear.

AIM

To describe the services provided by the Trauma Connect Clinic (TCC): a NP- led case management model, in trauma follow-up care.

METHODS

An exploratory descriptive study design was used. Data collected included patient and injury characteristics, clinic activities, attendance rates, referral patterns and complications.

RESULTS

Three-hundred and twenty-four TCC appointments were scheduled for 194 patients (n = 302) with an attendance rate of 93% (n = 302). Ongoing health issues included pain (n = 22, 37%), thrombotic events (n = 8, 13%) and infection (n = 7, 12%). Clinic activity included 77 referrals to the wider MDT (n = 77), radiology reviews (n = 225) and 39 prescribing events, consisting mainly of analgesia.

CONCLUSION

A case management model can successfully deliver trauma follow-up care and efficiently use limited resources. Key elements involve careful assessment and management of patients' physical and emotional needs. Evaluation of longer-term outcomes of this model of care in trauma settings is required.

Doctors' experience providing primary care for refugee women living with chronic pain: a qualitative study

BACKGROUND

The experiences of GPs in Australia highlight key considerations regarding workload demands, remuneration incentives and the practical implications of working in regions with high ethnic density. This exploration helps to understand the elements that influence GPs delivery of care, particular for refugee women who exhibit disproportionately higher rates of chronic pain. This qualitative study explored the experiences of GPs providing care for refugee women living with chronic pain.

METHODS

Semi-structured interviews were undertaken with 10 GPs (9 female and 1 male) practicing across metropolitan Melbourne, Australia. GPs were recruited via purposive sampling and a snowballing strategy. Participants work experience ranged from one to 32 years. Audio recordings of the interviews were transcribed verbatim and stored in qualitative data Nvivo 12 software for coding. Transcripts of interviews were analysed thematically using a phenomenological approach.

RESULTS

Three overarching themes were identified: (1) meeting the needs of refugee women living with chronic pain; (2) the role of the GP; and (3) the challenges of the health care system. These themes reflected the complexity of consultations which arose, in part, from factors such as trust, the competencies of clinician's and the limitations posed by time, funding and interpreter use.

CONCLUSION

GPs acknowledged the uniqueness of refugee women's chronic pain needs and whilst doctors welcomed care, many were often challenged by the complex nature of consultations. Those that worked in settings that aligned with refugee women's needs highlighted the importance of cultivating culturally safe clinical environments and listening to their patients' stories. However, system level challenges such as time, funding and resource constraints created significant challenges for GPs. Exploring GPs experiences allows for a better understanding of how vectors of disadvantage intersect in health care and highlights the need to better support doctors to improve health care provision for refugee women living with chronic pain.

Clinical Education: Addressing Prior Trauma and Its Impacts in Medical Settings

Prior trauma exposure significantly increases the risk of developing PTSD following medical stressors and may contribute to the development of medically induced PTSD. However, healthcare systems often overlook the interaction between prior trauma and current medical stressors, contributing to negative psychosocial and health-related outcomes for patients. Integration of both trauma-informed and trauma-focused practices into psychosocial programming in medical settings may be key to effectively addressing the needs of trauma-exposed patients. Yet, there is a lack of practical guidance on how clinical psychologists in medical settings can respond to trauma's effects in routine clinical practice. This paper aims to provide an overview of trauma-focused theory, assessment, and treatment considerations within medical settings, emphasizing the importance of incorporating trauma-focused intervention into integrated psychosocial programming to address prior trauma and its impacts on care in order to improve patient outcomes.

Preventing retraumatisation in torture survivors during surgical care: results of a guideline-development project and qualitative study exploring healthcare providers' experiences

OBJECTIVES

Insufficient training and the absence of guidelines increase the risk of retraumatisation in torture survivors during surgical procedures. This study aims to develop guidelines to mitigate this risk and gather healthcare professionals' experiences treating torture survivors and insights on the guideline's feasibility and acceptability.

DESIGN

The study was conducted in two phases. Phase 'a' involved developing guidelines based on reviews of torture survivors' encounters in somatic care and potential retraumatisation triggers, as well as a qualitative study on survivors' experiences during surgical interventions. The development process adhered to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) principles and the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument for methodological rigour. Phase 'b' involved focus groups and individual interviews with healthcare professionals to explore challenges in caring for torture survivors and to evaluate the guidelines.

SETTING

The study, conducted from May to August 2023, involved participants from surgical departments in three hospitals in southern and southeastern Norway.

PARTICIPANTS

Twenty-one healthcare professionals, including surgeons, anaesthesiologists, nurses and a dentist, participated in the study. Both focus group interviews and individual interviews were conducted.

RESULTS

Phase 'a': guidelines comprising six sections were developed: an introduction, general guidelines and four sections covering the preoperative, perioperative and postoperative surgical stages. Phase 'b': healthcare professionals struggled to understand torture's complexities and identify survivors' unique needs. They faced challenges using interpreters and assisting patients with strong reactions. While the guidelines were viewed as practical and useful for raising awareness, their length was questioned.

CONCLUSIONS

We provide recommendations for preventing retraumatisation in torture survivors undergoing surgical treatment. The guidelines may serve as a starting point for offering safe and individualised care to torture survivors. Teaching institutions and hospitals may incorporate the guidelines into healthcare professionals' education.

