Reflective Practice as a Tool to Overcome the Barriers to Adverse Childhood Experiences Screening in Adults

Abstract

Problem: There is a significant dose-dependent relationship between traumatic experiences faced in childhood and poor adult health outcomes including substance abuse, chronic psychological and physical disease, and early mortality. Childhood trauma alters the chemistry of the developing brain and body, negatively influencing long-term health. The Adverse Childhood Experiences (ACE) screening tool is a binary response questionnaire consisting of ten questions that assess for history of childhood trauma. Despite mounting evidence to support the use of this tool and the great potential to enhance preventive, trauma-informed care, screening of adults for Adverse Childhood Experiences in primary care is not common practice. Perceived barriers to implementation cited by providers include time constraints, lack of training and confidence in screening and management of patients with a history of childhood trauma. Duchesne Clinic began the process of screening for ACEs by admission staff during the qualifying process. However, providers required support and guidance as they began to discuss the screening results with their patients and integrate ACE screening scores into plans of care. Project Aim: The aim of this project was to implement a guided reflective practice intervention with Duchesne Clinic providers to facilitate management of patients with high ACE scores. Project Method: This was a quality improvement (QI) DNP project at a safety net clinic in Kansas City, KS. Pre and post-intervention survey data was analyzed to assess changes in providers’ confidence and perceived barriers to management of patients with high ACE scores after four weeks of guided reflective practice intervention. Additionally, thematic analysis was performed to identify themes expressed by the providers in their reflection of their encounters with patients and their perceptions regarding management of patients with high ACE scores. Findings: Each of the seven questions on the ACE Provider Questionnaire yielded mean gains ranging between 0.25 to 1.2. A thematic analysis of the notes taken during all the interviews over the four-week guided reflective practice intervention produced the following themes: time as a barrier; feeling unprepared and unable to help patients with trauma history; re-traumatization; and strategies and tools for caring for patients with a history of trauma. Conclusions: Guided reflective practice was a successful tool to assist the providers at Duchesne Clinic to gain confidence and reduce the barriers to caring for patients with high ACE scores. Additionally, the sessions facilitated rich, honest and productive conversations between the Project Director, the Medical Director of Duchesne and each of the five providers and yielded a set of best practices for ACE screening and management at Duchesne Clinic.