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This article introduces a Social Work Model of Historical Trauma. The model draws from social work perspectives (ecosystems theory and the life model, human rights philosophy, race-based traumatic stress injury theory and attachment theory), disparities research, social work issues and policy statements, social work ethics and epigenetics. Assessment and intervention in micro, mezzo and macro domains are discussed. The article concludes with a case vignette and model application.

Many clinicians have limited knowledge about the challenges of living in poverty, leading to stigma and differential treatment in healthcare settings. A poverty simulation event may help clinicians gain empathy and knowledge about the ways that poverty impacts health and well-being.This study evaluated the impact of a poverty simulation and the effect of personal characteristics on clinicians' attitudes towards poverty.Using a prospective longitudinal mixed-methods study design, a convenience sampling of clinicians from a freestanding children's hospital was recruited to participate in a poverty simulation event. The 21-item Attitudes Towards Poverty (ATP) tool was administered pre- and post-simulation and at 3 follow-up time points. Multiple linear regression analysis and linear mixed effects models were used to analyze ATP data. Qualitative data were analyzed to identify broad themes.Mean scores in the ATP domains of stigma and structural perspective increased post-simulation, but only stigma scores demonstrated sustained improvement. Scores in the personal deficiency domain remained unchanged. Being male, White, and having Liberal political views were associated with lower ATP scores in our data. Qualitative data show participants felt the simulation generated feelings of compassion and empathy.Simulation participation improved ATP scores in two domains immediately post-event, suggesting the simulation positively impacted clinicians' attitudes towards poverty. Follow-up data suggest the impact of the simulation may be temporary.Experiential learning activities, like poverty simulations, help foster awareness and empathy among clinicians but may not have long-term impact. Ongoing education is needed to create a workforce sensitized and equipped to care for families from all backgrounds.

BACKGROUND AND OBJECTIVES Hospitalized children with medical complexity (CMC) are at high risk of medical errors. Their families are an underutilized source of hospital safety data. We evaluated safety concerns from families of hospitalized CMC and patient/parent characteristics associated with family safety concerns. METHODS We conducted a 12-month prospective cohort study of English- and Spanish-speaking parents/staff of hospitalized CMC on 5 units caring for complex care patients at a tertiary care children’s hospital. Parents completed safety and experience surveys predischarge. Staff completed surveys during meetings and shifts. Mixed-effects logistic regression with random intercepts controlling for clustering and other patient/parent factors evaluated associations between family safety concerns and patient/parent characteristics. RESULTS A total of 155 parents and 214 staff completed surveys (>89% response rates). 43% (n = 66) had ≥1 hospital safety concerns, totaling 115 concerns (1–6 concerns each). On physician review, 69% of concerns were medical errors and 22% nonsafety-related quality issues. Most parents (68%) reported concerns to staff, particularly bedside nurses. Only 32% of parents recalled being told how to report safety concerns. Higher education (adjusted odds ratio 2.94, 95% confidence interval [1.21–7.14], P = .02) and longer length of stay (3.08 [1.29–7.38], P = .01) were associated with family safety concerns. CONCLUSIONS Although parents of CMC were infrequently advised about how to report safety concerns, they frequently identified medical errors during hospitalization. Hospitals should provide clear mechanisms for families, particularly of CMC and those from disadvantaged backgrounds, to share safety concerns. Actively engaging patients/families in reporting will allow hospitals to develop a more comprehensive, patient-centered view of safety.

