Shoshana Aronowitz’s first nursing job brought her to a methadone clinic in Vermont, where she worked with people experiencing substance use disorders and, in some cases, people who had survived opioid overdoses. “This was before fentanyl had changed the drug supply and led to this massive spike in opioid overdoses,” Aronowitz, PhD, MSHP, FNP-BC recalls. She became increasingly interested in how clinician hesitancy to prescribe opioids in the context of the opioid overdose crisis might impact how they managed the pain experienced by patients with serious injuries, especially violent injuries such as gunshot wounds and stabbings. Before long, this led Aronowitz to Penn Nursing to pursue her PhD as a Robert Wood Johnson pre-doctoral fellow associated with the Penn Injury Science Center (PISC).

It was here, at one of the U.S. injury science research centers with funding from the Centers for Disease Control and Prevention, where Aronowitz found herself engaging with an intriguing question—what if the American opioid overdose crisis could be classified as an event of mass injury?

Injuries are often thought of as physical events arising from bad luck—an ankle fracture from slipping on ice, or whiplash suffered in a car accident. But at PISC, the definition of “injury” and our understanding of why injuries occur is expanding and acknowledging the context in which injuries happen. “Oftentimes, policies that come from the War On Drugs make it hard for us to offer evidence-based treatment to overdose survivors, or to pursue interventions that can prevent future overdoses,” Aronowitz says, nodding to the historic criminalization of substances in the U.S. Underscoring contexts like this—the backdrop against which injuries can occur—reflects the way that health care providers and researchers are pinpointing the physical and social forces that shape health outcomes in the U.S. As racial and economic inequalities, and outdated public policies contribute to disparate standards of living, injuries are increasingly being recognized as structural problems, which must be addressed with structural thinking.

 

“There are potential physical and emotional injuries that come from motor vehicle crashes among adolescents. An unexpected event …exposes them to visual, auditory and sensory traumas.”

At the Penn Injury Science Center, this type of holistic “systems mindset” is the guiding light for nurse scientists whose research focuses on not just injury treatment and recovery, but also on prevention. It’s a three-step framework— stop injuries from occurring, fix injuries at the right time and place, and make it possible for those who’ve suffered injuries to heal and live on. And the best way to see this model in action is to meet Penn Nursing’s injury science researchers.

 

What Makes An Injury?

To successfully prevent or treat an injury, it’s necessary to agree on what an injury can be. But defining “injury” is more than just expanding the list of physical and psychosocial events that can lead to pain and suffering for an individual person. The total impact of those events is also a crucial consideration for injury science researchers. Sara Jacoby, PhD, MPH, MSN, FAAN, the Calvin Bland Fellow at Penn Nursing and an Assistant Professor of Nursing whose work focuses on structural inequities and health outcomes in urban areas, once worked as an ICU nurse in Philadelphia: an experience which illustrated how surviving an acute hospitalization is often just “the tip of an iceberg” for people who’ve suffered injuries. “The social, economic, and psychological ramifications of injury can alter the course of an entire life,” Jacoby says. “There’s still this tremendous invisibility of the actual consequences of an injuring event.”

According to Jacoby, recognition of that invisibility in relation to the tremendous burden that injuries create for individuals and populations, is one of the things that helped spark the recent interest in growing injury science as a research field in the U.S. “Historically, most of the national data on injuries culled through federal agencies like the CDC is based on the reporting of injury-related deaths,” Jacoby explains. “We know a lot about people who die from injury, but many more people will survive their injuries and what’s difficult is understanding the true burdens they face. Especially within privatized health systems where data that would give us a clearer picture isn’t necessarily routinely shared or available for research.” The job of researchers in injury science, at a foundational level, is to create that picture by engaging with people who’ve suffered injury—to understand the etiology of injurious events and identify interventions.

