Behavior In Clinical Settings Research Articles

Circadian Mechanisms of Prefrontal Cortex Dependent Memory in Trace Fear Conditioning

Abstract Circadian rhythms are physiological and behavioral processes that follow an approximately 24-hour cycle. They arise from internal biological clocks, which are synchronized mainly by environmental light. Fear-based mental disorders, such as post-traumatic stress disorder (PTSD), are associated with disruptions in circadian rhythms. Understanding this relationship is important for developing more effective treatments. In delayed fear conditioning, the most common form of fear conditioning, the presentation of a tone (conditioned stimulus) is paired with a foot shock (unconditioned stimulus), causing experimental subjects to associate tone presentation with shock delivery. In trace fear conditioning, a brief temporal gap occurs between the tone and foot shock, causing different brain circuits to get engaged. Past work in our laboratory and others has shown circadian rhythms in the extinction of delayed conditioned fear. More recent work in our laboratory has shown that the recall of trace conditioned fear similarly exhibits a rhythm, with recall being stronger during the inactive phase of the rest-activity cycle. The purpose of this experiment was to test whether stronger recall for trace fear is dependent on the time of conditioning or the time of recall. Additionally, I analyzed brain tissue to assess whether rhythms in behavior were reflected in circadian and activity-dependent gene expression in the prefrontal cortex. Rats were fear conditioned at either ZT4 (the inactive phase) or ZT16 (the active phase) and then underwent fear recall after 24 h (same time of day as training), 36 h (opposite time of day as training), and 48 h (same time of day as training). Results showed an interaction between the time of training and the interval between training and testing for trace fear conditioning. Specifically, ZT4 rats showed strong fear recall at all intervals, whereas ZT16 rats showed increased recall over a greater recall interval. The mRNA expression of Per1, a key circadian gene, showed opposite results, with the ZT4 expression decreasing over recall intervals and ZT16 expression remaining constant. For c-Fos, an immediate early gene whose expression is used to approximate recent neuronal activation, mRNA expression tended to be higher at ZT16 regardless of the time of training. Notably, however, ZT4-36 h rats showed higher c-Fos expression than ZT16-36 h rats in the infralimbic but not prelimbic prefrontal cortex, suggesting differential engagement of the prelimbic cortex during trace fear recall. These results suggest that learned fear may be consolidated more quickly during the inactive phase, leading to signs of prefrontal engagement at later recall intervals during the active phase. In turn, these findings pave the way for circadian assessments, treatments, and prevention for fear-based mental disorders in clinical settings. Lay Summary Circadian rhythms are physiological and behavioral processes that follow an approximately 24-hour cycle. They arise from internal biological clocks, which are synchronized mainly by environmental light. Fear-based mental disorders, such as post-traumatic stress disorder (PTSD), are associated with disruptions in circadian rhythms. Understanding this relationship is important for developing more effective treatments. In trace fear conditioning, a brief temporal gap occurs between the presentation of the tone (conditioned stimulus) and foot shock (unconditioned stimulus). Recent work in our laboratory has shown that the recall of trace conditioned fear exhibits a rhythm, with recall being stronger during the inactive phase of the rest-activity cycle. The purpose of this experiment was to test whether stronger recall for trace fear is dependent on the time of conditioning or the time of recall. Additionally, I analyzed brain tissue to assess whether time-of-day differences in behavior were reflected in circadian and activity-dependent gene expression in the prefrontal cortex. Rats were fear conditioned at either ZT4 (the inactive phase) or ZT16 (the active phase) and thenunderwent fear recall after 24 h, 36 h, and 48 h. Results showed that for behavior the time of testing for trace fear conditioning, ZT4, is what was the most important, and ZT16 rats increase in freezing behavior over a time interval. Per1 mRNA expression in the PFC showed opposite results with the ZT4 expression decreasing over recall intervals and ZT16 expression remaining constant. The time of recall interval was the most important for c-Fos neuronal activity in the PFC. These results show that learned fear behavior is expressed more during the inactive phase training, ZT4, but the neuronal circuitry shows more memory consolidation during the ZT16 recall intervals. These findings suggest that learned fear may be expressed differently through underlying neuronal circuits than through behavior in clinical settings. For the full text, please visit https://scholar.colorado.edu/concern/undergraduate_honors_theses/x059c890d.

Development and validation of bioanalytical methods to support clinical study of disitamab vedotin.

Disitamab vedotin (RC48), a humanized anti-HER2 antibody conjugated with monomethyl auristatin E (MMAE), is the first antibody-drug conjugate in China with an approved biological license application. A bioanalytical method was established for three analytes (total antibody, conjugate antibody and free payload) to help characterize their pharmacokinetic behavior in clinical settings. The bioanalytical methods were validated according to M10 guidance. Electrochemiluminescence assaymethods were used for thequantitative measurement of total antibody and conjugated antibody in human serum. A LC-MS/MSmethod was used to quantify the concentration of MMAE in human serum. The method had high specificity and sensitivity with a quantitative range of 19.531-1250.000ng/ml (total antibody), 39.063-5000.000ng/ml (conjugated antibody)and 0.04-10.0ng/ml (MMAE), respectively.

The mediating role of psychological capital on the relationship between authentic leadership and nurses’ caring behavior: a cross-sectional study

BackgroundCaring behavior among nurses would have an impact on patient outcomes. External organizational job resources and personal internal psychological resources are correlated to nurses’ caring behavior. Authentic leadership and psychological capital were shown to be correlated with nurses’ caring behavior in previous studies. However, the relationships among the three are nevertheless unclear. This study aimed to examine if psychological capital could act as a mediator between nursing managers’ authentic leadership and nurses’ caring behavior.MethodsIn December 2021, a total of 3,662 nurses were recruited from 37 hospitals in Anhui Province, China. They filled out online surveys, including general demographic information, the Authentic Leadership Questionnaire, the Psychological Capital Questionnaire, and the Caring Behavior Inventory. Structural Equation Modeling and the bootstrapping procedure were used to examine the mediating role of psychological capital.ResultsThe scores of authentic leadership, psychological capital, and caring behavior of 3,495 nurses were 52.04 ± 13.24, 96.89 ± 17.78, and 104.28 ± 17.01, respectively. Psychological capital significantly mediated the relationship between authentic leadership and nurses’ caring behavior (β = 0.378, p < 0.001, 95% confidence interval: 0.350 ~ 0.402), which made up 78.75% of the total impact (0.480).ConclusionThe findings of this study suggested that nursing managers should develop an authentic leadership style, which can effectively improve nurses’ caring behaviors toward patients in clinical practice. Meanwhile, nursing leaders should strengthen nurses’ psychological evaluation and training, and promote nurses’ caring behavior in clinical settings.