Positive PTSD Screening and Its Health Correlates in Patients With HIV in Urban Primary Care Settings

Posttraumatic stress disorder (PTSD) is underdiagnosed and undertreated in primary care, especially among African American individuals. The current study assessed documentation rates of PTSD and clinical health correlates among 135 predominantly African American patients with HIV and positive PTSD screens in a primary care unit. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) and a retrospective chart review of 135 patients with HIV were conducted. On the PCPTSD-5 (cut point of 3), approximately one half of patients (49.6%; n = 67) had probable PTSD; however, only 11.9% of patients (n = 16) had a chart diagnosis of PTSD. A positive PTSD screen was associated with higher rates of depression and insomnia, but not anxiety, alcohol use, drug use, or pain in patients with HIV. Multi-morbidity of HIV, major depression, and positive PTSD screens was associated with increased risk for asthma, number of medical diagnoses, depression, insomnia, and anxiety. Findings highlight the need for trauma-informed care in primary care settings for people with PTSD and HIV. Larger samples are warranted to further explore health correlates of PTSD. [Journal of Psychosocial Nursing and Mental Health Services, 62(8), 25-36.].

Unmasking the Impact: Exploring the Role of Masks in Trauma-Informed Care Communication

INTRODUCTION

The COVID pandemic has necessitated mask-wearing by inpatient providers; however, the impact of masks on the acute care surgeon-patient relationship is unknown. We hypothesized that mask-wearing, while necessary, has a negative impact by acting as a barrier to communication, empathy, and trust between patients and surgeons.

METHODS

A cross-sectional study was performed by administering a written survey in English or Spanish to trauma, emergency general surgery, burn, and surgical critical care inpatients aged ≥18 y at a University Level 1 Trauma Center between January 2023 and June 2023. Patients were asked seven questions about their perception of mask effect on interactions with their surgery providers. Responses were scored on a five-point Likert scale and binarized for multivariable logistic regression.

RESULTS

There were 188 patients who completed the survey. The patients were 68% male, 44% Hispanic, and 17% Spanish speaking, with a median age of 45-54 y. A third of patients agreed that surgeon mask-wearing made it harder to understand the details of their surgical procedure and made them less comfortable in giving consent. Twenty three percent agreed that it was harder to trust their provider; increasing age was associated with lower levels of trust, odds ratio 1.36 (confidence interval 1.10-1.71, P = 0.006). Findings were consistent among patients of different sex, race/ethnicity, language, and pre-COVID hospital experience.

CONCLUSIONS

Mask-wearing, while important, has a negative impact on the patient-surgeon relationship in trauma and acute care surgery. Providers must be conscious of this effect while wearing masks and strive to optimize communication with patients to ensure high-quality trauma-informed care.

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.

Trauma-informed climate scale-10 and attitudes related to trauma-informed care-10: An examination of scale psychometrics using data from disability service providers

BACKGROUND

Assessment is fundamental to the implementation of trauma-informed care. As trauma-informed care advances among organizations supporting people with intellectual and developmental disabilities (IDD), it is critical that they have access to validated assessment tools.

OBJECTIVE

This is the first study to examine the psychometric properties of two brief measures associated with trauma-informed care, Trauma-Informed Climate Scale (TICS-10) and Attitudes Related to Trauma-Informed Care (ARTIC-10), using data from the IDD service industry.

METHODS

We employed structural equation modeling to examine the factor structure, reliability of TICS-10 and ARTIC-10, and construct validity with the ProQOL using secondary data from 374 service providers.

RESULTS

We confirmed the factorial validity of TICS-10 and ARTIC-10 with single factor solutions; however, modifications were necessary to achieve adequate model fit.

CONCLUSIONS

The current study provides initial evidence of the validity and reliability of TICS-10 and ARTIC-10 when used within organizations supporting people with IDD. Recommendations for subsequent improvements and future research of the scales are provided.

Applying a Trauma-Informed Lens to Challenging Adolescent Encounters: A Faculty Development Session for Pediatricians

Introduction

Patient encounters perceived to be challenging are common and contribute to both suboptimal patient health outcomes and provider burnout. A trauma-informed care (TIC) approach to these encounters is critical, as many of the characteristics associated with challenging patient encounters can be linked to a history of trauma exposure.

Methods

Our team created and delivered a 1-hour synchronous virtual session intended to bolster provider knowledge of TIC principles and their application to challenging adolescent encounters. Participants were all faculty and staff engaged in pediatric primary care at an urban academic center, including physicians, nurse practitioners, psychologists, and social workers. The content was rooted in adult learning principles and included didactic components anchored to case-based learning with facilitated group discussions and opportunities for reflection. We used paired pre- and postsession self-assessments of provider knowledge, confidence, and practice related to TIC using Likert-scale and free-text questions. Descriptive statistics and a paired t test were used to determine the impact of the session on these metrics.

Results

In 24 paired surveys, there were statistically significant increases (p ≤ .001) in participant perceived knowledge, confidence, and practice, with 100% of participants having a statistically significant improvement in one or more of these domains. There were also strongly positive Likert-scale and free-text responses regarding content relevance and delivery.

Discussion

We demonstrate that a brief session can create improvement in pediatric providers' perceived knowledge about the application of TIC principles to challenging adolescent encounters as well as confidence in their ability to put these into practice.

