ORIGINAL ARTICLE
A survey of resident attitudes and behaviors regarding youth violence prevention in the acute care setting Alison Riese, MD, MPH, Frances Turcotte Benedict, MD, MPH, and Melissa A. Clark, PhD, MS, Providence, Rhode Island Surgery, emergency medicine (EM), and pediatric resident physicians play an integral role in treating youth violence patients. We assessed these residents’ behaviors, attitudes, and perceived barriers to youth violence prevention (YVP) in the acute care setting. METHODS: A cross-sectional survey of EM, surgery, and pediatric residents at one large medical institution was conducted using a theorybased self-administered paper questionnaire. Data were analyzed using descriptive statistics and Fisher’s exact tests to examine differences between resident specialties. RESULTS: Of 73 residents, 55 completed the questionnaire, composed of 23 EM (42%), 18 pediatrics (33%), and 14 surgery (25%) residents, with a response rate of 75%. Fifteen percent (n = 8) of the respondents received YVP training during residency. The majority (n = 49, 91%.) of the respondents reported consistently collecting a history of events leading to violent injury. A smaller percentage of residents reported consistent assessment of retaliation risk (n = 11, 20%), referral to social work (n = 37, 69%), and screening for substance abuse (n = 37, 69%) and mental health (n = 35, 65%). Surgery residents were more likely than pediatric and EM residents to refer to social work (100% vs. 72% and 45%, p G 0.01) and screen for substance abuse (93% vs. 78% and 45%, p = 0.01). While the majority of residents agreed that youth violence is preventable (n = 50, 91%) and physicians should play a role in prevention (n = 47, 85%), there was less agreement that YVP should be a resident task (n = 38, 69%). Less than half of residents (n = 26, 47%) felt competent discussing safety risks and plans. Residents cited lack of time and training as the top two barriers for conducting risk assessments and referring to support services. CONCLUSION: While EM, surgery, and pediatric residents agree that YVP is essential and should involve physicians, many do not perceive this as part of their responsibilities, and they do not feel competent in this role. (J Trauma Acute Care Surg. 2014;77: S29YS35. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic study, level III. KEY WORDS: Youth violence; residents; injury prevention. BACKGROUND:
Y
outh violence remains a widespread public health problem in the United States. According to the Center for Disease Control, homicide is the second leading cause of death among youth aged 10 years to 24 years.1 Nonfatal injuries sustained from assaults are also a significant societal burden, with 670,697 injured youths aged 10 years to 24 years treated in emergency departments (EDs) in 2009.1 EDs, inpatient units, and primary care clinics are important locations for screening, prevention, and intervention programs for many modifiable high-risk health behaviors including violence.2 The American Trauma Society, the American Pediatric Surgical Association, the American Medical Association, and the American Academy of Pediatrics have adopted policies for firearm injuries and youth violence prevention (YVP).3Y7 Furthermore, a task force of representatives from the 10 Academic Centers of Excellence on Youth Violence Prevention, the Submitted: January 9, 2014, Revised: April 1, 2014, Accepted: April 16, 2014. From the Injury Prevention Center of Rhode Island Hospital (A.R., F.T.B.); Department of Emergency Medicine, Alpert Medical School of Brown University (A.R., F.T.B.), and Brown University School of Public Health (A.R., F.T.B., M.A.C.), Providence, Rhode Island. This article was presented at the 18th annual conference of the Injury Free Coalition for Kids, November 8Y10, 2013, in Fort Lauderdale, Florida. Address for reprints: Alison Riese, MD, MPH 593 Eddy St, Claverick 2, Providence, RI 02903; email: [email protected]. DOI: 10.1097/TA.0000000000000318
American Medical Association, and outside experts on youth violence convened to identify core competencies and training materials on youth violence for health professionals. They identified knowledge of youth violence as a major public health problem, the important role of the physician in YVP, and the need for expertise in focused history taking, risk assessment, and effective counseling and referral in the setting of acute injury.8 In addition, these competencies include the larger goal of physician involvement in hospital-based interventions, community programs, and political advocacy.8 There is significant literature addressing the need for YVP education as part of medical school, residency, and postgraduate training.8Y10 Residency training, in particular, is a critical time for shaping physician knowledge base and establishing standard practice parameters. Previous research examining resident knowledge and training experiences in violence prevention shows that resident physicians are poorly educated on this topic.9Y11 Not surprisingly, studies that examine prevalence of physician YVP behaviors demonstrate that training experience is a major determinant of adherence to recommended practices.12 However, most studies that examined physician behaviors in YVP focused on the outpatient setting.12Y14 A paucity of research exists regarding physician behaviors and practices in the hospital when treating youth violence patients at the time of injury.15 Focusing on YVP practices in the acute care setting is particularly important
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because these caregivers span across multiple specialties and may have practices and understanding of their role in youth violence treatment and prevention very different from that of clinicians in the outpatient settings. Variation between specialties’ YVP behaviors may exist because of difference in training experiences and perceived expectations. Previous literature shows variability of intimate partner violence screening between specialties and, subsequently, variation in preventative care of these patients.16,17 Furthermore, the time of the injury has been shown to be a teachable moment because it is a time where both youth and their families are more accepting of assistance and interventions and can recognize that a need for change exists.18 Therefore, screening, counseling, and referral practices in the acute care setting are of the utmost importance for this very high-risk group. Our study examined resident physicians’ attitudes, behaviors, and barriers toward YVP while caring for violently injured youth in the acute care setting (i.e. the ED and inpatient wards). This study is the first to compare YVP practices across resident specialties in the acute care setting. We hypothesized that all residency groups (surgical, emergency medicine [EM], and pediatric residents) do not practice YVP consistently with highrisk patients, although differences in specific behaviors and attitudes may exist. We expected lack of training, low perceived self-efficacy, and lack of time to be identified as major barriers for all three groups.