Experiencing Pain Invalidation is Associated with Under-Reporting of Pain: A Social Psychological Perspective on Acute Pain Communication

Pain invalidation involves the dismissal or lack of understanding of another’s pain, undermining their subjective experience. Frequent exposure to invalidation negatively impacts mental and physical health as well as pain-related behaviors, potentially leading people to conceal their pain from others in the future and/or withdraw from potential sources of support. It is therefore possible that experiencing pain invalidation may also impact pain-reporting behavior in clinical settings. Across 2 separate samples of emerging adults, we examined whether exposure to invalidation of one’s pain was associated with cognizant modulation of one’s subjective acute pain ratings within routine medical and dental settings. Drawing upon social psychological theories of impression management and self-presentation, we hypothesized that exposure to pain invalidation would be associated with the under-rating of one’s pain. In Study 1, previous experiences of invalidation were associated with under-rating of one’s pain when visiting the doctor and the dentist. Study 2 found that invalidation from family and medical professionals—but not from friends—was associated with under-rating pain in both settings. Findings provide further evidence for the harmful effects of pain invalidation, particularly for emerging adults, as the dismissal of one’s subjective experience may sow self-doubt while reinforcing cultural stigmas against pain, leading to alterations in pain communication that ultimately creates barriers to efficacious clinical treatment and care and increase pain-related suffering. PerspectivePain invalidation imparts harm to those who already suffer from pain, be it mentally, physically, and/or behaviorally. We show that people who have encountered invalidation are more likely to under-rate their pain when seeking care, impeding assessment and treatment, and further highlighting the importance of clinical validation of pain experiences.

The 24-hour food frequency assessment screening tool (FAST24): Development and evaluation of a novel dietary screener to identify foods associated with weight change

Brief screening questionnaires can identify 'at risk' behaviors in clinical settings. However, there is currently no screener for dietary intake specifically developed using foods associated with body weight change and increased risk for multiple chronic conditions and diseases. We developed a novel brief dietary screener, the 24-Hour Food Frequency Assessment Screening Tool Questionnaire (FAST24), to identify intake of foods associated with weight change. University students completed the FAST24 and the Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24) at two time points to assess acceptability and determine preliminary criterion validity against food categories from the United States Department of Agriculture (USDA) Food Patterns Equivalents Database (FPED). 202 individuals (age 20.4±3.6 years; 65.7% females) completed the FAST24 in an average time of 2min compared to 24min for the ASA24. Over half of the food items from the FAST24 were matched to, and correlated with, standard USDA food pattern components (r's ranging from .15 to .58, p's<.05). Food items from the dietary data from the FAST24 were also highly correlated with the more intensive ASA24 application (r's ranging from .23 to .82, p's<.01), and were less time-consuming and burdensome to complete (p's<.0001). Findings support the continued refinement of the FAST24 as a rapid, valid primary care assessment tool for measuring USDA dietary intake patterns. Use of a short, simple screener such as the FAST24 has the potential for integration into large healthcare delivery settings to help establish a baseline for promoting relative behavior changes critical for long-term health and well-being.

Nurses' Lived Experiences of Moral Courage Inhibitors: A Qualitative Descriptive Study.

Moral courage (MC) has been characterized among the vital strategies, adopted by nurses, for dealing with moral distress; even though there are some factors hindering the development of this behavior in clinical settings. The present study accordingly aimed to shed light on Iranian nurses' lived experiences regarding MC inhibitors. This qualitative descriptive study was fulfilled, using conventional content analysis. For this purpose, the participants comprised of 15 nurses were recruited purposively from teaching hospitals in Iran. As well, in-depth, individual semistructured interviews in a face-to-face mode were held for data collection. The data were further analyzed by Graneheim and Lundman's method. The analysis of the interviews revealed some MC inhibitors, including the individual factors (viz., personality traits, fear of job loss, poor scientific/practical skills, lack of ethical knowledge, and phobia of unpleasant experience recurrence), and the organizational ones (namely, no reward system, lack of power at work and physician dominance, inadequate organizational support, and suppressive environment). The study findings demonstrated that the MC inhibitors in the nursing practice could be split into two general themes, that is, the individual and organizational ones. Accordingly, organizations could motivate nurses to make ethical decisions courageously, using supporting strategies, such as giving importance to nurses and empowering them, applying appropriate evaluation criteria, and appreciating ethical performance in these frontline healthcare workers.

An Evaluation of Uncivil Behaviors in Clinical Learning Environments from the Perspective of Nursing Students in Western Iran in 2020

Background: Uncivil behavior in clinical learning environments is a growing challenge that severely disrupts the teaching and learning process. Objectives: The aim of this study is to evaluate the incidence of uncivil behavior in clinical learning environments from the perspective of nursing students in western Iran. Methods: In this self-report descriptive cross-sectional study in the 2020 year, 135 undergraduate nursing students of semesters 3, 4, 6, and 8, who were taking training and internship courses, were enrolled. The standard UBCNE questionnaire with 20 questions based on the Likert scale and subscales of exclusionary, hostile/rude, and dismissive behaviors constituted research tools. Data were analyzed using SPSS version 21 and descriptive and inferential statistics. Results: 103 (76.3%) trainees and 32 (23.7%) interns with a mean age of 21.53 years (1.60) participated in this study. According to the results of the Kruskal-Wallis test, the mean scores of hostile/rude, exclusionary, and dismissive behaviors and the total score in different semesters were significantly different (P &lt; 0.001). In terms of the semester, these behaviors had the highest rate in semester 6 students and the lowest in semester 8 students. There was no statistically significant relationship between gender and the mean incidence of these behaviors in students. Conclusions: The results show the students’ experience with different behaviors in clinical settings according to different contexts. Further research is required to understand these behaviors in clinical settings better and to provide strategies to minimize such behaviors.

