Establishing Trauma-Informed Primary Care: Qualitative Guidance from Patients and Staff in an Urban Healthcare Clinic
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Participants
2.3. Procedures
2.4. Data Analysis
3. Results
3.1. Topic: Meaning and Impact of Trauma
3.2. Topic: Barriers to Trauma-Informed Care
3.3. Topic: Facilitators and Recipients of Trauma-Informed Care
3.4. Topic: Ways to Increase and Improve Trauma-Informed Care
3.5. Topic: Coping Mechanisms
3.6. Group-Specific Themes
4. Discussion
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Acknowledgments
Conflicts of Interest
References
- Marmot, M.; Allen, J.; Bell, R.; Bloomer, E.; Goldblatt, P. WHO European review of social determinants of health and the health divide. Lancet 2012, 380, 1011–1029. [Google Scholar] [CrossRef]
- Compton, M.T.; Shim, R.S. The social determinants of mental health. Focus 2015, 13, 419–425. [Google Scholar] [CrossRef] [Green Version]
- Murphey, D.; Bartlett, J.D. Childhood adversity screenings are just one part of an effective policy response to childhood trauma. Child Trends Brief 2019. Available online: https://www.childtrends.org/publications/childhood-adversity-screeings-are-just-one-part-of-an-effective-policy-response-to-childhood-trauma-2 (accessed on 11 July 2020).
- Merrick, M.T.; Ford, D.C.; Ports, K.A.; Guinn, A.S.; Chen, J.; Klevens, J.; Metzler, M.; Jones, C.M.; Simon, T.R.; Daniel, V.M.; et al. Vital signs: Estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention—25 States, 2015–2017. MMWR Morb. Mortal. Wkly. Rep. 2019, 68, 999–1005. [Google Scholar] [CrossRef] [Green Version]
- Sacks, V.; Murphey, D. The Prevalence of Adverse Childhood Experiences, Nationally, by State, and by Race or Ethnicity; Child Trends: Bethesda, MD, USA, 2018. [Google Scholar]
- Felitti, V.J.; Anda, R.F.; Nordenberg, D.; Williamson, D.F.; Spitz, A.M.; Edwards, V.; Marks, J.S. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Am. J. Prev. Med. 1998, 14, 245–258. [Google Scholar] [CrossRef]
- Jones, C.M.; Merrick, M.T.; Houry, D.E. Identifying and preventing adverse childhood experiences: Implications for clinical practice. JAMA 2020, 323, 25. [Google Scholar] [CrossRef]
- Burke, N.J.; Hellman, J.L.; Scott, B.G.; Weems, C.F.; Carrion, V.G. The impact of adverse childhood experiences on an urban pediatric population. Child Abus. Negl. 2011, 35, 408–413. [Google Scholar] [CrossRef] [Green Version]
- Bellis, M.A.; Hughes, K.; Ford, K.; Ramos Rodriguez, G.; Sethi, D.; Passmore, J. Life course health consequences and associated annual costs of adverse childhood experiences across Europe and North America: A systematic review and meta-analysis. Lancet Public Health 2019, 4, e517–e528. [Google Scholar] [CrossRef] [Green Version]
- Substance Abuse and Mental Health Services Administration. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach; HHS Publication No. (SMA) 14-4884; Substance Abuse and Mental Health Services Administration: Rockville, MD, USA, 2014.
- National Council on Behavioral Health. Fostering Resilience and Recovery: A Change Package for Advancing Trauma-Informed Primary Care. 2019. Available online: https://www.bettercareplaybook.org/resources/fostering-resilience-and-recovery-change-package-advancing-trauma-informed-primary-care (accessed on 10 January 2020).