PATIENTS AND METHODS Study Population and Design Our study population was surgical, EM, and pediatric residents at a large urban teaching hospital that is the state’s only Level 1 adult and pediatric trauma center. These resident specialties are regularly part of the trauma team and care for youth violence patients in the acute care setting. We invited all levels of residents (postgraduate years [PGYs] 1 through 5) to participate in the survey. We excluded attending physician and medical student respondents. The study design was an anonymous cross-sectional paper-based self-administered questionnaire of a convenience sample of residents who were present at mandatory didactic conferences at the time of survey administration and completed our questionnaires. Didactic conferences were of routine medical topics, not injury or violence prevention, to avoid priming of the topic. A single administration of a paper-based questionnaire was conducted in April 2013. A paper-based questionnaire was chosen over a Webbased survey to maximize our response rate since previous studies have shown low response rate of providers and residents to Web and mailed surveys.19Y22
Questionnaire Design Our questionnaire addressed resident behaviors when treating acutely injured youth violence patients, along with resident attitudes and perceptions of social norms regarding youth violence and YVP, perceived barriers to YVP practices in the acute care setting, and demographic information. Questions were based on the Theory of Planned Behavior (TPB), which is the theory most used in examining clinicians’ behaviors.23Y25 The S30
TPB proposes a model of human action and describes the events that lead to intentional behaviors. It has been applied in both patient health-related behavior change and in clinician’s practice behaviors and adherence to guidelines. The TPB suggests that a person’s attitudes, subjective norms, and perceived behavioral control lead to behavioral intention and subsequently the intended behavior.26,27 By developing a questionnaire based on this model, we evaluated the presence or absence of the behaviors themselves and assessed the attitudes and perceived barriers that may hinder the execution of YVP practices. At the start of the questionnaire, residents were informed that all questions pertained to resident attitudes and behaviors regarding acute care of teens and young adults age 10 years to 24 years with gunshot, stabbing, or assault-related injuries. We based our behavior-based questions on standard competencies for YVP recommended by major medical organizations and educational leaders, including history taking, identification of risk factors such as mental health and substance abuse screening, safety assessment, and appropriate referrals.8,28 For each behavior, respondents were asked how often they performed the behavior in the acute care setting, with response options that gave an overall percentage as a guide: almost never (G25% of the time), some of the time (25Y50%), most of the time (50Y75%), and almost always (975%). The attitude questions included items aimed to evaluate residents’ views on youth violence as an issue in general as well as the role and ability of physicians to make change through YVP efforts in the acute care setting. Subjective norms and perceived behavioral control, theorized to be key factors within the behavior pathway according to the TPB, were assessed by items inquiring about perceptions of attending physicians’ expectations of YVP, self-competency in YVP, and whether YVP falls within their role and is applicable to their career. For all of these questions, respondents were asked whether they do not agree at all, agree a little, agree somewhat, or agree very much. As suggested by the TPB, we also included items assessing the barriers to the two main components of YVP, namely, risk assessment and referral. We asked respondents to identify barriers from a list of options and gave the opportunity to write in any barriers not included. For each component of care, we noted whether each barrier was cited by the respondent. The proportion of residents who identified each barrier was calculated. We also tallied the total number of barriers cited for each respondent and reported mean number of barriers for each component of care. Demographic and background training information was also collected since these factors have been shown to affect likelihood of screening and counseling behaviors among residents.11,16 These factors include sex, race/ethnicity, residency training level, specialty (EM, surgery, or pediatrics,) and whether they received youth violence training in medical school and residency.
Data Analysis STATA 12.1 (StataCorp., College Station, TX) was used to perform all statistical analyses. Descriptive statistics (counts and percentages) and the Fisher’s exact test were used to compare attitudes, behaviors, and social norms between resident subspecialties. All Likert scale data were then grouped to * 2014 Lippincott Williams & Wilkins
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TABLE 1. Demographic and Training Characteristics of Resident Survey Participants Characteristics Sex Male Female PGY level 1 2 3 4 Race Black Asian White Multiracial Hispanic Yes No Training* Medical School Residency Both
All Residents, EM, Pediatrics, Surgery, n = 55 n = 23 (42%) n = 18 (33%) n = 14 (25%) 26 (47) 29 (53)
14 (61) 9 (39)
6 (33) 12 (67)
6 (43) 8 (57)
22 (40) 16 (29) 8 (15) 9 (16)
6 (26) 7 (30) 4 (18) 6 (26)
9 (50) 5 (28) 3 (17) 1 (5)
7 (50) 4 (29) 1 (7) 2 (14)
1 8 43 3
0 (0) 3 (13) 19 (83) 1 (4)
1 (6) 0 (0) 15 (83) 2 (11)
0 (0) 5 (36) 9 (64) 0 (0)
2 (4) 53 (96) 15 (27) 11 (20)
0 (0) 23 (100) 5 (22) 3 (13)
2 (11) 16 (89) 4 (22) 3 (17)
0 (0) 14 (100) 6 (43) 5 (36)
8 (15) 4 (7)
5 (22) 3 (13)
2 (11) 1 (6)
1 (7) 0 (0)
*Training refers to YVP training during either medical school or residency. Both refers to individuals who received training in both medical school and residency.
surgery, 50% (14 of 28); EM, 85% (23 of 27); and pediatrics, 100% (18 of 18). Of the total respondents, 42% were EM, 33% were pediatric, and 25% were surgical residents. Table 1 shows the demographic characteristics of the respondents. In this sample, 53% (n = 29) of the participants were female. A large proportion of the respondents (40%) were in their first year of residency. Only a small proportion of respondents reported receiving YVP training during medical school (20%) and an even smaller proportion during residency (15%). More experience with youth violence education was reported for each subsequent year of residency training (0% [0 of 22] PGY1 vs. 18% [3 of 16] PGY2 vs. 25% [2 of 8] PGY3 vs. 33% [3 of 9] PGY4). The eight residents who received training during residency reported training was delivered in the form of a lecture (n = 5), online training module (n = 2), or at the bedside/ during rounds (n = 6).
Resident Behaviors Table 2 compares resident behaviors when treating a patient with violent-related injuries by type of residency. Combined, more than 90% of all residents reported collecting a history about the situation leading to the violent injury ‘‘consistently’’ (950% of the time), and there was no difference between residency groups. However, there was less consistent inquiry about retaliation risk (20% of residents) or patient safety plan (59% of residents), without significant difference TABLE 2. Resident Behaviors Treating Violently Injured Youth
form binary categories for each item. The behavior questions were dichotomized into ‘‘almost never/some of the time,’’ thus representing behaviors occurring less than 50% of the time, and ‘‘most of the time/almost always,’’ for behaviors occurring more than 50% of the time. Attitude items were similarly dichotomized into ‘‘do not agree at all/agree at little,’’ and ‘‘agree somewhat/agree very much.’’ One surgery intern enrolled in subspecialty training was included in the surgery group since many surgical subspecialists treat patients with violent-related injuries frequently in their career. Similarly, we grouped two medicine/pediatrics and two triple-board (integrated training program for pediatrics, general psychiatry, and child and adolescent psychiatry) residents into pediatrics because of the same methodology and reasoning. One participant noted that he or she had not yet treated a youth violence patient and therefore did not complete the behavior section. We included the data for the rest of this questionnaire because of our interest in the resident’s attitudes and perceived social norms/behavioral control. All other questionnaires were completed fully. This study was deemed exempt by the Brown University Institutional Review Board for Human Subjects.
RESULTS Demographics and Training Among the 73 residents who were present at didactic conference at the time of survey administration, 55 residents completed the questionnaire for an overall response rate of 75%. The response rate for each specialty was as follows:
Resident Behaviors Asks history leading to injury G50% of the time 950% of the time Asks retaliation risk G50% of the time 950% of the time Asks safety plan G50% of the time 950% of the time Refers to social work G50% of the time 950% of the time Refers to community program G50% of the time 950% of the time Assess/refer for mental health G50% of the time 950% of the time Screen/refer for substance abuse G50% of the time 950% of the time
Overall, EM, Pediatrics, Surgery, n = 55 n = 23 n = 18 n = 14
p*
5 (9) 49 (91)
4 (18) 18 (82)
1 (6) 17 (94)
0 (0) 14 (100)
0.20
43 (80) 11 (20)
18 (82) 4 (18)
13 (72) 5 (28)
12 (86) 2 (14)
0.69
22 (41) 32 (59)
10 (45) 12 (55)
8 (44) 10 (56)
4 (29) 10 (71)
0.61
17 (31) 37 (69)
12 (55) 10 (45)
5 (28) 13 (72)
0 (0) G0.01 14 (100)
43 (80) 11 (20)
18 (82) 4 (18)
16 (89) 2 (11)
9 (64) 5 (36)
0.25
19 (35) 35 (65)
11 (50) 11 (50)
3 (17) 15 (83)
5 (36) 9 (64)
0.08
17 (31) 37(69)
12 (55) 10 (45)
4 (22) 14 (78)
1 (7) 13 (93)
0.01
*p values are based on cross-tabs with Fisher’s exact tests for comparisons across the three resident groups and do not reflect any pairwise comparisons.
