Obstetric Outcomes Among Women With a History of Intimate Partner Violence in the United States.

OBJECTIVE: To evaluate the association between exposure to intimate partner violence (IPV) and delivery method in a U.S. obstetric cohort. METHODS: The study population included U.S. women with a history of recent live birth, drawn from the 2009-2018 PRAMS (Pregnancy Risk Assessment Monitoring System) cohort. The primary exposure was self-reported IPV. The primary outcome of interest was method of delivery (vaginal or cesarean). Secondary outcomes included preterm birth, small for gestational age (SGA), and admission to the neonatal intensive care unit (NICU). Bivariate associations between the primary exposure (ie, self-report of IPV vs no self-report of IPV) and each covariate of interest were assessed with weighted quasibinomial logistic regression. Weighted multivariable logistic regression was conducted to evaluate the association between IPV and delivery method controlling for confounders. RESULTS: A total of 130,000 women were included in this secondary analysis of a cross-sectional sample, representing 7,500,000 women nationwide based on PRAMS sampling design. Of these, 0.8% reported abuse in the 12 months before their current pregnancy and 1.3% reported abuse during pregnancy; 1.6% of the study population reported abuse both before and during pregnancy. After adjusting for maternal sociodemographic characteristics, IPV exposure at any time was not significantly associated with cesarean delivery, compared with no IPV exposure (odds ratio [OR] 0.98, 95% CI 0.86-1.11). Of secondary outcomes, 9.4% of women experienced preterm birth and 15.1% had neonates admitted to the NICU. Exposure to IPV was associated with a 21.0% increased risk of preterm birth, compared with women without exposure (OR 1.21, 95% CI 1.05-1.40), and a 33.3% increased risk of NICU admission (OR 1.33, 95% CI 1.17-1.52) after controlling for confounders. There was no difference in the risk of delivering a neonate who was SGA. CONCLUSION: Intimate partner violence was not associated with an increased risk of cesarean delivery. Intimate partner violence before or during pregnancy was associated with increased risk of adverse obstetric outcomes, such as preterm birth and NICU admission, corroborating previous research findings.

Multistakeholder Perspectives on Interventions to Support Youth During Mental Health Boarding.

OBJECTIVE: To identify and prioritize opportunities to improve the psychiatric boarding experience for youth awaiting admission or transfer to inpatient psychiatric care. STUDY DESIGN: This study utilized an exploratory mixed methods design. The study team convened multidisciplinary stakeholder focus groups to discuss proposed hospital-based solutions to mental health boarding, potential psychosocial interventions deliverable during boarding, and outcomes measurement. Focus group responses were transcribed and analyzed to extract themes pertaining to these improvement opportunities. These results informed a follow-up survey which was then sent to the stakeholders to rate the feasibility and importance of modifications using a modified RAND-UCLA Appropriateness Method. RESULTS: Qualitative analyses revealed 9 themes across 2 domains related to psychiatric boarding care: in-hospital improvements and transitions of care. The follow-up survey identified 6 improvement opportunities rated as both feasible and important. Additionally, 6 psychosocial interventions, 2 delivery modalities, and 5 outcomes were rated as both feasible and important. CONCLUSIONS: Stakeholders concerned with the psychiatric boarding of youth identified numerous opportunities for improving the boarding process within 2 domains of in-hospital improvements and transitions of care. Most of the improvements were considered feasible and important with several serving as particularly viable strategies. These have the potential for implementation to improve the care of this vulnerable population and inform local and national quality improvement efforts.

An Injustice to the Justice-Involved: A Brief Report on the Impact of Traumatic Brain Injury on Incarcerated Mothers.

ABSTRACT: Traumatic brain injury (TBI) is one of the leading causes of death and long-term disability among young adults worldwide and in the United States. TBIs are often associated with a high prevalence of morbidity, mortality, and other behavioral and cognitive problems. Several studies have shown that women living with TBIs have significantly higher odds of committing criminal acts, yet the impact of TBI on incarcerated women remains an underresearched area. By contrast, the effect of TBI on men is more prevalent in current literature, particularly relating to sports-related injuries. Given that an estimate of 80% of incarcerated women are mothers, we conducted a literature review in two phases focused on TBI in incarcerated mothers. The initial search of TBI in incarcerated mothers returned no results, so we proceeded in two phases. Phase 1 searched maternal outcomes of TBI, using the terms "maternal health" and "traumatic brain injury," whereas Phase 2 searched "traumatic brain injury" and "incarcerated women." Because so little information is available regarding TBI in incarcerated mothers, we used what we could find in these two phases to highlight the scarcity of knowledge about this population. This brief report addresses the knowledge gap that exists for incarcerated mothers living with TBI to encourage regular TBI screening to raise awareness and advocate for accommodated care. Correctional forensic nurses are perfectly placed to do TBI screening and to provide continuous rehabilitation after release to prevent reoffending.

