Emergency Department Preparedness to Care for Sexual Assault Survivors: A Nationwide Study.

INTRODUCTION: Emergency departments (ED) provide trauma-informed care to sexual assault (SA) survivors and connect them with comprehensive services. Through surveying SA survivor advocates, we aimed to 1) document updated trends in the quality of care and resources offered to SA survivors and 2) identify potential disparities according to geographic regions in the US, urban vs rural clinic locations, and the availability of sexual assault nurse examiners (SANE). METHODS: We conducted a cross-sectional study between June-August 2021, surveying SA advocates who were dispatched from rape crisis centers to support survivors during ED care. Survey questions addressed two major themes in quality of care: staff preparedness to provide trauma-response care; and available resources. Staff preparedness to provide trauma-informed care was assessed through observations of staff behaviors. We used Wilcoxon rank-sum and Kruskal-Wallis tests to analyze differences in responses according to geographic regions and SANE presence. RESULTS: A total of 315 advocates from 99 crisis centers completed the survey. The survey had a participation rate of 88.7% and a completion rate of 87.9%. Advocates who indicated that a higher proportion of their cases were attended by SANEs were more likely to report higher rates of trauma-informed staff behaviors. For example, the recalled rate of staff asking patients for consent at every step of the exam was significantly associated with SANE presence (P < 0.001). With respect to access to resources, 66.7% of advocates reported that hospitals often or always have evidence collection kits available; 30.6% reported that resources such as transportation and housing are often or always available, and 55.3% reported that SANEs are often or always part of the care team. The SANEs were reported to be more frequently available in the Southwest than in other US regions (P < 0.001) and in urban as opposed to rural areas (P < 0.001). CONCLUSION: Our study indicates that support from sexual assault nurse examiners is highly associated with trauma-informed staff behaviors and comprehensive resources. Urban-rural and regional disparities exist regarding access to SANEs, suggesting that elevating nationwide quality and equity in care of survivors of sexual assault requires increased investments in SANE training and coverage.

Prescription of Long-Acting Injectable Antipsychotic Medications Among Outpatient Mental Health Care Service Providers.

OBJECTIVE: Long-acting injectable antipsychotic medications (LAIAPs) are a valuable and underused treatment for patients with chronic mental illnesses such as schizophrenia and bipolar disorder. This study aimed to examine prescription patterns of LAIAPs among outpatient mental health care service providers in the United States. METHODS: The authors conducted a secondary analysis of the 2020-2021 National Mental Health Services Survey to assess the percentage of outpatient mental health care service providers (N=9,433) that prescribed LAIAPs to patients. Descriptive statistics were calculated to describe the overall frequency of outpatient facilities prescribing LAIAPs and differences in the specific LAIAPs prescribed. The authors also conducted multivariable analyses to identify facility characteristics associated with likelihood of LAIAP prescribing. RESULTS: Across all outpatient mental health care service providers, 30.6% prescribed LAIAPs. Community mental health centers were most likely to prescribe LAIAPs (62.6%), whereas partial hospitalization and day programs were least likely (32.1%). The most used LAIAP was paliperidone palmitate (77.7%), and the least used was olanzapine pamoate (29.6%). Providers with programs specifically for patients with serious mental illness (59.5%) and providers with a dedicated first-episode psychosis program (58.2%) were more likely to prescribe LAIAPs than were providers without such programming. CONCLUSIONS: Prescription of LAIAPs is limited at outpatient mental health care service providers in the United States. Expansion of these services and diversification of delivery models are needed to improve LAIAP prescriptions, which are associated with improved patient outcomes across a broad range of measures.

Trauma of abortion restrictions and forced pregnancy: urgent implications for acute care surgeons.

In the aftermath of the Supreme Court's Dobbs vs. Jackson Women's Health decision, acute care surgeons face an increased likelihood of seeing patients with complications from both self-managed abortions and forced pregnancy in underserved areas of reproductive and maternity care throughout the USA. Acute care surgeons have an ethical and legal duty to provide care to these patients, especially in obstetrics and gynecology deserts, which already exist in much of the country and are likely to be exacerbated by legislation banning abortion. Structural inequities lead to an over-representation of poor individuals and people of color among patients seeking abortion care, and it is imperative to make central the fact that people of color who can become pregnant will be disproportionately affected by this legislation in every respect. Acute care surgeons must take action to become aware of and trained to treat both the direct clinical complications and the extragestational consequences of reproductive injustice, while also using their collective voices to reaffirm the right to abortion as essential healthcare in the USA.

"We're playing on the same team": Communication (dis)connections between trauma patients and surgical residents.