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among the three specialties. There was a significant difference between the resident groups when comparing consistent referrals to social work (45% of EM, 72% of pediatric, and 100% of surgery residents; p G 0.01); the statistical significance was attributable to the comparison between EM and surgery. This was similar for screening and referral to substance abuse programs (45% for EM, 78% for pediatric, and 93% for surgery; p = 0.01). In addition, as a whole, 65% of the residents reported consistently assessing and referring for mental health concerns (50% of EM, 83% of pediatric, and 64% of surgery residents; p = 0.08).
that their attending expected them to address youth violence issues with patients. Overall, 69% of the residents agreed that youth violence interventions/screening may be applicable to their future career, and only 36% of all residents agreed somewhat or very much with the statement, ‘‘It is the role of others (not mine) to screen/counsel violently-injured patients.’’ In addition, only 47% of all residents agreed somewhat or very much that they knew how to discuss safety risk and retaliation plans with violently injured youth.
Resident Attitudes
When asked about barriers to conducting risk assessments of violently injured youth, residents identified lack of time (89%) lack of training (75%), lack of in-hospital resources (42%), lack of out-of-hospital resources (42%), and not feeling competent (40%). When asked about barriers to making referrals to support services for violently injured youth, residents identified lack of time (42%), lack of training (50%), lack of in-hospital resources (33%), and lack of out-of-hospital resources as barriers. Because the TBP suggests that the number of perceived barriers by an individual affects the likelihood of performance of a behavior, we also summed the number of barriers reported by each respondent. Sixty-four percent and 65% of residents cited three or more barriers to assessing risk and making support service referrals, respectively. The mean number of barriers listed for conducting risk assessments was 3.1 (95% confidence interval [CI], 2.7Y3.5), while the mean number for making referrals was 2.1 (95% CI, 1.6Y2.5.) Surgery residents cited significantly lower numbers of barriers
Table 3 compares resident attitudes toward YVP. One hundred percent of the participants in each specialty agreed that youth violence is a major public health problem, and 91% of EM, 94% of pediatric, and 86% of surgery residents agreed that youth violence is preventable (p = 0.71). However, 94% of the pediatric residents agreed that youth violence screening is an important resident task compared with 52% of EM and 64% of surgery residents (p = 0.01). Similarly, more pediatric residents (89%) than EM (43%) and surgery (64%) residents agreed that YVP should be a resident priority (p = 0.01). Meanwhile, the majority of residents in each specialty agreed that ‘‘hospital personnel can do things to reduce reinjury risk’’ (EM, 83% vs. pediatric, 89% vs. surgery, 86%; p = 0.89).
Social Norms and Expectations Table 4 compares resident perceived social norms and behavior control. Approximately half (53%) the residents agreed
Barriers to Conducting Risk Assessments and Making Referrals
TABLE 3. Resident Attitudes Toward Youth Violence and Prevention Resident Attitudes
Overall, n (%) EM, n (%) Pediatrics, n (%) Surgery, n (%)
YV is a major public health problem Do not agree/agree a little Agree somewhat/very much YV is preventable Do not agree/agree a little Agree somewhat/very much Physicians should play role in YV prevention Do not agree/agree a little Agree somewhat/very much Nothing works with respect to treating/preventing YV Do not agree/agree a little Agree somewhat/very much YV screening is an important resident task Do not agree/agree a little Agree somewhat/very much YV prevention should be priority for residents Do not agree/agree a little Agree somewhat/very much Hospital personnel can do things for youth violence patients to reduce reinjury risk Do not agree/agree a little Agree somewhat/very much
p*
0 (0) 55 (100)
0 (0) 23 (100)
0 (0) 18 (100)
0 (0) 14 (100)
1.0
5 (9) 50 (91)
2 (9) 21 (91)
1 (6) 17 (94)
2 (14) 12 (86)
0.72
8 (15) 47 (85)
5 (22) 18 (78)
1 (6) 17 (94)
2 (14) 12 (86)
0.34
54 (98) 1 (2)
22 (96) 1 (4)
18 (100) 0 (0)
14 (100) 0 (0)
1.0
17 (31) 38 (69)
11 (48) 12 (52)
1 (6) 17 (94)
5 (36) 9 (64)
0.01
20 (36) 35 (64)
13 (57) 10 (43)
2 (11) 16 (89)
5 (36) 9 (64)
0.01
8 (15) 47 (85)
4 (17) 19 (83)
2 (11) 16 (89)
2 (14) 12 (86)
0.89
*p values are based on cross-tabs with Fisher’s exact tests for comparisons across the three resident groups and do not reflect any pairwise comparisons. YV, youth violence.
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TABLE 4. Resident Perceived Social Norms/Behavior Control Social Norms/Expectations Attending physicians expect me to address YV issues with patients Do not agree/agree a little Agree somewhat/very much YV interventions/screenings may be applicable to my future career Do not agree/agree a little Agree somewhat/very much It is the role of others (not mine) to screen/counsel violently injured patients Do not agree/agree a little Agree somewhat/very much I know how to discuss safety plan and retaliation risk with patients Do not agree/agree a little Agree somewhat/very much
Overall, n (%)
EM, n (%)
Pediatrics, n (%)
Surgery, n (%)
p*
26 (47) 29 (53)
12 (52) 11 (48)
7 (39) 11 (61)
7 (50) 7 (50)
0.70
17 (31) 38 (69)
7 (30) 16 (70)
4 (22) 14 (78)
6 (43) 8 (57)
0.46
35 (64) 20 (36)
11 (48) 12 (52)
15 (83) 3 (17)
9 (64) 5 (36)
0.06
29 (53) 26 (47)
14 (61) 9 (39)
11 (61) 7 (39)
4 (29) 10 (71)
0.13
*p values are based on cross-tabs with Fisher’s exact tests for comparisons across the three resident groups and do not reflect any pairwise comparisons. YV, youth violence.
for both risk assessment (1.9; 95% CI, 1.4Y2.5) and referral (0.9; 95% CI, 0.3Y1.6) practices than residents in the other two specialties.
