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

Abstract 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.


INTRODUCTION
A third of children aged under 15 years visit UK emergency departments (EDs) annually (Keeble & Kossarova, 2017). Data suggest these rates are steadily rising, particularly amongst children under 5 years old (Ruzangi et al., 2020). Children and young people more frequently visit EDs than adults, with attendance rates at 425 for every 1000 children and 345 for every 1000 adults (NHS Digital, 2017). Common reasons for ED visitations include unintentional injuries, such as road traffic accidents, burns and animal bites (Public This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
Analysis of national factors influencing clinicians' confidence can help inform relevant, tailored reform options for the provision of traumainformed care in EDs.
We examined ED clinicians' confidence in providing paediatric trauma-informed care within a UK and Ireland-specific context, and explored predictors of this confidence using the UK and Irish data subset of the aforementioned international ED clinician survey (Alisic et al., 2016). We investigated the relationship between both department-wide factors regarding psychosocial care and individual barriers experienced by UK and Irish ED clinicians, and their confidence levels. Specific aims were to examine: (i) UK and Irish ED clinicians' confidence in providing trauma-informed psychosocial care to children and families, (ii) barriers experienced by ED clinicians in providing trauma-informed care, (iii) whether ED clinical environments provide a positive context in terms of providing trauma-informed care, and (iv) the extent to which barriers identified and clinical contextual factors contribute to clinician confidence in providing trauma-informed psychosocial care to children.

Data and participants
Data in the present study were collected as part of a larger international study (Alisic et al., 2016), which assessed ED clinicians' perspectives on traumatic stress and psychosocial care in children using a web-based self-report questionnaire. Participants in the original study were recruited through Paediatric Emergency Research Networks in North America, Europe and Australasia, national health care provider forums and associations, and a snowball approach to collect responses from countries with less professional organisation and associations.
The present study analysed the UK and Irish subset of the data, in a total of 434 participants from the UK and Ireland. These  contact and engagement, safety and comfort, stabilisation, information gathering on current needs, practical assistance, connection with social support, information on coping, and linking with collaborative services (Shultz & Forbes, 2014). Each of the items were scored on a 4-point Likert scale ranging from 1 (poor) to 4 (excellent).
Given the novelty of this measure of department support for psychosocial care, Principle Components Analysis (PCA) with direct oblimin rotation was conducted to determine whether meaningful subscales could be extracted for analysis for UK and Irish data.

Confidence in providing paediatric trauma-informed care
Clinicians' confidence in providing trauma-informed care to children and families was measured across 18 items, each scored on a 4-point Likert scale ranging from 1 (not at all) to 4 (very). This measure was developed by Alisic et al. (2016) following previous research with ED clinicians (Alisic et al., 2014;Kassam-Adams et al., 2015). The items captured key domains of psychosocial and physical care required for potentially trauma-exposed children to prevent the development of emotional distress. Key domains of care included: recognising emotional distress, providing emotional assistance, eliciting trauma details, informing families about traumatic symptoms and how to access mental health support. An average confidence score ranging from 1-4 was used for the regression analysis in the present study (Alisic et al., 2016).

Covariates
Years of experience in patient care and profession were identified as covariates, as previous analyses have identified these as being significantly related to clinician confidence (Alisic et al., 2016). Years of experience was treated as a continuous variable whereas respondents' profession was coded as binary: (0) nurse and (1) physician.

Analysis plan
Statistical analyses were performed using IBM SPSS Statistics 27 (IBM Corp, 2017). Descriptive statistics were computed to explore respondent characteristics, confidence, barriers to implementing psychosocial care and departmental support for psychosocial care.
Bivariate correlations were computed to assess whether relationships between the main variables were statistically significant (2) the two department support scales (capturing departmental support for (a) access to psychosocial care/services, and (b) immediate stress responses), and (3) barriers to providing psychosocial care. The final model retained variables that were significantly related to clinician confidence.

RESULTS
Characteristics of survey respondents from the UK (90.8%) and Ireland (9.2%) (N = 434) are outlined in Table 1 Table 2 outlines mean scores for individual clinician confidence items in descending order. The mean overall confidence score in providing trauma-informed care amongst the survey respondents was 3.19 (SD = 0.46), which indicates a moderate level of confidence (a score of 3 = moderately confident). The top three items which clinicians reported being 'very' confident in were: (i) explaining medical procedures to children and parents, (ii) talking with children in ageappropriate language, and (iii) assessing and managing pain in children. Conversely, items where most respondents reported being only 'a little' confident were: (i) providing information to parents about emotional/behavioural reactions that indicated the child may need help, and (ii) educating children and families about common traumatic stress reactions.