This holistic approach to better understanding the story of injury is exemplified in the preventative research of Catherine C. McDonald, PhD, RN, FAAN, the Dr. Hildegarde Reynolds Endowed Term Professor of Primary Care Nursing and a pediatric nurse scientist appointed as one of PISC’s co-directors in 2022. McDonald notes that injury is the leading cause of death among adolescents in the U.S.; one of the most deadly causes of preventable injury—motor vehicle crashes—is a pillar of her research. “We are seeing in transportation safety an attention to not only reduction of motor vehicle crashes, but also ways to promote safe, independent driving that helps address inequities,” McDonald says. “Access to safe, independent transportation can help an adolescent access education, employment, and health care. Yes, we want to reduce motor vehicle crashes, but we don’t want to unnecessarily restrict driving to only those with resources.”

Bearing in mind equity of access to driving support systems, McDonald is currently teaming up with colleagues from the University of Edinburgh, Universities of Alabama Birmingham and the Children’s Hospital of Philadelphia, recruiting parent-teen pairs to test the effects of a comprehensive driver safety program—Drivingly—that was specifically developed for their research. “The Drivingly program involves two health coaching sessions for parents, access to online psychoeducational curriculum for parents and teens, an interventional on-road driving assessment and self-reflection session for teens, and a debrief for both the parents and teens after the on-road driving assessment,” McDonald explains. Toward the opposite end of the age spectrum, George Demiris, PhD, FACMI, a Penn Integrates Knowledge University Professor, has focused his research on the impact of injuries that older adults can suffer as they age. “Falls and fall-related injuries are common among older adults,” Demiris says. “And as we think about injury from a fall, we’ve come to recognize that the consequences are not only measurable in terms of hospitalization costs and use of health care services. The psychological impact can often lead to frailty.” Much of Demiris’s work has involved using smart home technology to create fall risk predictions in spaces where elders must contend with housing that lacks supports like grab bars and railings. But physical hazards can extend well beyond the home. “It’s often recommended that people with mobility limitations walk more outside their residence,” Demiris says. “But their residence may not be in a walkable area, so engaging in physical activity outdoors may not be a safe strategy. Air quality, ice or excessive heat, traffic, and pollution are all factors that can affect an older adult’s health, well-being, and their safety.”

What Demiris and McDonald’s respective research makes clear is that injuries don’t just happen to people. They are often precipitated by forces and circumstances that are often beyond any one person’s control. This means that injury science researchers have to move in two directions: venturing upstream and downstream to prevent injury from occurring, or to help patients begin the long process of recovering from injuries that have happened and the related traumas that linger.

Environmental Roots

“People tend to think about injury differently,” says Therese S. Richmond, PhD, RN, FAAN, the Andrea B. Laporte Professor of Nursing. “You can look at it as an acute physical moment where energy damages the body, but injury is so much more. It is the result of a web of social, economic, and environmental factors experienced by an individual that increase the chance that an injury will occur.” Richmond has spent more than 30 years studying the impact of injuries on people from marginalized communities and identifying the environmental forces—physical and social—that can lead to suboptimal recovery and lay the groundwork for subsequent injury. “We are now examining upstream factors such as adverse childhood experiences (ACEs) which tend to be hidden within the home and unknown, and neighborhood factors related to injury risk and recovery,” Richmond says.

In the U.S., some people are more affected by ACEs (adverse childhood experiences) than others. This includes Latina immigrant women. Carmen Alvarez, PhD, CRNP, CNM, FAAN, an Associate Professor of Nursing, witnessed the physiological effects of ACEs when working in community clinics and providing care for patients with chronic diseases such as diabetes and hypertension. “The people that I have been caring for are often very low income with low educational attainment, and with that comes managing crisis after crisis, day after day,” Alvarez says. “And so, I noticed that people who had a history of trauma in their lives— whether it was experiencing abuse in childhood or in a domestic partnership—really struggled a lot more with dealing with crises and managing their chronic diseases with steps like remembering to eat well or getting physical activity.” Alvarez’s clinical experience inspired her to study the impact of both ACEs and intimate partner violence on mental and physical health. To her surprise, suffering an ACE appeared to foreshadow more challenges with stress management in adult life. With this finding, interventions came into focus.

“In one research project, I adapted a program for Latina immigrant women with a history of early-life adversity and depression symptoms, that focuses on self-management of depression symptoms. In this program we tell women about how their early life adversities could be contributing to their health experiences as adults,” Alvarez says. “Quite often, these women were pretty mortified that they might be practicing the same behaviors with their children. Most parents want better for their children and are not intentionally trying to do harm. Raising these moms’ awareness and providing them with strategies that they can use to manage their symptoms and their behavior can be really helpful.”