DISCUSSION Our study found that while caring for violently injured youth, the majority of residents collect a history of events leading to the violent injury; however, they much less frequently ask about factors that affect future risk of youth violence and injury sequelae, including mental health and substance abuse risks. Referrals to social work were more likely to be made by surgery residents than EM and pediatric residents. While the majority of residents agreed that youth violence is a major public health problem, is preventable, can be reduced by hospitalbased interventions and that physicians should play a role in YVP, there was less agreement that YVP should be a resident task or priority, and this varied by resident specialty, with pediatrics agreeing significantly more than surgery and EM. While almost 70% thought youth violence screening/counseling would be a part of their future career, approximately half also felt that attending physicians did not expect them to address YVP, and although there were some differences by specialty, 53% overall did not feel competent in assessing risk of reinjury or retaliation. Our findings that residents working in the ED and inpatient setting are likely to ask history of events leading to injury but still do not report competence or consistency in assessing risk factors for reinjury and sequelae are similar to the findings of Fein et al.,15 who compared behaviors of pediatric versus adult ED staff (both physicians and nurses) caring for youth at risk for violence. In addition, our study revealed discrepancies between several YVP behaviors between resident specialties, specifically for referral frequency of EM and surgery residents. The discrepancy may be caused by the setting in which each specialty cares for youth violence patients. While all three resident specialties encounter youth violence patients in the ED, surgery residents are more likely to continue the care for these patients if injuries warrant hospital admission (at this
institution, all hospitalized trauma patients are admitted to the surgery team). This distinction is notable and raises the concern that support service referrals are infrequently provided to the overall majority of youth violence patients who are treated and discharged directly from the ED. Alternatively, surgery resident behaviors may also reflect their use of protocols for trauma patients, which include standardized screening instruments. This was prompted by the American College of Surgeons’ requirement of Level 1 trauma centers to use evidence-based screening processes to identify problem drinking in trauma patients.29 Our study highlights resident reported deficiencies in the core competencies of caring for violently injured youth. Training in youth violenceYfocused history taking and risk assessment as well as education on appropriate referral choices should be covered during medical school and encouraged during residency. Interventions promoting evidence-based YVP practices specific to the acute care setting should be incorporated for trainees and supervising faculty to ensure uptake. For example, screening and brief intervention for alcohol use, a common risk factor for youth violence injury, has been demonstrated to be effective in eliciting trauma patient behavior change.30 Attending physicians must set the expectation and role model YVP practices for residents while evaluating violently injured youth. Cited barriers of lack of time and training may be more of a perceived obstacle than a true barrier for certain interventions, for example, social worker referral, which is neither a time-intensive nor a labor-intensive behavior. Our results suggest that residents are aware of the importance of YVP and the need for intervention at the time of acute care; however, this does not translate into a shared sense of responsibility for YVP efforts. Other studies have also shown discrepancy between physicians’ importance placed on a violence prevention tasks and the execution of that behavior.31 A better understanding of this disconnect between attitudes and practice behavior is needed. Our study should be viewed in light of several limitations. First, the small sample and selection from only one large urban trauma center limits the generalizability of our findings.
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Residents’ roles in treating violently injured patients may differ from one institution to another. For example, pediatric residents in our sample often treat violently injured patients in the ED and are considered part of the trauma team. This may not be the culture or expectations of pediatric residents at other institutions. Next, it was not possible to examine the extent to which other factors, such as training level and demographic information, were associated with screening and counseling practices because of small sample sizes. In addition, the majority of our resident respondents were of PGY 1 and may receive youth violence training later in residency; thus, it is possible that resident YVP practices may be more prevalent than our estimations, although our findings were similar to other reported results.15 Although our response rate was adequate for a physician survey, we did note a significantly smaller response rate for the surgery group compared with the others. Two of the investigators are directly involved clinically with the EM and pediatrics residents, which may have contributed to the higher response rate for these groups. It is also possible that lower perceived saliency of the topic among surgery residents affected the likelihood and types of response. Finally, we acknowledge that our study used nonvalidated, newly constructed survey items and depended on accurate self-report. We based our items on published competencies of YVP and used behavior change theory to guide broad topics, since validated measures were not available. Since social desirability bias may have inflated self-reported behaviors, additional research could compare self-reported behaviors with chart reviews of documented behaviors. However, documentation of history, screening, and counseling components varies widely and may be similar to or less accurate than self-report. This study calls attention to the need for further study of physician behaviors when caring for patients presenting with youth violence-related injuries. Multisite studies assessing each resident specialty may clarify differences between the specialties that care for high-risk patients across the spectrum of training programs. Knowledge and understanding of where discrepancies and lack of competence lie will help direct focused interventions and educational opportunities among trainees to better support youth violence patients in the acute care setting. Further research examining which educational interventions are most influential in changing physicians’ YVP behaviors may help prompt more widespread adoption in medical education. Moreover, evidence showing efficacy of resident YVP efforts in the acute care setting in motivating patient behavior change or shifting their readiness for change may also reinforce standard practice of YVP in the acute care setting. AUTHORSHIP A.R. conceptualized and designed the study, performed the data analysis, drafted and critically revised the initial manuscript, and approved the final manuscript as submitted. F.T.-B. conceptualized and designed the study, performed the data analysis, drafted and critically revised the initial manuscript, and approved the final manuscript as submitted. M.A.C. provided guidance in the study design, survey development, and survey administration, imparting particular expertise in these areas. She critically reviewed the initial manuscript and subsequent revisions and approved of the manuscript as submitted.
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DISCLOSURE The authors declare no conflicts of interest.
REFERENCES 1. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) Atlanta, GA: National Center for Injury Prevention and Control. Available at: http://www.cdc.gov/injury/ wisqars/index.html. Accessed April 2, 2012. 2. Spivak HR, Prothrow-Stith D. Addressing violence in the emergency department. Clin Pediatr Emerg Med. 2003;4:135Y140. 3. Committee on Injury, Violence, and Poison Prevention. Policy statementV role of the pediatrician in youth violence prevention. Pediatrics. 2009;124(1): 393Y402. 4. Youth and Violence Medicine, Nursing, and Public Health: connecting the dots to prevent violence: American Medical Association; 2000. 1Y54. Available at: http://www.ama-assn.org/violence. Accessed March 13, 2013. 5. Position Statement 2013-2: Firearm Violence: American Trauma Sociaty; 2013. Available at: http://www.amtrauma.org/legislation/ats-positionstatements/index.aspx. Accessed December 11, 2013. 6. Nance ML, Krummel TM, Oldham KT, Trauma Committee of American Pediatric Surgical Association. Firearm injuries and children: a policy statement of the American Pediatric Surgical Association. J Am Coll Surg. 2013;217(5):940Y946. 7. Christoffel KK, Spivak H, Witwer M. Youth violence prevention: the physician’s role. JAMA. 2000;283(9):1202Y1203. 8. Knox LM, Spivak H. What health professionals should know: core competencies for effective practice in youth violence prevention. Am J Prev Med. 2005;29(5 Suppl 2):191Y199. 9. Sidelinger DE, Guerrero A, Rodrı´guez-Frau M, Mirabal-Colo´n B. Training healthcare professionals in youth violence prevention: an overview. Am J Prev Med. 2005;29(5 Suppl 2):200. 10. Alpert EJ. Interpersonal violence and the education of physicians. Acad Med. 1997;72(1):S41. 11. Solomon BS, Duggan AK, Webster D, Serwint JR. Pediatric residents’ attitudes and behaviors related to counseling adolescents and their parents about firearm safety. Arch Pediatr Adolesc Med. 2002;156(8):769. 12. Borowsky IW, Ireland M. National survey of pediatricians’ violence prevention counseling. Arch Pediatr Adolesc Med. 1999;153(11):1170Y1176. 13. Abraham A, Cheng TL, Wright JL, Addlestone I, Huang Z, Greenberg L. Assessing an educational intervention to improve physician violence screening skills. Pediatrics. 2001;107(5):E68. 14. Chaffee TA, Bridges M, Boyer CB. Adolescent violence prevention practices among California pediatricians. Arch Pediatr Adolesc Med. 2000;154(10):1034Y1041. 15. Fein JA, Ginsburg KR, McGrath ME, Shofer FS, Flamma JC Jr, Datner EM. Violence prevention in the emergency department: clinician attitudes and limitations. Arch Pediatr Adolesc Med. 2000;154(5):495Y498. 16. Baig A, Shadigian E, Heisler M. Hidden from plain sight: residents’ domestic violence screening attitudes and reported practices. J Gen Intern Med. 2006;21(9):949Y954. 17. McCloskey LA, Lichter E, Ganz ML, Williams CM, Gerber MR, Sege R, et al. Intimate partner violence and patient screening across medical specialties. Acad Emerg Med. 2005;12(8):712Y722. 18. Johnson SB, Bradshaw CP, Wright JL, Haynie DL, Simons-Morton BG, Cheng TL. Characterizing the teachable moment: is an emergency department visit a teachable moment for intervention among assaultinjured youth and their parents? Pediatr Emerg Ccare. 2007;23(8): 553Y559. 19. Cummings SM, Savitz LA, Konrad TR. Reported response rates to mailed physician questionnaires. Health Serv Res. 2001;35(6):1347Y1355. 20. Cull WL, O’Connor KG, Sharp S, Tang SF. Response rates and response bias for 50 surveys of pediatricians. Health Serv Res. 2005;40(1):213Y226. 21. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol. 1997;50(10):1129Y1136.