Documentation of Trauma-Informed Care Elements for Young People Hospitalized After Assault Trauma

INTRODUCTION

Violent traumatic injury, including firearm violence, can adversely impact individual and community health. Trauma-informed care (TIC) can promote resilience and prevent future violence in patients who have experienced trauma. However, few protocols exist to facilitate implementation of TIC for patients who survive traumatic injury. The purpose of the study is to characterize documentation of TIC practices and identify opportunities for intervention in a single academic quaternary care center.

METHODS

This study is a retrospective chart review analyzing the documentation of trauma-informed elements in the electronic medical record of a random sample of youth patients (ages 12-23) admitted for assault trauma to the pediatric (n = 50) and adult trauma (n = 200) services between 2016 and mid-2021. Descriptive statistics were used to summarize patient demographics, hospitalization characteristics, and documentation of trauma-informed elements. Chi-square analyses were performed to compare pediatric and adult trauma services.

RESULTS

Among pediatric and adult assault trauma patients, 36.0% and 80.5% were hospitalized for firearm injury, respectively. More patients admitted to the pediatric trauma service (96%) had at least one trauma-informed element documented than patients admitted to the adult service (82.5%). Social workers were the most likely clinicians to document a trauma-informed element. Pain assessment and social support were most frequently documented. Safety assessments for suicidal ideation, retaliatory violence, and access to a firearm were rarely documented.

CONCLUSIONS

Results highlight opportunities to develop trauma-informed interventions for youth admitted for assault trauma. Standardized TIC documentation could be used to assess risk of violent reinjury and mitigate sequelae of trauma.

Headache in Children and Adolescents

OBJECTIVE

This article reviews the assessment of children and adolescents presenting with headache, provides an overview of primary headache disorders, and reviews evidence-based management of headache in this age group.

LATEST DEVELOPMENTS

In the last few years, new epidemiological data have shed light on less common pediatric headache disorders (eg, pediatric trigeminal autonomic cephalalgias) and psychosocial risk factors associated with primary headache disorders in children and adolescents. There has also recently been a substantial increase in interventions that target the calcitonin gene-related peptide pathway and that treat primary headache disorders using noninvasive neuromodulation. Although these interventions have primarily been studied in adults, there is emerging evidence of their use in the pediatric population.

ESSENTIAL POINTS

Primary headache disorders are very common in youth, and the most commonly encountered headache diagnosis in neurology practice is migraine, which affects approximately 10% of children and adolescents. Diagnosing and effectively treating primary headache disorders before adulthood may have a sustained impact on the patient by improving long-term headache and mental health outcomes, thereby significantly reducing the burden of disability over time. There are several available and emerging acute and preventive interventions for youth with primary headache disorders, and treatment decisions should be made in the context of available evidence using a shared decision-making 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.

A New Kind of Academic MLP: Addressing Clients' Criminal Legal Needs to Promote Health Justice and Reduce Mass Incarceration

This article describes a new type of medical-legal partnership (MLP) that targets the health and justice concerns of people enmeshed in the U.S criminal justice system: a partnership between clinicians who care for people with criminal system involvement and public defenders. This partnership offers an opportunity to not only improve patient health outcomes but also to facilitate less punitive court dispositions, such as jointly advocating for community-based rehabilitation and treatment rather than incarceration.

A practical guide to the trauma-informed physical examination

ABSTRACT

About two-thirds of patients have a trauma history, such as experiencing abuse or community violence. Clinicians must be knowledgeable about trauma because of its high prevalence and long-lasting effect on patients. The medical encounter can be triggering for patients with a history of trauma, especially when power differentials are intensified, such as during the physical examination. Clinicians can improve the interaction by incorporating simple trauma-informed techniques, such as adjusting communication, positioning, and contact during the physical examination. These modifications foster a sense of patient safety and collaborative decision-making. This article describes the background of trauma-informed care and outlines trauma-informed techniques for physical examinations.

M, Moon T, Furdock R, Vallier HA. Changes in interpersonal violence and utilization of trauma recovery services at an urban trauma center in the United States during the COVID-19 pandemic: a retrospective, comparative study

Purpose

This study investigated changes in interpersonal violence and utilization of trauma recovery services during the COVID-19 pandemic. At an urban level I trauma center, trauma recovery services (TRS) provide education, counseling, peer support, and coordination of rehabilitation and recovery to address social and mental health needs. The COVID-19 pandemic prompted considerable changes in hospital services and increases in interpersonal victimization.

Methods

A retrospective analysis was conducted between September 6, 2018 and December 20, 2020 for 1,908 victim-of-crime patients, including 574 victims of interpersonal violence. Outcomes included length of stay associated with initial TRS presentation, number of subsequent emergency department visits, number of outpatient appointments, and utilization of specific specialties within the year following the initial traumatic event.

Results

Patients were primarily female (59.4%), single (80.1%), non-Hispanic (86.7%), and Black (59.2%). The mean age was 33.0 years, and 247 patients (49.2%) presented due to physical assault, 132 (26.3%) due to gunshot wounds, and 76 (15.1%) due to sexual assault. The perpetrators were primarily partners (27.9%) or strangers (23.3%). During the study period, 266 patients (mean, 14.9 patients per month) presented before the declaration of COVID-19 as a national emergency on March 13, 2020, while 236 patients (mean, 25.9 patients per month) presented afterward, representing a 74.6% increase in victim-of-crime patients treated. Interactions with TRS decreased during the COVID-19 period, with an average of 3.0 interactions per patient before COVID-19 versus 1.9 after emergency declaration (P<0.01). Similarly, reductions in length of stay were noted; the pre-COVID-19 average was 3.6 days, compared to 2.1 days post-COVID-19 (P=0.01).

