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

Survey of OB/GYN Residents Knowledge and Practice of Trauma Informed Care

BACKGROUND

There is a high prevalence of a history of traumatic experiences among those seeking obstetric/gynecologic care. OB/GYN clinicians must use trauma-informed care practices to avoid re-traumatization and to provide supportive care. The objective of this study was to describe the knowledge and use of trauma-informed care practices by OB/GYN residents in the outpatient setting.

METHODS

A descriptive research design was used. In February 2022, an email with a link to an electronic survey was sent to US OB/GYN residency program directors via a listserv. OB/GYN program directors were asked to forward the survey to residents in their program. The survey included closed-response questions, some of which were Likert scale, to assess the frequency of use of certain trauma-informed care practices during the provision of pelvic examinations.

RESULTS

Seventy US OB/GYN residents responded to the survey. Only half of residents surveyed reported that they practiced trauma-informed care and half reported either not receiving education or were not sure if they had training on the subject. Additionally, half of the respondents were unaware of the ACOG Committee Opinion 825: Care of Patients with History of Trauma.

CONCLUSION

There was limited use of trauma-informed care practices among OB/GYN residents in this study. Considering the high prevalence of traumatic experiences among individuals seeking gynecologic care, a framework for trauma-informed pelvic exams should be included in the residency curriculum and applied universally.

A cross-sectional needs assessment for a trauma-informed care curriculum for multidisciplinary healthcare providers

BACKGROUND

Trauma-informed care (TIC) is a framework that recognizes the pervasive impact of trauma, aiming to enhance both patient outcomes and provider well-being. Given the high prevalence of trauma among individuals seeking healthcare, it is essential for healthcare providers (HCPs) to be trauma informed. However, standardized TIC curricula for training healthcare staff are lacking. This study assessed perceptions towards TIC among multidisciplinary HCPs, patients, and leadership staff at two urban hospitals in Canada.

METHODS

This mixed-methods prospective cross-sectional study employed Kern's six-step approach for curriculum development. A needs assessment was conducted via an online questionnaire for HCPs and semi-structed interviews with individuals from the three participant groups: HCPs, patients, and leadership staff. The questionnaire assessed knowledge, skills, and attitudes regarding TIC. Semi-structured interviews explored perspectives on TIC, including curriculum priorities and potential implementation barriers. Findings informed the development of a virtual TIC curriculum, with iterative feedback collected to refine and assess its acceptability.

RESULTS

Among 106 HCP questionnaire respondents including Medical Doctors, Social Workers and Registered Nurses, 96 (90.6%) identified as women, and 97 (91.5%) as providers of direct patient care. Despite 93 (87.7%) having prior TIC education, 77 (72.6%) reported low confidence in applying TIC knowledge in clinical practice. Key perceived challenges to TIC training implementation included time constraints and lack of standardization across disciplines. A multimedia, self-paced course was the preferred solution. Thematic analysis of interviews with 28 participants (10 HCPs, 10 patients, 8 leadership staff) revealed six major themes: healthcare interactions, TIC implementation, training needs, system level barriers, curriculum preferences, and systems level improvements. Participants underscored the risk of re-traumatization to patients in healthcare settings without TIC and emphasized the need for universal TIC training for all staff.

CONCLUSION

This study revealed a strong interest in a TIC course for multidisciplinary HCPs, supports the translation of knowledge into practice and incorporates a focus on cultural humility. Integrating insights from key stakeholders in this needs assessment phase resulted in the development of a TIC curriculum inclusive of diverse voices and viewpoints and strengthened the understanding of contextual factors that will support effective TIC implementation.

