Perspectives of hospital emergency department staff on trauma-informed care for injured children: An Australian and New Zealand analysis

Assessing Emergency Department Staff Knowledge, Competency, and Implementation of Pre- and Post-Trauma-Informed Care Training

INTRODUCTION

Trauma-informed care has been posited as a framework for creating ideal and safe environments for patients to participate in treatment. However, there are limited studies that demonstrate the impact of a focused trauma-informed care training on ED staff. We implemented a 4-hour trauma-informed care training in a general emergency department. We aimed to measure changes in knowledge, opinions, self-rated competency, barriers, and recent practices before and after implementing trauma-informed care training. We hypothesized that the training would result in significant self-reported improvement in all domains.

METHODS

We performed a pre/post interventional study with the intervention being a trauma-informed care training adapted for ED clinical care staff. A validated, publicly available survey tool (Center for Pediatric Stress Trauma-Informed Care [TIC] Provider Survey) was used to assess knowledge, opinions, competency, and utilization of and perceived barriers to trauma-informed care. Pre- and post-training surveys were collected. Responses were stratified by role. Continuous variables were compared using analysis of variance; categorical variables compared using Pearson's chi-square.

RESULTS

Participants demonstrated a high level of perceived knowledge and opinions of trauma-informed care before and after training. We observed significant increases in self-reported competence for all ED staff, some increase in utilization of trauma-informed care in recent practice, and significant decreases in perceived barriers to providing trauma-informed care.

DISCUSSION

Trauma-informed care training is an effective means to improving ED staff self-perceived competence and practice of trauma-informed care even among those with high self-perceived knowledge and opinions of trauma-informed care before the training. Future study should explore the patient-level impact of trauma-informed care training, as well as how to continue to reduce barriers to system-wide implementation of trauma-informed care practices.

How does trauma informed care education for paediatric healthcare professionals' impact self-reported knowledge and practice. An integrative review

AIM

To examine the literature on the impact of Trauma Informed Care education on paediatric health care practitioners' self-reported knowledge and practice.

BACKGROUND

Psychosocial trauma during childhood is prevalent and linked to increased risk of adverse physical and mental health outcomes. Trauma Informed Care recognises the significant impact of childhood trauma in health outcomes. Education is key to health care practitioners' integrating Trauma Informed Care into practice.

DESIGN

Integrative review of the literature.

METHODS

The review employed Whittemore and Knafl's (2005) framework and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2021 statement. A systematic search of Medline, CINAHL and SCOPUS, covering 2019 toMay 2024. Data were critically appraised using the Mixed Methods Appraisal Tool.

RESULTS

Nine studies were included, identifying four themes using Braun and Clarke's thematic analysis: (1) 'awareness and understanding', (2)'self-efficacy and feeling competent', (3)'applying knowledge to practice' and (4)'barriers to implementation'. Following educational intervention, health care practitioners experienced increased knowledge regarding prevalence and impact of trauma for children and families and developed confidence to respond with trauma informed practices.

CONCLUSIONS

Findings closely relate to the four components of Trauma Informed Care practice; realising the widespread impact of trauma, recognising symptomology, responding through integrating trauma knowledge into policies and practice and resisting re-traumatisation. The findings illustrate that Trauma Informed Care educational interventions significantly improves health care practitioners' knowledge and practice. In addition, this review supports the implementation of routine Trauma Informed Care education and associated practice policies into paediatric practice settings.

What are the barriers and enablers to trauma-informed emergency departments? A scoping review protocol

INTRODUCTION

There is a high prevalence of psychological trauma among the population. Such people are more likely to have poorer health outcomes and these factors may contribute to increased use of the emergency department. There has been some attempt to implement a trauma-informed approach across public services, especially in health and social care. However, it is unclear how this concept applies to the challenging and high-demand emergency department context. The review aims to locate, examine and describe the literature on trauma-informed care in the unique and challenging healthcare delivery context that is the emergency department. The review aims to identify the barriers and enablers that may facilitate trauma-informed care in the emergency department context.

