Trauma-informed Care Training Research Articles

Evaluating a Trauma-Informed Care Training Program for Mental Health Clinicians

AbstractThe aim of this study was to evaluate the interRAI Trauma-Informed Care (TIC) training program based on evidence-informed Collaborative Action Plans. Focus groups and the Attitude Related Trauma-Informed Care (ARTIC) questionnaire addressed clinicians’ and mental health professionals’ attitudes toward the application of TIC with their child and youth clients. An explanatory sequential design was conducted. In total, 105 clinicians and mental health professionals who participated in a 4-hour, in-person or virtual TIC training, two comprehensive seminars, and 28 trauma-informed training web-based modules completed the ARTIC questionnaire. Researchers conducted seven focus groups with clinicians/participants (N = 23) to discuss the views and effectiveness of the interRAI TIC educational training modules. To quantitatively measure the change of attitudes towards TIC, descriptive statistical analysis was completed using the means and standard deviation of the ARTIC scores at the initial time point, the follow-up time point, and the difference between scores at both time points. Paired sample t-tests were conducted on both the overall score and each of the subscales in each of the three samples (total sample, online subsample, and hybrid subsample). A thematic analysis was conducted to generate qualitative findings from the focus groups. Findings from the quantitative and qualitative analyses suggest that the interRAI TIC training provided clinicians with an improved sense of knowledge and ability to apply trauma-informed care planning with their clients.

Occupational Therapists' Perspectives and Role With Illness-Induced Trauma From Medical Conditions.

Illness-induced trauma (IIT) might cause a disruption in an individual's occupational performance. To examine occupational therapy practitioners' (OTPs) perspectives and role in addressing IIT. In this descriptive mixed-methods design, 24 OTPs completed an online survey and 10 OTPs participated in a semi-structured 1:1 interview. Survey questions asked about knowledge regarding IIT. Interviews addressed incorporation of IIT knowledge and trauma-informed care (TIC) into practice. Quantitative results showed most OTPs (64%) did not receive TIC training and believed training was inadequate. Qualitative results indicated three major themes: "Impact on Rehabilitation," "Variety of OT Approaches for IIT," and "Barriers to Providing Trauma-Informed Care." Although OTPs report inconsistencies with incorporating TIC into practice, there are similarities with foundational OT skills and TIC. Findings suggest OTPs utilize a TIC approach to support clients with IIT to process and re-engage in meaningful occupations.

Trauma-informed Care Training in Trauma and Emergency Medicine: A Review of the Existing Curricula.

Greater lifetime exposure to psychological trauma correlates with a higher number of health comorbidities and negative health outcomes. However, physicians often are not specifically trained in how to care for patients with trauma, especially in acute care settings. Our objective was to identify implemented trauma-informed care (TIC) training protocols for emergency and/or trauma service physicians that have both sufficient detail that they can be adapted and outcome data indicating positive impact. We conducted a comprehensive literature search in MEDLINE (Ovid), Scopus, PsycInfo, Web of Science, Cochrane Library, Ebsco's Academic Search Premier, and MedEdPORTAL. Inclusion criteria were EM and trauma service clinicians (medical doctors, physician assistants and nurse practitioners, residents), adult and/or pediatric patients, and training evaluation. Evaluation was based on the Kirkpatrick Model. We screened 2,280 unique articles and identified two different training protocols. Results demonstrated the training included patient-centered communication and interprofessional collaboration. One curriculum demonstrated that targeted outcomes were due to the training (Level 4). Both curricula received overall positive reactions (Level 1) and illustrated behavioral change (Level 3). Neither were found to specifically illustrate learning due to the training (Level 2). Study findings from our review show a paucity of published TIC training protocols that demonstrate positive impact and are described sufficiently to be adopted broadly. Current training protocols demonstrated an increasing comfort level with the TIC approach, integration into current practices, and referrals to trauma intervention specialists.