“My interest is to move away from the idea that a person embodies injury risks based on behavioral choices, and to show how they embody the social and environmental context in which they live and spend time.”

Alvarez’s work with Latina women exemplifies how recognizing warning signs of injury upstream can double as a preventative measure and a means of treatment for the injured. It also reflects the medical sector’s increasing awareness of social determinants of health—the non-medical factors that can raise or lower the risk of injury for specific populations. These factors are at the heart of Richmond and Jacoby’s joint research on links between injury recovery, adverse childhood experiences, and neighborhood-level exposures in cities like Philadelphia. Jacoby points to discriminatory policing as one example of a force that can render a neighborhood more injurious to residents, particularly in the context of structural racism. “My interest is to move away from the idea that a person embodies injury risks based on behavioral choices, and to show how they embody the social and environmental context in which they live and spend time,” Jacoby says.

When it comes to injury science and the preventative side of the equation, an “environment” can be as vast as a major city or as localized as the interior of a single family household. In a house where there are firearms, prevention may mean ensuring that those guns are stored safely. This is an area of interest for Katelin Hoskins, PhD, MBE, CRNP, an Assistant Professor of Nursing. “Many people own firearms for personal protection, and the presence of firearms may confer a feeling of safety for some,” Hoskins says. “But here’s the paradox: research shows that access to firearms in the home is linked with increased risk for suicide, unintentional injury, and homicide.” With firearm purchases surging since the onset of the pandemic, Hoskins has been hard at work with colleagues studying effective and equitable ways to implement safe firearm storage programs in pediatric settings. Going forward, she aims to make it easier for clinicians and organizations to expand such interventions to families, “especially for those who have been historically underrepresented in suicide prevention research,” Hoskins adds.

Living On

Even with the most sound injury mitigation practices in place, recuperation poses its own challenges and opportunities. In theory, treating an injury during its acute phase and helping a patient make a full recovery are two tasks that should go hand-in-hand. But often, the length of a recuperation process and the needs of a recovering patient are underappreciated. Shoshana Aronowitz sees this reflected in the hurdles that often stand between patients with substance abuse disorders and the proven medications like methadone which can help them recover from an opioid overdose. “There’s no real comparison between treatment that involves medication and treatment that doesn’t,” Aronowitz says. “And sadly, not everyone is offered medications.”

Lingering symptoms in people who’ve been injured can be physiological or psychosocial, and some survivors may experience both kinds. A concussion sustained in a car vehicle accident can impact a person’s cognition, concentration, processing speeds, and their reflexes—all of which could make resuming driving difficult and dangerous. More than half of the 1.9 million concussions suffered by Americans each year occur in adolescents, and through her research, McDonald has found that many of these young people are returning to the road within two weeks of their injuries: even before returning to sports and exercise. “There are potential physical and emotional injuries that come from motor vehicle crashes among adolescents,” McDonald says. “An unexpected event for an adolescent like a motor vehicle crash exposes them to visual, auditory, and sensory traumas.” Treating injuries must account for these realities—especially in a country like the U.S., where a modest social safety net and a historic racial wealth gap can contribute to disparate health outcomes for different populations.

In the same way that preventing injuries necessitates a close investigation of whether a person’s environment is helping or impeding their health, promoting recovery can also be a question of environmental assessment. In cities across the U.S.—cities that were once designed to accommodate cars at the expense of pedestrians and cyclists—streets are being re-shaped and modified to force safer driving behavior. Speed humps, serpentine curves in the road, and rounded curb extensions are just a few of the traffic calming measures that urban planners are deploying. The benefit of these design changes can be dual fold: accidents are prevented and local streets are rendered calmer, which can help people suffering from the reverberating trauma of a motor vehicle crash regain mobility—whether it’s getting behind the wheel of a car again or being able to take a walk or a bike ride without lingering memories of their injury event.