METHODS AND ANALYSIS

This scoping review will use the Joanna Briggs Institute methodology for scoping reviews. Systematic searches of relevant databases (CINAHL, MEDLINE, PsycINFO, EMBASE, Knowledge Network and Web of Science) will be conducted. Empirical studies of any methodological approach, published in English between January 2001 and September 2023 will be included. The 'grey' literature will also be accessed. Two reviewers will independently screen all studies. Data will be extracted, collated and charted to summarise all the relevant methods, outcomes and key findings in the articles.

ETHICS AND DISSEMINATION

Formal ethical approval is not required. The findings of this study will be disseminated through peer-reviewed publications, conference presentations and condensed summaries for key stakeholders in the field. The data generated will be used to inform a programme of work related to trauma-informed care.

Emergency department clinicians' views on implementing psychosocial care following acute paediatric injury: a qualitative study

Introduction: The early post-trauma period is a key time to provide psychological support to acutely injured children. This is often when they present to emergency departments (EDs) with their families. However, there is limited understanding of the feasibility of implementing psychological support for children and their families in EDs. The aim of this study was to explore UK and Irish ED clinicians' perspectives on developing and implementing psychosocial care which educates families on their children's post-trauma psychological recovery.Methods: Semi-structured individual and group interviews were conducted with 24 UK and Irish ED clinicians recruited via a paediatric emergency research network.Results: Clinicians expressed that there is value in offering psychological support for injured children and their families; however, there are barriers which can prevent this from being effectively implemented. Namely, the prioritisation of physical health, time constraints, understaffing, and a lack of training. Therefore, a potential intervention would need to be brief and accessible, and all staff should be empowered to deliver it to all families.Conclusion: Overall, participants' views are consistent with trauma-informed approaches where a psychosocial intervention should be able to be implemented into the existing ED system and culture. These findings can inform implementation strategies and intervention development to facilitate the development and delivery of an accessible digital intervention for acutely injured children and their families.

Factors that influence interprofessional implementation of trauma-informed care in the emergency department

Background

To describe factors that influence interprofessional staff decisions and ability to implement trauma-informed care (TIC) in a level-one emergency department (ED) trauma center.

Methods

This qualitative research study consisted of semi-structured interviews and quantitative surveys that were conducted between March and December 2020 at an urban trauma center. Eligible participants were staff working in the ED. Interview questions were developed using the Theoretical Domains Framework (TDF), which is designed to identify influences on health professional behavior related to implementation of evidence-based recommendations. Interview responses were transcribed, coded using Atlas software, and analyzed using thematic analysis.

Results

Key themes identified included awareness of TIC principles, impact of TIC on staff and patients, and experiences of bias. Participants identified opportunities to improve care for patients with a trauma history, including staff training, more time with patients, and efforts to decrease bias toward patients. Most participants (85.7%) felt that a TIC plan, tiered trauma inquiry, and warm handovers would be easy or very easy to implement.

Conclusion

We identified key interprofessional staff beliefs and attitudes that influence implementation of TIC in the ED. These factors represent potential individual, team-based, and organizational targets for behavior change interventions to improve staff response to patient trauma and to address secondary trauma experienced by ED staff.

Trauma-Informed Care Curricula for the Health Professions: A Scoping Review of Best Practices for Design, Implementation, and Evaluation

PURPOSE

Trauma-exposed persons often experience difficulties accessing medical care, remaining engaged in treatment plans, and feeling psychologically safe when receiving care. Trauma-informed care (TIC) is an established framework for health care professionals, but best practices for TIC education remain unclear. To remedy this, the authors conducted a multidisciplinary scoping literature review to discern best practices for the design, implementation, and evaluation of TIC curricula for health care professionals.

METHOD

The research team searched Ovid MEDLINE, Cochrane Library, Elsevier's Scopus, Elsevier's Embase, Web of Science, and the PTSDpubs database from the database inception date until May 14, 2021. Worldwide English language studies on previously implemented TIC curricula for trainees or professionals in health care were included in this review.

RESULTS

Fifty-five studies met the inclusion criteria, with medicine being the most common discipline represented. The most prevalent learning objectives were cultivating skills in screening for trauma and responding to subsequent disclosures (41 studies [74.5%]), defining trauma (34 studies [61.8%]), and understanding trauma's impact on health (33 studies [60.0%]). Fifty-one of the studies included curricular evaluations, with the most common survey items being confidence in TIC skills (38 studies [74.5%]), training content knowledge assessment (25 studies [49.0%]), participant demographic characteristics (21 studies [41.2%]), and attitudes regarding the importance of TIC (19 studies [37.3%]).