BACKGROUND AND OBJECTIVES Despite compelling evidence that patients and families report valid and unique safety information, particularly for children with medical complexity (CMC), hospitals typically do not proactively solicit patient or family concerns about patient safety. We sought to understand parent, staff, and hospital leader perspectives about family safety reporting in CMC to inform future interventions. METHODS This qualitative study was conducted at 2 tertiary care children’s hospitals with dedicated inpatient complex care services. A research team conducted approximately 60-minute semistructured, individual interviews with English and Spanish-speaking parents of CMC, physicians, nurses, and hospital leaders. Audio-recorded interviews were translated, transcribed, and verified. Two researchers coded data inductively and deductively developed and iteratively refined the codebook with validation by a third researcher. Thematic analysis allowed for identification of emerging themes. RESULTS We interviewed 80 participants (34 parents, 19 nurses and allied health professionals, 11 physicians, and 16 hospital leaders). Four themes related to family safety reporting were identified: (1) unclear, nontransparent, and variable existing processes, (2) a continuum of staff and leadership buy-in, (3) a family decision-making calculus about whether to report, and (4) misaligned staff and parent priorities and expectations. We also identified potential strategies for engaging families and staff in family reporting. CONCLUSIONS Although parents were deemed experts about their children, buy-in about the value of family safety reporting among staff and leaders varied, staff and parent priorities and expectations were misaligned, and family decision-making around reporting was complex. Strategies to address these areas can inform design of family safety reporting interventions attuned to all stakeholder groups.

As patients, family members, and health care providers serving on the Family Advisory Council (FAC) of the Patient and Family-Centered I-PASS Safer Communication On Round Every Time study,1,2 we read, with interest, the scoping review by Knighton and Bass3 on the implementation of family-centered rounds (FCRs). In their review, the authors highlighted several challenges in implementing and evaluating FCRs. They note that limited high-quality research exists to reveal what constitutes a successful FCR rounding encounter. They, additionally, describe the gaps regarding the clinical effectiveness of various interventions to improve FCRs as well as if and how FCRs lead to improvements patient safety and outcomes or changes in clinical decision-making. Although we look forward to further research to better target these gaps, we wish to first share our reflections on the current evidence and make suggestions for the future of patient- and family-centered rounds (PFCRs) from the patient and family viewpoint. As family members, the majority of us did not know what rounds were before we experienced them during an admission. The learning curve is steep, pressure is immense, and fears of somehow failing our children, appearing dumb, or seeming like an incompetent parent can almost paralyze you. As a result, it may appear that we are disengaged or do not value PFCR. It would help us prepare for PFCRs if were to learn what it constitutes at the time of admission, instead of as the team is walking through the door. A brief orientation to PFCRs by the admitting team is highly valued, and, just like your trainees, it may take us several iterations of PFCR to learn how to best participate. But we quickly see that PFCRs are an essential point of communication to engage with providers, share our expertise, and understand the medical plan …

Background Burnout is a substantial phenomenon across healthcare settings, affecting more than half of healthcare professionals and leading to negative patient and health system outcomes. Infusion center professionals (ICPs) are at increased risk of burnout attributed to high patient volume and acuity levels. Strategies to address burnout have been developed and prioritized by the American Medical Association (AMA), the World Health Organization, and other organizations. Aims This quality improvement project aimed to address perceived burnout, job-related stress, and job satisfaction among nurses, physician assistants, and medical assistants at a large pediatric hospital through integration of two infusion center (IC)-based staff engagement interventions. Methods A pre- and post-test study design was used. Existing team huddles in the IC were modified based on the AMA STEPS Forward program recommendations to incorporate appreciative inquiry and recognition into team and department events. Peer recognition was tailored toward institutional core values. The Mini-Z Burnout survey was administered before and 3 months after implementation of both interventions. Findings Pre- to post-intervention responses revealed a higher percentage of staff reporting no burnout (57.7% vs. 75%), low levels of job-related stress (58.8% vs. 65.5%), and satisfaction with current job (70.6% vs. 82.8%). Most participants agreed or strongly agreed that structured huddles (69%) and recognition events (82.8%) were beneficial and recommended continuation (65.5% and 82.8%, respectively). Open-ended responses regarding workplace stressors focused heavily on staffing and patient acuity. Linking evidence to action Project outcomes support the integration of tailored interventions to reduce burnout among pediatric ICPs. Organizational commitment to addressing burnout can provide incentive to scale up institution-wide staff engagement interventions. Further study is needed to assess the efficiency and effectiveness of such tailored interventions across diverse settings.