Anxiety provoking behaviors of nursing clinical instructors and effects on undergraduate nursing students' wellbeing: A mixed methods design

AimThis study aimed to investigate the relationships between anxiety-provoking teaching behaviors in clinical settings and nursing students’ self-reported anxiety levels, perceived quality of life and demographic characteristics. BackgroundAnxiety has been consistently reported in the literature as a major barrier to nursing education. Peplau's Interpersonal Relations Theory (1992, 1997) served as a theoretical framework in the study to explore anxiety-provoking teaching behaviors in clinical settings. DesignA cross-sectional, correlational, mixed methods design was used. MethodsFifty-eight participants were recruited from the undergraduate nursing program at a Canadian university in the spring of 2021. An online survey, including demographic characteristics, the State-Trait Anxiety Inventory (STAI) and World Health Organization Quality of Life Instruments (WHOQOL-BREF), was distributed to the participants before a face-to-face interview. The interview was conducted by peer nursing students in the program to reduce the power imbalance relationship, given the sensitivity of the topic. The interview data were thematically analyzed and the subthemes were used to code the qualitative interview into quantitative data. Pearson's correlation was performed to analyze the relationships between the number of experienced anxiety-provoking teaching behaviors, the SATI and WHOQOL-BREF scores. ResultsThe qualitative findings revealed two main themes, interpersonal relations and instructional styles and ten anxiety-provoking teaching behaviors as the subthemes. A significant positive relationship was observed between the number of anxiety-provoking teaching behaviors reported and the SATI score (r = .392, p < .001) and a significant negative relationship was observed between the number of reported anxiety-provoking teaching behaviors and the WHOQOL-BREF score in the domain of psychological health (r = −.343, p = .008), thus indicating that a higher number of reported anxiety-provoking teaching behaviors correlated with greater anxiety and lower psychological health. ConclusionsThe study revealed that students’ perceptions of the clinical instructors' interpersonal relations and instructional styles significantly affected their anxiety levels and psychological health in life.

Current challenges faced by transgender and gender-diverse patients and providers in anesthesiology.

