Aims and objectives. Participant narratives from a feminist and queer phe- nomenological study aim to broaden current understandings of trauma. Examin- ing structural marginalisation within perinatal care relationships provides insights into the impact of dominant models of care on queer birthing women. More specifically, validation of queer experience as a key finding from the study offers trauma-informed strategies that reconstruct formerly disempowering perinatal relationships. Background. Heteronormativity governs birthing spaces and presents considerable challenges for queer birthing (...) women who may also have an increased risk of trauma due to structurally marginalising processes that create and maintain socially constructed differences. Design. Analysis of the qualitative data was guided by feminist and queer phe- nomenology. This was well suited to understanding queer women’s storied narra- tives of trauma, including disempowering processes of structural marginalisation. Methods. Semistructured and conversational interviews were conducted with a purposeful sample of thirteen queer-identified women who had experiences of birthing in rural Nova Scotia, Canada. Results. Validation was identified as meaningful for queer women in the context of perinatal care in rural Nova Scotia. Offering new perspectives on traditional models of assessment provide strategies to create a context of care that recon- structs the birthing space insofar as women at risk do not have to come out as queer in opposition to the expectation of heterosexuality. Conclusions. Normative practices were found to further the effects of structural marginalisation suggesting that perinatal care providers, including nurses, can challenge dominant models of care and reconstruct the relationality between queer women and formerly disempowering expectations of heteronormativity that govern birthing spaces. Relevance to clinical practice. New trauma-informed assessment strategies recon- struct the relationality within historically disempowering perinatal relationships through potentiating difference which avoids retraumatising women with re- experiencing the process of coming out as queer in opposition to the expectation of heterosexuality. (shrink)

The Experiential Therapist steps outside of the medical model to explore alternative ways of thinking about mental health disorders. Peter D. Ladd argues that successful treatment results from an informed understanding of a patient’s experience, not an ability to name and categorize difficult experiences as classical disorders.

Recognizing the links between childhood trauma and delinquency, many juvenile delinquency systems now emphasize trauma-informed care. This commentary examines established and emerging research on childhood trauma among American Indian and Alaska Native children and contrasts the development and implementation of “trauma-informed” approaches in state and tribal juvenile systems. It identifies three key innovations present in tribal models and calls for further research to identify best practices that work for Native children and tribal communities.

In ‘The ethics of consent during labour and birth: episiotomies,’ van der Pijl et al 1 respond to the prevalence of unconsented procedures during labour, proposing a set of necessary features for adequate consent to episiotomy. Their model emphasises information sharing, value exploration and trust between a pregnant person and their healthcare provider(s). While focused on consent to episiotomy, van der Pijl et al contend their approach may be applicable to consent for other procedures during labour and beyond pregnancy-related (...) care. One feature of their model for adequate informed consent is trust in the systems in which prenatal and labour and delivery care are provided. Yet, for some pregnant persons, mistrust in health systems is a reasonable sequela of experiences like racism and epistemic injustice. For a programme in which trust is central to adequate consent, it is important to identify—and counter—forms of mistrust toward pregnant persons within healthcare and acknowledge and rectify reasonable mistrust of pregnant persons toward healthcare. Like other kinds of healthcare disparities, van der Pijl et al note that ‘the burden of unconsented procedures is not evenly distributed over groups’ and tracks with ‘racial, socioeconomic and other disparities in maternity care’. They are drawing on data from a less diverse context than the one …. (shrink)

Having a decreased sense of security leads to unnecessary suffering and distress for patients. Establishing trust is critical for nurses to promote a patient's sense of security, consistent with trauma‐informed care. Research regarding nursing action, trust, and sense of security is wide‐ranging but fragmented. We used theory synthesis to organize the disparate existing knowledge into a testable middle‐range theory encompassing these concepts in hospitals. The resulting model illustrates how individuals are admitted to the hospital with some (...) predisposition to trust or mistrust the healthcare system and/or personnel. Patients encounter circumstances increasing their emotional and/or physical vulnerability to harm, leading to experiences of fear and anxiety. Without intervention, fear and anxiety lead to a decreased sense of security, increased distress, and suffering. Nurse action can ameliorate these effects by increasing a hospitalized person's sense of security or by promoting the development of interpersonal trust, also leading to an increased sense of security. Increased sense of security results in diminished anxiety and fear, and increased hopefulness, confidence, calm, sense of value, and sense of control. The consequences of a decreased sense of security are harmful to patients and nurses should know that they can intervene in ways that both increase interpersonal trust and sense of security. (shrink)

Not only is deception commonplace in medical encounters, according to Christopher Meyers (2021), but the clinical ethicist might have moral obligations to support and even enact deception. Descriptively Meyers is right that there are “opportunistic, self-interested and benevolent reasons” for deception through omission and commission in clinical medicine. But it is possible to retain this premise while rejecting the normative conclusion that the clinical ethicist “should sometimes be an active participant in the deception of patients and families.” One reason to (...) reject the normative conclusion is its incompatibility with providing trauma informed ethics consultation (TIEC). In the TIEC framework I developed with Uchenna Anani, we defend the integration of trauma informed care (TIC) into ethics consultation (Lanphier and Anani 2021). While ethicists narrowly attend to the question and scope of the ethics consults made to them, doing so in alignment with trauma informed principles is tantamount to providing good ethics consultation. According to Meyers, the clinical ethicist is an “advocate for the best ethical choices.” The best ethical choices are also trauma informed ones. (shrink)

The case of Xiang as described by Jane Carroll is indeed disconcerting well beyond the immediately apparent factors contained within the article. While Xiang’s direct medical expenses are excessive and his inability to pay for those expenses and further support his noncustodial family seem to be the main issues up for debate, Xiang, however, is likely going to need much more psychosocial support if he is to regain his previous independent functionality or retain any aspect of a quality of life (...) whilst continuing his indefinitely isolated treatment. In this response, I briefly outline the probable effects of Xiang’s current situation on his social identity and mental health as well as a potential way that we can minimize these adverse effects. (shrink)

Berger and Miller argue that cultural competency as an educational tool for physicians-in-training fails to address structural inequality and systemic oppression. Instead, it focuses on “cul...