Conclusions

While interpersonal violence increased, TRS interactions decreased during the COVID-19 pandemic, reflecting interruption of services, COVID-19 precautions, and postponement/cancellation of elective visits. Future direction of hospital policy to enable resource and service delivery to this population, despite internal and external challenges, appears warranted.

Pandemic impacts and experiences after disaster in Australia: qualitative study of compound impacts following the Black Summer bushfires

BACKGROUND

The first cases of the COVID-19 pandemic in Australia were recorded in January 2020, which was during the 'Black Summer' bushfires of 2019-20 and prior to additional disasters in some regions. Few studies have considered the compound impact of disasters and the pandemic.

AIMS

To improve understanding of the impact on mental health and well-being of the pandemic in disaster-affected communities.

METHOD

We conducted semi-structured interviews (n = 18) with community members and online focus groups (n = 31) with help providers from three regions of rural Australia affected by bushfires and the pandemic.

RESULTS

Six themes were produced: (a) 'Pulling together, pulling apart', describing experiences after bushfires and prior to impacts of the pandemic; (b) 'Disruption of the 'normal response', encompassing changes to post-disaster recovery processes attributed to the pandemic; (c) 'Escalating tensions and division in the community', describing impacts on relationships; (d) 'Everywhere you turn you get a slap in the face', acknowledging impacts of bureaucratic 'red tape'; (e) 'There are layers of trauma', highlighting intersecting traumas and pre-existing vulnerabilities; and (f) 'Where does the help come from when we can't do it?', encompassing difficulties accessing services and impacts on the helping workforce.

CONCLUSIONS

This study furthers our understanding of compound disasters and situates pandemic impacts in relation to processes of adjustment and recovery from bushfires. It highlights the need for long-term approaches to resilience and recovery, investment in social infrastructure, multi-component approaches to workforce issues, and strategies to increase mental health support and pathways across services.

Trauma-informed care: Insights from a Q-methodology study of advanced practice registered nursing students

BACKGROUND

Trauma-informed care (TIC) aims to create a safe and supportive healthcare environment that empowers patients and cultivates understanding of the role trauma plays in short-term and long-term health. TIC also has the potential to improve health outcomes and foster clinician wellness. Nurse educators must design evidence-based instruction to develop advanced practice registered nurses (APRNs) who deliver high-quality TIC while also protecting their own wellbeing.

OBJECTIVES

To identify patterns in subjective viewpoints about TIC among APRN students and describe how those patterns influence their learning experience in an advanced health assessment course.

DESIGN

Q methodology was used to explore student perceptions of TIC.

SETTING

A virtual advanced health assessment course at a large, midwestern university in the United States.

PARTICIPANTS

Ninety-five APRN students from six specialty APRN programs.

METHODS

Students completed an online Q-sort activity by ranking 32 TIC statements according to how well the statements aligned with their own perspectives. Q-sorts were analyzed using factor analysis and narrative responses to open-ended questions.

RESULTS

Four factors were extracted that revealed different student viewpoints on TIC and their learning experiences: Comfortable/Confident Learners, Uncomfortable/Apprehensive Learners, Empathetic/Hesitant Learners, and Inexperienced/Uncertain Learners.

CONCLUSIONS

All students acknowledged the need to learn about TIC to implement it effectively in practice. It is important for faculty to understand the potential range of divergent student viewpoints about TIC and acknowledge, accept, and support students who have anxiety related to learning about TIC.

Changing Policy for Inclusion: Peer-to-Peer Physical Exam Practice in Medical School

Issue: Across the United States, the majority of medical schools teach physical examination using some form of peer physical examination (PPE). The process of being physically exposed in the presence of colleagues can be uncomfortable and cause students distress for myriad reasons ranging from religious and cultural practices to body dysmorphia and previous trauma experiences. This is especially problematic in educational systems which offer no other options, or make PPE a requirement of the curriculum.Evidence: Across all U.S. medical schools, trainees spent a median of 59 hours teaching physical examination skills. Of this time, 30% is dedicated to PPE practice. Despite this prevalence, there are data that show some students find this uncomfortable, especially women. Literature on best practices around PPE highlights voluntary participation, informed consent, and an available alternative to learning physical xamination skills. These are not uniformly available in all learning environments. There are little data around the impact of PPE on students who have experienced or are experiencing sexual trauma. Authors have drawn conclusions about the potential for harm given the prevalence of sexual mistreatment in US higher education.Implications: Our medical school policy required students to participate in PPE practice, undressing for the exams wearing only shorts (and a sports bra for women) an and a hospital gown. Students who could not participate in this practice for reasons ranging from mobility to religious beliefs had to seek individual formal accommodations to be exempt, putting the onus of change on potentially vulnerable individuals. We evaluated the policy around PPE, and concluded that the school's requirements could be harmful and isolating, as they required students to disclose their personal vulnerabilities while seeking exemptions from being examined by peers. At our institution, a group of students instead advocated for the school to review the policy and create a PPE procedure that was safer and more inclusive while supporting student learning. Our experience emphasized the potential for students to advocate for change, while also highlighting the need for greater research in the field of trauma-informed curricular design for medical education.

Adverse childhood events and mental health problems in cancer survivors: a systematic review

PURPOSE

The purpose of this study was to systematically review the literature on the association between adverse childhood events (ACEs) and mental health problems in cancer survivors.

