Nurses' views and current practice of trauma-informed pediatric nursing care

Development of a Questionnaire for Measuring Trauma-Informed Care of Nurses Working with Traumatically Injured Patients

Purpose

To develop a new questionnaire for assessing nurses' current situation of knowledge, attitude and practice related to trauma-informed care (TIC) for patients with traumatic injury.

Methods

By literature review, qualitative interview and Delphi consultation, the 46 preliminary items about trauma-informed care of nurses working with traumatically injured patients were selected. After that, the preliminary questionnaire was distributed to 293 Chinese nurses in relevant departments. The collected data were analyzed by internal reliability, split-half reliability, structural validity and content validity.

Results

The questionnaire was developed with a total of 30 items in 3 dimensions: 8 items in the TIC knowledge dimension, 10 items in the TIC attitude dimension and 12 items in the TIC practice dimension. The Cronbach's alpha coefficient was 0.939, and the content validity was 0.971.

Conclusion

This designed questionnaire shews receptable reliability and validity, which could be used to assess the knowledge, attitude and practice of nurses in application of trauma-informed care for traumatically injured patients.

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.

Pediatric Medical Traumatic Stress and Trauma-Informed Care in Pediatric Chronic Illness: A Healthcare Provider Survey

OBJECTIVE

To inform approaches to pediatric medical traumatic stress (PMTS) by exploring providers' (1) perception of the impact of PMTS on the medical care of patients with pediatric-onset chronic illnesses, (2) self-reported competencies and practices of PMTS prevention, treatment, and counseling, and (3) perception of the barriers influencing the adoption of these practices.

STUDY DESIGN

A convenience sample of multidisciplinary healthcare providers was recruited through a multimodal recruitment strategy to participate in an electronic survey adapted from the Trauma-Informed Care Provider Survey.

RESULTS

Among participants (n = 304), 99% agreed that PMTS impacts patient health. Participants report altering medical care plans due to PMTS, including deferring or stopping treatments (n = 98 [32%]) and changing medication regimens (n = 88 [29%]). Sixty-eight percent (n = 208) report negative impact of PMTS on patient implementation of medical care plans, including medication nonadherence (n = 153 [50%]) and missed appointments (n = 119 [39%]). Although participants agreed it is their job to decrease patient stress (n = 292 [96%]) and perform PMTS assessments (n = 268 [88%]), few practiced PMTS-focused trauma informed care. Systems-level barriers to practice included insufficient training, absent clinical workflows, and lack of access to mental health experts.

CONCLUSIONS

Our findings have helped inform a conceptual framework for understanding the relationship between PMTS and health outcomes. Systems-level opportunities to optimize PMTS-focused trauma-informed care include (1) dissemination of provider training, (2) integrated workflows for PMTS mitigation, and (3) enhanced accessibility to mental health providers. Further work is required to determine if these interventions can improve health outcomes in patients with pediatric-onset chronic illnesses.

Primary Care Providers' Knowledge, Perceptions, and Practice of Trauma-Informed Care in a Public Health Care Setting

Despite serving patients with especially high rates of trauma exposure and related sequelae, many primary care providers do not receive specialized training in the provision of trauma-informed care (TIC). This study sought to document primary care providers' baseline rates of TIC training and their knowledge, perceptions, and practice of TIC at a large, urban public hospital in the Southeastern United States. Participants (n = 67; 68.7% women; 44.8% white; Mage = 36.7 years, standard deviation [SD]age = 9.8 years) completed an online self-report survey on their TIC training status, trauma-related knowledge, perceptions, and practices, as well as burnout and secondary traumatic stress. Less than half of participants (43.3%) endorsed TIC training exposure. Participants generally had adequate levels of trauma-related knowledge (76.5% of items correct) and favorable perceptions of TIC (endorsed 89.7% of TIC-supportive statements). Most participants (86.6%) endorsed recently using trauma-informed practices, but only 47.8% reported routinely screening for trauma-related disorders. Participants who reported receiving prior TIC training scored better on knowledge items and endorsed recently using more trauma-informed practices than those who did not have training exposure. TIC training status' associations with current screening practices and perceptions of TIC were trending toward significance. TIC training status was not related to burnout, and trained participants reported greater secondary traumatic stress than those without training exposure. Results point to system-wide TIC training as a well-received, translational strategy that can enhance the trauma-informed nature of primary care provision.

Nursing students' views on trauma-informed pediatric nursing care and family-centered care

PURPOSE

We studied the views of nursing students on family-centered care (FCC) and their knowledge, opinions, self-rated competence, current practice, and perceived implementation barriers with regard to trauma-informed pediatric nursing care.

METHODS

This survey was a descriptive correlational study. The sample consisted of 261 nursing students, 3rd and 4th years, who had completed the Child Health and Diseases Nursing Course. The data were obtained using the "Student Information Form," "Family-Centered Care Attitude Scale," and "trauma-informed care (TIC) Provider Survey."

RESULTS

Nursing students were knowledgeable and held favorable opinions about TIC. The survey showed that students with higher levels and those with a hospitalization experience during childhood had higher scores regarding TIC. A positive relationship was found between the students' TIC to mean score and FCC attitude mean score.

CONCLUSIONS

Nursing students are not competent to practice TIC, especially with pediatric patients. Therefore, they need to develop relevant skills for helping pediatric patients.

PRACTICE IMPLICATIONS

Efforts to improve nursing students' trauma-informed pediatric care should highlight specific skills related to helping pediatric patients manage emotional responses to difficult medical experiences. By integrating TIC into the baccalaureate curricula, nursing educators can provide the students with appropriate skills and facilities so that they can provide holistic and highly effective care to highly vulnerable patients.

Trauma-informed and family-centered paediatric resuscitation: Defining domains and practices

Aim

For paediatric patients and families, resuscitation can be an extremely stressful experience with significant medical and psychological consequences. Psychological sequelae may be reduced when healthcare teams apply patient- and family-centered care and trauma-informed care, yet there are few specific instructions for effective family-centered or trauma-informed behaviours that are observable and teachable. We aimed to develop a framework and tools to address this gap.