The biology of early life adversity explores how social experiences early in life affect physical and psychological health and well-being throughout the life course. In our previous work, we argued that narratives emerging from and about this research field tend to focus on harm and lasting damage with little discussion of reversibility and resilience. However, as the Science and Technology Studies literature has demonstrated, scientific research can be actively taken up and transformed as it moves through social worlds. Drawing on (...) fieldwork with actors in education and juvenile corrections in the US Pacific Northwest, we found that they employed the biology of early life adversity not only to promote prevention but also to argue for changes within their own institutions that would allow them to better serve children and youth who have experienced adversity and trauma. Our study shows that biosocial narratives are neither inherently liberatory nor inherently oppressive but that the situated narrative choreographies in which they are enrolled are essential for their political effects. In our case, we show how these biosocial narratives have been articulated with knowledge and practices from restorative justice and trauma-informed care to reimagine the social meaning of the biology of early life adversity. (shrink)

Currently there are several psychotherapy modalities utilising theory and research from neuroscience in treatment frameworks for mental health and recovery from trauma. In Australia this includes: the Conversational Model of Psychodynamic Psychotherapy, a contemporary psychodynamic approach used for treating Borderline Personality Disorder and other trauma-related disorders; Electroencephalogram Neurofeedback, a brain training therapy which has been used as an adjunct to counselling/psychotherapy in traumatic stress and developmental trauma; and Somatic Experiencing, an integrative mind-body approach based on body (...) responses to threat and fear, especially thwarted attempts to enact fight or flight in the face of threat. These modalities have a promising but still-limited evidence base. This paper explores the role of different types of evidence to frame a descriptive review of the current evidence base available for clinicians practicing in these three modalities. While large clinical trials can provide evidence of comparative effectiveness, case studies, observational, qualitative and practice-based enquiry can assist in discovering other aspects of therapy important for individual clients and practitioners. Existing frameworks of evidence- and ethics-informed health and clinical decision-making suggest an ethical approach can incorporate new, developing and evidence-building therapies. Recommendations include careful consideration of informed consent for therapy including disclosure of efficacy and safety, and specific to psychotherapies incorporating neuroscience, a need for practitioners to reflectively assess their own knowledge, competence, heuristic approaches and biases. (shrink)

We argue for the addition of trauma informed awareness, training, and skill in clinical ethics consultation by proposing a novel framework for Trauma Informed Ethics Consultation (TIEC). This approach expands on the American Society for Bioethics and Humanities (ASBH) framework for, and key insights from feminist approaches to, ethics consultation, and the literature on trauma informed care (TIC). TIEC keeps ethics consultation in line with the provision of TIC in other clinical settings. Most (...) crucially, TIEC (like TIC) is systematically sensitive to culture, history, difference, power, social exclusion, oppression, and marginalization. By engaging a neonatal intensive care ethics consult example, we define our TIEC approach and illustrate its application. Through TIEC we argue it is the role of ethics consultants to not only hold open moral spaces, but to furnish them in morally habitable ways for all stakeholders involved in the ethics consultation process, including patients, surrogates, and practitioners. (shrink)

Owing to its grappling with a motley of intricate socioeconomic, as well as medico-legal, crises, Haiti has found itself bereft of some of its people, many of whom have had to leave the Caribbean country in search of improved lives elsewhere. Receiving some of the Haitian refugees fleeing abject poverty, unemployment, and other harms and barriers has been the United States, one of Haiti's northern neighbors and a country that has played an outcome-determinative, if not outsized, role in steering the (...) country toward its presently hobbled state. Drawing on the U.S.’s recent treatment of Haitian refugees, this paper argues that U.S. reception of Haitian immigrants rubs salt in the wound of a long history of dehumanizing and oppressive abuses endured by Haitians. Furthermore, and more importantly, this paper posits that U.S. failure to wholly embrace its legal obligation to accept Haitian refugees under international law needs to be understood in the light of the specific horrors inflicted by science, in pre-independence Haiti, on non-consenting, Afro-Haitian experimental subjects. And by extension, such a contextually-nuanced understanding is crucial in shaping the delivery of healthcare services to Haitian refugees fortunate enough to remain in the U.S. —as an awareness and appreciation of the socio-historical context of patients' lived experiences, i.e., their complete social history, can furnish important clues vis-à-vis the presence and etiologies of disease, influence the foci of physical exams, and generally pave the way for the provision of cost-efficient and evidence-based care. (shrink)

We investigated whether, in the emergency department, educational video-assisted informed consent is superior to the conventional consent process, to inform trauma patients undergoing surgery about the procedure, benefits, risks, alternatives, and postoperative care. We conducted a prospective randomized controlled trial, with superiority study design. All trauma patients scheduled to receive trauma-related debridement surgery in the ED of Kaohsiung Medical University Hospital were included. Patients were assigned to one of two education protocols. Participants in the intervention (...) group watched an educational video illustrating informed consent information, whereas those in the control group read an informed consent document. The primary outcome was knowledge scores and the secondary outcome was assessment of patient satisfaction. A multivariable regression model, with predefined covariates, was used to analyze differences in knowledge scores and patient satisfaction levels between the groups. A total of 142 patients were enrolled, with 70 and 72 assigned to the intervention and control groups, respectively. Mean knowledge scores were higher in the intervention ) than in the control group. By multivariate analysis, the intervention group had significantly greater differences in knowledge scores. Age, injury severity score, and baseline knowledge score significantly affected the differences in knowledge scores. Significant improvements were observed in patients’ perception of statements addressing comprehension of the information provided, helpfulness of the supplied information for decision making, and satisfaction with the informed consent process. Multivariate analysis showed significant correlations between video education and patient satisfaction. Both the educational approach and severity of injury may have an impact on patient understanding during the informed consent process in an emergency environment. Video-assisted informed consent may improve the understanding of surgery and satisfaction with the informed consent process for trauma patients in the ED. Institutions should develop structured methods and other strategies to better inform trauma patients, facilitate treatment decisions, and improve patient satisfaction. The ClinicalTrials.gov Identifier is NCT01338480. The date of registration was April 18, 2011. (shrink)

Complex clinical ethics cases require a blend of compassion, sensitivity, and tenacity in order to navigate the hard work required of stakeholders. Each person comes to the table with rich historie...