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22. Burns KE, Duffett M, Kho ME, Meade MO, Adhikari NK, Sinuff T, et al. A guide for the design and conduct of self-administered surveys of clinicians. Can Med Assoc J. 2008;179(3):245Y252. 23. Eccles M, Grimshaw J, Walker A, Johnston M, Pitts N. Changing the behavior of healthcare professionals: the use of theory in promoting the uptake of research findings. J Clin Epidemiol. 2005;58(2):107Y112. 24. Grimshaw JM, Eccles MP, Walker AE, Thomas RE. Changing physicians’ behavior: what works and thoughts on getting more things to work. J Contin Educ Health Prof. 2002;22(4):237Y243. 25. Grimshaw JM, Shirran L, Thomas R, Mowatt G, Fraser C, Bero L, et al. Changing provider behavior: an overview of systematic reviews of interventions. Med Care. 2001; Aug 39(8 Suppl 2):112Y45. 26. Francis JJ, Eccles MP, Johnston M, Walker A, Grimshaw J, Foy R, et al. Constructing Questionnaires Based on the Theory of Planned Behaviour. A Manual for Health Services Researchers. 2004. Newcastle upon Tyne, UK: Centre for Health Services Research, University of Newcastle upon Tyne.
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27. Ajzen I. Constructing a TPB Questionnaire: Conceptual and Methodological Considerations. 2002;7:2007. Available at: http://chuang.epage. au.edu.tw/ezfiles/168/1168/attach/20/pta_41176_7688352_57138.pdf. Accessed March 11, 2013. 28. Denninghoff KR, Knox L, Cunningham R, Partain S. Emergency medicine: competencies for youth violence prevention and control. Acad Emerg Med. 2002;9(9):947Y956. 29. Gentilello LM. Alcohol and injury: American College of Surgeons Committee on trauma requirements for trauma center intervention. J Trauma. 2007;62(6):S44YS45. 30. American College of Surgeons Committee on Trauma. Alcohol Screening and Brief Intervention (SBI) for Trauma Patients. Committee on Trauma Quick Guide. Chicago, IL: ASCOT; 2007. 31. Cassel CK, Nelson EA, Smith TW, Schwab CW, Barlow B, Gary NE. Internists’ and surgeons’ attitudes toward guns and firearm injury prevention. Ann Intern Med. 1998;128(3):224Y230.
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A survey of resident attitudes and behaviors regarding youth violence prevention in the acute care setting Alison Riese, MD, MPH, Frances Turcotte Benedict, MD, MPH, and Melissa A. Clark, PhD, MS, Providence, Rhode Island Surgery, emergency medicine (EM), and pediatric resident physicians play an integral role in treating youth violence patients. We assessed these residents’ behaviors, attitudes, and perceived barriers to youth violence prevention (YVP) in the acute care setting. METHODS: A cross-sectional survey of EM, surgery, and pediatric residents at one large medical institution was conducted using a theorybased self-administered paper questionnaire. Data were analyzed using descriptive statistics and Fisher’s exact tests to examine differences between resident specialties. RESULTS: Of 73 residents, 55 completed the questionnaire, composed of 23 EM (42%), 18 pediatrics (33%), and 14 surgery (25%) residents, with a response rate of 75%. Fifteen percent (n = 8) of the respondents received YVP training during residency. The majority (n = 49, 91%.) of the respondents reported consistently collecting a history of events leading to violent injury. A smaller percentage of residents reported consistent assessment of retaliation risk (n = 11, 20%), referral to social work (n = 37, 69%), and screening for substance abuse (n = 37, 69%) and mental health (n = 35, 65%). Surgery residents were more likely than pediatric and EM residents to refer to social work (100% vs. 72% and 45%, p G 0.01) and screen for substance abuse (93% vs. 78% and 45%, p = 0.01). While the majority of residents agreed that youth violence is preventable (n = 50, 91%) and physicians should play a role in prevention (n = 47, 85%), there was less agreement that YVP should be a resident task (n = 38, 69%). Less than half of residents (n = 26, 47%) felt competent discussing safety risks and plans. Residents cited lack of time and training as the top two barriers for conducting risk assessments and referring to support services. CONCLUSION: While EM, surgery, and pediatric residents agree that YVP is essential and should involve physicians, many do not perceive this as part of their responsibilities, and they do not feel competent in this role. (J Trauma Acute Care Surg. 2014;77: S29YS35. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic study, level III. KEY WORDS: Youth violence; residents; injury prevention. BACKGROUND:
Y
outh violence remains a widespread public health problem in the United States. According to the Center for Disease Control, homicide is the second leading cause of death among youth aged 10 years to 24 years.1 Nonfatal injuries sustained from assaults are also a significant societal burden, with 670,697 injured youths aged 10 years to 24 years treated in emergency departments (EDs) in 2009.1 EDs, inpatient units, and primary care clinics are important locations for screening, prevention, and intervention programs for many modifiable high-risk health behaviors including violence.2 The American Trauma Society, the American Pediatric Surgical Association, the American Medical Association, and the American Academy of Pediatrics have adopted policies for firearm injuries and youth violence prevention (YVP).3Y7 Furthermore, a task force of representatives from the 10 Academic Centers of Excellence on Youth Violence Prevention, the Submitted: January 9, 2014, Revised: April 1, 2014, Accepted: April 16, 2014. From the Injury Prevention Center of Rhode Island Hospital (A.R., F.T.B.); Department of Emergency Medicine, Alpert Medical School of Brown University (A.R., F.T.B.), and Brown University School of Public Health (A.R., F.T.B., M.A.C.), Providence, Rhode Island. This article was presented at the 18th annual conference of the Injury Free Coalition for Kids, November 8Y10, 2013, in Fort Lauderdale, Florida. Address for reprints: Alison Riese, MD, MPH 593 Eddy St, Claverick 2, Providence, RI 02903; email: [email protected]. DOI: 10.1097/TA.0000000000000318
American Medical Association, and outside experts on youth violence convened to identify core competencies and training materials on youth violence for health professionals. They identified knowledge of youth violence as a major public health problem, the important role of the physician in YVP, and the need for expertise in focused history taking, risk assessment, and effective counseling and referral in the setting of acute injury.8 In addition, these competencies include the larger goal of physician involvement in hospital-based interventions, community programs, and political advocacy.8 There is significant literature addressing the need for YVP education as part of medical school, residency, and postgraduate training.8Y10 Residency training, in particular, is a critical time for shaping physician knowledge base and establishing standard practice parameters. Previous research examining resident knowledge and training experiences in violence prevention shows that resident physicians are poorly educated on this topic.9Y11 Not surprisingly, studies that examine prevalence of physician YVP behaviors demonstrate that training experience is a major determinant of adherence to recommended practices.12 However, most studies that examined physician behaviors in YVP focused on the outpatient setting.12Y14 A paucity of research exists regarding physician behaviors and practices in the hospital when treating youth violence patients at the time of injury.15 Focusing on YVP practices in the acute care setting is particularly important
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because these caregivers span across multiple specialties and may have practices and understanding of their role in youth violence treatment and prevention very different from that of clinicians in the outpatient settings. Variation between specialties’ YVP behaviors may exist because of difference in training experiences and perceived expectations. Previous literature shows variability of intimate partner violence screening between specialties and, subsequently, variation in preventative care of these patients.16,17 Furthermore, the time of the injury has been shown to be a teachable moment because it is a time where both youth and their families are more accepting of assistance and interventions and can recognize that a need for change exists.18 Therefore, screening, counseling, and referral practices in the acute care setting are of the utmost importance for this very high-risk group. Our study examined resident physicians’ attitudes, behaviors, and barriers toward YVP while caring for violently injured youth in the acute care setting (i.e. the ED and inpatient wards). This study is the first to compare YVP practices across resident specialties in the acute care setting. We hypothesized that all residency groups (surgical, emergency medicine [EM], and pediatric residents) do not practice YVP consistently with highrisk patients, although differences in specific behaviors and attitudes may exist. We expected lack of training, low perceived self-efficacy, and lack of time to be identified as major barriers for all three groups.