The transgender and gender-diverse (TGD) population of the United States is estimated to be approximately 0.5% of the adult population or about 1.3 million adults.1 Of those adults, 38.5% are transgender women, 35.9% are transgender men, and 25.6% are gender-diverse.1 Mirroring the overall increase in the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) population of younger Americans, the population of TGD adolescents is also increasing, now estimated to be at around 1.4% (∼300,000) of adolescents aged 13 to 17 years.1 Although social representation and acceptance of TGD individuals have slowly increased over the past decade, significant discrimination and mistreatment persist and are prevalent even within the health care system.2 In a 2016 survey, 33% of gender-diverse adult respondents experienced discrimination when interacting with health care providers and 23% avoided seeking medical care because of the fear of further mistreatment.3 A 2022 study similarly revealed ∼33% of gender-diverse individuals who experienced health care discrimination and found one-third of respondents reported health care avoidance, an increase since the 2016 study.4 Anesthesiologists play an important role in providing gender-affirming perioperative care and can actively mitigate further health care discrimination against TGD patients of all ages.5–7 As patient advocates and anesthesiologists strive to provide informed and culturally competent care for all patients, educational materials and opportunities to learn about gender-affirming perioperative care are severely lacking.8 In a 2021 survey of nearly 400 pediatric anesthesiologists, 92% of respondents agreed or strongly agreed that learning about transgender health care was relevant to their practice, yet 65% believed the amount of formal education they received was inadequate.8 Only half of the respondents felt equipped with the knowledge necessary to provide perioperative care to TGD patients.8 In an evaluation of the sexual and gender minority (SGM) educational content within obstetric anesthesiology fellowship programs in the United States and Canada, only 19% of program directors reported that SGM education was included in their curriculum and only 31% wanted to include SGM educational content for their trainees.9 Blanchard and colleagues identified several behavioral factors that predict anesthesiologists’ intent to provide culturally competent care for TGD patients. They determined that a positive attitude toward gender-affirming care (GAC) was the strongest predictor of intent, whereas a general lack of understanding of the transgender community and scarcity of educational opportunities led to provider uncertainty and decreased intent.10 These publications highlight an obvious need for more education specifically directed to anesthesiology providers regarding gender-affirming perioperative care. Accordingly, this article seeks to expand anesthesiologists’ understanding of gender-affirming perioperative care within the relevant social and ethical contexts by (1) examining the current political and legislative challenges faced by TGD individuals, (2) discussing the complex role of conscientious objection in providing GAC, and (3) briefly exploring the experiences of TGD colleagues during medical education and within the field of anesthesiology. To improve the overall knowledge of perioperative considerations, this article will also include an overview of the major considerations for gender-affirming perioperative care for TGD adults and adolescents. Legislative challenges affecting access to gender-affirming care At the federal level, the LGBTQ+ community is currently protected from health care discrimination under the Health Care Rights Law (Section 1557 of the Affordable Care Act, ACA),11 which prohibits discrimination based on sex, but the road to achieve this was hindered by political and legislative battles. The Supreme Court of the United States determined that sexual orientation and gender identity would fit within the Title VII definition of “sex” in Bostock v. Clayton County, GA on June 15, 2020.12 Within a few days of the ruling, the Trump administration Department of Health and Human Services revoked the nondiscrimination protections, which included sexual orientation and gender identity, thus allowing legal health care discrimination against the LGBTQ+ community.13 In May 2021, an executive order from the Biden administration restored the inclusion of gender identity and sexual orientation within the health care discrimination protections outlined in the ACA.14 Although executive orders are useful protective steps, wide-reaching federal legislation would better protect the LGBTQ+ community.15 The Federal Equality Act, first introduced in 2015, would do exactly that but has failed to pass Congress 4 times. As of July 2022, the Equality Act (HR 5) has been idle in a Senate committee after being passed by the House in February 2021.16 In the absence of federal nondiscrimination protections, state legislatures have introduced a multitude of bills that aim to redefine and limit the rights of TGD Americans. Before 2020, no state had considered antitrans legislation; yet from January 2021 to the present, 39 antitrans bills have been passed, while 20 more are being considered across the country.17 As of March 2022, 238 anti-LGBTQ+ bills had been filed—with nearly half targeting TGD Americans.17 Although access to GAC is the primary focus of this discussion, it should be noted that numerous states are attempting to restrict public school educational curricula that include gender identity, deny TGD individuals’ access to public restrooms, and ban transgender youth from participating in sports. Ohio’s Save Women’s Sports Act (passed in the Ohio House of Representatives and now awaiting Senate vote) requires an internal and external reproductive anatomy exam, testosterone measurements, and a chromosomal analysis of any athlete thought to be a transgender.18 The juridical vulnerability experienced when TGD individuals are subjected to the legal authority of lawmakers cannot be underestimated. Societal and legislative discrimination likely weigh heavily on TGD Americans, negatively affecting mental health, much like the experiences of lesbian, gay, and bisexual Americans during the legal battles for marriage equality.19 In fact, 94% of LGBTQ+ youth in 2021 reported politics negatively impacted their mental health.20 TGD adolescents are already at increased risk for mental health issues, substance use, and suicide, with roughly 35% of transgender adolescents attempting suicide.21,22 This already-vulnerable population is currently contending with a large-scale legislative movement seeking to restrict their access to GAC—including puberty suppression, affirming hormone therapy, and certain surgical procedures—which has long been accepted by nearly all American major medical associations as medically necessary treatment for TGD individuals experiencing gender dysphoria.23–25 Despite this, most state bills opposing GAC for adolescents are based largely on medical misinformation, which promotes inaccurate beliefs and perpetuates societal stigma against the TGD community. The Williams Institute estimates that ∼58,000 transgender youth (ages 13 to 17) are at risk of losing access to GAC and being forcefully detransitioned due to the current proposed state bans and policies.1 Currently, 15 states are considering or have already passed laws impacting adolescent access to GAC (Table 1).1,17 The Arkansas “Save Adolescents From Experimentation (SAFE) Act” was passed in April 2021, overriding the governor’s veto, becoming the first state law in the nation prohibiting and criminalizing gender-affirming health care for adolescents.26 This law also requires teachers and school counselors to inform parents if their child reveals that they are transgender, forcefully outing them and placing them at potential risk of physical harm, homelessness, or even increased suicidality. This law was subsequently blocked by a district court in July 2021. Another strategy employed by politicians to ban GAC has been the use of state regulations and executive orders by governors to sidestep the legislative process and enact restrictions without formal law. The governor and district attorney of Texas unilaterally declared GAC as “child abuse,” thus subjecting parents of TGD adolescents to investigation and family separation. This order has since been blocked.27 Considering the current legal landscape, parents and patients alike are expressing fear that these discriminatory bills will lead to worsening mental health and increased suicidal ideation.28 Although most proposed legislation discussed so far aims to criminalize GAC for adolescents, there is growing concern that legislators intend to eventually ban GAC for all ages, not just minors. For instance, bills in Alabama, North Carolina, Oklahoma, Texas, and Missouri seek to ban GAC for individuals in their early twenties.1,17 Perhaps, the most extensive method of banning GAC for all ages can be seen in at least 12 states that prohibit access to GAC through Medicaid, which directly affects ∼32,000 TGD Medicaid beneficiaries living in these states.29 These are only a few examples predicting a more restrictive and harmful trajectory of antitrans legislation. Table 1 - State legislative bills (proposed and/or passed) seeking to restrict gender-affirming care. AZ (8) MO (7) OH (6) KY (6) TN (6) OK (5) LA (5) NC (4) AR (4) TX (3) GA (3) KS (3) AL (2) ID (2) SC (2) IA (2) Allows or requires state medical licensing boards to discipline HCPs ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Allows private citizens to file civil lawsuits against HCPs for providing any GAC to minors ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Classifies the act of providing GAC to minors as a felony (*TN: misdemeanor) ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Penalizes parents