Healthcare Quality for Acute Illness during the COVID-19 Pandemic: A Multisite Qualitative Analysis.

The coronavirus disease 2019 (COVID-19) pandemic incited substantial changes to acute care delivery, including the rapid scale-up of telehealth and numerous changes to in-person care. This study explored health system changes associated with the COVID-19 pandemic and their influences on pediatric acute care delivery and quality of care. METHODS: We conducted 38 semistructured interviews May-November 2020 with families and clinicians from 3 US regions, eliciting their perspectives and experiences regarding changes to acute care delivery during the pandemic. Interviews were analyzed using a general inductive approach to identify relationships between clinical care infrastructure, care processes, and healthcare quality. RESULTS: Emerging knowledge of COVID-19 epidemiology and associated restrictions influenced care-seeking behaviors and clinical infrastructure and processes. Infrastructure changes included the closure of some clinics, limited "sick visit" hours and locations, and increased resources for telehealth. Modified care processes included the assignment of clinicians to specific roles, limitations on sibling attendance, increased referrals to other clinics, and iterative development of procedures and protocols. Although intended to increase safety, these changes appear to have decreased access, timeliness, and equity of care. High-quality care was supported by telephone triage processes, in-person visits following initial assessments by telehealth, and identification of diagnoses and populations best-suited to telehealth versus in-person care. CONCLUSIONS: Changes in acute care delivery during the COVID-19 pandemic may have negatively impacted healthcare quality in some domains. Implementation of pediatric-specific guidelines and decision aids describing diagnoses, populations, and procedures best-suited to telehealth may improve the quality of acute care delivery.

Accessing Healthcare Services During the COVID-19 Pandemic: The Plight of Sexual Assault Survivors.

INTRODUCTION: Despite a global focus on intimate partner violence during the COVID-19 pandemic, there has been little exploration into how the pandemic and its associated restrictions have impacted sexual assault survivors and their ability to access specialized care and resources. The purpose of this research brief is to use longitudinal data to compare the number of medical forensic examinations done seasonally prepandemic and during the COVID-19 pandemic shelter-in-place order. METHODS: This analysis uses retrospective data on medical forensic examinations from January 2010 through November 2020 from one large academic Midwestern hospital. RESULTS: Results show that monthly medical forensic examinations have increased over time, from a mean of 4.5 cases per month (range: 1-9) in 2010 to a mean of 9 cases per month (range: 7-11) in 2019. In April 2020, when COVID-19-related shutdowns were at their first peak, cases dropped to a historic low of 0 examinations (the lowest number of cases in the past 10 years). CONCLUSIONS: The data show an initial drop in the number of survivors seeking postassault care after the COVID shutdown; however, cases rebounded through the second full month of shutdown orders. Programs that provide medical forensic examinations need to be prepared for subsequent waves of survivors, who may be COVID-19 positive. We must be better prepared for many of the adverse consequences impacting individuals around the country related to COVID-19 responses.

Acquired Brain Injuries and Intimate Partner Violence: A Situational Analysis of Help Seeking Barriers in Rural Northern New England.

Nurses care for women experiencing non-fatal strangulation and acquired brain injuries whether or not it is disclosed. Situational analysis was used to analyze 23 interviews from Northern New England with survivors, healthcare workers, and violence/legal advocates to explore overlapping relationships between violence, acquired brain injuries, non-fatal strangulation, and seeking care. Findings included the concepts of paying social consequences and the normalization of violence. Non-fatal strangulation was described as increasingly related to violence and other areas. Repetitive acquired brain injuries can impair functioning needed to address violence and healthcare providers and advocates are generally unaware of the impact of acquired brain injuries. A lack of resources, training, and tools for acquired brain injury screening were barriers in recognizing and responding to it, causing hidden symptoms. This study adds to the literature examining intimate partner violence in rural areas; specifically intimate partner violence-related acquired brain injuries in rural areas.

A retrospective study on the acceptability, feasibility, and effectiveness of LoveYourBrain Yoga for people with traumatic brain injury and caregivers.

