BITTEN at the Bedside: An Application Guide for Nurse Practitioners

Published:February 18, 2021DOI:https://doi.org/10.1016/j.nurpra.2020.12.006

      Highlights

      • Past medical experiences impact current health care encounters as well as patients’ current and future health care expectations and needs.
      • The BITTEN (Betrayal, Indicator, Trauma, Trust, Expectation, Needs) model provides a framework for nurse practitioners to assess the impact of past experiences on a patient’s current situation as well as on the patient’s future expectations and needs.
      • Nurse practitioners are ideally situated to recognize and respond to a patient’s previous medical care in ways that resist patient retraumatization and improves care for patients often perceived as difficult to treat.

      Abstract

      Patients with complex medical conditions may have a medical history that includes multiple negative/traumatic experiences with the health care system over the course of their diagnosis and treatment. The BITTEN (Betrayal history by health-related institutions; Indicator for health care engagement; Trauma symptoms related to health care; Trust in health care providers; Expectation of patient; Needs of patient) model posits that health care providers can recognize and respond in a way that encourages resisting patient retraumatization. We present a hypothetical case study applying the BITTEN model as a patient-centered framework to include in a standard visit. Increased awareness of the patient’s risk for institutional betrayal, trauma, and overall negative past health care experiences can help the NP better understand the patient’s current and future health care needs and expectations.

      Keywords

      American Association of Nurse Practitioners (AANP) members may receive 1.0 continuing education contact hour, approved by AANP, by reading this article and completing the online posttest and evaluation at aanp.inreachce.com.
      Given the pervasiveness of trauma exposure and its adverse outcomes on mental and physical health, trauma-informed care (TIC) can prevent retraumatization of patients, improve rapport between patients and staff, and increase quality of care. In addition, while a history of trauma exposure and previous negative health care experiences can influence a patient’s health care presentation, in the absence of universal screening, nurse practitioners (NPs) are not always aware of patients’ trauma histories. However, even without concrete trauma-specific knowledge, applying TIC can be particularly helpful when approaching chronic care patients, because they are potentially more at risk from previous negative health care experiences due to continuous interactions with the health care system.
      This report uses BITTEN (Betrayal history by health-related institutions; Indicator for health care engagement; Trauma symptoms related to health care; Trust in health care providers; Expectation of patient; Needs of patient), a theoretical framework of TIC, to illustrate how NPs can apply TIC in their own practice. Through a case study of a hypothetical patient with fibromyalgia, chosen because of its complex and chronic presentation, we demonstrate how previous negative health care experiences and past trauma exposure can influence a patient’s current presentation, trust in provider, needs, and expectations. We also provide a frame for how NPs can manage the effects of this history.
      As advanced practice providers, NPs facilitate interdisciplinary collaboration while reducing costs associated with the chronic care needs of primary care patients.
      • Johnson J.E.
      • Smith A.L.
      • Mastro K.A.
      From Toyota to the bedside.
      Accordingly, NPs have a responsibility to quickly and accurately understand their patient’s presenting problem, medication use, treatment history, and current needs and expectations for care. Given the evidence linking past and recent trauma to adverse health outcomes,
      • Lewis C.L.
      • Langhinrichsen-Rohling J.
      • Selwyn C.N.
      • Lathan E.C.
      Once BITTEN, twice shy: an applied trauma-informed healthcare model.
      TIC refers to a set of overarching principles that recognize (1) the prevalence of trauma and (2) its long-lasting effects. Consequently, TIC involves being mindful about processes that could retraumatize and seeks to include and empower the patient.
      • Hughes K.
      • Hardcastle K.
      • Bellis M.A.
      The impact of adverse childhood experiences on health: a systematic review and meta-analysis.
      In 2019, the BITTEN theoretical framework of trauma-informed health care was proposed to help nurses work more effectively with patients who may have an undisclosed trauma history or previous negative health care experiences.
      • Hopper E.K.
      • Bassuk E.L.
      • Olivet J.
      Shelter from the storm: trauma-informed care in homelessness services settings.
      BITTEN provides an approach to aid health care providers in assessing a patient’s past institutional betrayals and trauma related to medical care experiences to increase patient trust, promote better care for their current health indicator, and address their expectations and holistic care needs. By using the BITTEN theoretical framework, NPs can efficiently and effectively recognize and respond to vulnerable patients’ trauma histories and previous adverse medical care experiences in ways that resist patient retraumatization among patients sometimes interpreted as being “difficult to treat.”
      Possible guideposts for the necessity of TIC include mentioning a history of gaslighting or difficulty getting appropriate treatment, including having symptoms attributed to psychogenic causes. Being mindful of these indicators is particularly important for health care providers, because providers’ efforts to resist patient retraumatization are a hallmark feature of providing TIC.
      Substance Abuse and Mental Health Services Administration
      Trauma-Informed Care in Behavioral Health Services: Treatment Improvement Protocol (TIP) Series No. 57. Center for Substance Abuse Treatment (US); 2014.
      The BITTEN theoretical framework provides a worksheet that NPs can use to apply TIC in a systematic manner.
      Even among those who are not psychiatric mental health NPs, being aware of the defining features of trauma is still highly valuable because trauma is a transdiagnostic phenomenon that directly affects the health and well-being of patients for whom NPs provide care. The Substance Abuse and Mental Health Services Administration (SAMHSA), an acknowledged leader in the TIC movement, defines trauma according to the three Es: the event, the experience of the event, and its effects.
      Substance Abuse and Mental Health Services Administration
      Trauma-Informed Care in Behavioral Health Services: Treatment Improvement Protocol (TIP) Series No. 57. Center for Substance Abuse Treatment (US); 2014.
      The event consists of the characteristics of the actual trauma, such as type (eg, rape, war, neglect, medical trauma) or duration. The experience of the event is the individual’s subjective experience of the trauma or the meaning they made of it (eg, thoughts such as “It was horrible and all my fault,” “No one can be trusted,” etc). Finally, the effects are the health consequences of the traumatic event.
      As an NP, it is important to note that the effects of trauma can include not only acute physical effects but can also shape the future behavioral responses of the survivor through long-lasting psychologic or cognitive effects. As a representative of a larger institution (ie, the health care system) on which individuals’ health and well-being depend, an NP’s response to a patient’s experience of or overt disclosure of a traumatic event can influence that patient’s experience of the current health care visit and thus also contribute to their experience of positive or negative effects associated with the original trauma.
      In addition to understanding the definition of trauma, NPs should also be familiar with the key components of TIC, known as the 4Rs: realizing, recognizing, responding, and resisting retraumatization.
      Substance Abuse and Mental Health Services Administration
      Trauma-Informed Care in Behavioral Health Services: Treatment Improvement Protocol (TIP) Series No. 57. Center for Substance Abuse Treatment (US); 2014.
      Selwyn and Lathan