Evaluating the effectiveness of trauma-informed care training delivered to staff in community Older Adult Mental Health Services

Purpose By older adulthood, the majority of individuals will have experienced at least one traumatic event. Trauma-informed care (TIC) is proposed to improve effectivity of health-care provision and to reduce likelihood of services causing retraumatisation. This study aims to assess the effectiveness of staff training in TIC in older adult services. Design/methodology/approach TIC training was delivered across eight Older Adult Community Mental Health Teams in the same UK organisation. Questionnaires were administered before and after training: a psychometrically robust measure, the Attitudes Related to Trauma-Informed Care, was used to assess TIC-related attitudes, and a service-developed scale was used to measure changes in TIC competence. Data was analysed using linear mixed effects modelling (LMM). Qualitative data regarding the impact of training was gathered one month after training through a free-text questionnaire. Findings There were 45 participants, all of whom were white British. LMM on pre- and post-data revealed that staff training significantly increased competencies across all measured TIC domains. Overall, staff attitudes were also significantly more trauma-informed after training. Qualitatively, staff identified time as the only additional resource required to deliver the skills and knowledge gained from training. Practical implications Training was found to be effective in increasing TIC-related skills and attitudes. Organisations aiming to become trauma-informed should consider staff training as one aspect of a wider development plan. Originality/value To the best of the authors’ knowledge, this paper is the first to examine TIC training for staff working in Older Adults Mental Health Services. Recommendations for services aiming to develop a trauma-informed culture have been provided.

Trauma-Informed Care Training in Forensic Mental Health Services: A Scoping Review

Within forensic populations, exposure to traumatic experiences is high. These experiences are associated with multiple mental and physical health problems later in life. Forensic services would therefore ideally adopt a trauma-informed approach. The aim of this scoping review is to identify trauma-informed training or education for staff within forensic mental health care. A database search of English or Dutch language articles from PubMed, PsycINFO, Embase, Scopus and Web of Science was performed. Researchers reviewed 6,386 articles and nine were included for final analysis, all in justice-involved youth populations. Results show that training in trauma-informed care may facilitate the relationship between staff members and residents and create safer treatment units. Besides this, a reduction in post-traumatic stress symptoms and greater clinical improvement in depression, anxiety, hope and optimism among justice-involved youth was noted. Trauma-informed staff training may also lead to a decrease in incidents taking place as well as a decrease in use of restraints and seclusion.

Trauma-Informed Care Training in U.S. and Canadian Ob/Gyn Residencies.

This is a cross-sectional study investigating the prevalence and nature of trauma-informed care (TIC) training in obstetrics and gynecology residency programs. In our sample, 20% of programs had annual TIC training, 53% had less than annual training, and 27% had no training at all. Only 25.3% of respondents were satisfied with their current training in interpersonal trauma and TIC. A lack of facilitators to conduct such training was the primary barrier to implementing TIC. Significant opportunity exists to improve TIC education for Ob/Gyn trainees.

Trauma-Informed Primary Healthcare for Parents: Multidisciplinary Experiences in Rural Service Implementation

ABSTRACT Trauma-informed approaches to service delivery increase awareness of the pervasiveness of trauma exposure and acknowledge the lifelong effects of traumatic stress on health and wellbeing. This study explored workforce experiences of trauma-informed primary healthcare for parents. A face-to-face workshop was conducted with 14 Victorian rural professionals in 2021. Local workforce survey results (n = 63) about trauma-informed care were presented to the group (50% social workers) and they discussed strategies for system implementation. Content analysis was used to develop four categories from the transcribed workshop discussion: (1) primary healthcare understanding of complex trauma; (2) primary healthcare responses to parents; (3) trauma-informed care training; and (4) community and relational strategies to foster trauma-informed care. Our findings highlighted that structural barriers relating to resource control and restrictive program design negatively impact trauma-informed approaches. In contrast, trauma-informed service delivery is enabled by collaboration and building relationships between clients, the workforce, and organisations. In discussing these findings, we draw upon notions of power: namely, discursive, epistemic, and material power, which affect equity. To ensure the client’s voice is prioritised when planning trauma-informed care, we recommend the integration of local knowledge and the embedding of community-based strategies throughout all implementation processes. IMPLICATIONS Preparation for trauma-informed care implementation in rural primary healthcare requires strategies to identify and address structural barriers. Increased use of implementation frameworks would enhance multidisciplinary innovation in trauma-informed practice and adaptation when supporting parents. Employing a typology of discursive, epistemic, and material power to implementation processes has beneficial application in social work to challenge systemic reproduction of inequity.

What is known about the application of trauma-informed care within services for people with intellectual and/or development disabilities?