Methods

We reviewed relevant policy statements, guidelines, and research to define core domains of family-centered and trauma-informed care, and identified observable evidence-based practices in each domain. We refined this list of practices via review of provider/team behaviours in simulated paediatric resuscitation scenarios, then developed and piloted an observational checklist.

Results

Six domains were identified: (1) Sharing information with patient and family; (2) Promoting family involvement in care and decisions; (3) Addressing family needs and distress; (4) Addressing child distress; (5) Promoting effective emotional support for child; (6) Practicing developmental and cultural competence. A 71-item observational checklist assessing these domains was feasible for use during video review of paediatric resuscitation.

Conclusion

This framework can guide future research and provide tools for training and implementation efforts to improve patient outcomes through patient- and family-centered and trauma-informed care.

Research note reliability and validity of Japanese version of the trauma-informed care provider survey (TIC provider survey)

OBJECTIVE

Robust instruments to evaluate the ability of trauma-informed care among healthcare workers need to be developed, as this would help the implementation of trauma-informed care to prevent re-traumatization of patients. This study aims to assess the reliability and validity of the Japanese version of the Trauma-Informed Care (TIC) Provider Survey. A total of 794 healthcare workers were surveyed using a self-administered questionnaire, including the TIC Provider Survey, and six measures that were considered to be correlated with it. We calculated the Cronbach's alpha coefficient to investigate the internal consistency of each category of the TIC Provider Survey (knowledge, opinions, self-rated competence, practices, and barriers). Spearman's rank correlation coefficients were used to investigate the correlation between each category of the TIC Provider Survey, and other measures of construct validity.

RESULTS

Cronbach's alpha coefficients of each category of the TIC Provider Survey were 0.40 (Knowledge), 0.63 (Opinions), 0.92 (Self-rated competence), 0.93 (Practices), and 0.87 (Barriers). The Spearman's rank correlation coefficients were small. We confirmed the reliability of the acceptable levels and examined the validity of modest or unacceptable levels of the Japanese version of the TIC provider survey among Japanese workers in a healthcare setting.

Youth Firearm Injury: A Review for Pediatric Critical Care Clinicians

Firearms are now the leading cause of death among youth in the United States, with rates of homicide and suicide rising even more steeply during the SARS-CoV-2 pandemic. These injuries and deaths have wide-ranging consequences for the physical and emotional health of youth and families. While pediatric critical care clinicians must treat the injured survivors, they can also play a role in prevention by understanding the risks and consequences of firearm injuries; taking a trauma-informed approach to the care of injured youth; counseling patients and families on firearm access; and advocating for youth safety policy and programming.

Trauma-informed care for perinatal women during the COVID-19 pandemic: A survey of nurses and midwives in Turkey

OBJECTIVES

There is a paucity of evidence on the provision of trauma-informed care among nurses and midwives during the pandemic.Therefore, this online survey of Turkish nurses and midwives aimed to: describe reported maternal concerns and anxieties during the COVID-19 pandemic; and explore aspects of trauma-informed care for perinatal women during the COVID-19 pandemic (i.e., nurses' and midwives' knowledge, opinions, perceived competence, current practices, and implementation barriers).

DESIGN

A cross-sectional descriptive survey design.

SETTING AND PARTICIPANTS

A web-based survey conducted between June 2021 to December 2021. A total of 102 nurses and midwives comprised the final sample of this study.

FINDINGS

The safety of COVID-19 vaccine was both the most common maternal concern (73%) and the most frequently noted maternal source of anxiety (79%) reported to nurses and midwives by perinatal women. Most nurses and midwives were knowledgeable of, held favorable opinion about, and perceived moderate competence in trauma-informed care. The most frequently provided practice was encouraging mothers to make use of their own social support system (82%). Time constrains and lack of resources were perceived as somewhat to significant barriers to providing trauma-informed care during the pandemic.

CONCLUSIONS

Access to correct information related to COVID-19 vaccination is necessary to reduce maternal anxiety. Since perinatal nurses and midwives had favorable opinions concerning implementing trauma-informed care, successful strategies for mitigating the implementation barriers are essential to facilitate the provision of trauma-informed care during the pandemic.

Trauma-Informed Care: Pediatric Intensive Care Nurses at the Root of Children’s Safety and Trust

Any experience that a child perceives as threatening or detrimental and has long-term consequences for the child’s holistic health and welfare qualifies as trauma. Whether an experience is traumatic depends on the 3 E’s of trauma: the event, the experience of the event, and the effects. Traumatic events can affect an infant’s or child’s development and have lifelong repercussions. Because of the prevalence of pediatric trauma, trauma-informed care has become the standard of care. Nurses are perfectly positioned to lead trauma-informed care in the pediatric intensive care unit. This article explores the components of trauma-informed care and the application of this standard of care to children in the pediatric intensive care unit. The nurse providing trauma-informed care understands the impact of trauma on the child, the family, and the staff and responds by integrating knowledge about trauma into care, both individually and systemwide, seeking to actively avoid retraumatization. This article presents the 6 principles of trauma-informed care and 3 case examples illustrating the application of these principles in the pediatric intensive care unit. Additional resources are provided to equip critical care nurses to fully implement this standard of care for critically ill children.

Understanding the Conceptualization and Operationalization of Trauma-Informed Care Within and Across Systems: A Critical Interpretive Synthesis

Policy Points In order to achieve successful operationalization of trauma-informed care (TIC), TIC policies must include conceptual clarity regarding the definition of both trauma and TIC. Furthermore, TIC requires clear and cohesive policies that address operational factors such as clearly delineated roles of service providers, protocol for positive trauma screens, necessary financial infrastructure, and mechanisms of intersectoral collaboration. Additionally, policy procedures need to be considered for how TIC is provided at the program and service level as well as what TIC means at the organizational, system, and intersectoral level.