Health equity is a global concern. Although health equity extends far beyond the equitable distribution of healthcare, equitable access to healthcare is essential to the achievement of health equity. In Canada, Indigenous Peoples experience inequities in health and healthcare access. Cultural safety and trauma‐ and violence‐informed care have been proposed as models of care to improve healthcare access, yet practitioners lack guidance on how to implement these models. In this paper, we build upon an existing framework (...) of equity‐oriented care for primary healthcare settings by proposing strategies to guide nurses in operationalizing cultural safety and trauma‐ and violence‐informed care into nursing practice at the individual level. This component is one strategy to redress inequitable access to care among Indigenous Peoples in Canada. We conceptualize barriers to accessing healthcare as intrapersonal, interpersonal, and structural. We then define three domains for nursing action: practicing reflexivity, prioritizing relationships, and considering the context. We have applied this expanded framework within the context of Indigenous Peoples in Canada as a way of illustrating specific concepts and focusing our argument; however, this framework is relevant to other groups experiencing marginalizing conditions and inequitable access to healthcare, and thus is applicable to many areas of nursing practice. (shrink)

Trauma-informed care in pediatrics is an organizing principle for health care delivery that is based on the science of toxic stress and the insights of attachment theory. In their groundbreak...

Aim:The purpose of this study was to explore how adolescent patients displaying developmental trauma experience and describe meaning in life. Schnell’s model of meaning in life is applied to explore meaningfulness, crises of meaning and sources of meaning. Method: The study has a qualitative design based on individual interviews with eight adolescents aged 14–18 years in treatment in an outpatient clinic for mental health care for children and adolescents. The interviews were transcribed and analyzed using systematic text (...) condensation. Results: The adolescents related meaning in life to the experience of coherence, intrinsic values, progress and belonging, or the absence of these. Examples of sources of meaning among the informants were positive relations with meaningful others, structure and routines, moments of well-being, achieving goals related to education, work and family, and seeking something else outside oneself such as playing computer games, being engaged in politics, being with animals, having a belief in a god or being outdoors in natural surroundings. Conclusion: Although the topic of meaning in life was unknown to this group, they used sources of meaning intuitively. This group seems to have similar preferences to the general population. More knowledge is needed on how the topic of meaning in life can be useful in therapy for adolescents with development trauma. (shrink)

We read with interest Lanphier and Anani’s manuscript on trauma-informed ethics consultation. Their model rightly integrates trauma-informed principles within the ethics c...

Teaching students to build resilience is necessary to keep imagining and fighting for a path towards social justice. To do so, clinicians can draw from the communities facing oppression and examine how they remain resilient despite oppression.

This case raises questions of what “trauma-informed care” (TIC) means to the medical team caring for Maurice and how they embrace a TIC approach. There are established principles of trauma-informed...

Marshall et al. (2024) raise questions regarding patient refusals of care. In this commentary we address refusals of care from the lens of patient autonomy and provide suggestions for patient cente...

In lieu of an abstract, here is a brief excerpt of the content:Positive Change in Perception and Care for a Difficult PatientMelissa CavanaughIf you asked any healthcare professional if they had ever cared for a difficult patient, I am certain the answer would be a resounding "Yes!" I have encountered many over my forty-two years as an RN. The story of Ms. E. is one of exceptional challenge and, I hope, success.I met Ms. E. in 2012 when I took (...) a nursing position in an outpatient primary care Geriatric Clinic. The clinic was located within an inner city, Level 1 Trauma health system whose mission is to care for the underserved. This organization had cared for the most vulnerable in the area for decades. The clinic model is unique in that it provides a "one-stop shop" for the common medical needs of the older adult. Other specialties, including podiatry, rheumatology, dementia care, and stroke, held appointments in this clinic area. The supporting staff team members assisted in each of these clinics, leading them to interact with the same patients frequently.Most of my previous experiences had been in inpatient units with a quick turnover of patients. There was no time or need to develop a long-term relationship with the patients in these settings. However, the comprehensive services found in this clinic coupled with the low staff turnover, led to a stable group of seniors receiving care in this office. Many of these individuals had been attending this clinic for over twenty years.I heard about Ms. E. before I ever met her. She was well known to the clinic team as a "problem" patient. The general response when she was on the schedule was eye rolling and audible moans. I soon learned that in addition to her scheduled visits, she would randomly appear outside the full glass interior doors. She would hover in the area, tapping on the glass to get the attention of a staff member. She did not hesitate to interrupt staff and other patients to make her needs known when she was in the exam room hallway. Often team members would scatter and hide to avoid dealing with her. If she was not in the building, she was on the triage line with a question or physical complaint. To complicate matters even further, her husband was our patient as well, and they always attended appointments together.Ms. E. suffered from common geriatric chronic diseases such as hypertension, diabetes, and osteoarthritis. Her morbid obesity complicated her diagnoses. Though she was able to safely ambulate with an assistive device such as a cane or walker, she routinely used a motorized chair. She and her husband admitted visiting fast food restaurants often even though they had met with a dietician for counseling on several occasions. They often requested help obtaining medications, yet related stories about visiting the local casino. Ms. E. spoke with a small, weak voice that added to the countenance of helplessness and pity. Unfortunately, these behaviors of noncompliance, attention seeking, and dependency on others extended to her immediate community, and she is estranged from family and friends who may have been a source of support to her. [End Page E1]Ms. E.'s appointments were scheduled at the end of the day due to the expectation and pattern of the extended time they would take. No matter her expressed concerns or needs, our recommendations and interventions were never enough. She continually questioned the assessment information and did not want to accept the education and orders given as the correct response to her problems. As one can see, her appointments could be exhausting!Ms. E. certainly deserved the best and most comprehensive care available from our team. Developing a more therapeutic relationship for her within the clinic became a priority for me. However, it was a daunting task to provide this level of care and to convince her that she deserved and was receiving such care. She presented a laundry list of characteristics that could lead to biases from the staff. Overcoming such individual biases toward her may be a barrier as well. These included her obesity, her lack of initiative, her self-centered behaviors, and her constant need for attention.As healthcare professionals... (shrink)