Trauma-informed care (TIC) is gaining momentum in various health, social, and educational settings globally in response to the widespread pervasiveness of adverse experiences and resultant psychological trauma. Given that people with intellectual and/or developmental disabilities (IDD) are more likely to experience traumatic life events than the general population, it makes sense that TIC should be in place within services supporting individuals with IDD. Yet there is a dearth of empirical research exploring the integration of TIC in such organisations and the spread of limited available literature is diverse. Thus, this paper aimed to scope and synthesise the emerging literature to elucidate what is known -regarding TIC in the context of IDD. A scoping review was conducted using the Arksey & O’Malley (2005) guidelines. Three databases, PsycINFO, Web of Science, and PubMed, were searched using relevant search terms to retrieve 69 papers published since 2000, which were systematically screened for eligibility. Twenty-three papers comprising a range of source types met inclusion criteria and were reviewed rigorously, with included empirical studies appraised using the mixed methods appraisal tool (MMAT; Hong et al., 2018). The PAGER framework (Bradbury-Jones et al., 2022) was followed to generate four patterns from the findings: (1) Opportunities for Embedding TIC within IDD Contexts, (2) Incorporating TIC Principles into Specific IDD Service Models, (3) Implementing TIC across Micro, Meso, and Macro Levels, and (4) Challenges and Barriers to Implementing TIC in IDD Organisations. There is a growing body of literature exploring the implementation of TIC within IDD organisations, including newly emerging TIC training programmes for staff. Yet there remains a lack of empirical implementation research examining outcomes for service providers and recipients. Tentative evidence for clinical practice and research recommendations from each pattern of findings are discussed, along with strengths and limitations of this review.

Brief trauma-informed care training to enhance health care providers' knowledge, comfort, and implementation of trauma-informed care in primary care clinics: A pilot effectiveness study.

Trauma-informed care (TIC) training may be valuable for patient-facing health care providers within primary care in urban health care settings serving patients with high levels of trauma exposure. This study tested the pilot effectiveness of a clinic-wide TIC initiative to enhance providers' knowledge, comfort in caring for trauma-exposed patients, and implementation of TIC within a primary care clinic of an urban safety net hospital using a single-arm longitudinal within-subjects design. Measures were obtained at baseline (T1), posttraining (T2), 1-month (T3), and 6-months (T4). Twenty-nine providers who completed TIC training were included in study analyses. Twenty-one completed T2 and 14 completed T3 and T4. Knowledge was measured with the Providers' Knowledge Regarding Injury-Related Posttraumatic Stress, comfort with a researcher-generated two-item measure, and TIC implementation with an eight-item binary scale from the Trauma Provider Survey. Repeated-measures general linear model examining within-subjects change over time in knowledge was significant (n = 8; F₃ = 4.74, p = .01, ηp² = .40); the model measuring change in comfort was not significant but trending (n = 9; F₃ = 4.56, p = .06). The model examining change in TIC implementation from T1 to T4 was not significant (n = 14; F3 = 4.32, p = .21). This pilot study demonstrated the preliminary effectiveness of a brief TIC training on improving health care provider knowledge and comfort working with trauma-exposed patients that sustained through 6-months posttraining. The findings indicate that additional support is needed to change behaviors in provider implementation of TIC in primary care clinic settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Trauma-Informed Care Training for Dietetic Interns Improves Attitudes Toward Women Who Have Experienced Trauma

ObjectiveTo assess change in attitudes toward women who have experienced trauma and to describe interns’ reflections regarding the provision of universal trauma precautions and the training sessions. MethodsDietetic interns participated in 3 2-hour trauma-informed care (TIC) training sessions. A multiple-methods design was used, incorporating a presurvey and postsurvey to assess change in attitudes and thematic analysis to assess self-reflections. ResultsThe attitudes of the interns improved across all statements. Two components measuring attitudes about sympathetic feelings toward mothers with underlying trauma and substance use disorder during pregnancy and retaining custody of their children reached statistical significance (P < 0.05). Four themes were identified in the self-reflections: TIC training was informative, valuable, and warranted, and interns felt comfortable discussing TIC. Conclusions and ImplicationsStudents positively assessed the TIC training and changed their attitudes. Trauma-informed care can be effectively incorporated within dietetics education to support students in developing therapeutic relationships in their future nutrition care standards.