CONTEXT

Increased recognition of the epidemiology of trauma and its impact on individuals within and across human service delivery systems has contributed to the development of trauma-informed care (TIC). How TIC can be conceptualized and implemented, however, remains unclear. This study seeks to review and analyze the TIC literature from within and across systems of care and to generate a conceptual framework regarding TIC.

METHODS

Our study followed a critical interpretive synthesis methodology. We searched multiple databases (Campbell Collaboration, Econlit, Health Systems Evidence, Embase, ERIC, HealthSTAR, IPSA, JSTOR, Medline, PsychINFO, Social Sciences Abstracts, Sociological Abstracts and Web of Science),as well as relevant gray literature and information-rich websites. We used a coding tool, adapted to the TIC literature, for data extraction.

FINDINGS

Electronic database searches yielded 2,439 results and after inclusion/exclusion criteria were applied, a purposive sample of 98 information-rich articles was generated. Conceptual clarity and definitional understanding of TIC is lacking in the literature, which has led to poor operationalization of TIC. Additionally, infrastructural and ideological barriers, such as insufficient funding and service provider "buy-in," have hindered TIC implementation. The resulting conceptual framework defines trauma and depicts critical elements of vertical TIC, including the bidirectional relationship between the trauma-affected individual and the system, and horizontal TIC, which requires intersectoral collaboration, an established referral network, and standardized TIC language.

CONCLUSIONS

Successful operationalization of TIC requires policies that address current gaps in systems arrangements, such as the lack of funding structures for TIC, and political factors, such as the role of policy legacies. The emergent conceptual framework acknowledges critical factors affecting operationalization.

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.

Predictors of 12 month functional outcomes and length of stay of severely injured children in NSW, Australia. A longitudinal multi-centre study

BACKGROUND

The majority of paediatric injury outcomes studies focus on mortality rather than the impact on long-term quality of life, health care use and other health-related outcomes. This study sought to determine predictors of 12-month functional and psychosocial outcomes for children sustaining major injury in NSW.

METHODS

The study included all children < 16 years requiring intensive care or an injury severity score (ISS) ≥ 9 treated in NSW at a paediatric trauma centre (PTC). Children were identified through the three PTCs and NSW Trauma Registry. The paediatric Quality of Life Inventory (PedsQL) and EuroQol five-dimensional EQ-5D-Y were used to measure HRQoL post-injury, completed via parent/carer proxy recruited through NSW PTCs.

RESULTS

There were 510 children treated at the three NSW PTCs during the 15-month study period. The mean (SD) age was 6.7 (6.0) years, with a median NISS (New Injury Severity Score) of 11 (IQR: 9-18). Regression analysis showed worse psychosocial health at twelve months was associated with hospital length of stay (LoS) and number of body regions injured (F₂,₆₅ = 5.85, p = 0.005). Physical outcome was associated with LoS and intensive care unit (ICU) admission (F_2,66 = 13.48, p < 0.001). Hospital LoS was significantly associated with NISS and head injury (F_2,398 = 51.5, p < 0.001).

CONCLUSION

Hospital length of stay and polytrauma are independent factors that negatively influence psychological and physical outcomes of children with major injuries. Early intervention to enable emotional well-being, discharge home and long-term follow up such as dedicated family support and rehabilitation at home could reduce preventable poor outcomes.

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.

Incorporating a Trauma-Informed Care Protocol Into Pediatric Trauma Evaluation: The Pediatric PAUSE Does Not Delay Imaging or Disposition

OBJECTIVES

Trauma evaluation in the emergency department (ED) can be a stressful event for children. With the goal of minimizing pain, anxiety, and unneeded interventions in stable patients, we implemented the Pediatric PAUSE at our level 1 adult/level 2 pediatric trauma center. The Pediatric PAUSE is a brief protocol performed after the primary survey, which addresses Pain/Privacy, Anxiety/IV Access, Urinary Catheter/Rectal exam/Genital exam, Support from family or staff, and Explain to patient/Engage with PICU team. The aim was to assess whether performing the PAUSE interfered with timeliness of emergent imaging in pediatric patients and their disposition.

METHODS

We identified all patients aged 0 to 18 years evaluated as trauma activations at our institution after the Pediatric PAUSE was implemented (October 1, 2016-March 31, 2017) as well as 2 analogous 6-month pre-PAUSE periods. Patient demographics, time to imaging studies, and time to ED disposition were analyzed.

RESULTS

One hundred seventy-two patients met the study criteria, with a mean age of 10.9 years and mean injury severity score of 10.6. One hundred fifteen participants (68.5%) were transferred from other hospitals, and 101 (87.8%) had ≥1 imaging study performed before arrival. The Pediatric PAUSE was performed for 41 (25%) of 163 study participants. There was no difference in time to first imaging study in participants for whom the PAUSE was performed (18.4 vs 15.0 minutes, P = 0.09).

CONCLUSIONS

The PAUSE is a practice intervention designed to address the psychosocial needs of pediatric trauma patients and their families to help prevent posttraumatic stress symptoms. Implementation did not interfere with the timeliness of first imaging in pediatric trauma patients.

Understanding the meaning of trauma-informed care for burns health care professionals in a pediatric hospital: A qualitative study using interpretive phenomenological analysis

BACKGROUND

Trauma-informed care includes a range of practices that build a culture of safety, empowerment, and healing. Limited information is available regarding the lived experience of trauma-informed care by healthcare professionals treating burns in a multidisciplinary setting.

OBJECTIVE

The primary aim of this study was to understand what 'trauma-informed care' means to staff and students working in burns at a tertiary pediatric hospital.

METHODS

Semi-structured interviews and focus group were conducted with healthcare professionals (medical, nursing, allied health, pre-graduate students) working in paediatric burn care (or their line manager). Analysis of the dataset was undertaken using qualitative methods (interpretive phenomenological approach and qualitative content analysis).