- Champine, R.B.; Lang, J.M.; Nelson, A.M.; Hanson, R.F.; Tebes, J.K. Systems measures of a trauma-informed approach: A systematic review. Am. J. Community Psychol. 2019, 64, 418–437. [Google Scholar] [CrossRef] [PubMed]
- Oral, R.; Coohey, C.; Zarei, K.; Conrad, A.; Nielsen, A.; Wibbenmeyer, L.; Segal, R.; Wojciak, A.S.; Jennissen, C.; Peek-Asa, C. Nationwide efforts for trauma-informed care implementation and workforce development in healthcare and related fields: A systematic review. Turk. J. Pediatrics 2020, 62, 906. [Google Scholar] [CrossRef]
- Giano, Z.; Wheeler, D.L.; Hubach, R.D. The frequencies and disparities of adverse childhood experiences in the U.S. BMC Public Health 2020, 20, 1–12. [Google Scholar] [CrossRef] [PubMed]
- Giovanelli, A.; Reynolds, A.J. Adverse childhood experiences in a low-income black cohort: The importance of context. Prev. Med. 2021, 148, 106557. [Google Scholar] [CrossRef] [PubMed]
- Maguire-Jack, K.; Lanier, P.; Lombardi, B. Investigating racial differences in clusters of adverse childhood experiences. Am. J. Orthopsychiatry 2020, 90, 106–114. [Google Scholar] [CrossRef] [PubMed]
- Reeves, E. A Synthesis of the literature on trauma-informed care. Issues Ment. Health Nurs. 2015, 36, 698–709. [Google Scholar] [CrossRef] [PubMed]
- Bartlett, J.D. Screening for childhood adversity: Contemporary challenges and recommendations. Advers. Resil. Sci. 2020, 1, 65–79. [Google Scholar] [CrossRef] [Green Version]
- Olsen, J.M. Integrative review of pregnancy health risks and outcomes associated with adverse childhood experiences. J. Obstet. Gynecol. Neonatal Nurs. 2018, 47, 783–794. [Google Scholar] [CrossRef] [PubMed]
- Conn, A.-M.; Szilagyi, M.A.; Jee, S.H.; Manly, J.T.; Briggs, R.; Szilagyi, P.G. Parental perspectives of screening for adverse childhood experiences in pediatric primary care. Fam. Syst. Health 2018, 36, 62–72. [Google Scholar] [CrossRef] [PubMed]
- Goldstein, E. Patient preferences for discussing childhood trauma in primary care. Perm. J. 2017, 21, 16–055. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Hardcastle, K.; Bellis, M. Routine Enquiry for History of Adverse Childhood Experiences (ACEs) in the Adult Patient Population in a General Practice Setting: A Pathfinder Study. Technical Report. 2018. Available online: https://www.researchgate.net/publication/327418846 (accessed on 3 March 2020).
- Gillespie, R.J.; Folger, A.T. Feasibility of assessing parental ACEs in pediatric primary care: Implications for practice-based implementation. J. Child Adolesc. Trauma 2017, 10, 249–256. [Google Scholar] [CrossRef]
- Glowa, P.T.; Olson, A.L.; Johnson, D.J. Screening for adverse childhood experiences in a family medicine setting: A feasibility study. J. Am. Board Fam. Med. 2016, 29, 303–307. [Google Scholar] [CrossRef] [PubMed]
- McEwen, C.A.; Gregerson, S.F. A critical assessment of the adverse childhood experiences study at 20 years. Am. J. Prev. Med. 2019, 56, 790–794. [Google Scholar] [CrossRef]
- Finkelhor, D. Screening for adverse childhood experiences (ACEs): Cautions and suggestions. Child Abus. Negl. 2018, 85, 174–179. [Google Scholar] [CrossRef] [PubMed]
- Angen, M.J. Evaluating interpretive inquiry: Reviewing the validity debate and opening the dialogue. Qual. Health Res. 2000, 10, 378–395. [Google Scholar] [CrossRef] [PubMed]
- Palmer, M.; Larkin, M.; De Visser, R.; Fadden, G. Developing an interpretative phenomenological approach to focus group data. Qual. Res. Psychol. 2010, 7, 99–121. [Google Scholar] [CrossRef]
- Love, B.; Vetere, A.; Davis, P. Should interpretative phenomenological analysis (IPA) be used with focus groups? Navigating the bumpy road of “iterative loops,” idiographic journeys, and “phenomenological bridges”. Int. J. Qual. Methods 2020, 19, 1609406920921600. [Google Scholar] [CrossRef]
- Matua, G.A.; Van Der Wal, D.M. Differentiating between descriptive and interpretive phenomenological research approaches. Nurse Res. 2015, 22, 22–27. [Google Scholar] [CrossRef] [PubMed]
- Morris, A.S.; Hays-Grudo, J.; Treat, A.; Williamson, A.; Roblyer, M.; Staton, J. Protecting parents and children from adverse childhood experiences (ACEs): Preliminary evidence for the validity of the PACEs. Presented at the Society for Research in Child Development Special Topics Meeting: New Conceptualizations in the Study of Parenting At-Risk, San Diego, CA, USA, 13–15 November 2014. [Google Scholar]