CONCLUSIONS

Future curricula should be rooted in cultural humility and an understanding of the impacts of marginalization and oppression on individual and collective experiences of trauma. Moreover, curricula are needed for clinicians in more diverse specialties and across different cadres of care teams. Additional considerations include mandated reporting, medical record documentation, and vicarious trauma experienced by health care professionals.

Quality of life in paediatric burn patients with non-severe burns

BACKGROUND

Burns are common worldwide, and the vast majority are non-severe burns of less than 20% of the total body surface area (TBSA). In Australia, paediatric burns account for a third of all burn admissions, thus understanding the quality-of-life outcomes after a non-severe burn in children is important.

METHODS

This retrospective cohort study describes a paediatric cohort from Western Australia with non-severe burns occurring between 2018 and 2020 and characterises the child's quality-of-life outcomes which is measured using the Paediatric quality of life survey (PedsQL). The PedsQL included a parent-report and child-report assessment, each with a physical function domain and a psychosocial function domain which comprised of an emotional, a social and a school category.

RESULTS

Data collected from 249 patients; 50.6% were male, 45.6% were toddlers. The most common cause was scald (48.19%), the majority had burns smaller than 5% TBSA (91.97%), and most included visible areas such as head, neck or hands (77.51%). The parent-report PedsQL scores were significantly different for both physical and psychosocial domains between the different age groups (p = 0.002, p = 0.001, respectively) and for burn cause (p = 0.004, p = 0.005, respectively). For child-reported scores we found evidence of an effect of burn cause across both domains that did not reach a statistical significance (p = 0.076, p = 0.078, respectively). The psychosocial functions in both the parent-report and the self-report were significantly different for the socioeconomic status groups (p = 0.015, p = 0.032, respectively). Quality of life scores were critically low in 16.46% of paediatric burn patients at three months after burn.

CONCLUSION

Parent-reported and child-reported psychosocial function was significantly poorer in higher socioeconomic groups, for older children and for those with flame burns. About 16% of patients had scores below the critical cut off. These data provide insight into the quality-of-life outcomes of paediatric patients with non-severe burns, allowing future studies to investigate burn prevention strategies and services to help paediatric burn patients in their recovery.

Barriers to emergency department clinicians' confidence in providing paediatric trauma-informed care

Background

It has been estimated that around 31% of children will experience a traumatic event during childhood, most commonly serious accidents that lead to hospitalisation. Around 15% of children who experience such events go onto develop post-traumatic stress disorder. Emergency department (ED) clinicians have a unique opportunity to intervene during the early peri-trauma period, which can involve incorporating a trauma-informed approach within their care. The available evidence indicates that clinicians internationally need further education and training to enhance their knowledge and confidence in providing trauma-informed psychosocial care. However, UK/Ireland specific knowledge is limited.

Methods

The current study analysed the UK and Irish subset of data (N = 434) that was collected as part of an international survey of ED clinicians. Questionnaires indexed clinician confidence in providing psychosocial care, and a range of potential barriers to providing that care. Hierarchical linear regression was used to identify predictors of clinician confidence.

Results

Clinicians reported moderate levels of confidence in providing psychosocial care to injured children and families (M = 3.19, SD = 0.46). Regression analyses identified negative predictors of clinical confidence, including a lack of training, worrying about further upsetting children and parents, and low levels of perceived departmental performance in providing psychosocial care (R 2 = 0.389).

Conclusions

The findings highlight the need for further training in psychosocial care for ED clinicians. Future research must identify nationally relevant pathways to implement training programmes for clinicians, in order to improve their skills in relation to paediatric traumatic stress and to reduce the perception of barriers identified in the present study.