Patient and family-centered rounds (PFCRs) are an important element of family-centered care often used in the inpatient pediatric setting. However, techniques and best practices vary, and faculty, trainees, nurses, and advanced care providers may not receive formal education in strategies that specifically enhance communication on PFCRs.Harnessing the use of structured communication, we developed the Patient and Family-Centered I-PASS Safer Communication on Rounds Every Time (SCORE) Program. The program uses a standardized framework for rounds communication via the I-PASS mnemonic, principles of health literacy, and techniques for patient/family engagement and bidirectional communication. The resident and advanced care provider training materials, a component of the larger SCORE Program, incorporate a flipped classroom approach as well as interactive exercises, simulations, and virtual learning options to optimize learning and retention via a 90-minute workshop.Two hundred forty-six residents completed the training and were evaluated on their knowledge and confidence regarding key elements of the curriculum. Eighty-eight percent of residents agreed/strongly agreed that after training they could activate and engage families and all members of the interprofessional team to create a shared mental model; 90% agreed/strongly agreed that they could discuss the roles/responsibilities of various team members during PFCRs.The Patient and Family-Centered I-PASS SCORE Program provides a structured framework for teaching advanced communication techniques that can improve provider knowledge of and confidence with engaging and communicating with patients/families and other members of the interprofessional team during PFCRs.

Many things that we now call ‘archaeological archives’ are actually personal collections of documentation made and amassed by archaeologists, some of which have found their way into institutions. This is indeed the case for the collections of Harald Ingholt (1896–1985), a Danish archaeologist and philologist who worked at Palmyra in the 1920s and 1930s and had a long career that was spent mostly in the USA at Yale University, studying Syrian and Gandharan sites. Ingholt's field diaries, published in the volumes under review, make up part of a collection which he donated, following his retirement, to the Ny Carlsberg Glyptotek in Copenhagen in the early 1980s; that collection also includes his personal reference material, known as ‘The Ingholt Archive’. Comprising sheets with Palmyrene images glued to them, the Archive is planned for separate publication by Brepols in the near future.

This article presents an integrated trauma-informed, mutual aid model of group work. It applies the concepts and evidence of the trauma-informed care movement in mental health to the group work mod...

This article addresses the current and desired future state of interprofessional practice in pediatric hospital medicine. It focuses on identifying optimal team composition and work patterns, describing the value of parent involvement on both the patient's care team and on operational teams, describing the need for interprofessional education, and identifying outcomes associated with interprofessional teamwork. The article also identifies challenges and opportunities for growth as interprofessional teamwork increasingly becomes a standard practice within healthcare settings.

OBJECTIVES Partnership with parents is a tenet of pediatric medicine; however, initiatives to include parents in education and research have been limited. Through focus groups, we included parents at the beginning of curriculum development by asking them to identify the priorities, existing supports, and opportunities for improvement in their child’s end-of-life (EOL) care. METHODS English and Spanish-speaking bereaved parents whose child had been cared for by the palliative care team and had died >18 months before the study initiation were invited to participate. In-person focus groups and a follow-up phone call were used to elicit opinions and capture a diversity of viewpoints. Themes were identified and clustered through an iterative analytic process. RESULTS Twenty-seven parents of 17 children participated, with the total sample size determined by thematic saturation. Four themes were identified as important to parents in their child’s EOL care: (1) honoring the role of the parent, (2) having confidence in the care team, (3) receiving gestures of love and caring, and (4) navigating logistic challenges. CONCLUSIONS We asked parents to be partners in guiding priorities for health care education and professional development to improve pediatric EOL care. In addition to strengthening skills in communication, confidence in the team, and compassion, parents in this study identified a need for hospital staff to anticipate financial and social stressors and provide supportive resources more readily. Additionally, parents described clinical and nonclinical staff as providing support, suggesting that a multidisciplinary and interdisciplinary curriculum be developed to improve pediatric EOL care.

