Creating Spaces for Safety: Q&A with Ashlee Murray, MD, MPH

Ashlee Murray, MD, MPH, shares an example of a domestic violence screening card with Christine Norris, former outreach team member for the Center for Injury Research and Prevention.

Editor's Note: In this Q&A, meet Ashlee Murray, MD, MPH, an attending physician in the Division of Emergency Medicine and a Practice-based Scholar in the Center for Violence Prevention (CVP) at Children's Hospital of Philadelphia. She explains how practice-based study affects her research, how her efforts have led to expansive programming for domestic violence (DV) survivors, and why it's important to be educated on trauma-informed practices.

What does it mean to be a CVP Practice-based Scholar, and how does it impact your research?

Practice-based means I am a clinician, which lends itself to having a closer glimpse at the lived experiences of families and patients. These intimate insights support many of the problems that CVP tries to address. An experience I had as a resident almost 15 years ago propelled my interest in pursuing this career path. I wanted to improve how we care for families coming in with similar experiences at CHOP, and that's the practice basis. With that comes research, as you discover and think about questions with the families you work with.

Another aspect of practice-based research is understanding the day-to-day operations of clinical medicine and what families experience in the medical space. In the space of DV and intimate partner violence (IPV), it's also important to know the policies and procedures that the hospital follows so we can ensure they are trauma-informed.

Your Interdisciplinary Research Leaders project, "Centering Survivor Voices to Improve Medical-Community Partnerships Addressing Intimate Partner Violence," is a wonderful example of community partnerships in research. Why is it important to form these partnerships, especially when studying IPV?

Everything we do is survivor-centered because the community knows the lived experiences of these survivors better than we do and has been supporting them for decades. Our job is to help fill the gaps if one of our community partners has a research question. As researchers and clinicians, we must listen to what the community needs because otherwise, we're coming in with our own priorities in mind.

Our team was awarded the Foerderer grant last year, which is an internally funded award designed to allow ongoing research to move into new and productive areas, to support a community needs assessment to better under gaps and challenges in supporting parent survivors in Philadelphia. Our community partner was involved from the beginning and throughout the entire project, including active recruitment, helping us develop the interview guides, summarizing the findings, as well as dissemination. Survivor participants through the form of focus groups shared their real-world challenges and successes. These insights have subsequently informed the STOP IPV Program's future directions in survivor programming and research endeavors.

Dr. Murray presents on research conducted by the STOP IPV Program.

You were one of the original developers of the STOP IPV Program in 2014. How has this initiative grown in the last decade?

Through STOP IPV, CHOP partners with IPV agencies to promote universal assessment and resource allocation by pediatric healthcare providers for IPV, teen dating violence, referral to on-site specialists who can help. The program started with one part-time medical advocate, an IPV specialist from Lutheran Settlement House (LSH)—a non-profit community based-organization that serves children, adults, and families in Philadelphia—who worked on-site at CHOP. Now we have two full-time advocates from LSH and a part-time advocate from Laurel House in Montgomery County who serves the King of Prussia campus. This service is available for free and is entirely confidential, and we've seen more employees using our resources because of this. If someone needs to take DV leave with Human Resources, our advocates can support them through that process. We're training hundreds of providers every year, and that number continues to grow along with our referral numbers, which are upwards of almost 350 per year.

Prior to last year, a referral could only come through a provider such as a physician, nurse, or social worker, but that situation could make people uncomfortable. Now we've updated our materials so patients, families, and employees can refer themselves without going through a provider.

We also now offer routine education and screening in the Emergency Department, as well as in Karabots and South Philly primary care centers. We're becoming more prevalent and consistent in different places, and our goal is to become even more expansive. In the last year, we got involved in the Well Baby Nursery at the Hospital of the University of Pennsylvania to help integrate IPV referrals and resources as a routine part of their practice.

In addition to expansion of the program, we have also grown in our research productivity and interests. We have published several key manuscripts sharing how we used quality improvement to increase screening and universal education rates in the Emergency Department (ED). We conducted a 5-year follow up studying post-program implementation in the ED to better understand the cultural shift as well as continued challenges of the program. Most recently, we published a manuscript discussing disparities in screening and how best we can improve the system to address these disparities.

What is your role in Students Talking about Relationships (STAR), and what are your hopes for the program?