PATIENTS AND METHODS Study Population and Design Our study population was surgical, EM, and pediatric residents at a large urban teaching hospital that is the state’s only Level 1 adult and pediatric trauma center. These resident specialties are regularly part of the trauma team and care for youth violence patients in the acute care setting. We invited all levels of residents (postgraduate years [PGYs] 1 through 5) to participate in the survey. We excluded attending physician and medical student respondents. The study design was an anonymous cross-sectional paper-based self-administered questionnaire of a convenience sample of residents who were present at mandatory didactic conferences at the time of survey administration and completed our questionnaires. Didactic conferences were of routine medical topics, not injury or violence prevention, to avoid priming of the topic. A single administration of a paper-based questionnaire was conducted in April 2013. A paper-based questionnaire was chosen over a Webbased survey to maximize our response rate since previous studies have shown low response rate of providers and residents to Web and mailed surveys.19Y22
Questionnaire Design Our questionnaire addressed resident behaviors when treating acutely injured youth violence patients, along with resident attitudes and perceptions of social norms regarding youth violence and YVP, perceived barriers to YVP practices in the acute care setting, and demographic information. Questions were based on the Theory of Planned Behavior (TPB), which is the theory most used in examining clinicians’ behaviors.23Y25 The S30
TPB proposes a model of human action and describes the events that lead to intentional behaviors. It has been applied in both patient health-related behavior change and in clinician’s practice behaviors and adherence to guidelines. The TPB suggests that a person’s attitudes, subjective norms, and perceived behavioral control lead to behavioral intention and subsequently the intended behavior.26,27 By developing a questionnaire based on this model, we evaluated the presence or absence of the behaviors themselves and assessed the attitudes and perceived barriers that may hinder the execution of YVP practices. At the start of the questionnaire, residents were informed that all questions pertained to resident attitudes and behaviors regarding acute care of teens and young adults age 10 years to 24 years with gunshot, stabbing, or assault-related injuries. We based our behavior-based questions on standard competencies for YVP recommended by major medical organizations and educational leaders, including history taking, identification of risk factors such as mental health and substance abuse screening, safety assessment, and appropriate referrals.8,28 For each behavior, respondents were asked how often they performed the behavior in the acute care setting, with response options that gave an overall percentage as a guide: almost never (G25% of the time), some of the time (25Y50%), most of the time (50Y75%), and almost always (975%). The attitude questions included items aimed to evaluate residents’ views on youth violence as an issue in general as well as the role and ability of physicians to make change through YVP efforts in the acute care setting. Subjective norms and perceived behavioral control, theorized to be key factors within the behavior pathway according to the TPB, were assessed by items inquiring about perceptions of attending physicians’ expectations of YVP, self-competency in YVP, and whether YVP falls within their role and is applicable to their career. For all of these questions, respondents were asked whether they do not agree at all, agree a little, agree somewhat, or agree very much. As suggested by the TPB, we also included items assessing the barriers to the two main components of YVP, namely, risk assessment and referral. We asked respondents to identify barriers from a list of options and gave the opportunity to write in any barriers not included. For each component of care, we noted whether each barrier was cited by the respondent. The proportion of residents who identified each barrier was calculated. We also tallied the total number of barriers cited for each respondent and reported mean number of barriers for each component of care. Demographic and background training information was also collected since these factors have been shown to affect likelihood of screening and counseling behaviors among residents.11,16 These factors include sex, race/ethnicity, residency training level, specialty (EM, surgery, or pediatrics,) and whether they received youth violence training in medical school and residency.
Data Analysis STATA 12.1 (StataCorp., College Station, TX) was used to perform all statistical analyses. Descriptive statistics (counts and percentages) and the Fisher’s exact test were used to compare attitudes, behaviors, and social norms between resident subspecialties. All Likert scale data were then grouped to * 2014 Lippincott Williams & Wilkins
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TABLE 1. Demographic and Training Characteristics of Resident Survey Participants Characteristics Sex Male Female PGY level 1 2 3 4 Race Black Asian White Multiracial Hispanic Yes No Training* Medical School Residency Both
All Residents, EM, Pediatrics, Surgery, n = 55 n = 23 (42%) n = 18 (33%) n = 14 (25%) 26 (47) 29 (53)
14 (61) 9 (39)
6 (33) 12 (67)
6 (43) 8 (57)
22 (40) 16 (29) 8 (15) 9 (16)
6 (26) 7 (30) 4 (18) 6 (26)
9 (50) 5 (28) 3 (17) 1 (5)
7 (50) 4 (29) 1 (7) 2 (14)
1 8 43 3
0 (0) 3 (13) 19 (83) 1 (4)
1 (6) 0 (0) 15 (83) 2 (11)
0 (0) 5 (36) 9 (64) 0 (0)
2 (4) 53 (96) 15 (27) 11 (20)
0 (0) 23 (100) 5 (22) 3 (13)
2 (11) 16 (89) 4 (22) 3 (17)
0 (0) 14 (100) 6 (43) 5 (36)
8 (15) 4 (7)
5 (22) 3 (13)
2 (11) 1 (6)
1 (7) 0 (0)
*Training refers to YVP training during either medical school or residency. Both refers to individuals who received training in both medical school and residency.
surgery, 50% (14 of 28); EM, 85% (23 of 27); and pediatrics, 100% (18 of 18). Of the total respondents, 42% were EM, 33% were pediatric, and 25% were surgical residents. Table 1 shows the demographic characteristics of the respondents. In this sample, 53% (n = 29) of the participants were female. A large proportion of the respondents (40%) were in their first year of residency. Only a small proportion of respondents reported receiving YVP training during medical school (20%) and an even smaller proportion during residency (15%). More experience with youth violence education was reported for each subsequent year of residency training (0% [0 of 22] PGY1 vs. 18% [3 of 16] PGY2 vs. 25% [2 of 8] PGY3 vs. 33% [3 of 9] PGY4). The eight residents who received training during residency reported training was delivered in the form of a lecture (n = 5), online training module (n = 2), or at the bedside/ during rounds (n = 6).