Barriers to trauma-informed care
Barriers to providing trauma-informed care are illustrated in Figure 1 (N = 402). Across all six barriers the majority of the sample endorsed them as being present (rated as either somewhat or significant barrier). The barriers most frequently identified as significant were time constraints (38.1%), lack of training (36.1%) and lack of dedicated space for psychosocial care (33.6%).    The current analysis found that rates of UK and Irish clinician confidence were highest amongst aspects of trauma-informed care based on medical knowledge, including explaining medical procedures to children/parents and assessing and managing pain in children.

Associations with clinician confidence
Importantly, rates of confidence were lower for areas which required clinicians to use psychosocial knowledge, including providing information about traumatic symptoms, accessing relevant mental health services and teaching relaxation techniques (e.g., breathing).
These findings are consistent with previous international research, in which ED clinicians reported lower rates of confidence in domains of trauma-informed care requiring specific post-traumatic stress (PTS) knowledge, as opposed to domains of pain management . The current results are also consistent with previous findings from the Australian/New Zealand and international F I G U R E 1 Percentages indicate the extent to which specific barriers to providing trauma-informed care are experienced by ED clinicians. ED, emergency department  (Alisic et al., 2016;Hoysted et al., 2017).

Rate the performance of your ED in… Poor (%) Fair (%) Good (%) Excellent (%) Mean score (SD)
Lack of clinician confidence in providing psychosocial care for trauma exposed children is an important issue. For children and for wellbeing (Marsac et al., 2016). Therefore, presentation at the ED may be a key clinical contact point at which children displaying disabling acute stress responses could be identified and appropriate signposting to future resources provided (Hiller et al., 2016).
Clinicians in the current sample identified significant obstacles to providing such psychosocial care. Notably, a high proportion perceived time constraints and lack of training as barriers. Previous research has highlighted that time constraints are a prominent obstacle in providing psychosocial care, as medical needs are prioritised over psychological needs within ED time restrictions (Alisic et al., 2014;Hoysted et al., 2017;Moss, Healy et al., 2019). However, the present analyses also identified which barriers were robustly and independently related to clinician confidence and identified that clinician confidence was influenced by a lack of training and worrying about further upsetting children. Dueweke et al. (2019) found that brief training in psychosocial care not only increased clinician confidence, but also reduced their perception that they did not have time to make this provision. Therefore, whilst interventions must be sensitive to space and time constraints, it is also possible that perceptions of these barriers are a consequence of limited knowledge of what providing psychosocial care entails.
The present analyses also suggest wider departmental culture is related to clinician confidence in trauma-informed care. The contribution of departmental culture to clinician confidence has not been investigated by previous analyses conducted on the wider international dataset (Alisic et al., 2016). The current analysis suggests that poorer perceived departmental performance in providing immediate psychosocial care and informing families about how to access psychosocial care were both related to reduced clinician confidence in the UK and Ireland. These findings support suggestions that a department-wide culture which recognises the importance of trauma-informed care, and readily implements measures to facilitate this, is vital to providing effective support for trauma-exposed children and their families (Marsac et al., 2016). More generally there is evidence that the organisational environment within EDs shapes clinicians' own attitudes and confidence when addressing mental health difficulties in patients (Clarke et al., 2014). Therefore, a department-wide commitment to improving psychosocial aspects of trauma-informed care is likely to be particularly effective in supporting clinicians in integrating this into their interactions with trauma-exposed children and their families (DeCandia et al., 2014).
Overall, the current analyses highlight a clear need to improve UK and Irish ED clinicians' understanding and application of PTSspecific knowledge. Previous research highlights that a lack of relevant training leads to inconsistencies in clinicians' knowledge of PTS following paediatric injury, and a reliance on providing psychosocial care based upon experience, rather than skills acquired through training (Alisic et al., 2014;Hoysted et al., 2017). Therefore, training is needed to equip clinicians with the necessary skills to provide emotional support and to offer anticipatory guidance for trauma recovery and service access.
Previous studies have investigated brief, trauma-informed training programmes which aimed to improve clinicians' knowledge of traumatic stress and ability to translate knowledge into practice.