who help minors access GAC ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Prohibits specific insurance companies from covering GAC ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Prohibits the use of state funds and denies additional funding to any organizations that provide GAC ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Prohibits the use of government facilities and prohibits government employees from providing GAC ✓ ✓ ✓ ✓ ✓ ✓ Excludes GAC as tax deductible expense ✓ ✓ ✓ ✓ Classifies GAC as ‘Child Abuse’ ✓ ✓ ✓ Source: Williams Institute 1 and Trans Formation Project Legislation Tracker.17AL indicates Alabama; AR, Arkansas; AZ, Arizona; GA, Georgia; GAC, Gender-Affirming Care; HCP, Health care Providers; IA, Iowa; ID, Idaho; KS, Kansas; KY, Kentucky; LA, Louisiana; MO, Missouri; NC, North Carolina; OH, Ohio; OK, Oklahoma; SC, South Carolina; TN, Tennessee; TX, Texas. Some alarming themes found within the current antiGAC bills are the consequences laid out for parents and the criminalization of providers who support TGD adolescents’ access to GAC. In 8 states, the proposed bills penalize parents for supporting children through their gender journey and 3 states are attempting to classify GAC as child abuse (Table 1).1,17 Similarly, anesthesiologists and other providers in these states may face fines, medical license suspensions, and criminal prosecution for providing perioperative GAC to TGD individuals undergoing gender-affirming procedures. Many bills classify the act of providing GAC as a felony, subject to a prison sentence of 1 to 10 years.1,17 Numerous states also allow or require state medical boards to discipline their licensees if accused of providing GAC for adolescents.1,17 Moreover, 10 states are also considering bills that allow private citizens to file civil lawsuits against those providing GAC for adolescents.1,17 The disturbing trend—allowing criminal and civil litigation against medical professionals providing standard of care—emulates the same legal strategy directed against abortion providers. When the government interferes with the physician-patient relationship, anesthesiologists are faced with the dilemma of providing treatment for TGD adolescents at the personal and professional risk of being fined, imprisoned, or even sued in civil court. What remains to be seen is if state medical boards will respond to new bills by protecting providers or allowing punitive action. The myriad of antitrans bills in state legislatures across the country leaves the current legal landscape full of uncertainty with no guaranteed federal protections for TGD individuals. The legislative challenges affecting access to GAC are dynamic and will likely be different by the time this article is published; however, given the possible legal repercussions of providing GAC in antagonistic states, anesthesiologists are encouraged to familiarize themselves with their specific state laws. The progress of antitrans state bills can be followed through the Trans Formations Project website.17 Conscientious objection and discrimination when providing care for TGD patients Anesthesiologists would be naive to imagine practicing in a setting where they will not encounter TGD patients and be responsible for providing safe, high-quality anesthetic care. But what happens if an anesthesiologist desires not to be involved? Is there a role for conscientious objection, and is it permissible to “opt-out” or refuse to care for a specific patient population? Does it matter if the procedure is a gender-affirming surgery, an elective orthopedic procedure, or an emergent appendectomy? What if the person objecting is a trainee? Conscientious objection in health care refers to a health care professional’s “refusal to provide certain types of legal health care services to a patient based upon the provider’s personal moral, ethical, or religious beliefs.”30 While commonly applied to abortion, it has also been invoked regarding elective sterilization, emergency contraception, physician-assisted death, and in caring for LGBTQ+ patients.31 Similarly, in anesthesiology, it may be used to refrain from the care of patients seeking abortion or who refuse blood transfusion. Not surprisingly, the issue of conscientious objection in health care is controversial. An absolutist stance argues that the right to refuse should be protected on whatever grounds a provider uses to justify their refusal, supporting the notion that health care professionals have a right to define their scope of practice.32 However, without some restriction or oversight, there is risk of religious, ethical, or moral disagreement being used as “pretext for discrimination.”30 The incompatibility thesis, on the other hand, views conscientious objection as being contradictory to the obligations of the profession whereby doctors should provide services that are legal, efficient, and beneficial even if it conflicts with their personal values.33 Anesthesiologists have an obligation to provide medically appropriate and legal care when necessary; otherwise, there is risk that perioperative care will be inequitable or discriminatory. However, even Savulescu states, “When a doctor’s values can be accommodated without compromising the quality and efficiency of public medicine, they should, of course, be accommodated.”33 A third approach based on compromise is supported by many medical organizations, including the American Medical Association (AMA)34 and the British Medical Association (BMA),35 wherein a doctor’s right to conscientiously object is recognized but with limitations. To invoke conscientious objection, it is expected that (1) the reason for refusal is not discriminatory in nature, (2) principles of informed consent are upheld (including informing the patient of all relevant options, even if it includes ones that the provider morally objects to), (3) the care needed is not emergent, and (4) the doctor will refer the patient to other providers as to not delay appropriate care. The American Society of Anesthesiologists (ASA) has adopted the AMA Principles of Ethics36 and has additional guidance on conscientious objection in its ethics handbook.37 The lines between a provider’s personal, religious, or moral objections and outright discrimination may not always be clear. Refusal to provide care for a transgender patient solely because of their gender identity would be considered an objection against working with an entire group of people and, therefore, not justifiable. In contrast, an anesthesiologist’s objection to providing anesthesia for a specific gender-affirming surgery may not necessarily be discriminatory if they would morally object to the same procedure being performed for other types of people,31 but there is risk that it might be used to mask discriminatory intentions. All anesthesiologists should be expected to approach every patient with dignity, which at minimum includes respecting a patient’s pronouns and chosen name while refraining from misgendering, deadnaming, or using other stigmatizing language. Health care providers in the United States who choose to conscientiously object are protected by the federal law.30,38 Most states also have conscience protections, but these vary in scope and extent.30 Invoking conscience to refuse a medical service should not be viewed only as an issue of individual rights because it will always affect someone else, and health care providers exercising this right should be ready to handle potential consequences.39 Colleagues and associates may take offense to their beliefs or with the extra burden placed upon them to ensure the care of the patient is not interrupted. Any failure to fulfill professional obligations, compromise in care, or discriminatory action against the patient could result in professional disciplinary action or legal liability. For anesthesiologists contemplating invoking conscientious objection, careful consideration should be made to ensure their objection is not based on discrimination and that any potential legal or professional consequences have been considered. A unique concern for training program leadership teams is how to handle a trainee that reports a conscientious objection to working with TGD patients. Teelin et al40 lay out strategies for educators to employ in this specific situation, including 1) engaging the trainee in an honest discussion about their concerns to evaluate the legitimacy of their objection, 2) avoiding propagating stigma by modeling appropriate behavior in clinical settings approaching all patients with dignity, and 3) directing learners to evidence-based resources to ensure they acquire the necessary knowledge to professionally interact with the population in question. Care must be taken that trainees do not prioritize their own conscientious objection over their obligation to treat all patients with respect. Gender minority representation and experience within anesthesiology Until recently, gender minority demographic data was rarely, if ever, included in studies examining diversity within anesthesiology. Asking survey respondents to self-disclose gender identity is difficult since doing so relies on the respondent feeling safe enough to disclose; therefore, most estimates are likely underreported. The American Board of Anesthesiology (ABA) conducted a diversity survey in 2021, which revealed that 1% and 1.3% of diplomats were transgender or gender-diverse, respectively.41 The Accreditation Council for Graduate Medical Education (ACGME) does collect gender identity data (eg, male, female, and nonbinary), but does not ask about sex assigned at birth to help better determine the number of TGD anesthesiology trainees. In 2021, only 1 trainee reported being nonbinary, representing 0.01% of all anesthesiology trainees.42 The Society of Pediatric Anesthesia (SPA) also recently conducted a survey of its membership and found that 0.27% of respondents were transgender and no one selected identities