Resident Behaviors Table 2 compares resident behaviors when treating a patient with violent-related injuries by type of residency. Combined, more than 90% of all residents reported collecting a history about the situation leading to the violent injury ‘‘consistently’’ (950% of the time), and there was no difference between residency groups. However, there was less consistent inquiry about retaliation risk (20% of residents) or patient safety plan (59% of residents), without significant difference TABLE 2. Resident Behaviors Treating Violently Injured Youth
form binary categories for each item. The behavior questions were dichotomized into ‘‘almost never/some of the time,’’ thus representing behaviors occurring less than 50% of the time, and ‘‘most of the time/almost always,’’ for behaviors occurring more than 50% of the time. Attitude items were similarly dichotomized into ‘‘do not agree at all/agree at little,’’ and ‘‘agree somewhat/agree very much.’’ One surgery intern enrolled in subspecialty training was included in the surgery group since many surgical subspecialists treat patients with violent-related injuries frequently in their career. Similarly, we grouped two medicine/pediatrics and two triple-board (integrated training program for pediatrics, general psychiatry, and child and adolescent psychiatry) residents into pediatrics because of the same methodology and reasoning. One participant noted that he or she had not yet treated a youth violence patient and therefore did not complete the behavior section. We included the data for the rest of this questionnaire because of our interest in the resident’s attitudes and perceived social norms/behavioral control. All other questionnaires were completed fully. This study was deemed exempt by the Brown University Institutional Review Board for Human Subjects.
RESULTS Demographics and Training Among the 73 residents who were present at didactic conference at the time of survey administration, 55 residents completed the questionnaire for an overall response rate of 75%. The response rate for each specialty was as follows:
Resident Behaviors Asks history leading to injury G50% of the time 950% of the time Asks retaliation risk G50% of the time 950% of the time Asks safety plan G50% of the time 950% of the time Refers to social work G50% of the time 950% of the time Refers to community program G50% of the time 950% of the time Assess/refer for mental health G50% of the time 950% of the time Screen/refer for substance abuse G50% of the time 950% of the time
Overall, EM, Pediatrics, Surgery, n = 55 n = 23 n = 18 n = 14
p*
5 (9) 49 (91)
4 (18) 18 (82)
1 (6) 17 (94)
0 (0) 14 (100)
0.20
43 (80) 11 (20)
18 (82) 4 (18)
13 (72) 5 (28)
12 (86) 2 (14)
0.69
22 (41) 32 (59)
10 (45) 12 (55)
8 (44) 10 (56)
4 (29) 10 (71)
0.61
17 (31) 37 (69)
12 (55) 10 (45)
5 (28) 13 (72)
0 (0) G0.01 14 (100)
43 (80) 11 (20)
18 (82) 4 (18)
16 (89) 2 (11)
9 (64) 5 (36)
0.25
19 (35) 35 (65)
11 (50) 11 (50)
3 (17) 15 (83)
5 (36) 9 (64)
0.08
17 (31) 37(69)
12 (55) 10 (45)
4 (22) 14 (78)
1 (7) 13 (93)
0.01
*p values are based on cross-tabs with Fisher’s exact tests for comparisons across the three resident groups and do not reflect any pairwise comparisons.
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among the three specialties. There was a significant difference between the resident groups when comparing consistent referrals to social work (45% of EM, 72% of pediatric, and 100% of surgery residents; p G 0.01); the statistical significance was attributable to the comparison between EM and surgery. This was similar for screening and referral to substance abuse programs (45% for EM, 78% for pediatric, and 93% for surgery; p = 0.01). In addition, as a whole, 65% of the residents reported consistently assessing and referring for mental health concerns (50% of EM, 83% of pediatric, and 64% of surgery residents; p = 0.08).
that their attending expected them to address youth violence issues with patients. Overall, 69% of the residents agreed that youth violence interventions/screening may be applicable to their future career, and only 36% of all residents agreed somewhat or very much with the statement, ‘‘It is the role of others (not mine) to screen/counsel violently-injured patients.’’ In addition, only 47% of all residents agreed somewhat or very much that they knew how to discuss safety risk and retaliation plans with violently injured youth.
Resident Attitudes
When asked about barriers to conducting risk assessments of violently injured youth, residents identified lack of time (89%) lack of training (75%), lack of in-hospital resources (42%), lack of out-of-hospital resources (42%), and not feeling competent (40%). When asked about barriers to making referrals to support services for violently injured youth, residents identified lack of time (42%), lack of training (50%), lack of in-hospital resources (33%), and lack of out-of-hospital resources as barriers. Because the TBP suggests that the number of perceived barriers by an individual affects the likelihood of performance of a behavior, we also summed the number of barriers reported by each respondent. Sixty-four percent and 65% of residents cited three or more barriers to assessing risk and making support service referrals, respectively. The mean number of barriers listed for conducting risk assessments was 3.1 (95% confidence interval [CI], 2.7Y3.5), while the mean number for making referrals was 2.1 (95% CI, 1.6Y2.5.) Surgery residents cited significantly lower numbers of barriers
Table 3 compares resident attitudes toward YVP. One hundred percent of the participants in each specialty agreed that youth violence is a major public health problem, and 91% of EM, 94% of pediatric, and 86% of surgery residents agreed that youth violence is preventable (p = 0.71). However, 94% of the pediatric residents agreed that youth violence screening is an important resident task compared with 52% of EM and 64% of surgery residents (p = 0.01). Similarly, more pediatric residents (89%) than EM (43%) and surgery (64%) residents agreed that YVP should be a resident priority (p = 0.01). Meanwhile, the majority of residents in each specialty agreed that ‘‘hospital personnel can do things to reduce reinjury risk’’ (EM, 83% vs. pediatric, 89% vs. surgery, 86%; p = 0.89).
Social Norms and Expectations Table 4 compares resident perceived social norms and behavior control. Approximately half (53%) the residents agreed
Barriers to Conducting Risk Assessments and Making Referrals
TABLE 3. Resident Attitudes Toward Youth Violence and Prevention Resident Attitudes
Overall, n (%) EM, n (%) Pediatrics, n (%) Surgery, n (%)
YV is a major public health problem Do not agree/agree a little Agree somewhat/very much YV is preventable Do not agree/agree a little Agree somewhat/very much Physicians should play role in YV prevention Do not agree/agree a little Agree somewhat/very much Nothing works with respect to treating/preventing YV Do not agree/agree a little Agree somewhat/very much YV screening is an important resident task Do not agree/agree a little Agree somewhat/very much YV prevention should be priority for residents Do not agree/agree a little Agree somewhat/very much Hospital personnel can do things for youth violence patients to reduce reinjury risk Do not agree/agree a little Agree somewhat/very much
p*
0 (0) 55 (100)
0 (0) 23 (100)
0 (0) 18 (100)
0 (0) 14 (100)
1.0
5 (9) 50 (91)
2 (9) 21 (91)
1 (6) 17 (94)
2 (14) 12 (86)
0.72
8 (15) 47 (85)
5 (22) 18 (78)
1 (6) 17 (94)
2 (14) 12 (86)
0.34
54 (98) 1 (2)
22 (96) 1 (4)
18 (100) 0 (0)
14 (100) 0 (0)
1.0
17 (31) 38 (69)
11 (48) 12 (52)
1 (6) 17 (94)
5 (36) 9 (64)
0.01
20 (36) 35 (64)
13 (57) 10 (43)
2 (11) 16 (89)
5 (36) 9 (64)
0.01
8 (15) 47 (85)
4 (17) 19 (83)
2 (11) 16 (89)
2 (14) 12 (86)
0.89
*p values are based on cross-tabs with Fisher’s exact tests for comparisons across the three resident groups and do not reflect any pairwise comparisons. YV, youth violence.