- Dubowitz, H.; Felgelman, S.; Lane, W.; Kim, J. Pediatric primary care to help prevent child maltreatment: The Safe Environment for Every Kid (SEEK) model. Pediatrics 2009, 123, 857–864. [Google Scholar] [CrossRef] [PubMed]
- Dubowitz, H.; Lane, W.G.; Semiatin, J.N.; Magder, L.S.; Venepally, M.; Jans, M. The safe environment for every kid model: Impact on pediatric primary care professionals. Pediatrics 2011, 127, e962–e970. [Google Scholar] [CrossRef] [Green Version]
- Cronholm, P.F.; Forke, C.M.; Wade, R.; Bair-Merritt, M.H.; Davis, M.; Harkins-Schwarz, M.; Pachter, L.M.; Fein, J.A. Adverse childhood experiences: Expanding the concept of adversity. Am. J. Prev. Med. 2015, 49, 354–361. [Google Scholar] [CrossRef] [PubMed]
- Borken, J. Immersion/Crystallization. In Doing Qualitative Research, 2nd ed.; Crabtree, B.F., Miller, W.L., Eds.; Sage Publications: Thousand Oaks, CA, USA, 1999; pp. 179–194. [Google Scholar]
- Bethell, C.; Davis, M.B.; Gombojav, N.; Stumbo, S.; Powers, K. Issue Brief: A National and Across-State Profile on Adverse Childhood Experiences Among Children and Possibilities to Heal and Thrive. 2017. Available online: https://www.cahmi.org/wp-content/uploads/2018/05/aces_brief_final.pdf (accessed on 11 November 2018).
- Orbuch, R.; Sheehan, K.; Rosenow, W.; Yousuf, S. Childhood protective factors and adult health outcomes. Pediatrics 2021, 147, 196. [Google Scholar] [CrossRef]
- Lincoln, K.D.; Chatters, L.M.; Taylor, R.J. Social support, traumatic events, and depressive symptoms among African Americans. J. Marriage Fam. 2005, 67, 754–766. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Garner, A.; Yogman, M. Preventing childhood toxic stress by partnering with families and communities to promote relational health. Pediatrics 2021, 148, e2021052582. [Google Scholar] [CrossRef] [PubMed]
- Strait, J.; Meagher, S. Trauma-informed care in pediatrics: A developmental perspective in twelve cases with narratives. Perm. J. 2020, 24. [Google Scholar] [CrossRef]
- Dueweke, A.R.; Hanson, R.F.; Wallis, E.; Fanguy, E.; Newman, C. Training Pediatric primary care residents in trauma-informed care: A feasibility trial. Clin. Pediatr. 2019, 58, 1239–1249. [Google Scholar] [CrossRef] [PubMed]
Employees (N = 30) | Patients (N = 6) | |
---|---|---|
Gender | ||
Female | 30 (100%) | 6 (100%) |
Male | 0 (0%) | 0 (0%) |
Employee Service Area | ||
Women’s Health Clinic | 18 (60%) | NA |
Pediatric Clinic | 10 (33%) | NA |
Both Women’s & Pediatrics | 2 (7%) | NA |
Employee Role | ||
Nurse, Medical Assistant | 17 (57%) | NA |
Physician or Nurse Practitioner | 4 (13%) | NA |
Mental-Behavioral Health Staff | 3 (10%) | NA |
Administrative/Leadership | 2 (7%) | NA |
Other | 4 (13%) | NA |
Theme | Participant | Quote |
---|---|---|
Violence and Loss | Patient | “People need to get out in the community and work together to get the guns off the streets.” “Where we’re at right now is bad. There’s been a lot of shooting going on.” “Safety is the key thing I worry about.” “[Trauma] can be grief, it can be loss, stressors, pain, hurt…” |
Staff | “We have had several people whose babies have died this week…and so all of those things are traumatic.” “Parents abuse their children… and it’s because of trauma that they experienced too as a child.” | |
Distress | Patient | “When I hear trauma, it means something serious…it means something needs to be done as soon as possible.” “I just left one place where my house was robbed. …The environment we live in, a lot of people have a lack of respect for each other. And when I say lack of respect, these are kids. These are our future. These are our lawyers, our doctors, our nurses.” |
Staff | “Trauma to me can be any action or event that would cause a negative or fearful perception of what’s going on.” “Trauma to me is something that causes discomfort, pain, anxiety in one’s life after something has occurred.” |
Theme | Participant | Quote |
---|---|---|
Continuity | Patient | “I have a fit when I got to see somebody different…I have to explain everything off to you over again.” “That’s my kid’s doctor. Me and her are really close so I don’t’ mind talking to her if something is going on with my kids because I know she will help…people talk to certain people.” |