outside of the male/female binary (unpublished data). Both the ACGME and SPA survey data suggest a lack of equitable TGD representation within anesthesiology that fails to reflect the populations served. Although comprehensive gender diversity data for anesthesiology trainees is lacking, similar data about medical students is available from the American Academy of Medical Colleges (AAMC). An encouraging trend is seen as the number of TGD individuals entering the medical school has been consistently increasing. The graduating medical students in 2021 were 0.7% gender-diverse43 and the incoming medical students reported 1.2% gender diversity.44 Unfortunately, TGD patients are not the only victims of discrimination and harassment within the health care system. SGM medical students also face higher incidences of bullying, harassment, burnout, depression, and suicidal ideation during their medical training when compared with nonSGM trainees, often leading to increased self-censorship (remaining in the closet) and concerns regarding specialty choice and career trajectory.45 Madrigal et al45 found that 39.8% of SGM medical students were advised to remain closeted and not be their authentic selves at work or in residency applications, whereas 67% also reported feeling anxious that their sexuality or gender identity would negatively affect their career trajectory. Regrettably, the field of anesthesiology had a low perceived acceptance of SGM identities, only scoring higher than the surgical specialties and neurology.45 It is unclear to what extent these trends in harassment and discrimination continue for TGD anesthesiologists after completing medical training because no TGD-specific data exists. Even in the absence of more comprehensive data, it is highly likely that TGD anesthesiologists experience increased harassment and discrimination within the anesthesiology workforce. Understanding the overall acceptance of and attitudes toward TGD anesthesiologists from colleagues remains difficult, but a 2021 ABA DEI survey revealed 73 disparaging comments made by diplomats regarding gender identity.41 Another recent study revealed that SGM individuals whose behaviors fit in with societal expectations for their gender role could better succeed within anesthesiology, whereas individuals who ‘stand out’ experience higher rates of workplace discrimination.46 This additional minority stress contributes to the higher rate of burnout and workplace discrimination experienced by LGBTQ+ attending anesthesiologists in the United States and discourages SGM anesthesiologists from being their true, authentic selves at work.47 This is unfortunate as increasing the visibility of TGD anesthesiologists is an important obstacle to overcome, not only to help improve the acceptance of gender minority identities within the specialty but also to make more TGD providers feel comfortable being their authentic selves at work, thus further increasing the much-needed visibility. Special care should be taken to protect TGD trainees and colleagues from discrimination within anesthesiology departments. Supporting SGM anesthesiologists should be of paramount importance to decrease the burnout and mental health disparities experienced by this population, and because role models and mentors were cited by 67.2% of medical student respondents as the most important factor when deciding to pursue anesthesiology training.48 If TGD anesthesiologists are not currently supported in the workforce, how can it be expected to recruit and retain enough TGD trainees to finally achieve adequate representation in our specialty? Considerations for gender-affirming perioperative care TGD individuals present with a similar range of surgical care needs as the majority cisgender population. A succinct, curated discussion for both adult and pediatric providers follows below to better educate anesthesiologists on the many nuances of providing gender-affirming perioperative care. Medical and surgical history In many cases, the initial medical treatment of gender dysphoria involves the use of gender-affirming hormone therapy (GAHT) (eg, testosterone, estrogen) and/or medications that block the effects of endogenous hormones (eg, spironolactone).24 As part of the preoperative assessment, it is critical to ascertain the patient’s treatment regimen and be aware of the associated side effects, pharmacologic interactions, and practice guidelines. Whether or not to discontinue hormone therapy is a common concern, mainly over concern for increased venous thrombo-embolism risk in transfeminine patients taking estrogen. The lack of evidence to support routine discontinuation of estrogen before undergoing planned surgeries leads to inconsistencies in general practice. Leading organizations such as the World Professional Association for Transgender Health (WPATH) recommend the continuation of estrogen therapy before and after surgical procedures in transgender women who lack specific additional risk factors, such as smoking, family history, or the use of synthetic estrogens.23,49 Nevertheless, if the decision is made to stop estrogen before surgery it should always be discussed with the patient and decided in collaboration with their prescriber. Evidence also suggests there is no need to routinely discontinue testosterone in transmasculine patients before surgery. Testosterone can be aromatized to estradiol, theoretically increasing clotting risk; however, a recent systematic review did not demonstrate any increased association between venous thrombo-embolism complications and perioperative testosterone use.50,51 Hormones in cisgender individuals have been implicated in the development of obstructive sleep apnea (OSA). Both testosterone deficiency and replacement therapy are associated with increased risk of OSA.52 In a case series, 2 transgender men started on testosterone had new-onset OSA requiring continuous positive airway pressure therapy.52 In addition, the perioperative morbidity and mortality associated with spironolactone (frequently used by transfeminine individuals) have been studied extensively in the cisgender population. A placebo-controlled randomized trial showed no heightened risk of kidney injury for those taking spironolactone before surgery.53 A history of prior gender-affirming surgery may also be discovered during the preoperative interview. Anesthesiologists should be familiar with the range of facial feminization and masculinization procedures and their potential impact on airway anatomy. Mandibular angle reduction and a decrease in chin width and height may be performed as part of feminizing the lower face. Chondrolaryngoplasty involves reducing or shaving the thyroid cartilage prominence to minimize the appearance of the “Adam’s apple.”54 Procedures such as these can result in changes that may alter the alignment of the laryngeal and pharyngeal axes (eg, crowded oropharynx, shorter thyromental distance, decreased mandibular space) that may increase the difficulty of tracheal intubation. Scar tissue may decrease tissue mobility making mask ventilation challenging or obscuring anatomic landmarks needed when performing an emergent surgical airway. Vocal surgery also warrants special attention. Transgender women who have undergone vocal feminization, usually by anterior glottoplasty and vocal cord web formation, may have smaller glottic openings and require smaller endotracheal tubes.55 It is important to note that cricothyroid approximation may effectively remove the entire cricothyroid membrane and space. Transgender men who have had masculinization of the thyroid cartilage, usually by augmentation using a graft of rib cartilage, may have altered thyromental distance. Similar to the above, these procedures may lead to changes that make mask ventilation, intubation, and surgical airways more difficult.55 Risk stratification Risk models designed to estimate patients’ perioperative risk often include binary sex in the scoring systems (as opposed to gender-diverse variations), but do not account for the use of GAHT. The male sex is usually scored higher when these tools are used, and there is a significant chance of underestimating risk in transgender women if the tool for the female sex is improperly utilized. Examples of commonly used perioperative risk calculators that incorporate sex but fail to address GAHT include the: American College of Surgeons National Surgery Quality Improvement Program (NSQIP) Surgical Risk calculator, STOP-BANG score for obstructive sleep apnea, and the CHADS2-Vasc score for atrial fibrillation stroke risk. Given the lack of prospective data available, it may be advisable to select the binary sex that confers the highest risk for the particular risk being assessed so as to not underestimate it, but results must be interpreted with caution. Lab testing It is important to assess the appropriateness of a preoperative pregnancy test. The ASA Practice Advisory for Perinaesthesia Evaluation recommends that pregnancy testing may be offered to female sex patients of childbearing age for whom the result would alter the patient’s medical management, but it also states that the testing should not be mandatory and that each patient has the right to refuse screening. The 2021 update does not comment on transmasculine patients that were assigned female at birth56 and has subsequently caused confusion and even resulted in lawsuits. Fertility is unpredictably impacted by testosterone therapy, and transgender men with intact ovaries and uteri have conceived and carried pregnancies. Testosterone is not a form of contraception, and transgender men may have unintended pregnancies while amenorrheic.57 Moreover, there are many calculated laboratory parameters and reference ranges that routinely incorporate binary sex (eg, Cockcroft–Gault formula for creatinine clearance, modification of diet in renal disease glomerular filtration rate equation, hematocrit reference ranges). Refer