RESULTS

Eleven interviews and one focus group were completed and transcribed verbatim. Three superordinate themes were applicable across the five cohorts: 'what does trauma-informed care mean?', 'being able to deliver trauma-informed care' (agency) and 'impact of the setting'. Eleven components of trauma-informed care practice (for example, everyday interactions with patients and colleagues, screening and assessment) and service-level approaches (for example, service provider training) were described by participants.

CONCLUSIONS

Healthcare professionals' experiences of delivering trauma-informed care in a burns centre highlighted the need to clarify the concept of 'trauma-informed care' as a first step. Enabling the workforce to understand trauma-informed care and apply it in everyday interactions with patients and colleagues, and a strategic commitment to practice change needs to be actioned more systematically to support implementation of a trauma-informed care approach in pediatric health services.

Exploring How Sexual Assault Nurse Examiners Practise Trauma-Informed Care

BACKGROUND

Sexual violence is a term describing sexual acts where consent is not freely given. Registered nurses employed as sexual assault nurse examiners (SANEs) provide care to address the medical and legal needs of victims/survivors of sexual violence. Trauma-informed care (TIC) is an approach recommended when caring for individuals who have experienced trauma.

PURPOSE

The study purpose was to understand how SANEs incorporate trauma-informed approaches in the care of adult and postpubescent adolescent victims/survivors of sexual violence.

METHODS

Eight SANEs were purposively recruited to participate in online semistructured interviews. Interview data were analyzed using qualitative interpretive description.

RESULTS

Six themes emerged from the analysis: (a) the importance of understanding the patient's experience; (b) personalized connection: developing a safe nurse-patient relationship; (c) choice: the framework of how we do things; (d) rebuilding strengths and skills to support healing and posttraumatic growth; (e) a wonderful way to practise: facilitators and benefits of trauma-informed practice; and (f) challenges to trauma-informed practice.

CONCLUSIONS

These findings indicate the perceived value of TIC and the need for enhanced support of providers who deliver TIC. More research is warranted to strengthen the evidence about trauma-informed practice in SANE programs and across healthcare settings.

Trauma-informed care as a rights-based "standard of care": A critical review

BACKGROUND

A growing body of literature on the concept of trauma-informed care (TIC) has emerged in response to greater recognition of the prevalence of childhood trauma. Currently, no review has examined the conceptualization of TIC in various child-serving systems, specifically TIC as a standard of care, the outcomes examined relevant to care, and whether child rights are part of the TIC discourse.

METHOD

A systematic search of 12 health and non-health databases, reviewed for relevance to children and youth specifically, was conducted to form a critical review of the literature.

RESULTS

Forty-nine documents were selected, which included articles from child welfare (n = 16), education (n = 15), juvenile justice (n = 8), health (n = 7), and multiple sectors (n = 3). A common theme across all sectors was a lack of clear understanding regarding what is TIC and how to implement it. While trauma symptoms are seemingly a good-fit outcome and reflective of a right to rehabilitative health, validated assessment tools were not commonly used. Few studies explicitly included a child rights perspective within TIC.

CONCLUSION

Emerging evidence encourages systematic inquiry into the operationalization of TIC to better assess whether it is an established model with consistent measurement. Empirical studies need to embrace established intervention methodology (e.g., improvement from baseline, control groups). From this expanded rigor, the issue as to whether TIC can evolve to a rights-based standard of care can be addressed.

Using Photovoice to Understand Survivors' Healthcare Experiences and Strategies

The unique, individual nature of traumatic experiences and trauma symptoms and the limited healthcare resources typically allocated for individual patients pose barriers to implementing trauma-informed care. Developing knowledge on how survivors of violence engage in healthcare and self-advocate can lead to more empowering and efficient implementation of trauma-informed care. However, survivor perspectives on trauma-informed care are underrepresented in current literature and survivors' strategies for navigating healthcare are understudied. The aims of this participatory Photovoice study were to describe the healthcare experiences of female survivors of violence and their strategies for dealing with difficult healthcare experiences, healthcare providers, and the healthcare system. A sample of community-based women participated in an iterative series of five Photovoice meetings. Participants discussed multifaceted vulnerability in healthcare settings with regard to past traumatic violence, triggering or retraumatizing health care experiences, medical knowledge, and provider-patient relationships. They agreed that providers believing their symptoms, health concerns, and trauma disclosures was essential for positive provider-patient relationships and healthcare experiences. Findings on the importance of perceived belief with regard to trauma disclosure and health concerns and survivors' healthcare strategies are unique contributions to the literature. Providers should be accountable for integrating survivors' self-knowledge in collaborative healthcare decision-making, for making medical records and information easily accessible, and for expressing belief in trauma disclosures and health concerns. Future research should continue using participatory methods to assess evolving trauma-informed practices and patient engagement among survivors and to hasten progress toward trauma-informed care that effectively meets the needs of survivors.

Training Hospital Personnel in Trauma-Informed Care: Assessing an Interprofessional Workshop With Patients as Teachers

OBJECTIVE

Trauma-informed care (TIC) and violence intervention programs (VIPs) facilitate psychosocial healing and reduce injury recidivism for children and families affected by community violence. To integrate a VIP into 2 Level 1 Pediatric Trauma Centers, an educational initiative was developed and co-taught by pediatricians and former patients. The primary aim was to increase provider-driven patient referrals to the VIP. A secondary aim was to improve all participants' comfort levels in 5 areas of TIC.

METHODS

Referrals to the VIP from 2014 to 2018 were tracked and analyzed. A curriculum based on Five Points of TIC was developed and offered to interprofessional groups of hospital employees. Pediatricians and former patients recovering from violent injury facilitated the workshops. Twenty-two workshops were attended by 318 providers and hospital staff members from 2015 to 2018. Pre- and postworkshop surveys asked participants to rate their comfort levels with 5 areas of TIC.