From Guidelines to Social Media: A Content Analysis of Trauma-Informed Care on YouTube

Trauma-informed care is an increasingly trending clinical and organizational approach globally. Multiple guidelines exist on implementing trauma-informed care across healthcare systems, behavioral health programs, academic institutions, and prisons, among other settings. Although many studies have assessed the implementation of trauma-informed care guidelines and the integration of training into curricula for healthcare providers, workforces, and in clinical practice with individuals and communities, there have been no studies previously conducted to date on assessing the existing state of coverage on trauma-informed care across social media to inform future, actionable interventions. This represents a critical gap in research and practice given the increasingly prevalent utilization and accessibility of information online, especially via a multitude of social media platforms. This study is the first to assess the sources, format, and content across one of these social media platforms on YouTube. Content on trauma-informed care was examined through conducting a descriptive, observational study to determine the depth and breadth of content that was widely covered and uncovered across the top 100 widely viewed videos. Findings revealed that most of the content was published by professional, nongovernmental sources. A wide range of resources and strategies was presented on social media for utilizing trauma-informed care across diverse settings on individual and community levels. The five principles of trauma-informed care (safety, trustworthiness, collaboration, empowerment, and choice) were heavily reviewed among the widely viewed videos. A multitude of benefits was presented in terms of implementing trauma-informed care on both micro and macro levels. Social determinants of health were not widely covered but formed some of the stressors and triggers examined among the videos. DEI principles were also scantly covered across the videos. Several clinical and organizational implications are presented. Recommendations to integrate widely covered and uncovered content as targets for intervention in informing future trauma-informed approaches are proposed.

Incorporation of Trauma-Informed Care Into Entrustable Professional Activities for Medical Student Assessment

PROBLEM

Trauma-informed care (TIC) provides a medical framework for addressing and mitigating the negative consequences of trauma. In response to student and faculty advocacy, medical schools are developing trauma-informed curricular content. However, medical education literature does not present a comprehensive assessment rubric to evaluate medical students' acquisition of trauma-informed clinical skills.

APPROACH

A committee of medical students, trainees, and faculty developed a longitudinal TIC curricular theme at Harvard Medical School (HMS). Guided by the National Collaborative on Trauma-Informed Health Care Education and Research competencies, the committee created a set of medical student TIC competencies from July to December 2019. From November 2021 to November 2022, 3 committee subgroups generated new TIC descriptors for each HMS entrustable professional activity (EPA), then circulated these to other subgroups, external experts, and stakeholders for review and feedback. From April to June 2023, the committee iteratively reviewed the materials until reaching consensus for content and pedagogy. The committee integrated TIC content into HMS's existing EPAs expected of students, provided anchoring descriptions of each level, and achieved consensus using a process of iterative review with TIC content experts.

OUTCOMES

The committee identified 10 TIC competencies and revised all 13 general HMS EPAs to include specific items based on these competencies. The committee incorporated at least 1 trauma-informed competency into each HMS EPA.

NEXT STEPS

This novel set of HMS EPAs provides a framework for assessment of TIC clinical skills. Faculty will be trained to correctly and reliably incorporate TIC competencies into patient care and to use the TIC-inclusive EPAs for student assessment, ensuring that TIC is standard medical practice at HMS. This work may facilitate the adoption of trauma-inclusive EPAs by other institutions to educate the next generation of physicians to practice TIC and thus promote a more accessible, safe, and equitable health care system.

Trauma-Informed Care as a Universal Precaution: A Brief, Case-Based, Educational Primer Featuring Role-Playing and Individual Self-Reflection Exercises

ABSTRACT

Despite its growing popularity, the implementation of Trauma-Informed Care (TIC) in standard medical practices remains insufficient. A workshop, featuring role-playing scenarios and individual self-reflection exercises, was developed to enhance compassion among health care providers. The workshop was created by a multidisciplinary team of community pediatricians, pediatric intensivists, psychologists, and palliative care physicians, was structured around key elements and principles of TIC, and was based on actual patient encounters. The 90-minute session included didactics, role-playing, writing and self-reflection exercises, and large-group debriefings, and it was presented at two academic meetings. It is currently available as an open-sourced, freely accessible website. The workshop was attended by individuals with varying levels of training and experience. Of approximated 80 participants, 39 responded to surveys about baseline knowledge and workshop satisfaction, and 24 completed self-perceived pre- and postknowledge surveys. Nearly 90% had limited prior exposure to TIC. All rated the workshop highly, with no significant differences based on workshop facilitation. Nearly 95% felt that they learned something that would impact their day-to-day practices. Self-perceived pre-post knowledge showed statistically significant improvements. This workshop is feasible and can potentially increase health care professionals' capacity to care, decrease moral injury, and alleviate burnout from difficult cases.