BACKGROUND: Patient-physician communication is key to better clinical outcomes and patient well-being. Communication between trauma patients and their physicians remains relatively unexplored. We aimed to identify and characterize the range of strengths and challenges in patient-physician communication in the setting of trauma care. METHODS: A qualitative, grounded theory approach was used to explore communication strengths and challenges for patients and residents. Patients previously admitted to the trauma service for violent injuries were recruited and interviewed in-person during their trauma clinic appointments. Surgical residents were recruited via email and interviewed virtually via Zoom. Anonymous, semistructured interviews were conducted until thematic saturation was reached. RESULTS: Twenty-nine interviews with patients and 14 interviews with residents were conducted. Patients reported feeling ignored and misunderstood and having inadequate communication with physicians. Residents cited lack of time, patients' lack of health literacy, differences in background, and emotional responses to trauma as barriers to effective communication with patients. Patients and residents reported an understanding of each other's stressors, similar emotional experiences regarding traumatic stress, and a desire to communicate with each other in greater depth both inside and outside of the hospital. CONCLUSION: Trauma patients and residents can feel disconnected due to the lack of time for thorough communication and differences in background; however, they understand each other's stressors and share similar emotional responses regarding trauma and a desire for increased communication, connection, and solidarity. Leveraging these shared values to guide interventions, such as a resident curriculum, may help bridge disconnects and improve their communication. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Impact of Sexual Assault Survivor Identity on Patient Care in the Emergency Department.

Interactions between emergency department (ED) staff and sexual assault (SA) survivors can be a source of retraumatization for survivors, increasing their risk of posttraumatic stress and decreasing utilization of longitudinal medical care. Little is known about nationwide trends in ED staff attitudes and behaviors toward survivors, including the impact of survivor identity. We conducted a survey to determine if survivor identity influenced ED staff behaviors. A nationwide survey of SA patient advocates was conducted between June and August 2021. Advocates are volunteers or staff dispatched from rape crisis centers to support survivors during ED care. Advocates participated in an online survey to determine the frequency of observing six potentially retraumatizing provider attitudes and behaviors. Adaptive questioning was used to explore the impact of survivor identity on each attitude or behavior and which identity groups were more likely to be affected. Three hundred fifteen advocates responded to the survey. Less than 10% indicated that ED staff often or always convey disbelief or blame to survivors. Almost 75% of advocates indicated that they often or always observe ED staff showing empathy to survivors. Disparities were found in provider attitudes. Over 75% of advocates observed that survivors' mental health status or substance use impacted conveyed belief from providers. Patients who were intoxicated when assaulted, had psychiatric disorders, were Black, Hispanic/LatinX, or indigenous, or were not cis-females were more likely to experience disbelief. Patients who were white and/or cis-gender females were more likely to be pressured by ED staff to complete the forensic exam and/or report to the police. Our study documents disparities in ED staff behavior towards SA survivors according to survivor identity. Given that post-assault ED interactions are critical turning points in survivors' future medical processes, disparities in ED care may be linked to larger disparities in healing from trauma.

Fostering Resilience in Nursing Through R.E.S.T.

ABSTRACT: With about one-third of nurses having expressed an intention to leave the profession or change jobs in 2022, the effects of nursing job stress are evident. For nurses to continue to provide care in high stress, they must practice self-compassion and build resilience. The importance of resilience education and self-compassion for nurses and in nursing education is discussed from a Christian perspective, along with self-care strategies using the R.E.S.T. (Relationship, Exercise, Self-Compassion, Transformative Thinking) framework. Strategies for building resilience for both individuals and organizations are offered.

Patient Advocates' Perspectives on the Care of Sexual Assault Survivors in Chicago-Area Emergency Departments.

Emergency departments (EDs) providing care and forensic examinations for sexual assault (SA) survivors are often supported by SA patient advocates. This study explored advocates' perspectives regarding problems and potential solutions in SA patient care through a focus group with 12 advocates. Thematic analysis identified two major themes: provider-patient interactions and ED-hospital systems. Challenging aspects of provider-patient interactions included (a) provider attitudes and (b) disempowering behaviors. Within ED-hospital systems, themes included time constraints, efficiencies, and hospital preparation. Advocates surveyed were optimistic about an increased presence of SA nurse examiners and enhanced protocols and provider training to improve survivors' experiences.

"It Got Likes, But I Don't Think People Understood": A Qualitative Study of Adolescent Experiences Discussing Type 1 Diabetes on Social Media.

BACKGROUND: The majority of adolescents with type 1 diabetes (T1D) integrate social media engagement into their daily lives. The aim of this study was to explore adolescents' experiences and perspectives discussing their T1D on social media. METHODS: Semi-structured interviews with adolescents with T1D were conducted in person and via telephone. Questions focused on the participant's experiences utilizing social media to discuss T1D and factors that informed the nature of T1D-related social media engagement. Open coding and thematic content analysis were used to identify emergent themes that aligned with accepted domains of social media affordances. RESULTS: Participants included 35 adolescents with T1D. Adolescents' experiences related to discussing T1D on social media aligned with four affordances of social media: identity, cognitive, emotional, and social. The identity affordances of social media platforms allowed adolescents to curate online personas that selectively included their diagnosis of T1D, while managing the potential negative emotional and social implications linked to the stigma of T1D. Adolescents who decided to discuss T1D on social media leveraged cognitive affordances by providing and receiving diabetes management advice, emotional affordances by obtaining affirmation from peers, and social affordances by extending their network to include other individuals with T1D. CONCLUSIONS: Adolescents with T1D flexibly leverage the affordances offered by social media to access emotional support, information, and identity affirmation resources while navigating stigma-based social consequences. Our findings highlight the value of developing tools to support adolescents with T1D in comfortably discussing and receiving appropriate support about T1D on social media.