RESULTS

Provider-driven patient identification increased from 34.8% to 86.8% over the study period. For the entire cohort, participants' self-assessment of comfort levels with TIC improved by 21% (P < .001), with medical students' scores improving the most (24%). Residents were less likely to complete the workshop than fellows or attendings (P = .03).

CONCLUSIONS

This novel curriculum was associated with a change in practice patterns, as well as a closer relationship between the VIP and pediatric hospital systems. All professional groups experienced an improvement in comfort levels with the Five Points of TIC. Future study on information retention and other patient care-related outcomes is needed.

Parent and Clinician Communication During Paediatric Burn Wound Care: A Qualitative Study

PURPOSE

To thematically describe parent-clinician communication during a child's first burn dressing change following emergency department presentation.

DESIGN AND METHODS

An observational study of parent-clinician communication during the first burn dressing change at a tertiary children's hospital. Verbal communication between those present at the dressing change for 87 families, was audio recorded. The recordings were transcribed verbatim and transcripts were analysed within NVivo11 qualitative data analysis software using qualitative content analysis.

FINDINGS

Three themes, underpinned by parent-clinician rapport-building, were identified. Firstly, knowledge sharing was demonstrated: Clinicians frequently informed the parent about the state of the child's wound, what the procedure will involve, and need for future treatment. Comparatively, parents informed the clinician about their child's temperament and coping since the accident. Secondly, child procedural distress management was discussed: Clinicians and parents had expectations about the likelihood of procedural distress, which was also related to communication about how to prevent and interpret procedural distress (i.e., pain/fear). Finally, parents communicated to clinicians about their own distress, worry and uncertainty, from the accident and wound care. Parents also communicated guilt and blame in relation to injury responsibility.

CONCLUSIONS

This study provides a description of parent-clinician communication during paediatric burn wound care.

PRACTICAL IMPLICATIONS

The results can assist healthcare professionals to be prepared for a range of conversations with parents during potentially distressing paediatric medical procedures.

Assessing Trauma History in Pregnant Patients: A Didactic Module and Role-Play for Obstetrics and Gynecology Residents

INTRODUCTION

Assessing and addressing patient histories of trauma constitute a critical component of care for vulnerable populations such as pregnant patients, yet they often go unrecognized in obstetric care. Obstetric providers may feel poorly equipped to address this issue comfortably and effectively.

METHODS

We designed this didactic module for obstetric residents with previous experience taking patient histories and delivering clinical care. The module was delivered with a faculty member and three additional facilitators with expertise in communication skills training. The session included 60 minutes of background information followed by a 15-minute presentation of a communication template for assessing trauma history. Using a practice case, residents had 45 minutes to practice in small groups, with the facilitators serving as the patient in the role-play.

RESULTS

In the 2015-2016 academic year, 21 obstetric residents participated in this module. All residents (100%) endorsed favorable beliefs regarding the importance of assessing trauma history and using trauma-informed care. On average, three-fourths (77%) demonstrated basic awareness of issues related to trauma in medical populations. Most residents (>85%) reported a high sense of efficacy in delivering trauma-informed care in some areas, while fewer (64%) reported efficacy specifically in educating patients about signs and symptoms of traumatic stress.

DISCUSSION

The module was well received overall, with participants indicating that clinical training in trauma-informed communication was needed to enhance their sense of efficacy in this area. This learning exercise provided training in a critical communication skill while highlighting areas for further development.

Knowledge of and Perceived Competence in Trauma-Informed Care and Attitudes of NICU Nurses Toward Mothers of Newborns With Neonatal Abstinence Syndrome

OBJECTIVE

To explore how knowledge of and perceived competence in trauma-informed care inform the attitudes of NICU nurses toward mothers of newborns with neonatal abstinence syndrome (NAS).

DESIGN

A cross-sectional survey study.

SETTING

A southern U.S. metropolitan children's hospital with 145 NICU beds.

PARTICIPANTS

Convenience sample of 150 NICU nurses.

METHODS

Participants completed an online survey questionnaire adapted from the Attitudes About Drug Abuse in Pregnancy questionnaire and the Trauma-Informed Pediatric Care survey. Participants also responded to one open-ended question about their experiences in working with mothers of newborns with NAS. We used descriptive and inferential statistics and content analysis to analyze the survey data.

RESULTS

Participants demonstrated low to moderate knowledge about and perceived competence in trauma-informed care and showed more judgmental attitudes toward mothers of newborns with NAS. Level of knowledge about mothers with substance use disorder and perceived competence in trauma-informed care were associated with participants' attitudes toward mothers of newborns with NAS. Emergent themes from qualitative data included the following: Mother-Newborn Dyads Shape Nurses' Judgmental Attitudes, Caring for Mothers of Newborns With NAS Is a Challenging Experience, and Need to Refine Care for Mothers Through Intra- and Interdisciplinary Collaboration.

CONCLUSION

NICU nurses need further education about mothers of newborns with NAS. Improved knowledge about these women and adaptation of the principles of trauma-informed care may influence NICU nurses' judgmental attitudes toward mothers of newborns with NAS.

Using the ARTIC-35 to Measure Nurses' Attitudes Related to Trauma-Informed Care

BACKGROUND AND PURPOSE

Trauma-informed care (TIC) acknowledges the lasting effects of trauma on individuals. The Attitudes Related to Trauma-Informed Care (ARTIC-35) scale was developed to examine healthcare providers' attitudes related to TIC. Here, we present an item-level analysis of the ARTIC-35 scale for use with nurses and compare our findings to the current ARTIC-35 structure.

METHODS

Principal components analysis, qualitative inter-item analysis, and qualitative intra-item analysis of the ARTIC-35.

FINDINGS

Our principal component analysis structure supported a nine-factor solution, inter-item qualitative analysis structure supported five subscales, and intra-item qualitative analysis identified 13 acceptable items and 22 items requiring revision for use with nurses.