      Selwyn CN, Lathan E. Helping primary care patients heal holistically via trauma-informed care. J Nurse Pract. Published online July 19, 2020. https://doi.org/10.1016/j.nurpra.2020.06.012

      suggest ways in which primary care NPs can enact these components as an initial step toward implementing TIC within their own clinical practices. The 4Rs were developed to provide a general guide for transforming systems to become trauma-informed, but several patient-level factors were omitted. Specifically, these components fail to include health care-related institutional betrayal, medical trauma, and patient-provider trust ruptures.
      Thus, BITTEN
      • Hopper E.K.
      • Bassuk E.L.
      • Olivet J.
      Shelter from the storm: trauma-informed care in homelessness services settings.
      builds upon and extends the 4Rs to equip health care providers with an applied theoretical framework for enacting trauma-informed health care. Notably, BITTEN focuses specifically on factors affecting traditionally medically complex patients and those belonging to populations that disproportionately experience health inequities. The BITTEN framework organizes events in the patient’s past and considers how these can influence the patient’s current and future health care experiences. The BITTEN framework postulates that if a patient has experienced health care-related institutional Betrayal in the past, this can influence the patient’s current Indicator for health care engagement, which may also promote retraumatization and retrigger Trauma symptoms. This in turn may influence a patient’s Trust in health care providers as well as alter their current and future Expectations and Needs. Complementary to the 4R framework, BITTEN
      • Hopper E.K.
      • Bassuk E.L.
      • Olivet J.
      Shelter from the storm: trauma-informed care in homelessness services settings.
      provides a patient-centered TIC framework designed specifically for health care providers.