Ethically incentivising healthy behaviours: views of parents and adolescents with type 1 diabetes.

BACKGROUND: To assess ethical concerns associated with participation in a financial incentive (FI) programme to help adolescents with type 1 diabetes improve diabetes self-management. METHODS: Focus groups with 46 adolescents with type 1 diabetes ages 12-17 and 38 of their parents were conducted in the Seattle, Washington metropolitan area. Semistructured focus group guides addressed ethical concerns related to the use of FI to promote change in diabetes self-management. Qualitative data were analysed and emergent themes identified. RESULTS: We identified three themes related to the ethical issues adolescents and parents anticipated with FI programme participation. First, FI programmes may variably change pressure and conflict in different families in ways that are not necessarily problematic. Second, the pressure to share FIs in some families and how FI payments are structured may lead to unfairness in some cases. Third, some adolescents may be likely to fabricate information in any circumstances, not simply because of FIs, but this could compromise the integrity of FI programmes relying on measures that cannot be externally verified. CONCLUSIONS: Many adolescents with type 1 diabetes and their parents see positive potential of FIs to help adolescents improve their self-management. However, ethical concerns about unfairness, potentially harmful increases in conflict/pressure and dishonesty should be addressed in the design and evaluation of FI programmes.

Emergency Department Design in Low- and Middle-Income Settings: Lessons from a University Hospital in Haiti.

Background: Studies from high-income settings have demonstrated that emergency department (ED) design is closely related to operational success; however, no standards exist for ED design in low- and middle-income countries (LMICs). Objective: We present ED design recommendations for LMICs based on our experience designing and operating the ED at Hôpital Universitaire de Mirebalais (HUM), an academic hospital in central Haiti. We also propose an ideal prototype for similar settings based on these recommendations. Methods: As part of a quality improvement project to redesign the HUM ED, we collected feedback on the current design from key stakeholders to identify design features impacting quality and efficiency of care. Feedback was reviewed by the clinical and design teams and consensus reached on key lessons learned, from which the prototype was designed. Findings and conclusions: ED design in LMICs must balance construction costs, sustainability in the local context, and the impact of physical infrastructure on care delivery. From our analysis, we propose seven key recommendations: 1) Design the "front end" of the ED with waiting areas that meet the needs of LMICs and dedicated space for triage to strengthen care delivery and patient safety. 2) Determine ED size and bed capacity with an understanding of the local health system and disease burden, and ensure line-of-sight visibility for ill patients, given limited monitoring equipment. 3) Accommodate for limited supply chains by building storage spaces that can manage large volumes of supplies. 4) Prioritize a maintainable system that can provide reliable oxygen. 5) Ensure infection prevention and control, including isolation rooms, by utilizing simple and affordable ventilation systems. 6) Give consideration to security, privacy, and well-being of patients, families, and staff. 7) Site the ED strategically within the hospital. Our prototype incorporates these features and may serve as a model for other EDs in LMICs.

Adolescent and parent perspectives on the acceptability of financial incentives to promote self-care in adolescents with type 1 diabetes.

BACKGROUND: An understanding of acceptability among potential intervention participants is critical to the design of successful real-world financial incentive (FI) programs. The purpose of this qualitative study was to explore adolescent and parent perspectives on the acceptability of using FI to promote engagement in diabetes self-care in adolescents with type 1 diabetes (T1D). METHODS: Focus groups with 46 adolescents with T1D (12-17 years old) and 39 parents of adolescents with T1D were conducted in the Seattle metropolitan area. Semistructured questions addressed participants' current use of incentives to promote change in diabetes self-care and receptivity to a theoretical incentive program administered by a third-party. Qualitative data were analyzed and emergent themes identified. RESULTS: Three thematic categories informed participant views about the acceptability of FI programs: (a) the extent to which using FIs in the context of diabetes management fit comfortably into a family's value system, (b) the perceived effectiveness for FIs to promote improved diabetes self-care, and (c) the urgent need for improved self-care due to the threat of diabetes-related health complications. These factors together led most parents and adolescents to be open to FI program participation. CONCLUSIONS: The results from this qualitative study suggest that well-designed FI programs to support diabetes management are acceptable to families with adolescents with T1D. Additionally, the use of FIs may have the potential to support adolescents with T1D in developing strong self-care habits and ease the often-turbulent transition to independent self-care.