On a neighborhood-sized scale, there are many other forms of environmental enhancement that can address injury upstream and downstream. “In a city, some interventions for injury recovery may have benefits that go beyond intent,” Sara Jacoby says. One tangible example of this is the expansion of public green spaces in neighborhoods that have been deprived of trees and safe park spaces. “Turning a vacant lot into a green space might facilitate healing in residents who’ve experienced physical trauma. But it may also improve the mental health of people who live in proximity,” Jacoby says.

But the flipside here is that it can be challenging to recover from injury in neighborhoods where environmental characteristics aren’t being realized—where people still have to deal with injurious factors such as gun violence, broken windows, policing, or dangerous roads. “Years ago, we worked with 10–16-year-old youths who lived in west and southwest Philadelphia,” Richmond recalls. “They talked about what it was like to navigate their environment, to go to their home or a rec center, and how nuanced their antennae were. Is this a safe place right now? Should I walk somewhere else?” Richmond has studied the links between environment and recovery by interviewing hundreds of seriously injured Black men, many of whom are from under-resourced urban communities where they were violently injured. “When you’re thinking about physically and psychologically healing, and you’re discharged from a hospital to the same neighborhood you came from, you can find yourself traversing the streets you traversed before and being unsure if the person standing next to you is the person who shot you,” Richmond says. “The psychological burden experienced here can be harmful to one’s ability to make a full recovery.”

Ultimately, the question of who fully recovers from an injury—who lives on—is a question of equity. As the field of injury science continues to evolve, the role of nurse scientists will extend beyond injury mitigation and treatment. Policy advisement could become a larger part of the job.

“Nurse scientists are in an advantageous position to convey the importance that policy has in preventing injuries, as well as promoting recovery.”

A Responsibility to the Public

“Nurse scientists are in an advantageous position to convey the importance that policy has in preventing injuries, as well as promoting recovery,” McDonald says. As she sees it, nurses are already in the position of educating the public on what it might take to prevent or fix injuries: translating injury science into something that can be absorbed more broadly. It’s a competency that can be tailored for engagement with different audiences, including elected officials and public officials who are tasked with policymaking. “Nurses are equipped with skills in therapeutic communication and health education that help convey in concise ways the scope and potential strategies to solve complex problems,” McDonald says. Given this occupational advantage, one might argue that policy advising isn’t just an opportunity for nurse scientists, but an obligation.

“I was on a federal advisory committee for Healthy People 2030, which sets national goals for health and well-being,” Richmond says. “One of the papers that came out of that committee was about the huge levers that law and policy have on improving the health and wellbeing of people. If we believe that—which we do—then we have no option but to get the data, build the science, and package it so that policymakers can easily digest. That’s our responsibility, period.”

The structural inequities that shape injury occurrence and recovery will not be fixed overnight, but at PISC, new paths to solutions are being blazed by faculty and postdoc researchers, postdocs, as well as current doctoral students. Laura Vargas, PhD, LMSW, MPA, a Penn Nursing alum who worked closely with Terry Richmond as a postdoc, focused her studies on the plight of Latinx immigrants who’ve made the rigorous journey from South or Central America to the United States, enduring violence and other traumas in the process. As migration from the global south increases in the future, particularly in the wake of climatological events, Vargas’s research and findings could aid the development of interventions and public policies that promote good mental health outcomes among immigrants.

Helena Addison, MSN, RN—a fourth year doctoral student at Penn Nursing—is busy digging into a similar issue: the experiences of formerly incarcerated Black men in the U.S. How does exposure to violence, trauma, and stress while incarcerated impact the process of reintegrating into a community, upon release? It’s a pertinent question to be investigating today, given the historic, disproportionately high rate at which Black men are sentenced to prison in the U.S., where over two million people are currently incarcerated. “In my work, I’ve gained quite a bit of exposure to how policies at local, state, and federal levels can directly impact the health outcomes of this community,” Addison says. “Whether it is the City of Philadelphia’s diversion and re-entry programs or the Medicaid Reentry Act at the federal level, such policies can have a significant impact on the resources that are available to formerly incarcerated people to address their health needs. It gives me hope to see how community engagement is continually embedded in the work of injury scientists, especially as we focus more on social justice and health equity.”

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