DISCUSSION

When used with nurses, there are important considerations regarding scale validity and challenges with the design of the original ARTIC-35 scale.

Trauma-informed education: Creating and pilot testing a nursing curriculum on trauma-informed care

BACKGROUND

Trauma is a significant contributor to morbidity and mortality. Trauma-informed care (TIC) provides a safe and supportive healthcare environment for patients who have experienced trauma. Educating healthcare providers improves knowledge, attitudes, and skills related to TIC. However, nursing programs do not systematically integrate TIC education.

PURPOSE

To create, implement, and evaluate nursing content on TIC at the graduate and undergraduate levels at one university.

METHOD

A pretest-posttest survey was utilized to assess changes in TIC knowledge, attitudes, and skills related to the delivery of content on trauma and TIC to students in three courses at one large Midwestern university in January 2019. Safety, acceptability, and transferability were also measured.

FINDINGS

The content improved nursing students' knowledge and skills related to providing TIC. Further, content on TIC is acceptable to both undergraduate and graduate students and is transferrable to non-nursing students.

DISCUSSION

The current study provides a trauma-informed nursing education model that is safe, appropriate, acceptable, and efficacious.

"We went as a team closer to the truth": impacts of interprofessional education on trauma- and violence- informed care for staff in primary care settings

Building on trauma-informed care (TIC), Trauma and Violence-Informed Care (TVIC) aims to minimize re-traumatization for people who have previously experienced violence, support people currently experiencing violence and draw attention to structural violence. Previous research has not explored how health care providers understand TVIC nor studied either TIC or TVIC in primary health care (PHC). This analysis of the perspectives of fourteen PHC staff regarding the impacts of interprofessional TVIC education sessions was conducted as part of a larger study of an intervention to promote equity in PHC. Researchers drew on general clinic observations and observations of TVIC training sessions and analyzed in-depth interviews with PHC staff who took part in TVIC training, using an interpretive description approach. While the impacts varied, all participants described enhancements in their knowledge, awareness and/or confidence in providing care related to trauma and violence. Factors intrinsic to the process of educating staff, including providing staff with data on trauma and violence in the patient population, and supporting interprofessional discussions, influenced how participants understood, integrated, and prioritized TVIC. Importantly, structural, organizational, and personal contexts significantly influenced how participants enacted TVIC in practice. This study contributes knowledge about interprofessional TVIC education and how diverse professionals understand and enact TVIC concepts in PHC, pointing to the role of TVIC in challenging the biomedical paradigm in PHC and the difficulties of using a structural lens in clinical practice.

Implementing Patient-Centered Trauma-Informed Care for the Perinatal Nurse

Adverse childhood experiences and trauma significantly impact physical and mental health. Increased maternal perinatal depression/anxiety, preterm labor, and low birth weight, as well as infant morbidity and mortality, are some examples of the impact of trauma on perinatal health. Trauma-informed care begins with knowledge about trauma, the ability to recognize signs of a trauma response, responding to patients effectively, and resisting retraumatization. As holistic providers, perinatal nurses can create safe care environments, establish collaborative patient relationships based on trust, demonstrate compassion, offer patients options when possible to support patient autonomy, and provide resources for trauma survivors. This can prevent or reduce the negative impact of trauma and improve the health and well-being of infants, mothers, and future generations. This clinical article outlines key strategies for implementation of patient-centered trauma-informed perinatal nursing care.

Training Pediatric Primary Care Residents in Trauma-Informed Care: A Feasibility Trial

This study examined the feasibility and outcomes of a training designed to enhance pediatric residents' trauma-informed practices in primary care. Paired samples t tests examined changes in 33 residents' attitudes, perceived competence, and perceived barriers toward trauma-informed care after a 2-hour training. Fisher's exact tests measured changes in residents' screening and referral behaviors. A subsample (n = 9) of residents were interviewed about the training. Residents reported increases in favorable attitudes (P = .065) and perceived competence (P < .001) and decreases in perceived barriers (P = .001 to .521) to implementing trauma-informed care practices. Chart reviews revealed a significant increase in completed trauma screens (0% to 8.0%, P < .001) but no difference in referrals for psychology/psychiatry services (1.9% to 4.2%, P = .200). Residents reported finding the training helpful. Although residents were willing and understood the utility of assessing for trauma, they faced substantial barriers.

Perceived lack of training moderates relationship between healthcare providers' personality and sense of efficacy in trauma-informed care

Background and Objectives: Medical patients often have trauma histories that are not routinely assessed, which can adversely affect health outcomes. Despite growing awareness of this issue, there is limited understanding of factors that influence provider competency in trauma-informed care (TIC). The study examined healthcare providers' personality traits in relation to their sense of TIC efficacy, taking into account perceived barriers to TIC and professional quality of life. Study Design: The study used cross-sectional survey methods to examine our central hypothesis that provider personality traits and perceived barriers to TIC would be associated with TIC-efficacy, and to explore interactions among study variables. Methods: Survey data were collected from 172 healthcare providers examining TIC knowledge, TIC-efficacy, perceived barriers to TIC, personality traits, and professional quality of life. Results: TIC-efficacy was positively correlated with "intellectence/openness" and inversely correlated with "neuroticism" and perceived lack of training as a barrier. "Intellectence/openness" interacted with perceived lack of training to predict TIC-efficacy, suggesting that providers with lower "intellectence/openness" report greater TIC-efficacy when lack of training is not perceived as a barrier. Conclusions: Provider personality traits and perceived barriers to TIC appear related to providers' TIC-efficacy. Implications for overcoming barriers to TIC through training and implementation are discussed.