Abstract The values of the healthcare sector are fairly ubiquitous across the globe, focusing on caring and respect, patient health, excellence in care delivery, and multi-stakeholder collaboration. Many individual pharmacists embrace these core values. But their ability to honor these values is significantly determined by the nature of the system they work in. -/- The paper starts with a model of the prevailing pharmacist workforce model in Scotland, in which core roles are predominantly separated into hierarchically disaggregated (...) jobs focused on one professional ‘pillar’: Clinician /Practice Provider; Educator; Leader/Manager; and Researcher. This is the ‘Atomistic’ Model. This skills-segregation yields a workforce of individuals working in isolation rather than collaborating together, and lacking a shared information flow, purpose and identity. Key strategic flaws include suboptimal responsiveness to population and subpopulation needs, inconsistency and inequity of care, an erosion of professional agency, and lower job satisfaction. It is conjectured that this results from a lack of congruence between values, professional ethos, and organizational structure. ‘Atomism’ culminates in a syndrome of widespread professional-level cognitive dissonance. -/- The paper contrasts this with a new emerging workforce vision, The Collaborative Care Model. This new model defines a systems-first-approach, built on the principle that all jobs must include all four professional ‘pillars’. Vertical skills integration, involving education and task sharing, will support sustainability and succession planning. Horizontal skills integration (across practice, leadership and research) is included to improve responsiveness to population need and individual professional agency. The working conditions, supportive ethos, and career structure needed to make the model work are described. Moral theory and workforce theory are used to justify why the model may be more effective for population health, delivering greater job satisfaction for individuals and ultimately helping systematically realize and honor healthcare values. Finally, the paper sketches the first steps needed to implement the model at the national level, starting with the operationalization of new multi-pillar professional curricula across the career spectrum. Potential pitfalls and challenges are also discussed. -/- Co-Authors: 1. Paul Forsyth (PF) Lead Pharmacist Clinical Cardiology, Pharmacy, NHS Greater Glasgow & Clyde. Contribution: Conceptualization; Model Curation; Model Theory; Model Visualization; Writing - original draft (lead author), Writing - review & editing (lead author) 2. Andrew Radley (AR), Consultant in Public Health Pharmacy, NHS Tayside. Contribution: Conceptualization; Model curation; Model Theory; Writing - review & editing 3. Gordon Rushworth (GR), MPharm MSc FFRPS FRPharmS (Consultant). Programme Director, Highland Pharmacy Education & Research Centre, NHS Highland, Inverness. Contribution: Model curation; Writing - review & editing 4. Fiona Marra (FM) National Lead Clinician Scottish Infection and Immunology Network (SPAIIN) / Advanced Pharmacist HCV / HIV, NHS Greater Glasgow & Clyde. Contribution: Model curation; Writing - review & editing 5. Susan Roberts (SR) Associate Postgraduate Pharmacy Dean, NHS Education for Scotland. Contribution: Model curation; Writing - review & editing 6. Roisin O’Hare (RO) Lead Teacher Practitioner Pharmacist, Northern Ireland University Network, Southern Health and Social Care Trust. Contribution: Model curation; Writing - review & editing 7. Catherine Duggan (CD) Chief Executive Officer, International Pharmaceutical Federation (FIP). Contribution: Model curation; Writing - review & editing 8. Barry Maguire (BM) Senior Lecturer, School of Philosophy, Psychology and Life Sciences, The University of Edinburgh. Contribution: Conceptualization; Model Curation; Model Theory; Model Visualization; Supervision; Writing - original draft (senior academic supervisor), Writing - review & editing (senior academic supervisor) -/- . (shrink)

People seeking asylum are at risk of receiving poorer quality healthcare due, in part, to racist and discriminatory attitudes, behaviours and policies in the health system. Despite fleeing war and conflict; exposure to torture and traumatic events and living with uncertainty; people seeking asylum are at high‐risk of experiencing long‐term poor physical and mental health outcomes in their host country. This article aims to raise awareness and bring attention to some common issues people seeking asylum face when seeking healthcare in (...) high‐income countries where the health system is dominated by a Western biomedical view of health. Clinical case scenarios are used to highlight instances of racist healthcare policies and practices that create and maintain ongoing health disparities; limited access to culturally and linguistically appropriate health services, and lack of trauma‐informed approaches to care. Nurses and midwives can play an important role in countering racism in healthcare settings; by identifying and calling out discriminatory practice and modelling tolerance, respect and empathy in daily practice. We present recommendations for individuals, organisations and governments that can inform changes to policies and practices that will reduce racism and improve health equity for people seeking asylum. (shrink)

Trauma informed care (TIC) “realizes the widespread impact of trauma… recognizes the signs and symptoms of trauma in clients, families and staff; responds by fully integrating knowledge of trauma i...

Layers of complexity arise when a person arrives in an Intensive Care Unit (ICU) due to self-harm intended to end their life and when there is known past personal trauma. We highlight three importa...