Development and Validation of a Trauma-Informed Care Communication Skills Assessment Tool

BACKGROUND

Trauma-informed care (TIC) is growing in medical education as health care systems recognize trauma's impact on health outcomes. TIC acknowledges and responds to the effects of trauma on physical, psychological, and emotional health. As TIC trainings are developed and delivered to health care professionals across the learner continuum, curricula need evaluation beyond learner satisfaction and knowledge to better assess changes in skills. We developed the Gap Kalamazoo Communication Skills Assessment Form for Trauma-Informed Care (GKCSAF-TIC) to evaluate pediatric trainees' communication skills in TIC. We describe the development and validity evidence of the GKCSAF-TIC in assessing pediatric residents' TIC skills during standardized patient encounters.

METHODS

We developed and implemented the TIC communication skills assessment tool in a one-year prospective cohort study involving pediatric residents. We conducted simulated patient encounters conducted before and after TIC training, with two pediatric faculty attendings assessing each encounter. We gathered validity evidence using Messick's framework, focusing on content, response process, internal structure, and relationship with other variables.

RESULTS

We analyzed 57 standardized patient encounters with 33 pediatric interns, including 23 pre-post matched pairs. The development process and rater training supported content and response process validity. Internal consistency, measured by Cronbach's alpha, ranged from 0.93 to 0.96, while inter-rater reliability, measured by intraclass correlations, ranged from 0.80 to 0.83. There was a significant improvement in scores from pre-training to post-training (3.7/5 to 4.05/5; P < 0.05).

CONCLUSION

The GKCSAF-TIC demonstrated strong preliminary validity and offers educators a valuable means to assess and provide formative feedback to pediatric trainees about TIC.

Enhancing trauma-informed care preparation through life story work

Trauma experience is common and may impact health and health care experiences for older adults. As such, training in trauma-informed care (TIC) is essential for health professions trainees. In this paper, we describe the use of life-story work, in the form of the My Life, My Story (MLMS) program as one platform to enhance TIC competencies. Trainees (N = 74) who were physician (57.0%) and other health professions trainees who did MLMS interviews completed a post-experience survey about trauma disclosures and confidence in responding to these. During these interviews, 36.5% of the patients described a traumatic event and 56.8% described a stressful event, framed by the patient as "ultimately positive" - leading to resilience (42.6%) or "ultimately negative" - leading to negative life outcomes (29.5%), with other responses as not sure or ambivalent. Confidence in responding to trauma disclosures increased following participation in MLMS (t(df = 60) = 5.52, p < .001). Qualitative comments indicated that MLMS helped them recognize the various expressions of trauma and provided insights into possible responses to trauma disclosure, among other TIC competencies. About half (50.8%) of trainees expressed interest in additional resources or training in responding to trauma disclosures. In conclusion, life-story work and MLMS may be one tool to enhance TIC.

Trauma-Informed Care in Nursing Curricula: Development of a Simulation-Based Educational Framework to Guide Health Professions

AIM

This research aimed to uncover elements of a comprehensive, trauma-informed (TI) multidisciplinary health professions simulation framework to improve the delivery of care to traumatized patients.

BACKGROUND

Trauma is a pervasive public health problem requiring a TI approach. Simulation is an evidence-based teaching strategy that advances knowledge and clinical reasoning. There is a lack of scientifically based simulation education models addressing the delivery of TI care for the health professions.

METHOD

A Delphi study utilizing a panel of experts was conducted to identify the most critical elements of a simulation framework.

RESULTS

Phase one identified 10 content areas and 111 subcontent areas. Phase two analysis revealed 99 percent of the 111 subcontent areas achieved expert consensus.

CONCLUSION

This Delphi study provides the first scientifically based framework to guide the development of a comprehensive, TI, multidisciplinary simulation framework to recognize trauma survivors and subsequently display concern and respect.