LSH culturally adapted STAR to better fit the Philadelphia area from Safe Dates, which is an evidence-based teen dating violence prevention program developed in the 90s. STAR is a teen leadership and violence prevention program that engages high school-age youth in conversations about healthy relationships, communication, and conflict resolution. LSH has been implementing the program in Philadelphia high schools for many years, but they've never studied it.

They asked me how they could create sustainable funding for the program by showing that the culturally adapted program was effective. While LSH comprises experts in the delivery of the program, I was brought on as a research consultant to help them understand the implementation process. We have a three-year grant that ends this July that is helping us implement STAR in 10 high schools in Philadelphia. We're collecting data on implementation measures like feasibility, fidelity, and reach. The second piece involves measuring the effectiveness of the program to determine if the program does what it sets out to do, which is to look at knowledge and help-seeking behavior.

(From left to right) Mary Oh, KOP IPV Specialist (Laurel House); Dr. Ashlee Murray; Julie Figueroa, Social Work Clinical Supervisor (CHOP); Julia Hackenberry, Social Worker (CHOP KOP); Cortney Marengo, KOP IPV Specialist (Laurel House).

Do you have any collaborations with CHOP departments, centers, or divisions that you're excited about?

Research has become a pillar of my work, and I am continuously expanding my partnerships. I work with the Center for Parent and Teen Communication, the Division of Adolescent Medicine, and I've worked with Clinical Futures. My colleagues and I in the STOP IPV Program are currently partnering with PolicyLab, a newer partnership this year, to do a quantitative study to analyze potential patterns and temporal trends in our STOP IPV Program referral database. We have almost 10 years of referral data now, and PolicyLab Director Meredith Matone, DrPH, MHS, agreed to support a statistician this year to help us do the analysis. What we learn from that database will help us inform future research, and program improvement and resource provision. Our goal is to develop an electronic medical record predictive model that could enhance early detection and support for survivors of IPV in the pediatric clinical space.

You received a Clinical Futures, a CHOP Research Institute Center of Emphasis, pilot grant for ongoing work that supports survivors of IPV as well as their children. Which aspects of this project you are most proud of so far?

Supported by a Foerderer grant last year, my team and I did a community needs assessment in Philadelphia where we interviewed key stakeholders including heads of domestic violence agencies, individuals in the school district, and other leaders in DV outreach and support to understand the gaps in services available for parents who experienced DV. We also held four focus group with survivors from our community during this needs assessment.

We learned that many parent survivors lose confidence and some of the skills that they need because their lives have focused on violence and trauma. We wanted to know how we could empower parents to regain those skills, which is how we discovered parenting coaching programs. As we did our literature review, we found a program called Family Vision, which is a parenting coaching program for parent survivors of trauma, including DV, based out of the United Kingdom. It was developed by a survivor and parent named Nina Farr, so we reached out to her last year to learn about her program and to understand her behavioral theory around it. We felt it could fill the gap identified during our community needs assessment.

The Clinical Futures grant allows us to prepare for the implementation of this program at CHOP and in the community, in conjunction with LSH. We're spending this year researching how the program could be culturally adapted to families in the Philadelphia area with help from four focus groups of parent survivors.

Nina Farr and I lead each focus group, where we go through the program manual step by step to get feedback from the survivors. These focus groups help us determine what's culturally relevant and what might need to be adapted. It's exciting because we're about halfway through the focus groups, and then we can put our data together to present the final adapted program. We'll look for our next wave of funding to support the implementation plan and a pilot study.

February is Teen Dating Violence Awareness Month, but why is it important to stay engaged and educated on these topics year-round?

Teen dating violence and DV are problems that have always existed. This issue can unexpectedly touch anyone at any moment. One out of four women, one out of seven men, and one out of three teens experience this in a lifetime. The odds of you or someone close to you experiencing some form of DV are high, and if we don't focus on it continuously, it doesn't move us any closer to solving the problem.

One thing I teach often is that it's hard to be prepared when someone discloses an experience with DV or IPV. There is no lab test that will indicate a problem ahead of time. Our reaction when someone discloses is so important to the survivor who's sharing it because our reactions could change their trajectory in their path to safety if it's not trauma-informed.

Keeping yourself educated and aware is important; you don't have to be a doctor to be that person. You could be a hair stylist or a bus driver, or anyone that someone could come to. In our profession, we are privileged to allow families to be vulnerable with us, and I think that privilege is something that we should not take lightly.