Informed consent is a central concept in the literature on the ethics of clinical care and human subjects research. There is a broad consensus that ethical practice in these domains requires the informed consent of patients and subjects. The requirements of informed consent in these domains, however, are matters of considerable controversy. Some argue that the requirements of informed consent have been inflated, others that they have not been taken seriously enough. This essay argues that (...) both sides are partly right. To advance this argument, the essay distinguishes a general doctrine of informed consent from what it characterizes as “models of informed consent.” A general doctrine articulates a set of requirements for informed consent and then adjusts these requirements to fit the context in which they are to be applied. In contrast, different models of informed consent impose different requirements in different contexts. The essay contends that different models of informed consent are needed for clinical care and clinical research. It outlines these two models, articulates the rationale for distinguishing them, and considers and rebuts the objection that clinical care and clinical research are too deeply intertwined in contemporary medicine for the models approach to apply to them. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Microaggressions in Medicine:Narratives, Trauma, and SilenceElizabeth Lanphier (bio)Lauren Freeman and Heather Stewart (2024) have written a richly researched and argued, while also highly engaging and accessible, book with Microaggressions in Medicine. They argue for why microaggressions are best understood on a harm-based account and situate this view within timely examples from a range of healthcare experiences. In their view, focusing on the harms produced by microaggressions shifts the (...) locus of concern from the agent committing a microaggression to the agent receiving it, and it enables an attribution of a microaggression regardless of an agent's intent or even awareness.Freeman and Stewart leave the reader with an expanded understanding of what microaggressions are and how they function. They also offer concrete and actionable suggestions for how healthcare environments and healthcare providers can work to prevent patients from receiving microaggressions in clinical care. Thinking alongside this book, I raise three points intended to further a conversation. The first is about narrative medicine as an additional resource. The second is the possibility for trauma-informed care to address background structural conditions that were beyond the book's scope. The third is to briefly inquire about whether this harm-based account could characterize certain cases of individual and institutional silence as a microaggression.1. Narrative medicineFreeman and Stewart situate their book within the philosophical literature on epistemic injustice, social justice, and feminist theory. So, it is not necessarily surprising that they only mention "narrative medicine," a term coined by Rita Charon (2001) about twenty-five years ago, in passing. They do cite core narrative medicine literature, including Sayantani DasGupta's (2008) account of "narrative humility," Arthur Frank's (1995) book The Wounded Storyteller, and a paper on listening to patient stories (Goldie 2011) in their recommendations and resources for mitigating microaggressions. When they do reference narrative [End Page 163] medicine, it is to suggest that "attending to the identities of patients ought to be more widely recognized as constitutive of good care" (Freeman and Stewart 2024, 182). But beyond illustrating the caring capacities of compassionate and skilled clinicians, narrative medicine offers a potential roadmap for how to get there.What I have elsewhere called a "technical definition of narrative medicine" (Lanphier 2021, 2024) is the narrative medicine methodology of close reading and reflective writing intended to produce three aims: attention (to texts or story), representation (trying to see the perspective of a story), and affiliation (partnering with a story's teller in a solidaristic way). This technical understanding of narrative medicine provides a method for developing skills of "ethical listening" and "medical humility" that Freeman and Stewart recommend. It also affords a structured form of training and practice that institutions can support to better enable healthcare workers to implement individual and environmental correctives to address microaggressions.Although narrative medicine is a resource poised to counter and respond to the very kinds of failures of listening, epistemic injustices, and quick assumptions with which Freeman and Stewart are concerned, narrative practices are not necessarily a fix for epistemic failures or bias. They also run their own risks, including narrative presumptions (Lanphier and Anani 2019), or narrative neglect (Saulnier 2020). Moreover, while the potential exists to scale narrative medicine through structured learning opportunities and broader institutional support, it primarily remains a tool for individual edification and enactment, not systems change.2. Trauma-informed careFreeman and Stewart (2024) describe how "microaggressions occur at the individual level and can be perpetrated by individuals, environments, or institutions" but that "ultimately, they are manifestations or symptoms of structural-level problems. Regardless of the level on which they occur, microaggressions always happen against the backdrop of social and structural oppression" (12). As other commentators point out, the authors recommend correctives primarily at individual and environmental levels (i.e., changing individual behaviors, making small modifications to clinical environments). Freeman and Stewart understand the limits of this scope, saying, "[W]e are well aware that such individual-level fixes can only ever take us so far and that they alone will never dismantle the oppressive structures themselves" (13). It is reasonable to identify achievable individual actions for the "unjust meantime" (Jaggar 2019) concurrent with social and structural... (shrink)

Inequitable access to health care, social inequities, and racist and discriminatory care has resulted in the trend toward poorer health outcomes for Indigenous infants and their families when compared to non‐Indigenous families in Canada. How Indigenous mothers experience care during an admission of their infant to the Neonatal Intensive Care Unit has implications for future health‐seeking behaviors which may influence infant health outcomes. Nurses are well positioned to promote positive health care interactions and improve health (...) outcomes by effectively meeting the needs of Indigenous families. This qualitative study was guided by interpretive description and the Two‐Eyed Seeing framework and aimed to understand how Indigenous mothers experience accessing and using the health care system for their infants. Data were collected by way of interviews and a discussion group with self‐identifying Indigenous mothers of infants less than two years of age living in Hamilton, Ontario, Canada. Data underwent thematic analysis, identifying nursing strategies to support positive health care interactions and promote the health and wellness of Indigenous infants and their families. Building relationships, providing holistic care, and taking a trauma‐informed approach to the involvement of child protection services are three key strategies that nurses can use to positively impact health care experiences for Indigenous families. (shrink)

Searching for information is critical in many situations. In medicine, for instance, careful choice of a diagnostic test can help narrow down the range of plausible diseases that the patient might have. In a probabilistic framework, test selection is often modeled by assuming that people's goal is to reduce uncertainty about possible states of the world. In cognitive science, psychology, and medical decision making, Shannon entropy is the most prominent and most widely used model to formalize probabilistic uncertainty and (...) the reduction thereof. However, a variety of alternative entropy metrics (Hartley, Quadratic, Tsallis, Rényi, and more) are popular in the social and the natural sciences, computer science, and philosophy of science. Particular entropy measures have been predominant in particular research areas, and it is often an open issue whether these divergences emerge from different theoretical and practical goals or are merely due to historical accident. Cutting across disciplinary boundaries, we show that several entropy and entropy reduction measures arise as special cases in a unified formalism, the Sharma–Mittal framework. Using mathematical results, computer simulations, and analyses of published behavioral data, we discuss four key questions: How do various entropy models relate to each other? What insights can be obtained by considering diverse entropy models within a unified framework? What is the psychological plausibility of different entropy models? What new questions and insights for research on human information acquisition follow? Our work provides several new pathways for theoretical and empirical research, reconciling apparently conflicting approaches and empirical findings within a comprehensive and unified information‐theoretic formalism. (shrink)