Trauma-Informed Undergraduate Medical Education: A Pathway to Flourishing with Adversity by Enhancing Psychological Safety

We describe the Life Experiences Curriculum (LEC), which attempts to integrate medical student well-being with trauma-informed medical education. The long-term goal of LEC is to help medical students flourish with adversity and trauma, where flourishing refers to having a sense of purpose that arises from awareness of one's strengths and limitations, shaped by life experiences. The short-term goal of LEC is to develop students' relational capacities, such as acceptance and awareness of self and others, while building and maintaining students' psychological safety. We describe the conceptual rationale for these goals and the curriculum's development, implementation, evaluation, and limitations. The curriculum extends over four years and involves a preclinical seminar and students' individual and group reflection sessions with LEC faculty. The seminar addresses the coexistence of trauma and flourishing across life experiences, as well as how safety in relationships is impaired by traumatic experiences and must be restored for healing and growth. The physician faculty have no role in student evaluation and co-lead all LEC activities. LEC is intended to provide students with new language for understanding the process of trauma and flourishing in both individuals and systems and to build and sustain students' relational capacities. There are ongoing efforts to re-imagine self-care as communal-care in which care and support are given and received in a community of students and faculty. Such a model may help build the relational capacities needed to deliver trauma-informed care and also promote flourishing with adversity in healers and in those seeking to be healed.

A systematic review of factors that impact reading comprehension in children with developmental language disorders

Children with developmental language disorder (DLD) have a high rate of co-occurring reading difficulties. The current study aims to (i) examine which factors within the Active View of Reading (AVR; Duke & Cartwright, 2021) apply to individuals with DLD and (ii) investigate other possible factors that relate to reading comprehension ability in individuals with DLD, outside the components in the AVR. Electronic database search and journal hand-search yielded 5058 studies published before March 2022 related to reading comprehension in children with DLD. 4802 articles were excluded during abstract screening, yielding 256 studies eligible for full-text review. Following full-text review, 44 studies were included and further coded for demographics, language of assessment, description of reported disabilities, behavioral assessment, and reading comprehension assessment. While the results aligned with the AVR model, three additional factors were identified as significantly relating to reading comprehension abilities in children with DLD: expressive language (oral and written), question types of reading assessment, and language disorder history. Specifically, expressive language was positively associated with reading comprehension ability, while resolved DLD showed higher reading comprehension abilities than persistent DLD. Furthermore, children with DLD may face additional difficulties in comprehending inference-based questions. This study provides factors for researchers, educators, and clinical professionals to consider when evaluating the reading comprehension of individuals with DLD. Future research should further explore the relative importance of factors of the AVR to reading comprehension outcomes throughout development.

Trauma-Informed Care Education Initiative Explores Impact on Perinatal Nurse Secondary Traumatic Stress and Workforce Challenges

BACKGROUND

Psychological trauma refers to long-lasting adverse effects on well-being precipitated by the experience of a distressing event or a combination of events. High rates of psychological birth trauma in patients contribute to secondary traumatic stress (STS) in perinatal nurses, creating workplace challenges and resulting in dissatisfaction, apathy, and attrition. Perinatal nurses experience high rates of STS, and researchers have called for a universal standard of trauma-informed care (TIC). However, there is a lack of published results on effectively creating TIC education in this nurse population.

METHODS

A pre/posttest design evaluated an online pilot evidence-based practice project addressing a perinatal nurse education initiative on STS and its correlation with nurse attitudes toward TIC. Participants include perinatal nurses in the United States (n = 29). Two scales measured the program's effect on nurses: the Secondary Traumatic Stress Scale (STSS) and the Attitudes Related to Trauma-Informed Care (ARTIC) scale.

RESULTS

A paired t test evaluating pre- and postprogram levels of the STSS showed a decrease in STS (t28 = -3.28, P = .003, Cohen's d = 0.609), the ARTIC scale results showed an increased receptiveness to TIC (t28 = 3.8, P < .001, Cohen's d = 0.706], and a not significant correlation was found between pretest STS and ARTIC scores (Spearman' ρ = -0.248, P = .194).

CONCLUSION

This program supported a significant reduction in nurses' identification of STS. Future perinatal nurse education can expand to build a standard of TIC that is patient-centered and reduces nurse STS.

Practical tips for starting a successful national postgraduate course

Background

Few start national courses, and those that do usually do it once. The aim of this paper is to outline an approach to conduct a successful national postgraduate course.

Methods

The practical tips were derived from personal experience.

