Culture Shift - Spreading Trauma-Informed Care Across a Health System

By Meghan Marsac, PhD

Editor's Note: View the original blog post here, and click here and here to learn more about CHOP's approach to trauma-informed care training. Over the past few years, VPI@CHOP has implemented trauma-informed care (TIC) training across the CHOP organization using a theory-based approach developed from the Institute for Healthcare Improvement’s Framework for Spread (FFS) and from VPI@CHOP’s own formative research (2016) to transform pediatric healthcare networks into trauma-informed institutions.The framework has three primary steps:

Step 1. Prepare for spread

• E.g., Meeting with hospital leadership and administration to establish champions

Step 2. Establish an aim for spread

• E.g., Setting goals for the network and identifying critical teams and departments for training

Step 3. Develop, execute, and refine a spread plan

• E.g., Selecting decision-makers

Implementing the Framework for Spread

Our initial formative research demonstrated that CHOP’s pediatric medical providers were ready to embrace TIC, but there was a large gap in access to on-the-job training and standardization of TIC practice.

The VPI@CHOP team used the FFS framework to address these barriers. To shift the culture and make TIC standard clinical practice at CHOP, we needed to establish leadership commitment and interest from clinical providers, which we accomplished via:

• Brief presentations highlighting the potential for TIC to improve patient healthcare outcomes and providing case examples and data;
• Pilot trainings which triggered additional requests, demonstrating the perceived value of TIC among clinicians.

In Step 2, we established training goals and developed content. In each training session, participants learn the prevalence and impact of emotional trauma, how to identify signs and symptoms, and how to respond--within the scope of standard medical care--to children exposed to trauma. We also review how caring for seriously ill or traumatized children can affect staff (called secondary trauma).

The team strategically targeted all employees who interact with patient families, including non-clinical staff. We planned for in-person, one-hour training workshops led by TIC expert trainers that included didactic presentation and group discussion. We tailored presentations to specific departments or teams to help with content relevancy and future collaborative support for TIC within teams.

To encourage participation, we offered continuing education credits for multiple disciplines (medical, nursing, social work, psychology), identified TIC champions within teams, and scheduled trainings during existing team meetings.

Quality Improvement Study Results

Importantly, we conduct ongoing Quality Improvement through a pre- and post-training survey. A 9-item survey measures changes in attitudes towards importance of TIC in participants’ work, confidence recognizing  traumatic stress symptoms, and recognition of how pre-existing trauma may affect a child’s reactions to current and future medical care. It also includes an open-ended item for views on how TIC changes health care practice.

The VPI@CHOP team recently published results of one QI study in The Journal of Continuing Education in the Health Professions, in which 294 participants completed pre- and post-surveys. We noted significant increases in favorable attitudes about and confidence in delivering TIC. Responses to the open-ended question revealed shifting perceptions of patient situations (e.g., increased empathy) and the need to deliver personalized care (e.g., seeing the patient as a whole person).

We found the FFS to be a very useful guide to develop a strategic approach to disseminating TIC trainings across a large pediatric healthcare network. With a goal to increase the number of pediatric patients that receive trauma-informed medical care as standard practice, we will use these findings to obtain additional support for trainings at CHOP and externally.

With our current capacity, it will take several years to train all the targeted employees at CHOP. Therefore, we’ll also consider how to adapt our in-person training to a web-based platform to extend our reach.

In future research, we would like to explore provider retention of knowledge to determine if further booster training is needed. We’d also like to measure impact on observed provider performance and the impact of TIC practice on patient health outcomes.