Parents of babies in the NICU have been studied extensively to evaluate their experience of mental health concerns and levels of post-traumatic stress(32). A recent meta-analysis including more than 6,000 NICU parents concluded that anxiety, mental health conditions, and levels of post-traumatic stress were significantly higher in these parents than those found in the general population. The American Academy of Pediatrics has clearly articulated the value of a trauma-informed perspective for all clinicians providing care for children and families(15). However, systematic incorporation of trauma-informed key principles is not consistent in pediatric healthcare (12). The need for widespread buy-in from a sufficient number of multi-disciplinary NICU health care team members may be one barrier to such incorporation.
We used a multidisciplinary workgroup to design this study and disseminate this curriculum to bolster the excitement for change. In alignment with the TIC concept that it is critical for persons with lived experience to be the driving forces of any restorative changes (33), the curriculum included brainstorming sessions (focus group and individual interviews) with NICU team members. These sessions allowed for learning directly from frontline staff how to best incorporate trauma-informed practice changes in the future. This research highlights the opportunities and challenges of successfully integrating trauma-informed education and willingness to make trauma-informed practice changes into complex large-scale systems like the NICU.
With review of the post-educational session surveys (53% completion rate of the educational opportunities), participants shared both revelations about how they see their patients and families differently and ideas for how they plan to apply the knowledge and change their practice. The educational brainstorming sessions sparked fresh ideas related to organizational trauma-informed practices and committee work.
The year-long progressive education and subsequent discourse resulted in generative reflection, shared insights, and new initiatives within the sample’s practice environment. While education alone is rarely enough to improve healthcare culture, it provides the foundation for realizing, recognizing, responding to, and avoiding re-traumatization (3, 16, 20). Frontline staff shared innovative ideas for trauma-sensitive practices through the unit-based improvement pathways. Leaders of the NICU journal club selected more articles about recognizing trauma. The wellness team grew in numbers, and overall, there was more consideration and dialogue about TIC. Examples of changes in practice included implementing “Code Lavender”(34) to recognize and support staff and families during crisis and “Butterfly movement” to alert team members to clear hallways when a baby is being moved during end-of-life care. The NICU also increased attention and celebration of developmental milestones, multidisciplinary team members routinely asked families about special or unique traditions/histories to individualize care, staff sat down with parents while updating them, and parents were empowered with choice when able. While these things might have happened without the study and its educational opportunities, these surfacing ideas brought a collective understanding and support that had not existed previously. The mixed methodologies of this study strengthen the idea that education that is collaborative, inclusive, and multidisciplinary in design and implementation must be followed by repeated opportunities for reflection, engagement, and mutual problem-solving(35).
The experience gained in this study highlights the importance of awareness as a foundational prerequisite to implementing TIC practice. Staff reported that awareness of trauma history and seeking to understand how and why NICU parents respond the way they do was critical. Participants frequently commented that they not only had an increased awareness of their biases, but a desire to mitigate them, consider alternative approaches based on this knowledge, and acknowledge the different life experiences of NICU parents, and NICU colleagues. A shared knowledge was recognized; and change in individual behaviors with leadership support was seen as a step forward toward changing the culture in the NICU. Other lessons learned in making this a feasible project include involving study team champions from each discipline to create buy-in from peers, using regularly scheduled and mandatory educational or department meeting time, and providing continuing education credits. Though not originally intended to be presented virtually, virtual delivery of this curriculum proved successful.
Completing TIC education provided knowledge, but we also attained the goals of a willingness to make changes in practice, increased multidisciplinary collaboration and communication, and the extension of TIC principles beyond the traditional use by psychosocial team members. We observed a rekindled interest in initiatives that promote TIC, in addition to a subsequent intentional expansion of these efforts.
Features that make this study unique include it being multidisciplinary in nature, inclusive of all NICU staff, and conducted at a single, large (84-bed) Level IV NICU in a free-standing, Midwestern children’s hospital. While the TIC curriculum and the ARTIC scales have been used in other settings, they have not previously been universally applied to healthcare on such a large scale with qualitative data support. The curriculum used was unique in that it was designed with cultural humility as a foundational principle and included optional brainstorming sessions among healthcare team members with various roles and disciplines. Portions of the curriculum have been shared with the Children’s Hospital Association to form a common language across pediatric centers. Locally a partnership with the NICU parent support coordinator ensured that the lived experience of parents guided this work from study design to implementation.
A limitation to this study was the rather homogeneous group of participants who completed the ARTIC surveys. Most ARTIC survey participants identified as female, White, and had worked less than 15 years. Demographics for respondents with data at both time points looked much like those for respondents with data at a single time point. In the former group, younger (< 30) and older (60+) respondents were under-represented, and physicians and nurse practitioners were over-represented. Additionally, due to the confidential and optional nature of the post-education surveys, it is not possible to determine which job roles or disciplines provided which comments or suggestions.
While this study had rich qualitative data, quantitative findings were not as robust. One consideration for why the ARTIC scores did not show more impressive results may be due to the relatively high baseline numbers (baseline means were already above 5 on a Likert Scale from 1 to 7), leaving limited room for improvement. While there has been a concerted effort on the part of the hospital to address family-centered care and equity, diversity, and inclusion, it remains challenging to precisely determine why the baseline cohort had high mean baseline scores of 5. Use of the ARTIC was limited by the small number of pre-post matched study participants and the fact that learning occurred within rather than across disciplines. It could be concluded, however, that there was overall growth given the higher post-intervention scores. The COVID-19 pandemic also affected the implementation of the education, extending the length of the study, and increased the potential number of staff who were not present either at the beginning or end of the study period. While ARTIC scores did increase, and qualitative data suggest that idea generation and motivation to adopt and incorporate trauma-informed practices resulted, follow-up data has to date not been acquired to demonstrate if participants actually made the changes they noted. Direct correlation with improved patient outcomes is an area for future study.
Future considerations include a tool to provide high-yield information designed to increase clinician awareness of parent trauma and offer ways to avoid re-traumatizing parents. Interest grew for a new initiative for a family guidance tool, “Thrive Guide,” a note in the electronic medical record that is derived from asking family members to share what they believe is important for clinicians to know about their family (including past stressful events, current stressors, preferred ways of coping, and preferred ways of communicating when learning information or interacting with the medical team)(36). We began to incorporate quality improvement methodology to measure outcomes after incorporating TIC principles into standard practice. In such actions we will continue to track such examples of how trauma-informed principles are incorporated into practice with staff, and developing an education sustainability plan for new staff are anticipated.
Culture change in healthcare occurs slowly and is difficult to measure. Our findings suggest TIC education can change attitudes and beliefs within a large level IV NICU by increasing awareness and understanding, enhancing self-awareness and the desire to mitigate unconscious bias, and prioritizing the desire to change practices to improve parental perceived safety, trust, and collaboration.