Commercial Sexual Exploitation of Children: An Update for the Forensic Nurse

Commercial sexual exploitation of children (CSEC) is the sexual abuse of children through buying, selling, or trading their sexual services. This may involve engaging a child under the age of 18 years in prostitution, pornography, stripping, exotic dancing, escort services, or other sexual services. CSEC is a problem of epidemic proportions throughout the world including the United States; however, the actual number of CSEC victims in the United States is unknown. Studies indicate that most child victims are seen by a healthcare provider while being trafficked and that many victims receive care at a pediatric hospital within 1 year of their identification as a victim. CSEC is a significant pediatric healthcare problem. It is vital that forensic nurses possess a thorough understanding of the problem and be poised to better identify, intervene, and prevent CSEC. In this article, we focus on risk factors commonly experienced by victims, recruitment strategies used by traffickers, indicators to identify child victims, and intervention and educational strategies of relevance to forensic nurses.

Opportunities for nurses to support recovery after pediatric injury: Relationships among posttraumatic stress, hope, and quality of life

PURPOSE

Nurses are at the forefront of children's postinjury recovery; this unique role provides an opportunity for nurses to recognize and screen for symptoms that may interfere with children's quality of life (QOL). As such, aims of the present investigation were to explore selected variables (e.g., posttraumatic stress symptoms [PTSS], hope) that have the potential to impact QOL after pediatric injury, with a larger goal of contributing to recommendations for nursing practice to support children's full (physical and emotional) recovery during the peritrauma period following injury.

DESIGN AND METHODS

Sixty children (aged 7-13) completed measures of PTSS, hope, and QOL while receiving injury treatment.

RESULTS

PTSS significantly predicted concurrent QOL, β = -0.42, p = 0.001. Exploratory results demonstrated that specific PTSS clusters (re-experiencing [ β = -0.39; p = 0.003), avoidance [ β = -0.35; p = 0.009], arousal [ β = -0.34; p = .012]) all significantly predicted QOL. Specific PTSS were explored. Hope (overall, domains of pathways, general agency, goal setting) did not significantly predict concurrent QOL.

PRACTICE IMPLICATIONS

While this study is exploratory and more research is needed, current results suggest that nurses' awareness of PTSS (including symptoms of re-experiencing, avoidance, arousal) may help medical teams in identifying children that are at risk for impaired functional recovery (e.g., QOL) during the peritrauma period. Nurses may want to consider advocating for the integration of PTSS screeners into standard medical care. In addition, nurses have the opportunity to serve as key medical professionals in the delivery of trauma-informed medical care (which aims to minimize further trauma or re-traumatization). Nursing leadership may want to consider offering training in how nurses can identify and respond to children who have experienced an injury (such as trauma-informed care).

Trauma Providers' Knowledge, Views, and Practice of Trauma-Informed Care

Trauma-informed interventions have been implemented in various settings, but trauma-informed care (TIC) has not been widely incorporated into the treatment of adult patients with traumatic injuries. The purpose of this study was to examine health care provider knowledge, attitudes, practices, competence, and perceived barriers to implementation of TIC. This cross-sectional study used an anonymous web-based survey to assess attitudes, knowledge, perceived competence, and practice of TIC among trauma providers from an urban academic medical center with a regional resource trauma center. Providers (nurses, physicians, therapists [physical, occupational, respiratory]) working in trauma resuscitation, trauma critical care, and trauma care units were recruited. Descriptive statistics summarized knowledge, attitudes, practice, competence, and perceived barriers to TIC and logistic regression analyses examined factors predicting the use of TIC in practice. Of 147 participants, the majority were nurses (65%), followed by therapists (18%) and physicians (17%), with a median 3 years of experience; 75% answered the knowledge items correctly and 89% held favorable opinions about TIC. Nineteen percent rated themselves as less than "somewhat competent." All participants rated the following as significant barriers to providing basic TIC: time constraints, need of training, confusing information about TIC, and worry about retraumatizing patients. Self-rated competence was the most consistent predictor of providers' reported use of specific TIC practices. Despite some variability, providers were generally knowledgeable and held favorable views toward incorporating TIC into their practice. TIC training for trauma providers is needed and should aim to build providers' perceived competence in providing TIC.

Describing the healthcare experiences and strategies of women survivors of violence

AIM AND OBJECTIVE

The purpose of this study was to develop knowledge on women survivors' healthcare experiences and strategies.

BACKGROUND

Survivors of traumatic life events are at an increased risk for an array of negative health consequences, which can be complicated when distressing healthcare experiences act as a barrier to accessing needed care. Implications for trauma-informed and sensitive practice are well established, but evidence to date on survivors' healthcare experiences and patient engagement is limited.

DESIGN

This study utilized individual interviews and qualitative description methods.

METHODS

Fourteen participants completed a demographic questionnaire and one semistructured interview focused on their exposure to violence, healthcare experiences and strategies for navigating health care. Thematic analysis in alignment with qualitative description methods was used to analyse interview transcripts and identify themes.

RESULTS

Participants in this study reported a variety of traumatic life experiences, ranging from childhood sexual abuse and intimate partner violence to severe car accidents. Experiencing a multiplicity of trauma sometimes complicated participants' later healthcare experiences. Although participants described ways in which providers helped them attain positive care experiences, they also acknowledged that limitations of the healthcare system could make trauma-informed practices difficult to implement. Participants described strategies they use to prepare for, navigate and recover after healthcare encounters including selecting providers, bringing support persons to appointments and engaging in relaxing activities after appointments.

CONCLUSIONS

Participants emphasised the importance of trusting and equitable provider-patient relationships and described several ways they prepare for, cope with and care for themselves after difficult healthcare experiences. Descriptive data on the patient engagement behaviours of survivors of violence is a unique contribution of this study to existing research.

RELEVANCE TO CLINICAL PRACTICE

Findings from this study indicate the importance of comprehensive trauma history screening during health assessments, development of trusting and mutually respectful provider-patient relationships and provider training programmes focused on trauma-informed care practices.

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.