      Incorporating BITTEN into the Diagnostic Process

      This report promotes incorporating the BITTEN theoretical framework
      • Hopper E.K.
      • Bassuk E.L.
      • Olivet J.
      Shelter from the storm: trauma-informed care in homelessness services settings.
      into routine patient encounters. Consistent with BITTEN, a patients’ diagnosis journeys can be quite traumatizing (eg, repeated dismissal/misunderstanding of patient symptoms; invasive medical procedures) and may result in some patients feeling betrayed by health care-related institutions, including hospitals and insurance agencies, among others. Some patients may even have specific experiences of medically traumatizing events and/or trust ruptures with particular providers.
      According to the BITTEN theoretical framework, assessment includes focusing on the patient’s potential Betrayal history with health care-related institutions or systems, Trauma history and current symptoms, and Trust in health care providers, with particular emphasis on understanding trust ruptures with the treating NP or other providers who are treating their disease Indicator.
      • Hopper E.K.
      • Bassuk E.L.
      • Olivet J.
      Shelter from the storm: trauma-informed care in homelessness services settings.
      Initially, the NP will need to realize the extent to which any particular trauma or betrayal can influence a patient’s health care-seeking behaviors while simultaneously recognizing trauma-related physical and mental signs and symptoms that may be misinterpreted as a patient being “difficult,” “quiet,” “noncompliant,” or “uncooperative.”
      The BITTEN theoretical framework is expected to be particularly useful for the NP when treating a patient from a group with a high likelihood of having experienced institutional betrayal, trauma (especially medical trauma), and/or a trust rupture with one or more providers.
      • Klest B.
      • Tamaian A.
      • Boughner E.
      A model exploring the relationship between betrayal trauma and health: the roles of mental health, attachment, trust in healthcare systems, and nonadherence to treatment.
      These groups might include those with frequent interactions with the health care system (ie, high utilizers), those with multiple chronic health conditions,
      • Hughes K.
      • Bellis M.A.
      • Hardcastle K.A.
      • et al.
      The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis.
      those with an intensive care unit or critical care experience,
      • Jackson J.C.
      • Jutte J.E.
      • Hunter C.H.
      • et al.
      Posttraumatic stress disorder (PTSD) after critical illness: a conceptual review of distinct clinical issues and their implications.
      those with autoimmune diseases,
      • Hughes K.
      • Bellis M.A.
      • Hardcastle K.A.
      • et al.
      The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis.
      or those from traditionally disenfranchised social groups who are likely to have encountered structural discrimination and racism. For example, posttraumatic stress disorder symptoms have been linked to autoimmune disorders such as rheumatoid arthritis
      • Song H.
      • Fang F.
      • Tomasson G.
      • et al.
      Association of stress-related disorders with subsequent autoimmune disease.
      ,
      • Boscarino J.A.
      • Forsberg C.W.
      • Goldberg J.
      A twin study of the association between PTSD symptoms and rheumatoid arthritis.
      and fibromyalgia.
      • Miró E.
      • Martínez M.P.
      • Sánchez A.I.
      • Cáliz R.
      Clinical manifestations of trauma exposure in fibromyalgia: the role of anxiety in the association between posttraumatic stress symptoms and fibromyalgia status.
      Moreover, in a study conducted with individuals with a chronic neurovascular condition, betrayal trauma predicted both mental health symptoms as well as the closeness of the relationship with health care providers.
      • Klest B.
      • Tamaian A.
      • Mutschler C.
      Betrayal trauma, health care relationships, and health in patients with a chronic neurovascular condition.
      In addition to these findings, health care relationships were also shown to predict self-rated health,
      • Klest B.
      • Tamaian A.
      • Mutschler C.
      Betrayal trauma, health care relationships, and health in patients with a chronic neurovascular condition.
      underscoring the importance of the patient-provider relationship.
      We reemphasize that we are recommending the incorporation of the BITTEN theoretical framework into the traditional workup, particularly when the presenting problem or Indicator is one that is likely to relate to the patient’s past betrayal and/or trauma history. BITTEN does not replace any component of a regular visit, but rather grounds the present patient encounter within the context of the patient’s past health care experiences, leaving the provider better equipped to determine the patient’s current and future expectations and needs.
      Of note, BITTEN promotes neither extensive exploration of nor treatment of a patient’s trauma history during the encounter. Instead, it calls attention to specific patient populations’ increased vulnerability to trauma exposure and its effects while encouraging providers to intentionally keep the patient’s increased risk in mind in order to respond in a manner that resists retraumatization during the present encounter. In fact, an NP is likely to be able to code for BITTEN after listening to a patient’s answer to even a simple question such as “What difficulties or concerns have you experienced with the treatment of your (chronic condition) that might be important for me to consider today?”
      Further, noting the presence of a betrayal and/or trauma history may help explain the patient’s current interpersonal behavior with health care providers, lack of medication adherence, and other barriers to treatment.
      • Klest B.
      • Tamaian A.
      • Boughner E.
      A model exploring the relationship between betrayal trauma and health: the roles of mental health, attachment, trust in healthcare systems, and nonadherence to treatment.
      Recognizing that a history of trauma may contribute to a patient’s current presentation can help providers approach a potentially difficult encounter in a patient-centered way rather than in a reactive or defensive manner. This recognition, in and of itself, can be healing and improve the encounter experience for both the patient and the provider. A sensitive provider response is particularly important when the patient is reporting an institutional betrayal related to their health care, such as a misdiagnosis that had catastrophic effects or the perception of gaslighting related to their medical condition, or a past experience of a medical trauma.
      Ultimately, the NP seeks to resist retraumatization of the patient by proactively addressing concerns that may have been previously overlooked and paying attention to details that may affect the patient’s current health care experience. The risk of retraumatization is also substantially reduced when the NP actively listens to, comprehends, and validates the patient’s current needs as well as their health care expectations.