PURPOSE: To conduct a mixed methods, pre-post, retrospective study on the feasibility, acceptability, and effectiveness of the LoveYourBrain Yoga program. MATERIALS AND METHODS: People were eligible if they were a traumatic brain injury survivor or caregiver, age 15-70, ambulatory, and capable of gentle exercise and group discussion. We analyzed attendance, satisfaction, and mean differences in scores on Quality of Life After Brain Injury Overall scale (QOLIBRI-OS) and four TBI-QOL/Neuro-QOL scales. Content analysis explored perceptions of benefits and areas of improvement. RESULTS: 1563 people (82.0%) participated ≥1 class in 156 programs across 18 states and 3 Canadian provinces. Mean satisfaction was 9.3 out of 10 (SD 1.0). Mixed effects linear regression found significant improvements in QOLIBRI-OS (B 9.70, 95% CI: 8.51, 10.90), Resilience (B 1.30, 95% CI: 0.60, 2.06), Positive Affect and Well-being (B 1.49, 95% CI: 1.14, 1.84), and Cognition (B 1.48, 95% CI: 0.78, 2.18) among traumatic brain injury survivors (n = 705). No improvement was found in Emotional and Behavioral Dysregulation, however, content analysis revealed better ability to regulate anxiety, anger, stress, and impulsivity. Caregivers perceived improvements in physical and psychological health. CONCLUSIONS: LoveYourBrain Yoga is feasible and acceptable and may be an effective mode of community-based rehabilitation.IMPLICATIONS FOR REHABILITATIONPeople with traumatic brain injury and their caregivers often experience poor quality of life and difficulty accessing community-based rehabilitation services.Yoga is a holistic, mind-body therapy with many benefits to quality of life, yet is largely inaccessible to people affected by traumatic brain injury in community settings.Participants in LoveYourBrain Yoga, a six-session, community-based yoga with psychoeducation program in 18 states and 3 Canadian provinces, experienced significant improvements in quality of life, resilience, cognition, and positive affect.LoveYourBrain Yoga is feasible and acceptable when implemented on a large scale and may be an effective mode of, or adjunct to, community-based rehabilitation.

Patient Perspectives on the Implementation of Risk-Aligned Bladder Cancer Surveillance: Systematic Evaluation Using the Tailored Implementation for Chronic Diseases Framework.

PURPOSE: Many patients living with bladder cancer do not undergo surveillance that is aligned with their risk for recurrence or progression, which exposes them to unnecessary risk and burden of procedures. To implement risk-aligned surveillance as recommended by multiple guidelines, we need to understand patient-, provider-, and system-level factors contributing to the delivery of risk-aligned surveillance. In this study, we sought to systematically assess patient-level factors. PARTICIPANTS AND METHODS: Guided by the Tailored Implementation for Chronic Diseases framework, we conducted semistructured interviews with 22 patients with bladder cancer undergoing surveillance cystoscopy procedures at three facilities within the Department of Veterans Affairs. Patients were sampled using quantitative data on bladder cancer risk category (low v high) and on surveillance category (aligned v not aligned with cancer risk). Interview transcripts were analyzed using a priori codes from the Tailored Implementation for Chronic Diseases framework. Quantitative and qualitative data were integrated by cross-tabulating determinants across risk and surveillance categories. RESULTS: Participants included seven low-risk and 15 high-risk patients; 10 underwent risk-aligned surveillance and 12 did not. In mixed-methods analyses, perception of risk appropriately differed by risk but not by surveillance category. Participants understood the recommended surveillance schedule according to their risk category. Participants emphatically expressed that adhering to providers' recommendations is prudent; intentions to adhere did not vary across risk and surveillance categories. CONCLUSION: Participants intended to adhere to providers' recommendations and strongly endorsed the importance of adherence. These findings suggest implementation strategies to improve risk-aligned surveillance may be most effective when targeting provider- and system-level factors rather than patient-level factors.

Advancing Health Equity and Social Justice in Forensic Nursing Research, Education, Practice, and Policy: Introducing Structural Violence and Trauma- and Violence-Informed Care.

Initial conceptualizations of violence and trauma in forensic nursing have remained relatively narrowly defined since the specialty's inception. The advent of trauma-informed care has been important but has limitations that obfuscate social and structural determinants of health, equity, and social justice. As forensic nursing practice becomes more complex, narrow definitions of violence and trauma limit the effectiveness of trauma-informed care in its current incarnation. In keeping with the nursing model of holistic care, we need ways to teach, practice, and conduct research that can accommodate these increasing levels of complexity, including expanding our conceptualizations of violence and trauma to advance health equity and social justice. The objective of this article is to introduce the concepts of structural violence and trauma- and violence-informed care as equity-oriented critical paradigms to embrace the increasing complexity and health inequities facing forensic nursing practice.

Influence of Gender on Surgical Residency Applicants' Recommendation Letters.