An evaluation of trauma informed care training to multi-agency professionals in Herefordshire

BackgroundAdverse experiences can have a significant impact on individuals mental and physical health. Trauma informed approaches have been called upon to address this, with a focus on Trauma Informed Care (TIC) across services. One element of this approach is the delivery of training.Aims &amp; RationaleAims of this evaluation are to consider attendees level of awareness, knowledge and perceived relevance of TIC before and after a TIC training session, in hope of spreading awareness of this approach. Further aims considered evaluating the attendees’ views about the most and least valuable parts of the session, including how they might implement TIC in their working practices.MethodologyA mixed method design was employed. Respondents completed pre- and post-training questionnaires regarding their awareness, knowledge and perceptions of relevance to their roles, as well as their views regarding the content of the training and how they might implement this in their work. Quantitative analysis using the Wilcoxon signed rank test was employed, alongside the use of template analysis for the qualitative data.ResultsThe analysis showed that attendee’s level of awareness, knowledge and relevance of TIC had significantly increased following attendance at the TIC training session. Qualitative template analysis identified nine sub themes within the three main themes.DiscussionResults revealed that the training had a positive effect on the awareness, knowledge and perceived relevance of TIC for attendees. These findings are discussed in relation to existing literature and the implications of these are considered, alongside possible recommendations for future training, based on possible limitations of the study.

The Importance of Multidisciplinary Trauma-Informed Training in Addressing Campus-Based Sexual Violence.

This study investigates the impact of a professional development training series among a multidisciplinary team (MDT) during establishment of a trauma-informed sexual assault response and prevention program at a midsized university in the southeastern United States. MDT members included forensic nurses, advocates, counselors, law enforcement officers, and relevant faculty and staff. After completion of a baseline survey assessing attitudes toward trauma-informed care and perceptions of the team climate within the MDT, team members engaged in a trauma-informed care (TIC) professional development training series consisting of (a) 4-hour-long didactic lectures with incorporated group discussion and (2) one 2-hour in-situ simulation-based training exercise. MDT members subsequently completed 3-month and long-term follow-up surveys to assess the immediate and enduring impacts of the training series.The TIC training series significantly increased MDT members' perceptions of participative safety, task orientation, and support for innovation within the group at the 3-month assessment. No long-term differences were found, likely because of a small sample size and low statistical power.Intensive TIC MDT professional development at the beginning of a campus-wide sexual assault prevention and response initiative enhances psychological safety within the group, evidenced by increased perceptions of participative safety and support for innovation, and builds team cohesiveness around a shared set of tasks. Within the present MDT, the professional development training series also appeared to facilitate adoption of a shared set of values for accomplishing the team's goal of preventing and responding to sexual assault on campus. Recommendations for MDTs with similar goals are discussed.

Primary Care Providers' Knowledge, Perceptions, and Practice of Trauma-Informed Care in a Public Health Care Setting.

Despite serving patients with especially high rates of trauma exposure and related sequelae, many primary care providers do not receive specialized training in the provision of trauma-informed care (TIC). This study sought to document primary care providers' baseline rates of TIC training and their knowledge, perceptions, and practice of TIC at a large, urban public hospital in the Southeastern United States. Participants (n = 67; 68.7% women; 44.8% white; Mage = 36.7 years, standard deviation [SD]age = 9.8 years) completed an online self-report survey on their TIC training status, trauma-related knowledge, perceptions, and practices, as well as burnout and secondary traumatic stress. Less than half of participants (43.3%) endorsed TIC training exposure. Participants generally had adequate levels of trauma-related knowledge (76.5% of items correct) and favorable perceptions of TIC (endorsed 89.7% of TIC-supportive statements). Most participants (86.6%) endorsed recently using trauma-informed practices, but only 47.8% reported routinely screening for trauma-related disorders. Participants who reported receiving prior TIC training scored better on knowledge items and endorsed recently using more trauma-informed practices than those who did not have training exposure. TIC training status' associations with current screening practices and perceptions of TIC were trending toward significance. TIC training status was not related to burnout, and trained participants reported greater secondary traumatic stress than those without training exposure. Results point to system-wide TIC training as a well-received, translational strategy that can enhance the trauma-informed nature of primary care provision.

Impact of Trauma-Informed Care Training on Attitudes Among Emergency Department Personnel, Staff Advocates, and Nursing Students.