      Case Study Application

      The patient represented in this case study is a composite of several different patients and is based on clinical experience. The case study and accompanying figures are intended to be a review of the BITTEN
      • Hopper E.K.
      • Bassuk E.L.
      • Olivet J.
      Shelter from the storm: trauma-informed care in homelessness services settings.
      theoretical framework, demonstrating how it promotes trauma-informed and patient-centered care provided by NPs. The patient presented here has been diagnosed with fibromyalgia after a long history of interacting with health care professionals. Fibromyalgia was deliberately selected as the patient diagnosis for this case study because it is a controversial, chronic, and hard-to-diagnose condition with multiple symptoms, thereby increasing the patient’s past risk for experiencing health care-related institutional betrayal, medical trauma, and/or a trust rupture with a previous health care provider. The International Classification of Diseases, 11th Revision, includes fibromyalgia within the code “MG30.01 Chronic widespread pain.”
      World Health Organization
      International Classification of Diseases 11th Revision. 2019. MG30.01 Chronic widespread pain.

       Presentation

      “Amy” is a 52-year-old White woman diagnosed with fibromyalgia who presents to your outpatient clinic toward the end of the day with complaints of recently exacerbated hip and leg pain as well as increased sleep disturbance and fatigue. Using the BITTEN theoretical framework, the NP probes Amy’s past health care experiences further by asking, “What, if any, worries or concerns do you have about today’s health care visit or your treatment plan?” Amy responds,Receiving treatment for my fibromyalgia is very difficult. I’ve seen three different doctors in three different offices, and none of them believe me. They just blame my symptoms on depression or tell me I’m exaggerating. Either way, I’m normally told there’s nothing they can do and I leave still in pain. The doctors do seem familiar with the basics of fibromyalgia, but I can’t help but think that some of them don’t even think my disease is real and they are gaslighting me; but maybe it’s my anxiety and depression making me think that. They don’t understand that my life is falling apart, and my anxiety and depression stem from real medical symptoms. It’s very frustrating, and I’m exhausted. I used to cook three meals a day, clean the house, and play with my young grandchild, but now, it takes everything I have just to get out of bed. I feel guilty because I have no desire or energy to socialize or be intimate with my husband. I feel like I have to explain and validate my symptoms—multiple times—to everyone, including my doctors and family. It’s getting harder and harder for me to cope, especially since I don’t have a therapist.
      Figure 1 provides a BITTEN assessment of Amy’s case. Figure 2 provides a side-by-side comparison of Amy’s case using treatment as usual vs implementing TIC through BITTEN.
      Figure thumbnail gr1
      Figure 1A BITTEN (Betrayal history by health-related institutions; Indicator for health care engagement; Trauma symptoms related to health care; Trust in health care providers; Expectation of patient; Needs of patient) assessment of Amy’s case.
      Figure thumbnail gr2
      Figure 2Side-by-side comparison of Amy’s case using treatment as usual vs implementing trauma-informed care through BITTEN (Betrayal history by health-related institutions; Indicator for health care engagement; Trauma symptoms related to health care; Trust in health care providers; Expectation of patient; Needs of patient).