METHODS

This review was conducted in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Four databases (PubMed, PsychINFO, Web of Science, and Cochrane) were searched on 27-08-2023.

RESULTS

Of the 1413 references yielded by the literature search, 25 papers met inclusion criteria and were reviewed. Most studies were performed in the USA, most included breast cancer survivors, and the number of included participants ranged between 20 and 1343. ACEs were relatively prevalent, with self-report rates ranging between 40 and 95%. Having been exposed to ACEs was a risk factor for heightened levels of emotional distress, anxiety, depressive symptoms, and fatigue during cancer treatment. Results varied depending on the variables included, and per subscale, but were consistent across different cultures and heterogenous patient groups.

CONCLUSION

The association between ACE and mental health outcomes was significant in most studies. In order to improve treatment for this vulnerable population, it may be necessary to screen for ACEs before cancer treatment and adjust treatment, for example, by means of trauma-informed care (TIC), which recognizes and responds to the impact of trauma on individuals seeking healthcare.

Strategies for enhancing the representation of women in clinical trials: an evidence map

BACKGROUND

Equitable sex- and gender-based representation in clinical trials is an essential step to ensuring evidence-based care for women. While multi-institutional actions have led to significant improvements in the inclusion of women in trials, inequity persists in areas like sex-neutral cancers and cardiovascular disease. We sought to identify strategies described or evaluated to boost the inclusion of women in clinical trials.

METHODS

We used evidence mapping methodology to examine the breadth of relevant literature. We developed an a priori protocol and followed reporting guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analysis where applicable. We searched MEDLINE® (via PubMed) and EMBASE (via Elsevier) databases from inception through April 4, 2023, and used standardized procedures incorporating duplication and data verification. We included articles that described strategies to improve the recruitment and retention of women in clinical trials.

RESULTS

We identified 122 articles describing recruitment and retention strategies for 136 trials (377,595 women). Only one article distinguished between the sex and gender identity of participants, and none defined their use of the terms such as "women" or "female". The majority of articles (95%) described recruitment for only women, and 64% were conducted in the USA. Ninety-two articles (75%) described strategies in the context of sex-specific conditions (e.g., gynecologic diagnosis). The majority of included articles evaluated a behavioral intervention (52%), with 23% evaluating pharmacologic interventions and 4% invasive interventions. The most common trial phase for reported strategies was during outreach to potential participants (116 articles), followed by intervention delivery (76), enrollment (40), outcomes assessment (21), analysis and interpretation (3), and dissemination (4). We describe specific types of strategies within each of these phases.

CONCLUSIONS

Most of the existing literature describing strategies to improve the inclusion of women draws from trials for sex-specific conditions and is largely related to outreach to potential participants. There is little information about how and if studies have attempted to proportionally increase the inclusion of women in trials with both men and women or those focused on invasive and pharmacologic interventions. Future work in this area should focus on how to increase the participation of women in mixed-sex studies and on those areas with remaining inequities in trial participation.

Incorporating Trauma-informed Approaches to Care in Vascularized Composite Allotransplantation

Since 1998, vascularized composite allotransplantation (VCA) has been a growing area of research in the field of reconstructive surgery. Although conditions treated with VCA often result from a traumatic injury, there has been limited emphasis on incorporating trauma-informed care (TIC) models in VCA. Considering the importance of psychosocial well-being in VCA candidates and recipients, applying best practices in TIC to the face, upper extremity, and penile transplantation may be critical in minimizing retraumatization throughout the perioperative process. There are six main principles of TIC: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment and choice; and cultural, historical, and gender issues, which may be further incorporated in care for VCA patients. Evaluating for PTSD and incorporating TIC may have substantial benefit to postoperative outcomes.

Recovery Services for Interpersonal Violence Victims on Healthcare Use at a Trauma Center

INTRODUCTION

Treatment of interpersonal violence (IPV) patients is often complicated by social and mental health comorbidities. New American College of Surgeons (ACS) requirements include provision of psychosocial support services for recovery after injury. We aim to describe utilization and patient outcomes after provision of Trauma Recovery Services (TRS) at our institution for the IPV population. These services include assistance with food, housing, criminal justice, and advocacy.

METHODS

IPV patients were identified between September 6, 2018 and December 20, 2020. Demographic information was collected. TRS utilization and specific services rendered were identified. Primary outcome measures included initial length of stay (LOS), number of subsequent emergency department (ED) visits, and outpatient visits within 1 y after the initial injury. Statistical analyses included t-tests, Chi-squared tests, and multivariate regression analyses.

RESULTS

A total of 502 patients were included in the final cohort, and 394 patients (78.5%) accepted the utilization of TRS services after initial interaction. Patients were on average 33.4 y old, and 59.4% were females. Patients who were older (P < 0.001) and homeless (P = 0.004) were more likely to use TRS, while victims of sexual assault (P < 0.001) and single patients (P = 0.041) were less likely. Patients who utilized TRS had longer initial LOS (P < 0.001), more ED visits (P < 0.001), and more outpatient visits (P = 0.01) related to the initial complaint, independent of potential confounders on multivariate linear regression. Food and housing service utilization associated with LOS (P = 0.01), ED visits (P < 0.001), and outpatient visits (P < 0.001). Additionally, transportation services were associated with longer LOS (P = 0.01) while patient advocacy services were associated with more ED visits (P = 0.03).