Wrist accelerometry for monitoring dementia agitation behaviour in clinical settings: A scoping review.

Agitated behaviour among elderly people with dementia is a challenge in clinical management. Wrist accelerometry could be a versatile tool for making objective, quantitative, and long-term assessments. The objective of this review was to summarise the clinical application of wrist accelerometry to agitation assessments and ways of analysing the data. Two authors independently searched the electronic databases CINAHL, PubMed, PsycInfo, EMBASE, and Web of Science. Nine (n = 9) articles were eligible for a review. Our review found a significant association between the activity levels (frequency and entropy) measured by accelerometers and the benchmark instrument of agitated behaviour. However, the performance of wrist accelerometry in identifying the occurrence of agitation episodes was unsatisfactory. Elderly people with dementia have also been monitored in existing studies by investigating the at-risk time for their agitation episodes (daytime and evening). Consideration may be given in future studies on wrist accelerometry to unifying the parameters of interest and the cut-off and measurement periods, and to using a sampling window to standardise the protocol for assessing agitated behaviour through wrist accelerometry.

“It’s not only the bad side” - Experiences reported by health professionals working with women victims of sexual violence in a Brazilian university specialized outpatient service: A qualitative study

IntroductionHealth Psychology is a scientific branch that studies interpersonal relationships in the field of emotions and behavior in clinical settings. Violence against women is a gender-based action that alarmingly affects the population, with sexual violence (SV) being one of its main phenomena. The complexity of the care offered to SV patients by clinical professionals impacts themselves, affecting their personal lives and the quality of their work.ObjectivesTo explore symbolic emotional meanings attributed by health professionals to care and follow-up of women victims of SV in state service of reference of the Unified Health System.MethodsClinical-Qualitative design was used to guide semi-directed interviews with open-ended questions in-depth. Clinical-Qualitative Content Analysis was employed to treat data. Five participants make up the multi-professional team at the Hospital of the Woman of the State University of Campinas. Theoretical framework chosen to interpret categories was Balintian Medical Psychology.ResultsThree categories were selected for this presentation: The human anguishes as the main challenge and handling of working with sexual violence; “To see things progressing”: to the patient and together with the team, a facilitator of the work; and “I try to leave it on the three’s leaves”: the difficult attempt to separate work from personal life.ConclusionsTaking care of SV is a very emotionally demanding task. Working with the team and see expected outcomes help clinical professionals deal with negative feelings, avoiding, for example, compensatory traumas. New research about social-cultural impacts of working with SV is important to develop institutional approaches of coping for health teams.DisclosureNo significant relationships.

Profiling nursing students' dishonest behaviour: Classroom versus clinical settings.

BackgroundWhile academic dishonesty among nursing students is becoming a global problem, the instruments used in studies on this topic are heterogeneous and, in many cases, not even validated. This makes it difficult or impossible to compare the findings on a global scale.ObjectivesTo investigate the profile of Croatian nursing students’ dishonest behaviour in classroom and clinical settings and to examine the relationship between the incidence of dishonest behaviour in both settings.Research designA quantitative cross-sectional study using a Croatian online version of the Nursing Student Perceptions of Dishonesty Scale (overall Cronbach’s alpha 0.933).Participants and research context446 nursing students from a higher education institution in Croatia, EU, in the academic year 2020/21.Ethical considerationsThe study was approved by the relevant committee of the higher education institution.Findings/resultsAlmost all participants (91.3%) performed dishonest behaviour on two or more occasions in the classroom and 32.5% did so in the clinical setting. The incidence of dishonest behaviour increased with the students’ year of BSc study (p = .008). All subscales of dishonest behaviour in the classroom were significantly and positively associated with dishonest behaviour in the clinical setting, except for the Not My Problem and Non-Compliance subscales.DiscussionBased on these results, the following should be taken into consideration: 1) dishonest behaviour in the classroom is associated with dishonest behaviour in the clinical setting; 2) even the slightest occurrence of dishonest behaviour in the clinical setting can lead to fatal events.ConclusionsThe gradual increase in BSc nursing students’ dishonest behaviour with their year of study raises several questions regarding the development of ethical and moral values in this population. This raises the need for early and continuous exposure of students to ethical content from the beginning of their studies and support from competent educators.

Historias de aprendizaje del profesionalismo en la formación de los médicos de urgencias en Colombia

IntroductionProfessionalism is a multidimensional competence based on attitudinal and cognitive skills that drives to better performances in medical practice, by stablishing effective interprofessional relationships, and offering a humanized and qualified service to the patient. However, the learning process of this competence particularly relevant in emergency rooms has not been formally developed in postgraduate medical training. The study sought to know the experiences of a group of residents and specialists in Emergency Medicine about learning professionalism during their postgraduate training, knowing the notions related to this concept and inquiring about the role model in learning professionalism during their training. postgraduate. MethodsWe developed a qualitative narrative research, with a total of 7 Emergency physicians (residents and emergency physicians) including the main researcher with his own autoethnographic text. Data collection involved narrative and interactive interviews, and reflective autoethnographic texts. A thematic analysis constructed patterns from the data. ResultsFive main themes emerged around the professionalism learning experience of emergency physicians: 1) role model, 2) anti-role model, 3) unsafe environment as a barrier to learning, 4) teaching of professionalism, 5) metacognition in the learning process. ConclusionsTeacher behavior in clinical settings become a role model to follow related to physician-patient relationship, interprofessional communication and teamwork. On the other hand, neglective behavior, missuses of clinical resources, discrimination, harassment, or bullying become anti-rol model behaviors. However, those unwanted behaviors may be learned even though students intend to act otherwise. It is necessary to design intentional curriculum in emergency postgraduate schools which include stablishing institutional cultural norms that do not tolerate aggression or other unprofessional behavior towards patients or students.

Pediatric Nursing Students' Experience of Bullying Behavior in Clinical Settings

Pediatric Nursing Students' Experience of Bullying Behavior in Clinical Settings

Nurses’ viewpoints on incivility in nursing in Iran

BackgroundIncivility behaviors in work environments are a serious threat and lead to shame and endanger the health of nurses and patients. AimThe purpose of this study was to evaluate nurses' viewpoints on Incivility behaviors in clinical setting in Bam University of Medical Sciences. MethodThis descriptive cross-sectional study was done on 221 nurses working in Pasteur Hospital in Bam. Data were collected through a demographic questionnaire and Nursing Incivility Scale by census sampling after obtaining the consent of the participants. Data were analyzed by SPSS 19 software using descriptive statistics, independent t-test, one-way ANOVA, Bonferroni post hoc and Spearman correlation tests with 95% confidence interval. ResultThe results of this study showed that the mean score of uncivil behavior among nurses was 85.99 ± 27.26. The most uncivil behaviors in nurses were related to interaction with patients and visitors (20.79 ± 8.01), and the lowest uncivil behavior was related to interaction with supervisors (13.46 ± 6.29). Results indicated that nurses experience moderate levels of Incivility. ConclusionReligious differences as one of the determinants of the occurrence of Incivility can lead to job pressures and job dissatisfaction. Therefore, specific attention should be paid to the factors that lead to the emergence of uncivil behavior in nurses' work environment. With training of religiosity, the strengthening of religious beliefs and religious conciliatory, it is possible to reduce the incidence of uncivil behaviors.