Health care providers may risk retraumatizing patients and intensifying patient distress unless they practice trauma-informed care. As the first line of defense in assisting trauma survivors' physical and emotional recovery, health care providers must use a strengths-based framework that promotes resilience and expands on the trauma survivor's existing resources. This study aimed to compare the effect of trauma-informed care training on the attitudes of emergency department personnel, staff advocates, and nursing students toward trauma-informed care. This study used a pretest-posttest design. Assessment of attitudes toward trauma-informed care was done before and after trauma-informed care training. Data collection occurred from February 2021 through August 2021. Participants included three cohorts of emergency department staff, advocates for trauma survivors, and nursing students. Attitudes toward trauma-informed care were measured using the Attitudes Related to Trauma-Informed Care (ARTIC) Scale. A total of 433 participants were studied, including 88 emergency department staff, 123 staff advocates, and 222 nursing students. All three cohorts significantly increased ARTIC Scale scores posttraining (p < .001). At preintervention, all three cohorts significantly differed from each other on ARTIC Scale scores (p < .01). In contrast, postintervention, ARTIC Scale scores did not significantly differ between nursing students and advocates (p = .99). Nursing students showed a significant increase in scores from pre- to postintervention compared with either advocates or emergency department staff. The results strongly suggest that health care providers can improve attitudes toward trauma-informed care after completing training on the principles and application of trauma-informed care.

Impact of Trauma-Informed Care Training on Attitudes Among Emergency Department Personnel, Staff Advocates, and Nursing Students.

Impact of Trauma-Informed Care Training on Attitudes Among Emergency Department Personnel, Staff Advocates, and Nursing Students.

Trusted residents and housing assistance to decrease violence exposure in New Haven (TRUE HAVEN): a strengths-based and community-driven stepped-wedge intervention to reduce gun violence

BackgroundWe describe the rationale and study design for “TRUsted rEsidents and Housing Assistance to decrease Violence Exposure in New Haven (TRUE HAVEN),” a prospective type 1 hybrid effectiveness/implementation study of a multi-level intervention using a stepped wedge design. TRUE HAVEN aims to lower rates of community gun violence by fostering the stability, wealth, and well-being of individuals and families directly impacted by incarceration through the provision of stable housing and by breaking the cycle of trauma.DesignTRUE HAVEN is an ongoing, multi-level intervention with three primary components: financial education paired with housing support (individual level), trauma-informed counseling (neighborhood level), and policy changes to address structural racism (city/state level). Six neighborhoods with among the highest rates of gun violence in New Haven, Connecticut, will receive the individual and neighborhood level intervention components sequentially beginning at staggered 6-month steps. Residents of these neighborhoods will be eligible to participate in the housing stability and financial education component if they were recently incarcerated or are family members of currently incarcerated people; participants will receive intense financial education and follow-up for six months and be eligible for special down payment and rental assistance programs. In addition, trusted community members and organization leaders within each target neighborhood will participate in trauma-informed care training sessions to then be able to recognize when their peers are suffering from trauma symptoms, to support these affected peers, and to destigmatize accessing professional mental health services and connect them to these services when needed. Finally, a multi-stakeholder coalition will be convened to address policies that act as barriers to housing stability or accessing mental healthcare. Interventions will be delivered through existing partnerships with community-based organizations and networks. The primary outcome is neighborhood rate of incident gun violence. To inform future implementation and optimize the intervention package as the study progresses, we will use the Learn As You Go approach to optimize and assess the effectiveness of the intervention package on the primary study outcome.DiscussionResults from this protocol will yield novel evidence for whether and how addressing structural racism citywide leads to a reduction in gun violence.Trial registrationClinicalTrials.gov Identifier: NCT05723614. Registration date: February 01, 2023. Please refer to https://clinicaltrials.gov/ct2/show/NCT05723614 for public and scientific inquiries.