       BITTEN Conceptualization

      Initially, an NP using the BITTEN theoretical framework would note that Amy is presenting with a diagnosis of fibromyalgia and noting a recent exacerbation of symptoms (Indicator). As noted above, understanding the diagnostic journey of the patient can be helpful in conceptualizing the patient’s history of betrayal and/or trauma. With regard to Amy’s diagnosis, fibromyalgia is characterized by diffuse symptoms ranging widely in severity, leading to an average of 5 years for fibromyalgia to be accurately diagnosed.
      National Fibromyalgia and Chronic Pain Association
      Fibromyalgia. Diagnosis.
      The lack of consensus about the fibromyalgia diagnosis and its treatment leaves patients vulnerable to disparate experiences across the health care system, thereby they are a vulnerable population for institutional betrayal and medical trauma.
      Incorporating the broader diagnostic and treatment context of fibromyalgia into Amy’s presentation can help provide a fuller picture for the NP of what this patient may have experienced in previous health care encounters. It also provides clues about how the NP might want to proceed currently. Indeed, Amy verbally notes symptoms indicative of a history of Betrayal (“I’ve seen 3 different doctors in 3 different offices, and none of them believe me. They just blame my symptoms on depression or tell me I’m exaggerating.”) Yet, without awareness of institutional betrayal and its effects on patient behavior, an NP may overlook Amy’s comments and/or feel unable to address past negative health care experiences within the current encounter.
      An investigation of the cooccurrence of fibromyalgia and posttraumatic stress disorder among 395 patients found that approximately 67% of patients developed fibromyalgia after onset of posttraumatic stress disorder.
      • Häuser W.
      • Fitzcharles M.A.
      Facts and myths pertaining to fibromyalgia.
      Without an understanding of the link between psychologic trauma and diseases that are difficult to diagnose and treat, NPs run the risk of inadvertently retraumatizing patients with histories of both institutional betrayal and undisclosed personal trauma.
      Yet, the current case example demonstrates the lack of information available about a patient’s trauma history without formal trauma screening, given that the current presentation of Amy fails to confirm or deny the presence of previous trauma exposure. For example, Amy mentions her repeated frustration with past health care providers as well as the impact these health care experiences have had on her current life, including the expression of trauma and mental health symptoms. The NP does not necessarily have to explore those past experiences, but rather be prepared to respond to Amy by hearing and validating the frustration she has experienced and treating her accordingly. However, without explicitly asking Amy about her history of exposure to potentially Traumatic events and in the absence of a brief mental health symptom screen, the NP may miss a key piece of the puzzle in understanding Amy’s symptoms, care Expectations, and treatment Needs.
      Understanding a patient’s betrayal and/or trauma history is also important for understanding their level of Trust toward health care providers in general and toward the NP present within the current encounter (Figure 1). A history of negative and/or harmful interactions with health care systems has been shown to directly affect trust in health care providers and health care engagement behaviors.
      • Smith C.P.
      First, do no harm: institutional betrayal and trust in health care organizations.
      Such a process can be noted in Amy’s statement, “The doctors seem familiar with the basics of fibromyalgia, but I can’t help but think that some of them don’t even think my disease is real and they are gaslighting me,” which suggests Amy is suspicious of her health care providers’ intentions and is thus less likely to fully buy into or comply with a treatment plan.

       Treatment

      NPs incorporate SAMHSA’s
      Substance Abuse and Mental Health Services Administration
      Trauma-Informed Care in Behavioral Health Services: Treatment Improvement Protocol (TIP) Series No. 57. Center for Substance Abuse Treatment (US); 2014.
      fourth R, resist retraumatization, into both the treatment and management phases of care planning. Of note, studies have consistently shown that health care providers tend to view fibromyalgia patients as exhausting to manage and as having unrealistic expectations for care, while they are perceived as demanding and perfectionistic.
      • Malin K.
      • Littlejohn G.O.
      Personality and fibromyalgia syndrome.
      Conversely, among patients with fibromyalgia, negative beliefs and mistrusting attitudes toward the health care system and individual providers are negatively related to treatment adherence and positively related to reduced physical and mental health-related quality of life.
      • Rowe C.A.
      • Sirois F.M.
      • Toussaint L.
      • et al.
      Health beliefs, attitudes, and health-related quality of life in persons with fibromyalgia: mediating role of treatment adherence.
      These findings highlight the provider’s need to first be aware of this potential patient-provider dynamic and then to work to establish a more positive and trusting patient-provider relationship for these vulnerable patients. For example, in a survey of 800 patients with fibromyalgia and 1,622 physicians, patients cited chronic pain, fatigue, and difficulty concentrating as being the most common symptoms that were not satisfactorily managed.
      • Choy E.
      • Perrot S.
      • Leon T.
      • et al.
      A patient survey of the impact of fibromyalgia and the journey to diagnosis.
      Furthermore, physicians across a variety of specialties (primary care, rheumatology, neurology, pain specialist) indicated that these symptoms are the most common for fibromyalgia patients yet they lack definitive treatments.
      • Choy E.
      • Perrot S.
      • Leon T.
      • et al.
      A patient survey of the impact of fibromyalgia and the journey to diagnosis.
      It is important to consider the multiple years and array of doctors it can take before a fibromyalgia patient receives a diagnosis, in addition to the cross-specialty difficulty in treating fibromyalgia symptoms; thus, there is a chance that the patient’s trust in any health care provider may already be damaged before the current visit. One way to foster trust between patient and provider could be to purposefully validate these concerns and join the patients in their frustration, such as in Amy’s case. For example, the NP could say:I hear your frustration, and it sounds like fibromyalgia has gotten in the way of things you enjoy doing. Unfortunately, the current medical community’s understanding of fibromyalgia is such that a lot of patients with fibromyalgia experience this frustration and don’t have an easy time getting the help they need. I wish we knew more and could be even more helpful. However, my team and I will work closely with you to help you get the best quality of life possible.