Staff | “The problem is that when we see a patient for the first time, they have no reason to trust you.” “I think if there’s continuity, I think parents are more apt to talk.” | |
Time | Patient | “Allow [patients] to vent and get it out even if you know…allow space to get their self together and collect their thoughts.” “If they shut down, give them time to open up.” |
Staff | “We need to realize that patients take a lot of time, and they need to change the amount of time that anyone has with them.” “You cannot help them in a 15 minute appointment.” “A lot of times we don’t’ have time…because we got other people coming…it’s rushed…we don’t really have time to sit down really and talk.” |
Theme | Participant | Quote |
---|---|---|
Sense of Community | Patient | “You know they’ll help me…they will actually take the time and listen…in essence, you got this home team around you.” |
Staff | “I think we’re doing a good job of having an open-door policy…just being visible in the community.” |
Theme | Participant | Quote |
---|---|---|
Standardization and Normalization | Patient | “I would say make some universal questions that pertains to trauma and experience.” “You know, even just having a questionnaire sometimes with just maybe 4–5 questions.” |
Staff | “I think screening and finding out about the events…that would be where I would say to start because if we don’t know these things are happening, we can’t help them.” “Standardizing and normalizing what you’re about to ask I think is the best way to kind of establish comfort.” | |
Community Resources | Patient | “Given people other places where they can look to, especially help if they have trouble finding clothes for their kids, utility help, farmers markets.” “Just give more out for the community.” |
Staff | “We tend to know agencies and organizations that are available but are tapped out…maybe reaching out to the community and gathering some more kinds of support.” |
Theme | Participant | Quote |
---|---|---|
Family and Friends | Patient | “I look at my kids. My kids are the reason. That’s what gets me up and keeps me going.” “I try my best to do what I can do for my kids, because it’s not just about me, it’s about my children.” |
Staff | “We all support each other to be honest, I think we have a really really good work family, we all help.” |
Theme | Participant | Quote |
---|---|---|
Patient Safe Space | Patient | “I would say…when they’re resistant, just try to work with them. Don’t try to over-talk them.” “Don’t be too pushy. Don’t be intrusive. Because if you start coming off shooting 1,000,001 questions, you lost her because it took a lot for her to come in there.” |
Effects on Employees | Staff | “It can trigger something that happened in our lives, I’ve seen employees have an issue before, it really takes a toll.” “You get frustrated, and you have a short fuse ourselves sometimes with patients that I think we try not to show, but we’re all human.” “It’s wearing. It’s hard. You can’t keep up. It’s emotionally and physically draining. Your brain is working, your heart is working, you’re physically working.” “I think when I can finish a day having helped somebody… that’s what keeps me going.” “You know our patients really need the help. And when they get it they really appreciate the help.” |
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. |
© 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Matthew, A.; Moffitt, C.; Huth-Bocks, A.; Ronis, S.; Gabriel, M.; Burkhart, K. Establishing Trauma-Informed Primary Care: Qualitative Guidance from Patients and Staff in an Urban Healthcare Clinic. Children 2022, 9, 616. https://doi.org/10.3390/children9050616
Matthew A, Moffitt C, Huth-Bocks A, Ronis S, Gabriel M, Burkhart K. Establishing Trauma-Informed Primary Care: Qualitative Guidance from Patients and Staff in an Urban Healthcare Clinic. Children. 2022; 9(5):616. https://doi.org/10.3390/children9050616
Chicago/Turabian StyleMatthew, Andrea, Cynthia Moffitt, Alissa Huth-Bocks, Sarah Ronis, Mary Gabriel, and Kimberly Burkhart. 2022. "Establishing Trauma-Informed Primary Care: Qualitative Guidance from Patients and Staff in an Urban Healthcare Clinic" Children 9, no. 5: 616. https://doi.org/10.3390/children9050616