Background Free Open-Access Medical education (FOAM) use among residents continues to rise. However, it often lacks quality assurance processes and residents receive little guidance on quality assessment. The Academic Life in Emergency Medicine Approved Instructional Resources tool (AAT) was created for FOAM appraisal by and for expert educators and has demonstrated validity in this context. It has yet to be evaluated in other populations. Objectives We assessed the AAT's usability in a diverse population of practicing emergency medicine (EM) physicians, residents, and medical students; solicited feedback; and developed a revised tool. Methods As part of the Medical Education Translational Resources: Impact and Quality (METRIQ) study, we recruited medical students, EM residents, and EM attendings to evaluate five FOAM posts with the AAT and provide quantitative and qualitative feedback via an online survey. Two independent analysts performed a qualitative thematic analysis with discrepancies resolved through discussion and negotiated consensus. This analysis informed development of an initial revised AAT, which was then further refined after pilot testing among the author group. The final tool was reassessed for reliability. Results Of 330 recruited international participants, 309 completed all ratings. The Best Evidence in Emergency Medicine (BEEM) score was the component most frequently reported as difficult to use. Several themes emerged from the qualitative analysis: for ease of use-understandable, logically structured, concise, and aligned with educational value. Limitations include deviation from questionnaire best practices, validity concerns, and challenges assessing evidence-based medicine. Themes supporting its use include evaluative utility and usability. The author group pilot tested the initial revised AAT, revealing a total score average measure intraclass correlation coefficient (ICC) of moderate reliability (ICC = 0.68, 95% confidence interval [CI] = 0 to 0.962). The final AAT's average measure ICC was 0.88 (95% CI = 0.77 to 0.95). Conclusions We developed the final revised AAT from usability feedback. The new score has significantly increased usability, but will need to be reassessed for reliability in a broad population.

BackgroundAssociations between the quality of nursing care and patient outcomes have been demonstrated globally. However, translation and application of this evidence to robust measurement in pediatric specialty nursing care has been limited.ObjectivesTo test the feasibility and performance of nurse-sensitive measures in pediatric cardiovascular programs.MethodsTen nurse-sensitive measures targeting nursing workforce, care process, and patient outcomes were implemented, and measurement data were collected for 6 months across 9 children’s hospitals in the Consortium of Congenital Cardiac Care–Measurement of Nursing Practice (C4-MNP). Participating sites evaluated the feasibility of collecting data and the usability of the data.ResultsVariations in nursing workforce characteristics were reported across sites, including proportion of registered nurses with 0 to 2 years of experience, nursing education, and nursing certification. Clinical measurement data on weight gain in infants who have undergone cardiac surgery, unplanned transfer to the cardiac intensive care unit, and pain management highlighted opportunities for improvement in care processes. Overall, each measure received a score of 75% or greater in feasibility and usability.ConclusionsCollaborative evaluation of measurement performance, feasibility, and usability provided important information for continued refinement of the measures, development of systems to support data collection, and selection of benchmarks across C4-MNP. Results supported the development of target benchmarks for C4-MNP sites to compare performance, share best practices for improving the quality of pediatric cardiovascular nursing care, and inform nurse staffing models.

Context There is potential value to home-based palliative care for children with serious illness delivered via telemedicine (TM HBPC). Evidence to guide optimal design and delivery of TM HBPC is urgently needed. Objectives To explore the existing literature to identify research on pediatric TM HBPC. Methods Systematic scoping review conducted following preferred reporting items for systematic reviews and meta-analysis for scoping reviews guidelines. PubMed, Embase, Cochrane CENTRAL, CINAHL, Web of Science, PsycINFO, and ERIC were searched (January-April 2020) using keywords and controlled vocabulary. The Reach, Effectiveness, Adoption, Implementation, Maintenance framework was used to identify components in the literature that facilitate or limit dissemination of TM HBPC interventions. Results Seventeen articles were included. Most of the literature comprised small descriptive studies, such as case reports, and feasibility trials. Many studies focused on acceptability, and the TM HBPC model was generally acceptable to both clinicians and families. Few studies measured patient access to care, patient, and family centered health or quality of life outcomes. While included studies addressed multiple criteria for each of the Reach, Effectiveness, Adoption, Implementation, Maintenance dimensions, much of the information was qualitative and subjective. Conclusion TM HBPC is a promising strategy to increase access to palliative care for children with serious illness. However, the current review found a need for more robust information describing implementation and effectiveness of TM HBPC models, adaptation across care settings, and maintenance over time to guide and facilitate broader dissemination.