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TABLE 4. Resident Perceived Social Norms/Behavior Control Social Norms/Expectations Attending physicians expect me to address YV issues with patients Do not agree/agree a little Agree somewhat/very much YV interventions/screenings may be applicable to my future career Do not agree/agree a little Agree somewhat/very much It is the role of others (not mine) to screen/counsel violently injured patients Do not agree/agree a little Agree somewhat/very much I know how to discuss safety plan and retaliation risk with patients Do not agree/agree a little Agree somewhat/very much
Overall, n (%)
EM, n (%)
Pediatrics, n (%)
Surgery, n (%)
p*
26 (47) 29 (53)
12 (52) 11 (48)
7 (39) 11 (61)
7 (50) 7 (50)
0.70
17 (31) 38 (69)
7 (30) 16 (70)
4 (22) 14 (78)
6 (43) 8 (57)
0.46
35 (64) 20 (36)
11 (48) 12 (52)
15 (83) 3 (17)
9 (64) 5 (36)
0.06
29 (53) 26 (47)
14 (61) 9 (39)
11 (61) 7 (39)
4 (29) 10 (71)
0.13
*p values are based on cross-tabs with Fisher’s exact tests for comparisons across the three resident groups and do not reflect any pairwise comparisons. YV, youth violence.
for both risk assessment (1.9; 95% CI, 1.4Y2.5) and referral (0.9; 95% CI, 0.3Y1.6) practices than residents in the other two specialties.
DISCUSSION Our study found that while caring for violently injured youth, the majority of residents collect a history of events leading to the violent injury; however, they much less frequently ask about factors that affect future risk of youth violence and injury sequelae, including mental health and substance abuse risks. Referrals to social work were more likely to be made by surgery residents than EM and pediatric residents. While the majority of residents agreed that youth violence is a major public health problem, is preventable, can be reduced by hospitalbased interventions and that physicians should play a role in YVP, there was less agreement that YVP should be a resident task or priority, and this varied by resident specialty, with pediatrics agreeing significantly more than surgery and EM. While almost 70% thought youth violence screening/counseling would be a part of their future career, approximately half also felt that attending physicians did not expect them to address YVP, and although there were some differences by specialty, 53% overall did not feel competent in assessing risk of reinjury or retaliation. Our findings that residents working in the ED and inpatient setting are likely to ask history of events leading to injury but still do not report competence or consistency in assessing risk factors for reinjury and sequelae are similar to the findings of Fein et al.,15 who compared behaviors of pediatric versus adult ED staff (both physicians and nurses) caring for youth at risk for violence. In addition, our study revealed discrepancies between several YVP behaviors between resident specialties, specifically for referral frequency of EM and surgery residents. The discrepancy may be caused by the setting in which each specialty cares for youth violence patients. While all three resident specialties encounter youth violence patients in the ED, surgery residents are more likely to continue the care for these patients if injuries warrant hospital admission (at this
institution, all hospitalized trauma patients are admitted to the surgery team). This distinction is notable and raises the concern that support service referrals are infrequently provided to the overall majority of youth violence patients who are treated and discharged directly from the ED. Alternatively, surgery resident behaviors may also reflect their use of protocols for trauma patients, which include standardized screening instruments. This was prompted by the American College of Surgeons’ requirement of Level 1 trauma centers to use evidence-based screening processes to identify problem drinking in trauma patients.29 Our study highlights resident reported deficiencies in the core competencies of caring for violently injured youth. Training in youth violenceYfocused history taking and risk assessment as well as education on appropriate referral choices should be covered during medical school and encouraged during residency. Interventions promoting evidence-based YVP practices specific to the acute care setting should be incorporated for trainees and supervising faculty to ensure uptake. For example, screening and brief intervention for alcohol use, a common risk factor for youth violence injury, has been demonstrated to be effective in eliciting trauma patient behavior change.30 Attending physicians must set the expectation and role model YVP practices for residents while evaluating violently injured youth. Cited barriers of lack of time and training may be more of a perceived obstacle than a true barrier for certain interventions, for example, social worker referral, which is neither a time-intensive nor a labor-intensive behavior. Our results suggest that residents are aware of the importance of YVP and the need for intervention at the time of acute care; however, this does not translate into a shared sense of responsibility for YVP efforts. Other studies have also shown discrepancy between physicians’ importance placed on a violence prevention tasks and the execution of that behavior.31 A better understanding of this disconnect between attitudes and practice behavior is needed. Our study should be viewed in light of several limitations. First, the small sample and selection from only one large urban trauma center limits the generalizability of our findings.
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Residents’ roles in treating violently injured patients may differ from one institution to another. For example, pediatric residents in our sample often treat violently injured patients in the ED and are considered part of the trauma team. This may not be the culture or expectations of pediatric residents at other institutions. Next, it was not possible to examine the extent to which other factors, such as training level and demographic information, were associated with screening and counseling practices because of small sample sizes. In addition, the majority of our resident respondents were of PGY 1 and may receive youth violence training later in residency; thus, it is possible that resident YVP practices may be more prevalent than our estimations, although our findings were similar to other reported results.15 Although our response rate was adequate for a physician survey, we did note a significantly smaller response rate for the surgery group compared with the others. Two of the investigators are directly involved clinically with the EM and pediatrics residents, which may have contributed to the higher response rate for these groups. It is also possible that lower perceived saliency of the topic among surgery residents affected the likelihood and types of response. Finally, we acknowledge that our study used nonvalidated, newly constructed survey items and depended on accurate self-report. We based our items on published competencies of YVP and used behavior change theory to guide broad topics, since validated measures were not available. Since social desirability bias may have inflated self-reported behaviors, additional research could compare self-reported behaviors with chart reviews of documented behaviors. However, documentation of history, screening, and counseling components varies widely and may be similar to or less accurate than self-report. This study calls attention to the need for further study of physician behaviors when caring for patients presenting with youth violence-related injuries. Multisite studies assessing each resident specialty may clarify differences between the specialties that care for high-risk patients across the spectrum of training programs. Knowledge and understanding of where discrepancies and lack of competence lie will help direct focused interventions and educational opportunities among trainees to better support youth violence patients in the acute care setting. Further research examining which educational interventions are most influential in changing physicians’ YVP behaviors may help prompt more widespread adoption in medical education. Moreover, evidence showing efficacy of resident YVP efforts in the acute care setting in motivating patient behavior change or shifting their readiness for change may also reinforce standard practice of YVP in the acute care setting. AUTHORSHIP A.R. conceptualized and designed the study, performed the data analysis, drafted and critically revised the initial manuscript, and approved the final manuscript as submitted. F.T.-B. conceptualized and designed the study, performed the data analysis, drafted and critically revised the initial manuscript, and approved the final manuscript as submitted. M.A.C. provided guidance in the study design, survey development, and survey administration, imparting particular expertise in these areas. She critically reviewed the initial manuscript and subsequent revisions and approved of the manuscript as submitted.
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DISCLOSURE The authors declare no conflicts of interest.
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