Exploring Nurses' Knowledge and Experiences Related to Trauma-Informed Care

Trauma-informed care is an emerging concept that acknowledges the lasting effects of trauma. Nurses are uniquely positioned to play an integral role in the advancement of trauma-informed care. However, knowledge related to trauma-informed care in nursing practice remains limited. The purpose of this article is to present the results of a qualitative study which explored nurses’ understandings and experiences related to trauma-informed care. Seven semistructured interviews were conducted with nurses and four categories emerged from the analysis: (a) Conceptualizing Trauma and Trauma-Informed Care, (b) Nursing Care and Trauma, (c) Context of Trauma-Informed Care, and (d) Dynamics of the Nurse–Patient Relationship in the Face of Trauma. These findings highlight important considerations for trauma-informed care including the complex dynamics of trauma that affect care, the need to push knowledge about trauma beyond mental health care, and noteworthy parallels between nursing care and trauma-informed care.

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

AIM

To examine Australian and New Zealand emergency department (ED) staff's training, knowledge and confidence regarding trauma-informed care for children after trauma, and barriers to implementation.

METHODS

ED staff's perspectives on trauma-informed care were assessed using a web-based self-report questionnaire. Participants included 468 ED staff (375 nursing and 111 medical staff) from hospitals in Australia and New Zealand. Data analyses included descriptive statistics, χ² tests and multiple regressions.

RESULTS

Over 90% of respondents had not received training in trauma-informed care and almost all respondents (94%) wanted training in this area. While knowledge was associated with a respondent's previous training and profession, confidence was associated with the respondent's previous training, experience level and workplace. Dominant barriers to the implementation of trauma-informed care were lack of time and lack of training.

CONCLUSIONS

There is a need and desire for training and education of Australian and New Zealand ED staff in trauma-informed care. This study demonstrates that experience alone is not sufficient for the development of knowledge of paediatric traumatic stress reactions and trauma-informed care practices. Existing education materials could be adapted for use in the ED and to accommodate the training preferences of Australian and New Zealand ED staff.

Application of a Framework to Implement Trauma-Informed Care Throughout a Pediatric Health Care Network

INTRODUCTION

To evaluate the initial application of a recently published three-step framework for implementing trauma-informed care (TIC) in a pediatric health care network by applying Framework for Spread.

METHODS

In steps 1 and 2 of the framework, we established commitment from the health care network leadership and initial interest in TIC among clinical providers (step 1), set evidence-based training goals and created the associated TIC training content (step 2). In step 3, 440 health care professionals (from 27 health care teams) participated in single-session, 1-hour training that covered the psychological impact of injury- and illness-related trauma, identification of traumatic stress symptoms, and how to respond to children exposed to potentially traumatic events. A concomitant quality improvement project allowed us to assess potential changes in training participants' favorable attitudes toward the integration of TIC and confidence in delivering TIC.

RESULTS

Compared with pretraining, participants demonstrated increases in attitude toward TIC, t(293) = 5.8, P < .001, Cohen's d = 0.32, and confidence in delivering TIC, t(293) = 20.9, P < .001, Cohen's d = 1.09.

DISCUSSION

Trainings were effective in achieving proximal goals targeting attitudes and confidence, thereby demonstrating the feasibility and clinical relevance of TIC training when implemented according to the three-step framework. Future research should examine methods of training to reach wide audiences to promote systematic change and evaluate changes in patient outcomes associated with providers' implementation of TIC.

Psychosocial Care for Injured Children: Worldwide Survey among Hospital Emergency Department Staff

OBJECTIVE

To examine emergency department (ED) staff's knowledge of traumatic stress in children, attitudes toward providing psychosocial care, and confidence in doing so, and also to examine differences in these outcomes according to demographic, professional, and organizational characteristics, and training preferences.

STUDY DESIGN

We conducted an online survey among staff in ED and equivalent hospital departments, based on the Psychological First Aid and Distress-Emotional Support-Family protocols. Main analyses involved descriptive statistics and multiple regressions. Respondents were 2648 ED staff from 87 countries (62.2% physicians and 37.8% nurses; mean years of experience in emergency care was 9.5 years with an SD of 7.5 years; 25.2% worked in a low- or middle-income country).

RESULTS

Of the respondents, 1.2% correctly answered all 7 knowledge questions, with 24.7% providing at least 4 correct answers. Almost all respondents (90.1%) saw all 18 identified aspects of psychosocial care as part of their job. Knowledge and confidence scores were associated with respondent characteristics (eg, years of experience, low/middle vs high-income country), although these explained no more than 11%-18% of the variance. Almost all respondents (93.1%) wished to receive training, predominantly through an interactive website or one-off group training. A small minority (11.1%) had previously received training.

CONCLUSIONS

More education of ED staff regarding child traumatic stress and psychosocial care appears needed and would be welcomed. Universal education packages that are readily available can be modified for use in the ED.

Implementing a Trauma-Informed Approach in Pediatric Health Care Networks

Pediatric health care networks serve millions of children each year. Pediatric illness and injury are among the most common potentially emotionally traumatic experiences for children and their families. In addition, millions of children who present for medical care (including well visits) have been exposed to prior traumatic events, such as violence or natural disasters. Given the daily challenges of working in pediatric health care networks, medical professionals and support staff can experience trauma symptoms related to their work. The application of a trauma-informed approach to medical care has the potential to mitigate these negative consequences. Trauma-informed care minimizes the potential for medical care to become traumatic or trigger trauma reactions, addresses distress, provides emotional support for the entire family, encourages positive coping, and provides anticipatory guidance regarding the recovery process. When used in conjunction with family-centered practices, trauma-informed approaches enhance the quality of care for patients and their families and the well-being of medical professionals and support staff. Barriers to routine integration of trauma-informed approaches into pediatric medicine include a lack of available training and unclear best-practice guidelines. This article highlights the importance of implementing a trauma-informed approach and offers a framework for training pediatric health care networks in trauma-informed care practices.