Pediatric Medical Traumatic Stress (PMTS) following Surgery in Childhood and Adolescence: a Systematic Review

The purpose of the present review was to systematically review, synthesize and quantify prevalence rates of subclinical and clinical psychological symptoms in children and adolescents who have undergone surgery. Systematic literature searches were conducted twofold in April 8, 2020 and March 7, 2021 in PsycInfo and PubMed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Manuscripts were screened against eligibility criteria and were included if they investigated psychological symptoms in children or adolescents (age between 1 to 21 years at the time of study) who were hospitalized for pediatric surgery. Means and standard deviations weighted by sample size were calculated. Eleven articles met inclusion criteria. The review revealed that a small but substantial number of children and adolescents are at an elevated risk for postoperative psychological symptoms and disorders. Up to 13% had symptoms consistent with a diagnosis of a posttraumatic stress disorder, 6% to 8% exhibited elevated symptoms of depression or anxiety, and about 25% showed internalizing and externalizing symptoms. This review provides preliminary evidence that children and adolescents experience significant psychological distress and posttraumatic stress symptoms after pediatric surgery. Apart from better training of clinicians, prevention, early psychological screening and psychosocial care in surgical wards of hospitals are recommended. Well-designed studies of high methodological quality are necessary to replicate existing findings and provide a broader base of evidence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-021-00391-9.

Optimising outcomes for complex trauma survivors: assessing the motivators, barriers and enablers for implementing trauma informed practice within a multidisciplinary health setting

BACKGROUND

Complex trauma is a significant public health issue with detrimental health, interpersonal and psychological impacts, which can impede client recovery and result in multiple representations. 'Trauma Informed Practice' (TIP) is an evidence-based model which ensures safe and effective services for clients and staff. This study examines health professional's use of TIP, and the motivators, enablers and barriers to implementation in a multidisciplinary setting.

METHODS

A mixed methods study with 24 front-line clinicians and managers within a community health setting in Australia. A purpose designed, expert validated TIP checklist was completed, followed by semi-structured focus groups. Survey data was reported using descriptive statistics. Focus group data was digitally recorded, transcribed and thematically analysed.

RESULTS

Ten key factors were identified motivating, restricting or enabling TIP implementation. Seven were organisational factors including supportive and informed management, flexibility of service models, levels of service demands, resource availability, education opportunities, good client outcomes, and reporting requirements. Philosophical approach, team orientation, and vicarious trauma/stress management were three individual professional factors. Critically, alignment in two ways was necessary for successful implementation, that is: in knowledge and understanding across organisational role levels - clinician, manager and executive; and, in professional philosophy and team orientation of individual clinicians.

CONCLUSION

Providing TIP is essential for ensuring optimum client outcomes for trauma survivors and for maintaining workforce wellbeing. Although the increasing uptake to TIP is evident within the health setting, further attention is required to address the tension between service models focused on efficiently servicing whole populations and those attuned to effectively meeting the needs of high risk groups. A complex strategy to unite therapeutic and managerial goals is necessary if client, professional and organisational needs are to be effectively met.

Addressing Adultification of Black Pediatric Patients in the Emergency Department: A Framework to Decrease Disparities

Systematic racism and structural discrimination in the United States are factors that have negatively affected the health of Black individuals and families. One form of racism that often goes unrecognized and yet has a profound negative impact on the health and safety of Black children is adultification. Adultification occurs when children are perceived, or treated, as being older than they are. We implemented the Racism as a Root Cause framework to identify ways health care providers and health care systems can work to dismantle inequities and address the adultification of Black children in the emergency department (ED). A shift to change policies, systems, and environments in the ED begins with recognition of blind spots through training, communication, and reflection. Utilizing methods to identify adultification and racism, such as the ICD-10-CM Diagnosis Code Z60.5 Target of (perceived) adverse discrimination and persecution, can assist providers in recognizing the prevalence of racism and discrimination. To reduce the harms of inequities, injustice, and impacts of racism on Black children in the ED, it is essential to use trauma-informed care in all interactions. It is crucial for all employees of the ED to understand that adultification is extremely prevalent, hard to recognize, and causes harm to the health of Black children and their families. Without conscious efforts to decrease the pervasiveness and detriment of adultification bias, the repercussions of such racism will continue to perpetuate medical mistrust and negative health care experiences for Black children and families.

A concept analysis of trauma-informed care

AIM

This concept analysis aims to provide an in-depth analysis of the concept of trauma-informed care and explore the use of this concept in nursing, using Walker and Avant's method.