CONCLUSIONS

TRS was extensively utilized by IPV patients, and associated with more follow-up appointments, ED visits, and longer LOS. Emphasis on injury mechanisms, baseline demographics, and social features may further characterize patients in need who tend toward utilization.

Transforming Healthcare: Prioritizing Psychological Trauma through Trauma-Informed Care

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The effect of adverse childhood experience training, screening, and response in primary care: a systematic review

Background

Adverse childhood experiences (ACEs) can have harmful, long-term health effects. Although primary care providers (PCPs) could help mitigate these effects, no studies have reviewed the impacts of ACE training, screening, and response in primary care.

Methods

This systematic review searched four electronic databases (PubMed, Web of Science, APA PsycInfo, CINAHL) for peer-reviewed articles on ACE training, screening, and/or response in primary care published between Jan 1, 1998, and May 31, 2023. Searches were limited to primary research articles in the primary care setting that reported provider-related outcomes (knowledge, confidence, screening behavior, clinical care) and/or patient-related outcomes (satisfaction, referral engagement, health outcomes). Summary data were extracted from published reports.

Findings

Of 6532 records, 58 met inclusion criteria. Fifty-two reported provider-related outcomes; 21 reported patient-related outcomes. 50 included pediatric populations, 12 included adults. A majority discussed screening interventions (n = 40). Equal numbers (n = 25) discussed training and clinical response interventions. Strength of evidence (SOE) was generally low, especially for adult studies. This was due to reliance on observational evidence, small samples, and self-report measures for heterogeneous outcomes. Exceptions with moderate SOE included the effect of training interventions on provider confidence/self-efficacy and the effect of screening interventions on screening uptake and patient satisfaction.

Interpretation

Primary care represents a potentially strategic setting for addressing ACEs, but evidence on patient- and provider-related outcomes remains scarce.

Funding

The California Department of Health Care Services and the Office of the California Surgeon General.

Impact of Trauma-Informed Care Training on Attitudes Among Emergency Department Personnel, Staff Advocates, and Nursing Students

BACKGROUND

Health care providers may risk retraumatizing patients and intensifying patient distress unless they practice trauma-informed care. As the first line of defense in assisting trauma survivors' physical and emotional recovery, health care providers must use a strengths-based framework that promotes resilience and expands on the trauma survivor's existing resources.

OBJECTIVE

This study aimed to compare the effect of trauma-informed care training on the attitudes of emergency department personnel, staff advocates, and nursing students toward trauma-informed care.

METHODS

This study used a pretest-posttest design. Assessment of attitudes toward trauma-informed care was done before and after trauma-informed care training. Data collection occurred from February 2021 through August 2021. Participants included three cohorts of emergency department staff, advocates for trauma survivors, and nursing students. Attitudes toward trauma-informed care were measured using the Attitudes Related to Trauma-Informed Care (ARTIC) Scale.

RESULTS

A total of 433 participants were studied, including 88 emergency department staff, 123 staff advocates, and 222 nursing students. All three cohorts significantly increased ARTIC Scale scores posttraining (p < .001). At preintervention, all three cohorts significantly differed from each other on ARTIC Scale scores (p < .01). In contrast, postintervention, ARTIC Scale scores did not significantly differ between nursing students and advocates (p = .99). Nursing students showed a significant increase in scores from pre- to postintervention compared with either advocates or emergency department staff.

CONCLUSION

The results strongly suggest that health care providers can improve attitudes toward trauma-informed care after completing training on the principles and application of trauma-informed care.

Unequal Treatment? Confronting Racial, Ethnic, and Socioeconomic Disparity in Management of Survivors of Violent Suicide Attempt

BACKGROUND

Psychiatric inpatient hospitalization is nearly always indicated for patients with recent suicidal behavior. We aimed to assess the factors associated with receiving mental health services during hospitalization or on discharge among survivors of suicide attempts in trauma centers.

STUDY DESIGN

A 3-year analysis of the 2017 to 2019 American College of Surgeons TQIP. Adults (≥18 years) presenting after suicide attempts were included. Patients who died, those with emergency department discharge disposition, those with superficial lacerations, and those who were transferred to nonpsychiatric care facilities were excluded. Backward stepwise regression analyses were performed to identify predictors of receiving mental health services (inpatient psychiatric consultation/psychotherapy, discharge/transfer to a psychiatric hospital, or admission to a distinct psychiatric unit of a hospital).

RESULTS

We identified 18,701 patients, and 56% received mental health services. The mean age was 40 ± 15 years, 72% were males, 73% were White, 57% had a preinjury psychiatric comorbidity, and 18% were uninsured. Of these 18,701 patients, 43% had moderate to severe injuries (Injury Severity Score > 8), and the most common injury was cut/stab (62%), followed by blunt mechanisms (falls, lying in front of a moving object, and intentional motor vehicle collisions) (18%) and firearm injuries (16%). On regression analyses, Black race, Hispanic ethnicity, male sex, younger age, and positive admission alcohol screen were associated with lower odds of receiving mental health services (p < 0.05). Increasing injury severity, being insured, having preinjury psychiatric diagnosis, and positive admission illicit drug screen were associated with higher odds of receiving mental health services (p < 0.05).

CONCLUSIONS

Significant disparities exist in the management of survivors of suicide attempts. There is a desperate need for improved access to mental health services. Further studies should focus on delineating the cause of these disparities, identifying the barriers, and finding solutions.