Purpose To examine whether primary attendings and/or nurses impact pediatric intensive care unit (PICU) length of stay (LOS) in long-stay patients (LSP). Materials and methods Retrospective observational cross-sectional study from 2012 to 2016 of 29,170 LSP (LOS ≥ 10 days) admitted to 64 PICUs that participated in the Virtual Pediatric Systems, LLC. Generalized linear mixed models were used to examine the association between being eligible for primary practices and LOS. Secondary outcomes of proportions of limitations and withdrawal of aggressive, life-sustaining interventions were also explored. Results After controlling for several factors, being eligible for primary nurses and for primary attendings and nurses were associated with significantly lower mean LOS (8.9% and 9.7% lower, respectively), compared to not being eligible for any primary practice. Being eligible for primary attendings was associated with significantly higher mean LOS (9.6% higher). When the primary attendings were used for larger proportions of LSP, the practice was associated with significantly lower mean LOS. Limitations and withdrawal of aggressive interventions were more common in LSPs cared for in PICUs that utilized primary attendings. Conclusions The findings of lower LOS in LSP who were eligible for primary practices should induce more rigorous research on the impact of these primary practices.

Purpose: Chemotherapy-induced nausea and vomiting (CINV) is a distressing, underrecognized effect of treatment that can occur in up to 80% of patients. The purpose of this quality improvement project was to evaluate the impact of implementation of a standardized nausea assessment tool, the Baxter Animated Retching Faces (BARF) scale, on nursing compliance with nausea assessment and the frequency and severity of patient-reported CINV for children with cancer. Method: The Plan-Do-Study-Act cycle was used to implement this practice change. With stakeholder support and hospital governance council approval, the BARF scale was introduced into the electronic medical record. Nurses were provided education about the assessment tool and were given badge buddy cards to prompt use of the tool, and workstation reminders were created. A root cause analysis was conducted to provide feedback for continuous quality improvement. Results: Retrospective, aggregate electronic medical record data from May 2018 to April 2019 were analyzed for assessment compliance, total number of admissions with vomiting episodes, and average BARF score. Over the 12-month implementation period, run charts demonstrated a shift in nursing practice with increased compliance in documented nausea assessments during the second 6-month period. There was not a significant decrease in patient-reported CINV. Conclusion: The use of standardized nausea assessments based on patient self-reporting can provide useful and consistent feedback for nurses and health care providers. This quality improvement project demonstrated increased compliance with nausea assessment documentation. Further studies are needed to demonstrate that improvements in nausea assessment may reduce the frequency and severity of CINV.

Ann Laura Stoler has asked what happens when we shift our scrutiny from the picturesque ruins of empire to the ongoing process of ruination. Examining some of the many and continuing ruinations of the site Dura-Europos on the Syrian Euphrates, this paper compares ancient and modern destructions by the Roman army, Sasanian forces, Yale archaeologists and ‘Islamic State’, and questions the different way these are understood. Through these stories of ruination I interrogate the relationship between archaeologists and processes of site destruction, examining archaeologists not only as those who evaluate loss but as agents of destruction themselves.

This article addresses the current and desired future state of interprofessional practice in pediatric hospital medicine. It focuses on identifying optimal team composition and work patterns, describing the value of parent involvement on both the patient's care team and on operational teams, describing the need for interprofessional education, and identifying outcomes associated with interprofessional teamwork. The article also identifies challenges and opportunities for growth as interprofessional teamwork increasingly becomes a standard practice within healthcare settings.