Investigating Physician Training, Knowledge, and Response to Human Trafficking at an Academic Medical Center in Texas

ABSTRACT Health-care settings are critical for identifying and assisting persons who have experienced human trafficking. Studies estimate that victims have been cared for at multiple clinical sites, but the majority of victimization remains undetected due to lack of awareness, training, and time. This study examined physician human-trafficking knowledge, training, usual practice regarding response, and education modality preferences at an academic medical center. A 24-item survey was distributed to residents and faculty in family medicine, emergency medicine, psychiatry, pediatrics, oral and maxillofacial surgery, and orthopedics. Univariate and bivariate analysis were used to measure associations, demographics, and training across human trafficking (HT) knowledge, training, and usual practice. Respondents were largely identified as female (71%) and trainees (68%). Most respondents specialized in family medicine (32%), pediatrics (30%), or emergency medicine (19%). Overall, 85% of participants agreed that recognizing HT is a physician’s responsibility, however only 31% felt comfortable discussing HT with patients. Knowledge of HT was generally higher among attendings compared to residents (p-value = .04). More than half of participants (60%) reported never receiving HT or trauma-informed care training, but most reported that standard training should include HT (86% agree or strongly agree). Sixty-four percent of clinicians reported a preference of training administered through webinars or during didactic sessions. Physicians across various training levels agree that recognizing HT is a key responsibility. Standard medical training should incorporate HT and trauma-informed care and address knowledge gaps in order to equip clinicians to better detect, treat, and refer victims for the care they need. This study supports progress toward the UN Sustainable Development Goal 16 promoting just, peaceful and inclusive societies.

A qualitative study on community-based doulas’ roles in providing culturally-responsive care to migrant women in Australia

BackgroundThere is limited exploration into how culturally-responsive care may be provided to migrant women through community-based doulas. AimWe aim to explore the roles of community-based doulas in providing culturally-responsive care to migrant women in Australian maternity settings, from the perspectives of maternity care providers and doulas. MethodsWe used an interpretive phenomenological qualitative approach with in-depth interviews with 30 maternity care providers and Birth for Humankind doulas, in Victoria, Australia. All interviews were conducted over video-call and inductive thematic analysis was performed using NVivo software. FindingsDoulas were seen to support and enhance migrant women’s maternity care experiences through numerous ways, strengthening cultural-responsive care provision. There were three domains which described the role of doulas in providing migrant women with culturally-responsive care: 1) enhanced care; 2) respectful care; and 3) supportive relationships with providers. The three domains included seven themes: 1) continuous individualised support; 2) social connectedness; 3) creating safe spaces; 4) cultural facilitator; 5) non-judgemental support; 6) enhancing communication and rapport with providers; and 7) making connections. DiscussionDoulas appeared to counter negative factors that impact migrant women’s maternity care experiences. Doulas with previous professional birth support qualifications and trauma-informed care training were equipped to create safe spaces and increase emotional safety for migrant women. Doulas may also have more responsibilities expected of them by providers when connecting migrant women with additional services in situations that may be missed through hospital care. ConclusionBirth for Humankind doulas in Victoria play an important role in providing culturally-responsive care to migrant women. Employment models may be the next steps in acknowledging their valuable contribution as a complementary service to maternity settings.

Integration of Trauma-informed Care Into the Doctor of Pharmacy Curriculum

Trauma-informed care (TIC) is a framework based on understanding and responding to individuals’ experiences of psychological trauma (defined as harmful circumstances that have a lasting impact on emotional well-being), as well as fostering their sense of safety and empowerment. Health profession degree programs are increasingly integrating TIC training into their curricula. Although literature is scarce regarding TIC education in academic pharmacy, student pharmacists will likely encounter patients, co-workers, and peers who have experienced psychological trauma. Students may also have experienced psychological trauma themselves. Therefore, student pharmacists would benefit from TIC learning, and pharmacy educators should consider implementing trauma-informed education. This commentary defines the TIC framework, explores its benefits, and considers an approach to implementing the TIC framework in pharmacy education with little disruption to existing curricula.

Trauma-Informed Care and How Social Media Contributes to Trauma.

Trauma has become an important part of medical care as we continue to understand further its effects on health over time. Trauma-informed care therefore has become a necessary part of medical services. Understanding the fundamentals of trauma-informed care and how it was developed is crucial to implementing this care into medical training and across all medical services involved in children's health. This leads to the framework created for the public health approach of trauma-informed care, with primary, secondary, and tertiary levels of management. Social media has also increasingly been implicated in contributing to trauma, including causing vicarious trauma, which can be just as detrimental to health and wellness. If we can encourage advocating for trauma-informed care training and policies across medical services, we can create a system with a focus on this growing factor in health care. [Pediatr Ann. 2023;52(3):e78-e80.].