Leveraging North Carolina's Assets to Prevent Child Trauma

Adverse childhood experiences increase risk for a range of health problems. A statewide summit, "Leveraging North Carolina's Assets to Prevent Child Trauma," convened researchers, practitioners, educators, government officials, policymakers, and community stakeholders to identify common goals and determine next steps in a statewide plan to prevent and heal child trauma.

Compassion fatigue in healthcare providers during the COVID-19 pandemic: a scoping review protocol

INTRODUCTION

The COVID-19 pandemic has negatively impacted the psychological health and well-being of healthcare providers. An amplification in chronic stressors, workload and fatalities may have increased the risk of compassion fatigue and disrupted the quality of patient care. Although current studies have explored the general psychological status of healthcare providers during the COVID-19 pandemic, few have focused on compassion fatigue. The purpose of this review is to explore the impacts of the COVID-19 pandemic on compassion fatigue in healthcare providers and the repercussions of compassion fatigue on patient care.

METHODS AND ANALYSIS

This scoping review will follow Joanna Briggs Institute and Arksey and O'Malley scoping review methodology. Comprehensive searches will be conducted in the following relevant databases: MEDLINE (Ovid), PsycINFO (Ovid), Embase (Ovid), CINAHL, Scopus, Web of Science. To expand the search, reference lists of included studies will be handsearched for additional relevant studies. Included studies must report on the impact of COVID-19 pandemic on compassion fatigue in healthcare providers and have been published in English since January 2020.

ETHICS AND DISSEMINATION

This review does not require research ethics board approval. By examining the impacts of the COVID-19 pandemic on compassion fatigue in healthcare providers, this scoping review can offer important insight into the possible risks, protective factors and strategies to support healthcare providers' psychological health and patient care amidst persisting stressful conditions.

Research note reliability and validity of Japanese version of the trauma-informed care provider survey (TIC provider survey)

OBJECTIVE

Robust instruments to evaluate the ability of trauma-informed care among healthcare workers need to be developed, as this would help the implementation of trauma-informed care to prevent re-traumatization of patients. This study aims to assess the reliability and validity of the Japanese version of the Trauma-Informed Care (TIC) Provider Survey. A total of 794 healthcare workers were surveyed using a self-administered questionnaire, including the TIC Provider Survey, and six measures that were considered to be correlated with it. We calculated the Cronbach's alpha coefficient to investigate the internal consistency of each category of the TIC Provider Survey (knowledge, opinions, self-rated competence, practices, and barriers). Spearman's rank correlation coefficients were used to investigate the correlation between each category of the TIC Provider Survey, and other measures of construct validity.

RESULTS

Cronbach's alpha coefficients of each category of the TIC Provider Survey were 0.40 (Knowledge), 0.63 (Opinions), 0.92 (Self-rated competence), 0.93 (Practices), and 0.87 (Barriers). The Spearman's rank correlation coefficients were small. We confirmed the reliability of the acceptable levels and examined the validity of modest or unacceptable levels of the Japanese version of the TIC provider survey among Japanese workers in a healthcare setting.

Exploring Collaborative Care Effects on the Mental and Physical Health of Patients With and Without Violent Victimization Histories

Collaborative care is a multicomponent intervention delivered by frontline social work, nursing, and physician providers to address patients' physical, emotional, and social needs. We argued that collaborative care may particularly benefit patients with a violent victimization history because it practices three principles of trauma-informed care: patient-provider collaboration, preventing repeat trauma in clinical and community settings, and delivering comprehensive mental and physical healthcare. We conducted an exploratory secondary data analysis of a collaborative care randomized clinical trial involving patients who presented with traumatic physical injury at a Level I trauma center in Washington state between 2006 and 2009. We used random-effect linear regression models to estimate how histories of multiple violent traumas moderated the effects of the collaborative care intervention on Short Form-36 Mental Component Summary (MCS) and Physical Component Summary (PCS) T-scores over time. Collaborative care significantly improved follow-up MCS scores among patients who experienced three to four types of violent victimization in their lifetime. Additionally, intervention effects on MCS scores at the 3- and 6-month follow-up were clinically stronger for patients who reported three to four types of violent victimization (3-month = 7.5, 95% confidence level [CI] = 5.1 to 18.7; 6-month = 11.9, 95% CI = 5.1 to 18.7) than those without a history of violent victimization (3-month = 0.8, 95% CI = -5.1, 6.6; 6-month = 5.6, -2.4 to 13.5). We did not find that intervention effects on PCS scores differed between these groups at any wave. Collaborative care may be a promising approach to delivering trauma-informed mental healthcare to patients with histories of multiple types of violent victimization.

Clinical review: Implementation of trauma informed care to optimally impact the treatment of childhood obesity

Background

Traumatic events that occur in infancy, childhood, and adolescence can be impactful over the course of a lifespan. Adverse childhood experiences (ACEs) are associated with chronic health problems and mental illness, and can negatively impact educational and job opportunities. There is a growing body of evidence about the relationship between ACEs and the risk of childhood obesity. Trauma informed care (TIC) is an approach to patient care both at the clinical and organizational level that is responsive to the impact past trauma can have on an individual.

Methods

This clinical review will focus on the impact of toxic stress from trauma on the child through threats to normal physiology, including the manifestation of obesity through energy regulation pathophysiology, followed by a discussion of TIC principles. Available resources and how trauma informed principles can be used in practice are discussed using case study methodology.