In Latin America, policies on inclusive education in the university are implemented in an irrelevant way, despite the foundations that seek a university that guarantees in all students the learning, skills and competences they need. To try to provide solutions, the Social Model of Inclusive Education (MSEI) is proposed, which allows identifying management in inclusive education, by calculating the effectiveness index, using the cause-effect structure among three variables: i) policies in inclusive education, ii) conditions presented by students and iii) (...) attitudes towards students. The variables are derived into indicator variables, developing items that allow the collection of information with all the members of a higher education institution; thus formalizing a mathematical model of structural equations. The MSEI was applied as a pilot plan in a higher education institution in Ecuador, showing that the management effectiveness index in inclusive education is 60.3%, related to a work of greater weight in indicator variables such as: support that provides the educational institution to the students, the socio-economic situation of the students and the differentiated assessment of learning. (shrink)

The ideal moral standard for surgical informed‐consent calls upon surgeons to carry out a disclosure dialogue with patients so they have as full as possible an understanding of the procedure before they sign the informed‐consent form. This study is the first to empirically explore patient preferences regarding disclosure dialogue. Twelve Israelis who underwent life‐saving surgeries participated in a narrative study. Three themes emerged from the analysis: objectification of patients, anxiety provoking processes and information, and lack of information that (...) was essential for patients. Findings contribute to existing debates among surgeons regarding the scope and importance of some disclosure components. Analysis led to our formulation of an augmented subjective model of information disclosure that participants prefer, which extends beyond the immediate present of the surgery to the period after discharge, and until return to routine. Surgeons should be aware of patient preferences in disclosure, and gaps between perceptions of surgeons, and preferences and needs of patients. (shrink)

Many authors have described the ethical issues associated with international adoption for all members of the adoption triad, including adoptive parents, birth parents and the adopted child, and for both sending and receiving countries. This paper explores how political variants of care ethics, combined with a narrative approach to practice, can be used as a conceptual framework for ethically informed practice with families formed via international adoption. Political variants of care ethics foreground the particularized needs of the (...) individual, but also take into account the broader social, political, economic and cultural dynamics in which the experience of individuals occurs. This framework is particularly applicable to collaborative work with individuals or groups, such as families formed via international adoption, whose experience is both highly individualized and shaped by broader contexts and issues of social justice. This paper describes how changes in the social construction of international adoption have meaning for applied ethics and practice. Political variants of care ethics are then explored as a framework for ethical decision making. Finally, the relevance of a narrative, approach to practice is considered. This approach focuses on understanding the needs and experiences of families from their own points of view and within the social, economic, cultural and political contexts in which they have lived; linking a relationship-based, narrative approach to practice to important assumptions in many models of care ethics. (shrink)

This essay argues that our national efforts at health reform ought to be informed by eleven key lessons from Oregon. Specifically, we must learn that the need for health care rationing is inescapable, that any rationing process must be public and visible, and that fair rationing protocols must be self-imposed through a process of rational democratic deliberation. Part I of this essay notes that rationing is a ubiquitous feature of our health care system at present, but it (...) is mostly hidden rationing, which is presumptively unjust. Part II argues that the need for health care rationing is inescapable. Although Oregon is flawed as a model of health rationing, it gives us worthy moral lessons for health reform at the national level, which I analyze and defend in Part III. The most significant of these lessons is the importance of rational democratic deliberation in articulating fair rationing protocols for a community. In Part IV I sketch the philosophic justification for this approach and respond to some important criticisms from Daniels. Keywords: cost containment, democratic deliberation, fairness, justice, rationing CiteULike Connotea Del.icio.us What's this? (shrink)

Background Caring behaviour is critical for nursing quality, and the clinical internship environment is a crucial setting for preparing nursing students for caring behaviours. Evidence about how to develop nursing students’ caring behaviour in the clinical environment is still emerging. However, the mechanism between the clinical internship environment and caring behaviour remains unclear, especially the mediating role of moral sensitivity and the moderating effect of self-efficacy. Research objective This study aimed to examine the mediating effect of moral sensitivity and the (...) moderating function of self-efficacy on the association between the clinical internship environment and caring behaviours. Research design A cross-sectional design used acceptable validity scales. The hypothesised moderated mediation model was tested in the SPSS PROCESS macro. Participants and research context This survey collected data from 504 nursing students in an internship at a teaching hospital in Changsha, China. Ethical considerations This study was pre-approved by the ethics committee of the medical school (No. E2022210). Informed consent was obtained from all students. Results The clinical internship environment ( B = 0.450, 95% CI = [0.371, 0.530]) and moral sensitivity ( B = 1.352, 95% CI = [1.090, 1.615]) had positive direct effects on nursing students' caring behaviours. Clinical internship environment also indirectly influenced students’ caring behaviours via moral sensitivity ( B = 0.161, 95% CI = [0.115, 0.206]). In addition, self-efficacy played a moderating role between the clinical internship environment and caring behaviours ( B = 0.019, 95% CI = [0.007, 0.031]), as well as the relationship between the clinical internship environment and moral sensitivity ( B = 0.006, 95% CI = [0.003, 0.010]). Conclusion Moral sensitivity mediates the effect of the clinical internship environment on caring behaviour, and self-efficacy strengthens both direct and indirect effects. This study emphasises the importance of self-efficacy in developing moral sensitivity and caring behaviours in nursing students. (shrink)