BACKGROUND: Implicit bias has been documented in candidate selection within academic medicine. Gender bias is exposed when writers systematically use different language to describe attributes of male and female applicants. This study examined the presence of gender bias in recommendation letters for surgical residency candidates. STUDY DESIGN: Recommendation letters for 2016 to 2017 surgery resident applicants selected for interview at an academic institution were analyzed using qualitative text analysis, quantitative text mining, and topic modeling. Dedoose, QDA Miner, and RStudio analytic software were used for analysis. RESULTS: There were 332 letters of recommendation for 89 applicants (51% male) analyzed. Of 265 letter writers, 86% were male, 21% chairs, and 50% professors. Average word count was 404. Letter writers for male compared with female applicants had a significantly higher average word count (male = 421, SD 144; female = 388, SD 140, p = 0.035). Standout adjectives (eg exceptional), reference to awards, achievement, ability, hardship, leadership, scholarship, and use of applicant's name were most often applied to male applicants. Comments on positive general terms (eg delightful), grindstone words (eg hard-working), physical description, doubt raisers, and work ethic were most often applied to female applicants. Topic modeling and term frequencies revealed achievement words (performance, career, leadership, and knowledge) used more often with male applicants, while caring words (care, time, patients, and support) were used more often with female applicants. CONCLUSIONS: Gendered differences examined through language and text exist in surgical residents' recommendation letters. Implementing tools to help faculty write recommendation letters with meaningful content and editing letters for reflections of stereotypes may improve the resident selection process by reducing bias.

Extreme Control and Instability: Insight Into Head Injury From Intimate Partner Violence.

AIM: The aim of this study was to understand the social context of the lives of women who experienced a head injury from intimate partner violence. BACKGROUND: Sixty percent to 92% of survivors of intimate partner violence receive head trauma during the abuse. Little research exists regarding the episodes of abuse when women receive a head injury, or the reasons women might not seek medical care for the head injury or the abuse. METHOD: Twenty-one interviews from nine women who self-reported passing out from being hit in the head were analyzed using thematic analysis. FINDINGS: Themes of extreme control and manipulation from abusers emerged, and women described living with instability from cycles of incarceration, drug and alcohol use, and fear of losing their children. Women did not receive medical care for head injury because the abusers often used forced sex immediately after the head injury to instill fear and authority. IMPLICATIONS FOR FORENSIC NURSING: Hitting women in the head is not only about physical abuse, but also about exerting dominance and creating an environment of extreme control. Forensic nurses are uniquely positioned to screen for head injuries during initial assessments and follow-up visits and connect women with appropriate resources.

Effect of Home Visiting with Pregnant Teens on Maternal Health.

PURPOSE: Determine the extent that participation in Resource Mothers Program (RMP) home visiting improves maternal health at 3 months postpartum. STUDY DESIGN AND METHODS: A randomized controlled trial using RMPs in two urban and one rural location in a mid-Atlantic state. Community health workers from these RMPs enrolled teens into the study and the research team assigned participants to either the intervention group or telephone support control group using computerized randomization assignments. Data collection from baseline and 3 months postpartum using the Edinburgh Postnatal Depression Scale (EPDS) and the Prenatal Psychosocial Profile (PPP) is reported. RESULTS: The sample included 150 pregnant teens with a mean age of 17 years. Mean self-esteem scores between groups were not significantly different at baseline, but the RMP group self-esteem scores improved significantly at the 3 months postpartum interview (36.40 ± 5.63 for RMP vs. 34.10 ± 4.29 telephone control group, p = 0.049). Neither group was at risk for depression at baseline or 3 months postpartum. Because 60% of the total sample identified as Hispanic, post hoc analysis revealed significantly different baseline stress mean scores between Hispanic and non-Hispanic teens (p = 0.038); however, these differences were no longer significant by 3 months postpartum (p = 0.073). The EPDS scores by ethnicity were not different at baseline (p = 0.875) but were significantly different at 3 months (p = 0.007). CLINICAL IMPLICATIONS: The RMP home-visiting intervention can lead to improved self-esteem scores in teens, particularly in Hispanic teens. Improved self-esteem has been shown to lead to better parenting.

Intimate Partner Violence and Traumatic Brain Injury: State of the Science and Next Steps.

Women who receive traumatic brain injuries (TBI) from intimate partner violence (IPV) are gaining attention; however, research studies are lacking in this area. A review of literature conducted on TBI from IPV found prevalence of 60% to 92% of abused women obtaining a TBI directly correlated with IPV. Adverse overlapping health outcomes are associated with both TBI and IPV. Genetic predisposition and epigenetic changes can occur after TBI and add increased vulnerability to receiving and inflicting a TBI. Health care providers and community health workers need awareness of the link between IPV/TBI to provide appropriate treatment and improve the health of women and families.