Results

TIC programs recognize the impact of trauma on both patients and clinicians. TIC implementation includes application of TIC four assumptions and six key principles out-lined by Substance Abuse and Mental Health Services Administration's guidance. Clinicians supported by well-designed systems recognize that disclosure is not the goal of TIC; instead, broad trauma inquiry, proceeding to risk and safety assessment if indicated, and connection to interventions is the focus. Best practice communication allows clinicians to access information without retraumatizing the patient with ongoing repetition of their trauma experience.

Conclusion

Combining the pillars of obesity treatment (i.e., nutrition, physical activity, behavior therapy, medical management) with the tenets of TIC (realize, recognize, respond, resist re-traumatization) affords patients holistic, intentional care and family support. The desired outcomes of TIC align with goals of obesity treatment in children, namely improvement of health and quality of life, sense of self (e.g., body image and self-esteem), and prevention of negative health outcomes.

Resources for Patient Mental Health and Well-being after Orthopaedic Trauma

Orthopaedic trauma is an unanticipated life-altering experience for patients. Additionally, the prevalence of psychiatric disorders has been found to be higher in patients with trauma than in the general adult population. Symptoms of depression, anxiety, or posttraumatic stress disorder have been reported in up to 56% of patients throughout their postoperative course. Furthermore, symptoms of any one of these illnesses have been consistently associated with worse patient outcomes after treatment of traumatic orthopaedic injuries. This includes increased levels of pain and disability, postoperative complications, and, in some cases, higher rates of hospital readmission. For most patients with trauma, focus is placed on physical therapy and rehabilitation in the acute postoperative setting to help patients regain function and strength; however, more recent studies have demonstrated equal importance of the social and psychological factors involved with trauma and their impact on outcomes. Therefore, it is essential for orthopaedic surgeons and other members of the care team to be adept in the screening and treatment of psychiatric disorders. For patients struggling with these conditions, several treatment resources exist, which can be used both during their admission and after discharge. Thus, earlier recognition and intervention with appropriate treatment and referrals should be emphasized to improve outcomes. This review discusses the social and psychological impacts of orthopaedic trauma on patients' mental health and well-being and outlines numerous resources available to patients as they recover from their injuries.

History of Equity, Diversity, and Inclusion in Trauma Surgery: for Our Patients, for Our Profession, and for Ourselves

Purpose of Review

Disparities exist in outcome after injury, particularly related to race, ethnicity, socioeconomics, geography, and age. The mechanisms for this outcome disparity continue to be investigated. As trauma care providers, we are challenged to be mindful of and mitigate the impact of these disparities so that all patients realize the same opportunities for recovery. As surgeons, we also have varied professional experiences and opportunities for achievement and advancement depending upon our gender, ethnicity, race, religion, and sexual orientation. Even within a profession associated with relative affluence, socioeconomic status conveys different professional opportunities for surgeons.

Recent Findings

Fortunately, the profession of trauma surgery has undergone significant progress in raising awareness of patient and professional inequity among trauma patients and surgeons and has implemented systematic changes to diminish these inequities. Herein we will discuss the history of equity and inclusion in trauma surgery as it has affected our patients, our profession, and our individual selves.

Summary

Our goal is to provide a historical context, a status report, and a list of key initiatives or objectives on which all of us must focus. In doing so, the best possible clinical outcomes can be achieved for patients and the best professional and personal "outcomes" can be achieved for practicing and future trauma surgeons.

Ensuring Trauma Informed Care in the Obstetric Setting: A vital role for the Psychiatrist

BACKGROUND

Trauma is highly prevalent, and women are twice as likely as men to develop post-traumatic stress disorder following a traumatic exposure. Consequently, many women entering the perinatal period have trauma histories. In the perinatal period, a trauma history, can negatively impact treatment engagement and adversely affect the experience of pregnancy, postpartum and parenting. A trauma informed care approach can mitigate these effects.

OBJECTIVES

This review aims to summarize literature that can aid psychiatrists in 1) identifying signs and symptoms of trauma in perinatal women 2) integrating elements of trauma informed care into perinatal mental health care, and 3) offering interventions that can minimize adverse outcomes for perinatal women and their children.

METHODS

A PubMed search was conducted with keywords including trauma, pregnancy, perinatal, post-traumatic stress disorder (PTSD), postpartum PTSD, trauma informed care.

RESULTS

Perinatal care, given its somewhat invasive nature, has the potential to traumatize or cause re-traumatization. Trauma related disorders are common and can present or worsen in the perinatal period. Trauma can manifest in multiple forms in this population, including exacerbation of pre-existing PTSD, new onset acute stress disorder in the perinatal period or postpartum PTSD secondary to traumatic childbirth. Unaddressed trauma can adversely affect the experience of pregnancy, postpartum and parenting. Psychiatrists caring for women in the perinatal period, are in an ideal position to screen for trauma and offer appropriate intervention. A trauma informed approach to obstetric care can help clinical teams respond to the unique trauma-related challenges that can arise during obstetric care. Trauma informed care, with its emphasis on establishing a culture of safety, transparency, trustworthiness, collaboration, and mutuality can empower health care providers and systems with powerful tools to respond to trauma and its myriad effects in a strengths-based manner. By applying a trauma-informed lens, psychiatrists can help their obstetric colleagues provide patient-centered compassionate care and treatment.

CONCLUSIONS

Applying a trauma informed approach to evaluation and treatment of perinatal populations could decrease the toll trauma has on affected women and their children.