BACKGROUND

Trauma-informed care is a priority for nurses caring for patients with previous trauma. Many forms of trauma exist. Various types of trauma may not be apparent without appropriate assessment. Therefore, nurses must approach all patients with the components of trauma-informed care.

DESIGN

Concept analysis.

DATA SOURCE

PubMed, Cumulative Index of Nursing and Allied Health Literature, and PsycINFO databases were searched for articles in English. The final sample consisted of 23 documents published from 2015 to 2020.

REVIEW METHODS

Concept analyzed using Walker and Avant's eight-step method.

RESULTS

Four defining attributes of trauma-informed care were identified as recognition, knowledge, concern, and respect. Definitions, the use of the concept of trauma-informed care, antecedents, consequences, and empirical referents are described. Model, borderline, and contrary cases are discussed.

CONCLUSION

Many forms of trauma exist. Various types of trauma may not be apparent without appropriate assessment. Therefore, establishing an operational definition of trauma-informed care has implications and significance in victim identification and the provision of trauma-informed care, advocacy, and nursing and interdisciplinary research.

A web-based educational intervention to implement trauma-informed care in a paediatric healthcare setting: protocol for a feasibility study using pre-post mixed methods design

Background

Adoption of responsive trauma-informed practices by staff in hospital-based paediatric care may help mitigate downstream costs associated with treatment delivery due to reduced pain and distress for children and care providers, improved health-related quality of life and increased satisfaction with care. A web-based education intervention (termed Responsive CARE) was developed to build self-efficacy of staff in a paediatric medical setting. This protocol paper describes a feasibility study (including preliminary effectiveness) of the implementation of Responsive CARE in a tertiary, outpatient burn clinical setting.

Methods

A pre-post, mixed methods design will be employed. Children and caregivers attending hospital for change of burn wound dressings or burn scar management during the 3-month control or 3-month intervention period will be eligible, with follow-up to 6-months post-baseline. All children and caregiver/s will receive “standard care” including burn interventions focused on wound healing, scar management, itch management (both pharmacological and non-pharmacological), counselling, age-appropriate procedural support and burn rehabilitation. Health professional participants will be those involved in the management of children with burns during the study period or their senior managers. Health professional participants who attend a weekly educational clinical meeting will be invited to complete the intervention during a 1-month timeframe between the control and intervention period (or upon their commencement in burn outpatients during the intervention period) using an individualised log-in process. A purposive sample of caregivers and health professionals will be sought for participation in semi-structured interviews. Qualitative data will be analysed using Framework analysis. Feasibility will be evaluated via interviews, digital records of intervention usage and technical assistance logs. The primary outcome measures of effectiveness (pain, itch and distress) will be measured using self-report or behavioural observation. Quantitative data will primarily be analysed descriptively and using generalised linear models.

Discussion

This study will provide insights into factors that impact upon the feasibility of a web-based trauma-informed care education intervention in a clinical practice setting. This knowledge may support other education approaches within healthcare settings related to improving and supporting patients to reduce the risk of healthcare interactions that result in paediatric medical traumatic stress.

Knowledge and training in paediatric medical traumatic stress and trauma-informed care among emergency medical professionals in low- and middle-income countries

Background: Provision of psychosocial care, in particular trauma-informed care, in the immediate aftermath of paediatric injury is a recommended strategy to minimize the risk of paediatric medical traumatic stress. Objective: To examine the knowledge of paediatric medical traumatic stress and perspectives on providing trauma-informed care among emergency staff working in low- and middle-income countries (LMICs). Method: Training status, knowledge of paediatric medical traumatic stress, attitudes towards incorporating psychosocial care and barriers experienced were assessed using an online self-report questionnaire. Respondents included 320 emergency staff from 58 LMICs. Data analyses included descriptive statistics, t-tests and multiple regression. Results: Participating emergency staff working in LMICs had a low level of knowledge of paediatric medical traumatic stress. Ninety-one percent of respondents had not received any training or education in paediatric medical traumatic stress, or trauma-informed care for injured children, while 94% of respondents indicated they wanted training in this area. Conclusions: There appears to be a need for training and education of emergency staff in LMICs regarding paediatric medical traumatic stress and trauma-informed care, in particular among staff working in comparatively lower income countries.