DUREY A, WYNADEN D, THOMPSON SC, DAVIDSON PM, BESSARAB D and KATZENELLENBOGEN JM. Nursing Inquiry 2012; 19: 144–152 [Epub ahead of print]Owning solutions: a collaborative model to improve quality in hospital care for Aboriginal AustraliansWell‐documented health disparities between Aboriginal and Torres Strait Islander (hereafter referred to as Aboriginal) and non‐Aboriginal Australians are underpinned by complex historical and social factors. The effects of colonisation including racism continue to impact negatively on Aboriginal health outcomes, despite being under‐recognised and under‐reported. Many (...) Aboriginal people find hospitals unwelcoming and are reluctant to attend for diagnosis and treatment, particularly with few Aboriginal health professionals employed on these facilities. In this paper, scientific literature and reports on Aboriginal health‐care, methodology and cross‐cultural education are reviewed to inform a collaborative model of hospital‐based organisational change. The paper proposes a collaborative model of care to improve health service delivery by building capacity in Aboriginal and non‐Aboriginal personnel by recruiting more Aboriginal health professionals, increasing knowledge and skills to establish good relationships between non‐Aboriginal care providers and Aboriginal patients and their families, delivering quality care that is respectful of culture and improving Aboriginal health outcomes. A key element of model design, implementation and evaluation is critical reflection on barriers and facilitators to providing respectful and culturally safe quality care at systemic, interpersonal and patient/family‐centred levels. Nurses are central to addressing the current state of inequity and are pivotal change agents within the proposed model. (shrink)

In 2016, the Atlanta Community Food Bank launched the Stabilizing Lives project to develop programs and policies that could better address clients’ needs as well as including clientele as part of the planning process. The ACFB partnered with a research team at the University of Georgia to conduct a participatory research project aimed at developing deeper insights into the factors contributing to both instability and stability in the lives of pantry clientele. This article describes the outcomes this research, offering both (...) a substantive contribution to scholarship on food insecurity and emergency food systems and a methodological innovation through a staged mixed-method participatory research project. Through use of a culture-centered approach, this project created discursive spaces within which to outline emergency food models that support informal networks of care. We used a range of methods, including photo elicitation, concept mapping, individual interviews, and focus groups, to facilitate conversation among agency staff, volunteers, and clientele about the effectiveness of current program models and potential new ideas. Specifically, we suggest that through such practices, food pantries and local agencies may help inform new program models that contribute to household stability, and push back against the sometimes alienating and atomizing paradigm found in current emergency food programs. (shrink)

The unexpected death of a child is one of the most challenging losses as it fractures survivors’ sense of parenthood and other layers of identity. Given that not all the bereaved parents who have need for support respond well to available treatments and that many have little access to further intervention or follow-up over time, online interventions featuring therapeutic writing and peer support have strong potential. In this article we explore how a group of bereaved mothers experienced the process of (...) participating in an online course in therapeutic writing for the integration of grief. Our research questions were: How do parents who have lost a child experience being part of an online course in therapeutic writing? What are the perceived benefits and challenges of writing in processing their grief? We followed an existential phenomenological approach and analyzed fieldwork notes (n= 13), qualitative data from the application and assessment surveys (n= 35;n= 21), excerpts from the journals of some participants (n= 3), and email correspondence with some participants (n= 5). We categorized the results in three meaning units: (1) where does my story begin? The “both and” of their silent chaos; (2) standing on the middle line: a pregnancy that does not end; (3) closures and openings: “careful optimism” and the need for community support. Participants experienced writing as an opportunity for self-exploration regarding their identities and their emotional world, as well as a means to develop and strengthen a bond with their children. They also experienced a sense of belonging, validation, and acceptance in the online group in a way that helped them make sense of their suffering. Online writing courses could be of benefit for bereaved parents who are grieving the unexpected death of a child, but do not replace other interventions such as psychotherapy. In addition to trauma and attachment informed models of grief, identity informed models with a developmental focus might enhance the impact of both low-threshold community interventions and more intensive clinical ones. Further studies and theoretical development in the area are needed, addressing dialogical notions such as the multivoicedness of the self. (shrink)

Current legal standards of informed consent send the wrong message to physicians about their moral and legal expectations. A “transparency” model that sees consent as a conversation process can enhance good medical practice and patient autonomy without foreclosing appropriate judicial review.

Obtaining adequate informed consent from trauma patients is challenging and time-consuming. Healthcare providers must communicate complicated medical information to enable patients to make informed decisions. This study aimed to explore the challenges of obtaining valid consent and methods of improving the quality of the informed consent process for surgical procedures in trauma patients. We conducted a systematic review of relevant English-language full-text original articles retrieved from PubMed that had experimental or observational study design and involved (...) adult trauma patients. Studies involving informed consent in clinical or research trials were excluded. Titles and abstracts of searched articles were reviewed and relevant data were extracted with a structured form. Results were synthesized with a narrative approach. A total of 2044 articles were identified in the initial search. Only eight studies were included in the review for narrative synthesis. Six studies involved orthopedic surgeries, one involved nasal bone surgeries, and one involved trauma-related limb debridement. Only one study was conducted in an emergency department. Information recall was poor for trauma patients. Risk recall and comprehension were greater when written or video information was provided than when information was provided only verbally. Patient satisfaction was also greater when both written and verbal information were provided than when verbal information alone was provided; patients who received video information were more satisfied than patients who received written or verbal information. Many articles have been published on the subject of informed consent, but very few of these have focused on trauma patients. More empirical evidence is needed to support the success of informed consent for trauma patients in the emergency department, especially within the necessarily very limited time frame. To improve the informed consent process for trauma patients, developing a structured and standardized informed consent process may be necessary and achievable; its effectiveness would require evaluation. Adequately educating and training healthcare providers to deliver structured, comprehensive information to trauma patients is crucial. Institutions should give top priority to ensuring patient-centered health care and improved quality of care for trauma patients. (shrink)

Psychological trauma is ubiquitous, an often hidden yet influential factor in care across clinical specialties. Interdisciplinary health professions education is mobilizing to address the importance of trauma-sensitive care. Given their attention to complex human realities, the health humanities are well-poised to shape healthcare learners’ responses to trauma. Indeed, many such arts and humanities curricula propose narrative exercises to strengthen empathy, self-reflection, and sensitive communication. Trauma, however, is often unwordable, fragmentary, and physically encoded, incompatible with (...) storying methods. This article presents a recent innovation, the Art is Patient seminar series, which focuses on aesthetic exercises to help learners access and share non-verbal, embodied, and relational responses to art. Based in an art museum context, it provides successive experiences of approaching, witnessing, and engaging with visual art as an analogue to developing trauma-sensitive relationships. Reflections on the process locate the seminar vis-à-vis health humanities practices, aesthetics, and trauma-informed approaches. (shrink)