Results

The 12 tips identified are: define learning needs and curriculum, create a functioning structure, recruit a committed faculty, obtain legitimacy, promote your course, try out the concept, establish administrative support, use modern techniques and accessories, create course-related social activities, keep all on board, collect ongoing evaluation, and stay in control.

Conclusion

It is hoped that these tips will make it easier for others to take the decisive first step in the exciting task of starting a national course; that is: 'to know the road ahead - ask those coming back'.

Adverse childhood experiences and trauma informed care for chiropractors: a call to awareness and action

BACKGROUND

Trauma is an emotional response to distressing events where coping and subsequent recovery are absent. Adverse Childhood Experiences (ACEs) are traumas, occurring before the age of 18 years, such as child abuse or neglect, caregiver instability, and household dysfunction. Sixty-four percent of the U.S. population report experiencing at least one ACE, with over 1 billion children experiencing abuse and neglect annually worldwide. Chronic exposure to stressful circumstances or multiple traumatic events has negative physiologic impacts. Persons who experience 3 or more ACEs in childhood are at greater risk of poor mental health outcomes and may be more likely to engage in high-risk behaviors, predisposing them to long-term health impacts, such as metabolic diseases, anxiety, depression, substance use, and chronic pain. Trauma informed care (TIC) is a recommended approach to healthcare delivery across professions, especially when a trauma history is suspected. This commentary aims to increase awareness of the impact of ACEs on health outcomes and introduce TIC concepts as they may apply to chiropractic care for adults with a history of ACEs.

DISCUSSION

This commentary reviews an introductory model (4R's: realize, recognize, respond, resist re-traumatization) as one TIC framework used by healthcare practitioners. Prior trauma can lessen trust, alter perceptions of physical touch, and hands-on examinations and chiropractic treatments may trigger stress responses. Using TIC after appropriate training, includes referrals to multidisciplinary providers to address trauma-related concerns outside the scope of chiropractic, and screening for ACEs if deemed appropriate. Creating safe spaces, communicating clearly, avoiding victimizing language, explaining procedures, asking for consent before physical contact, and giving patients choice and control in their own care may avoid triggering prior traumas.

CONCLUSION

Given the high worldwide prevalence of persons experiencing 3 or more ACEs, TIC principles are practical adaptations to chiropractic care for use with many patient populations. As TIC and ACEs are emerging concepts within chiropractic, students and practitioners are encouraged to undertake additional training to better understand these complex and sensitive topics. Exploratory research on the incidence, presentation, and impacts of various trauma types, including ACEs, to support adoption of TIC in chiropractic settings is essential.

Roadmap for Trauma-Informed Medical Education: Introducing an Essential Competency Set

Research has established that trauma is nearly universal and a root cause of numerous health and social problems, including 6 of the 10 leading causes of death, with devastating consequences across the life course. Scientific evidence now recognizes the complex injurious nature of structural and historical trauma (i.e., racism, discrimination, sexism, poverty, and community violence). Meanwhile, many physicians and trainees grapple with their own trauma histories and face direct and secondary traumatization on the job. These findings substantiate the profound impact of trauma on the brain and body and why trauma training is critical to the education and practice of physicians. However, a critical lag remains in translating essential research insights into clinical teaching and care. Recognizing this gap, the National Collaborative on Trauma-Informed Health Care Education and Research (TIHCER) formed a task force charged with developing and validating a summary of core trauma-related knowledge and skills for physicians. In 2022, TIHCER released the first-ever validated set of trauma-informed care competencies for undergraduate medical education. The task force focused on undergraduate medical education so that all physicians would be taught these foundational concepts and skills from the outset of training, recognizing that faculty development is needed to achieve this goal. In this Scholarly Perspective, the authors offer a roadmap for implementation of trauma-informed care competencies starting with medical school leadership, a faculty-student advisory committee, and sample resources. Medical schools can use the trauma-informed care competencies as a scaffold to customize integration of curricular content (what is taught) and efforts to transform the learning and clinical environments (how it is taught). Using the lens of trauma will ground undergraduate medical training in the latest science about the pathophysiology of disease and provide a framework to address many of our greatest challenges, including health disparities and professional burnout.