       Management

      Given the relation between trauma exposure and fibromyalgia, as well as the traditional difficulty in diagnosing and treating fibromyalgia from a health care provider perspective, the BITTEN theoretical framework is uniquely positioned to help the NP better understand and treat patients with this challenging condition by recognizing and linking the consequences of that past trauma with what the NP can do in the present encounter. In Amy’s case, previous providers ignored her description of pain, which was invalidating, and increased her feelings of powerlessness and hopelessness, which can be retraumatizing. Listening with compassion and provider humility is an important first step to repair the existing provider-patient trust ruptures. Of note, Amy’s experience is broadly representative of patients with fibromyalgia, as 57% of patients in the aforementioned study cited at least one experience of “not being taken seriously.”
      • Choy E.
      • Perrot S.
      • Leon T.
      • et al.
      A patient survey of the impact of fibromyalgia and the journey to diagnosis.
      As part of ongoing patient management using the BITTEN theoretical framework, the NP needs to have an open mind and listen respectfully to Amy’s fibromyalgia symptoms while recognizing the subjective toll her previous experiences have had on her quality of life, so her internal experience is validated, the patient-provider relationship is improved, and effective care may ensue.

      Conclusion

      Although this case presentation focused on a hypothetical patient with fibromyalgia, many patients have had prior negative experiences with health care in general (ie, institutional betrayal) as well as a history of trauma exposure to which you, as their health care provider, may not be privy. Importantly, fibromyalgia is a diagnosis that carries a stigma, thereby increasing the risk for institutional betrayal. NPs may also have some of their own preconceived ideas or biases about patients with fibromyalgia that may implicitly or explicitly affect their care. These experiences shape patients’ ongoing health care Expectations and Needs. Each initiation of care ultimately influences the patient’s ability to adhere to their treatment plan and work well with providers in the future.
      BITTEN, as a theoretical framework, provides a guide for interacting with patients in a trauma-informed, patient-centered manner. Rather than giving the patient a care-related ultimatum (do this, stop that), providers can develop a collaborative, trusting patient-provider relationship. Further, for patients with a betrayal or trauma history, replacing a power-based provider-vs-patient dynamic with an empowerment-based patient-provider partnership can be critical in correcting the course of the patient’s engagement with the health care system. An important message for these patients is: we are a team.
      BITTEN also provides an important guide for medical record review. Reading medical records with attention paid to your patients’ health care and trauma histories will allow you to tailor your intervention to their individual needs, resist retraumatization, and form a therapeutic, collaborative relationship. In sum, the BITTEN theoretical framework not only serves as an opportunity to help NPs bolster their skills in building rapport while reducing the likelihood of having frustrating patient encounters but also ultimately provides trauma-affected patients with holistic, healing, and patient-centered care.

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      Biography

      Chrystal L. Lewis, PhD, RN, is an assistant professor at the University of South Alabama College of Nursing, Mobile, and can be contacted at [email protected] .
      Emma C. Lathan, MS, is a graduate student at the Department of Psychology, University of South Alabama, Mobile.
      Candice N. Selwyn, PhD is a research assistant professor and Gabrielle A. Agnew, MS is a graduate student in Clinical Psychology PhD program at the University of Texas Southwestern Medical Center in Dallas, TX.
      Sean D. McCabe, BS, is a graduate of the University of North Carolina at Charlotte, Charlotte, NC. Margaret E. Gigler, BA, is a graduate student, and Jennifer Langhinrichsen-Rohling, PhD, is a professor in the Department of Psychological Science, University of North Carolina at Charlotte, Charlotte.