The aim of this study is to determine what kind of religious coping activities the refugee students forced to emigrate to Turkey due to the devastating reasons such as war and violation of rights apply in order to overcome their traumatic lives and the relationship between the use of these religious coping activities and their adaptation to the culture they live in. The fact that religion has important functions in dealing with all difficulties, especially forced migration, makes it a matter (...) of interest about what kind of religious coping process refugees have experienced for making their lives bearable. Therefore, this research is based on the assumption that the refugees mostly struggle with difficulties by using positive religious coping methods and try to achieve cultural adaptation through this struggle. The sample was selected from the refugee students from Syria, Iraq and Afghanistan continuing their education in different departments of Karabük University and in different high schools of Karabük National Education Directorate in 2017-2018 academic year. “Cultural Adaptation” and “Religious Coping Styles” scales were applied to the sample with an average age of 18. According to the research findings, cultural adaptation and positive religious coping levels of the sample group are above the average, and negative religious coping levels are below the average. There was found a positive meaningful correlation between cultural adaptation and positive religious coping of which relation was determined through some independent and demographic variables (r =.269). Therefore, it is thought that providing spiritual care for refugee students might increase the level of cultural adaptation.Summary: The aim of this study is to determine what kind of religious coping activities the refugee students forced to emigrate to Turkey due to the devastating reasons such as war and violation of rights apply in order to overcome their traumatic lives and the relationship between the use of these religious coping activities and their adaptation to the culture they live in. The fact that religion has important functions in dealing with all difficulties, especially forced migration, makes it a matter of interest about what kind of religious coping process refugees have experienced for making their lives bearable. Therefore, this research is based on the assumption that the refugees mostly struggle with difficulties by using positive religious coping methods and try to achieve cultural adaptation through this struggle. The study that was conducted according to correlational survey model, used the questionnaire technique by implementing the “Cultural Adaptation” and “Religious Coping Styles” scales together with a personal information form. The sample of the study was chosen by random sampling, and consisted of 112 volunteer refugee students from Syria, Iraq and Afghanistan, studying at different departments of Karabük University and different public high schools in Karabük. While analyzing the data, firstly, averages were calculated by obtaining total scores of the scales. In order to reveal whether students’ cultural adaptation levels differ by various variables or not, t-test (Independent Samples t-test), one-way analysis of variance (Oneway ANOVA) and Scheffe Test were applied. While analyzing relations related to religious coping, non-parametric ‘Man Whitney U’ and ‘Kruskall Wallis H’ tests were applied in accordance with the result of the normality test. In the study in which correlation test was applied to determine the relationship between cultural adaptation and religious coping, the lowest p-value was predicated as.05 to determine the level of statistical significance. According to the findings, sample group’s levels of cultural adaptation (=3,27) and positive religious coping (=3,42) were above the average, and the level of negative religious coping (=1,77) was below the average. Cultural adaptation levels of the sample group has shown significant statistical differences in terms of the nationality variable. Accordingly, Syrian students had higher cultural adaptation scores (=3,48) than Iraqi (=3,19) and Afghani students (=3,06), and the difference among them was statistically meaningful (p<.01). There wasn’t detected any significant relationship between ‘negative religious coping’ levels of the sample and demographic and other independent variables; however, there were seen statistically significant differences just in terms of nationality, gender and age range among other demographic variables. Accordingly, female students scored higher (= 64,46) in positive coping than male students (= 47,32). The difference between them is statistically meaningful (p<.01). Students at the ages of 21-24 scored higher in positive religious coping (= 70,54) and the difference between them and the students at the ages of 14-16 (= 47,47) reached meaningful level, next to this Syrian students had higher levels of positive religious coping (= 62,91) and this reached a meaningful difference (p<.01) when compared with the averages of Afghani students (= 42,63). Moreover, there was a positive significant relationship between cultural adaptation and positive religious coping (r=.269, n=112, p=.004).Forced migration caused by wars is a traumatic experience including material and moral loss. The greatest contribution of spirituality in this kind of negative experiences causing severe stress is through positive religious coping. Hence, religious and spiritual beliefs not only enable cognitive satisfaction by offering the most satisfying answers to traumatic victims’ search for meaning, yet also help them to accept the situation. This is caused due to a sense of devotion, and contribute to both their struggle with the trauma and their post-traumatic development. According to the research findings, there is a significant relationship between students’ cultural adaptation and ‘positive religious coping’ tendency. Therefore, providing these students with spiritual care and counseling might contribute to their integration process. Moreover, it has been seen that it is important to conduct value-centered projects and activities which would prevent both refugee students and locals to marginalize each other, and would improve the culture of living-together. It is also important to provide governmental and non-governmental support for these projects and activities. On the other hand, launching free language courses to resolve communication problems, which are obstacles for integration, and establishing socio-cultural networks in and around the campus for constituting more compatible relationships among the students would improve the students’ integration capability. (shrink)

This paper discusses how to apply a collective decision model of the principle of voluntary informed consent in African communitarian culture, in a culturally sensitive way, in order to protect research candidates from potential exploitations and abuses. Dismissing cultural and ethical skepticism surrounding the global application of the principle of voluntary informed consent, the paper ultimately concludes that international collaboration on diagnostic and therapeutic medical research in Africa, especially HIV vaccine trials, is a moral imperative.

Insight into animal biology and development provided by classical genetic analysis of the model organism Drosophila melanogaster was an incentive to develop advanced genetic tools for this insect. But genetic systems for the over one million other known insect species are largely undeveloped. With increasing information about insect genomes resulting from next generation sequencing, RNA interference is now the method of choice for reverse genetics, although it is constrained by the means of delivery of interfering RNA. A recent advance (...) to ensure sustained delivery with minimal experimental intervention or trauma to the insect is to exploit commensal bacteria for symbiont‐mediated RNA interference. This technology not only offers an efficient means for RNA interference in insects in laboratory conditions, but also has potential for use in the control of human disease vectors, agricultural pests and pathogens of beneficial insects. (shrink)