Measuring interprofessional education and collaborative practice competencies: a content validity study of the Jefferson Teamwork Observation Guide®

ABSTRACT Collaborative practice (CP) is integral in meeting the Quadruple Aim of healthcare, with effective team-based practice linked to improving all four components. Evidence of the validity of tools measuring collaborative practice competencies is lacking in educational and practice settings. The Jefferson Teamwork Observation Guide® (JTOG®), a real-time, 360-degree competency-based assessment tool administered via mobile app, provides formative feedback to learners in educational settings and helps practitioners develop and refine team-based behaviors in clinical settings. This study examines content validity evidence in terms of the linkage of JTOG items with the four Interprofessional Education Collaborative (IPEC) core competencies, along with two additional domains of leadership and patient-centeredness. Results provide content validity evidence to support use of the JTOG in interprofessional collaborative practice (IPCP) settings. The Teams and Teamwork competency was linked with every item, which is consistent with JTOG as a measure of teamwork. Aligning with the 2016 IPEC update, the JTOG items are all intercorrelated and together represent coverage across all competency areas. While items were typically linked to multiple competencies, each item only had one primary linkage. Analyses revealed that there is sufficient evidence of content validity relative to the intended IPCP competencies, and the JTOG tool is promising in its role to fill a gap in extant literature to measure collaborative practice behaviors.

Approach to aberrant social behaviors in clinical settings

Approach to aberrant social behaviors in clinical settings

Academic integrity in online examinations in a graduate nurse practitioner program: Student perceptions and lessons for nurse educators

BackgroundWhile nursing is repeatedly voted the most trusted profession, academic dishonesty is nearly as prevalent in nursing as it is in other disciplines and has been increasing for 30 years. The relationship between academic dishonesty in nursing programs and unethical behavior in clinical settings underscores the importance of exploring student perceptions of academic dishonesty. MethodThis descriptive study used a survey methodology to examine graduate nursing students’ perceptions of academic dishonesty (willingness to report cheating, exam cheating deterrents, and importance of academic integrity). ResultsThe results showed that students would report cheating, felt current processes were overall sufficient to deter cheating, value academic integrity, and take their studies seriously. Significant findings included this was more representative of students earlier in their programs vs. those nearer to graduation who felt the current program processes may not be as effective. ConclusionIt is vital that graduate nursing faculty hold students accountable and enact processes that deter cheating. Furthermore, based on the survey results, the researchers incorporated one new best practice from the literature: a syllabus statement for online courses.

Nudging healthcare professionals in clinical settings: a scoping review of the literature

BackgroundHealthcare organisations are in constant need of improvement and change. Nudging has been proposed as a strategy to affect people’s choices and has been used to affect patients’ behaviour in healthcare settings. However, little is known about how nudging is being interpreted and applied to change the behaviour of healthcare professionals (HCPs). The objective of this review is to identify interventions using nudge theory to affect the behaviour of HCPs in clinical settings.MethodsA scoping review. We searched PubMed and PsycINFO for articles published from 2010 to September 2019, including terms related to “nudging” in the title or abstract. Two reviewers screened articles for inclusion based on whether the articles described an intervention to change the behaviour of HCPs. Two reviewers extracted key information and categorized included articles. Descriptive analyses were performed on the data.ResultsSearch results yielded 997 unique articles, of which 25 articles satisfied the inclusion criteria. Five additional articles were selected from the reference lists of the included articles. We identified 11 nudging strategies: accountable justification, goal setting, suggested alternatives, feedback, information transparency, peer comparison, active choice, alerts and reminders, environmental cueing/priming, defaults/pre-orders, and education. These strategies were employed to affect the following 4 target behaviours: vaccination of staff, hand hygiene, clinical procedures, prescriptions and orders. To compare approaches across so many areas, we introduced two independent dimensions to describe nudging strategies: synchronous/asynchronous, and active/passive.ConclusionThere are relatively few studies published referring to nudge theory aimed at changing HCP behaviour in clinical settings. These studies reflect a diverse set of objectives and implement nudging strategies in a variety of ways. We suggest distinguishing active from passive nudging strategies. Passive nudging strategies may achieve the desired outcome but go unnoticed by the clinician thereby not really changing a behaviour and raising ethical concerns. Our review indicates that there are successful active strategies that engage with clinicians in a more deliberate way. However, more research is needed on how different nudging strategies impact HCP behaviour in the short and long term to improve clinical decision making.

How We Talk About "Perpetration of Intimate Partner Violence" Matters.

Many partners and children who are affected by intimate partner violence (IPV) are unable to leave abusive situations that put their health and safety at risk. Family physicians provide care for people who perpetrate IPV and are in a role that may allow them to recognize and counsel patients who are using violence. Appropriate referrals can potentially help these patients access effective interventions such as certified battering intervention programs in a manner that prevents violence for their families. The language used by physicians can facilitate or impede disclosures among patients perpetrating IPV who may be open or willing to discuss their use of violence. Talking about their behavior in ways that patients perceive as derogatory or confrontational may alienate people who use violence from initiating or engaging in meaningful discussions about their abusive behaviors in clinical settings and getting the help they need to stop their violence. To enable patients to safely talk about their own perpetration of violence, physicians need to develop appropriate language and a nuanced, evidence-based approach to broaching and discussing this issue with patients. As with other patient populations, being labelled may not accurately describe their identity, behavior, nor experiences, and result in them avoiding care. In keeping with trauma-informed approaches, we provide possible examples of respectful nonjudgmental language and nonthreatening clinically appropriate questions for people who use violence. Additional research is needed to identify how best to discuss perpetration of IPV with patients to help initiate change in their behavior while maintaining victim safety.