1 2 2 Acknowledgements To Cody, your courage and stillness have always inspired me. Your constant faith and love for me are written throughout this research. I will never be able to repay the kindness, patience, and unyielding love you have given me. I love you always. Dr. Mary Terwilliger, who from day one of my nursing career never gave up on me. You have mentored me to the woman, and Registered Nurse I am today. Thank you. 3 Implementation of Perinatal Trauma-Informed Care Randilyn Lewis, MSN, RN, CBC Abstract A lack of support and understanding by healthcare professionals can contribute to cascading events in the quality of their patients, newborns, and communities’ lives from experiencing birth trauma. Women who experience a traumatic birthing experience without support can hinder their feelings of having more children, create relationship problems, negatively affect the bonding with their newborn, and they may avoid medical interventions that are like their birthing experience such as pap smears (Birth Trauma Association, 2018). This project aims to answer, “Does implementing trauma-informed care practices education to perinatal nurses increase their knowledge, attitudes, and practices of trauma-informed care after educational implementation?” Trauma-informed care (TIC) is a concept that is grounded in a set of four assumptions and six principles. A trauma-informed approach to nursing care is inclusive of trauma-specific interventions; whether it includes assessment, treatment, or recovery supports, it also incorporates key trauma principles into the targeted organizational culture. The results of the project noted a positive Pearson correlation from p= 0.1 to 0.6 in all areas of the nurse’s knowledge, attitude, and practices (KAP) from pre- to post-survey results. These results conclude that educating perinatal nurses does positively impact their KAP and is beneficial to implementation. This implementation impacts future perinatal nursing and maternal newborn dyads for generations. The ability to change cultural thinking from “What is wrong with you?” to “What happened to you”? This demonstrates an improvement in care and is the first step in healing for all past and future trauma survivors. 4 Table of Contents Chapter 1 1. Introduction Background of the Problem Statement of the Problem Research Question(s) Operational Definition Need for the Study Significance of the Problem Assumptions Summary of the Problem Chapter 2 2. Review of Related Literature Related Research Conceptual Framework Summary of the Review of Literature Chapter 3 3. Methodology Introduction Design of the study/type of research Sample/recruitment/protection, inclusion/exclusion criteria with data Site from which the sample is selected Measuring instruments – reliability/validity Procedures for data collection Plans for treatment of the data Time schedule for conducting the study Information regarding any grants Summary of Methodology Chapter 4 4. Results and Discussion Introduction Results Discussion of Results Limitations Summary Chapter 5 5 5. Summary, Conclusions and Recommendations Summary of the Findings Limitations Implications for Nursing Recommendations for Further Research Summary References Appendices Appendix A: Perinatal Knowledge, Attitude, and Practice Pre-and PostSurvey Appendix B: UPMC Northwest and IRB Approval Letter Appendix C: Education Session Invite Flyer Appendix D: Participant Consent Letter Appendix E: Trauma-Informed Role Play Cards Appendix F: Implementing Perinatal Trauma-Informed Nursing Practice PowerPoint Presentation Appendix G: Director Permission for PowerPoint recording 6 List of Figures Figure Page 1: Perinatal Trauma-Informed Care 4 R’s Principals……………………………………44 2: TIC Question One…………………………………………………………….….……36 3: TIC Question Two…………………………………………………………………….37 4: TIC Question Seven…………………………………………………………………...38 5: TIC Question Nine…………………………………………………………………….39 6: TIC Question Sixteen…………………………………………………………………40 7: TIC Question Eighteen……………………………………………………………….41 8: TIC Question Twenty-Two…………………………………………………………...41 9: TIC Question Twenty-Six…………………………………………………………….43 10: TIC Question Twenty-Eight…………………………………………………………43 1 Chapter 1 Introduction According to the Birth Trauma Association (2018), birth trauma is a phrase for Post-Traumatic Stress Disorder (PTSD) after childbirth. Birth trauma also includes women who experience symptoms of PTSD after childbirth without a full diagnosis. Not everyone who has had a traumatic experience suffers from PTSD, but many do. It’s important to understand that it’s a normal response, and not a sign of weakness. It’s also involuntary: evidence has shown there is a difference between the brains of people with PTSD and those without (Birth Trauma Association, 2018). Stress results in acute and chronic changes in neurochemical systems and specific brain regions, which result in long-term changes in brain “circuits,” involved in the stress response (Bremmer, 2022). Bremmer noted lasting effects of trauma on the brain showing a long-term dysregulation of norepinephrine and Cortisol systems, and areas of hippocampus, amygdala, and medial prefrontal cortex that are affected by trauma. These brain areas play a role in the stress response. They also play a critical role in memory, highlighting the important interplay between memory and the traumatic stress response. For some women, the events experienced during childbirth or pregnancy are enough to be perceived as traumatic; for other women it doesn’t have to be a dramatic event to be considered traumatic. Factors such as the loss of control, loss of their dignity, the unfriendly attitude of those around them, and feelings of not being heard or the absence of informed consent to procedures all are common experiences by those expressed to have had a traumatic birth. A lack of support and understanding by healthcare professionals can contribute to cascading events in the quality of their patients, newborns, and communities’ lives from 2 experiencing birth trauma. Women who experience a traumatic birthing experience without support can hinder their feelings of having more children, create relationship problems, negatively affect the bonding with their newborn, and they may avoid medical interventions that are similar to their birthing experience such as pap smears (Birth Trauma Association, 2018). Trauma-informed care (TIC) is a concept that is grounded in a set of four assumptions and six principals. A trauma-informed approach to nursing care is inclusive to trauma-specific interventions; whether it includes assessment, treatment or recovery supports, it also incorporates key trauma principles into the targeted organizational culture (Substance Abuse and Mental Health Services [SAMHS], 2014). Perinatal nurses care for patients during the antepartum, intrapartum, and postpartum periods when unanticipated events or unwanted feelings may occur. Adopting the TIC four assumptions and key principals into practice can create positive outcomes and avoid re-traumatization of the patients in their care. This project enhanced current nursing practice by incorporating the understanding of TIC to perinatal Registered Nurses. The project provided education to the nursing staff to assist in their knowledge of perinatal TIC, reevaluate their attitudes towards TIC, and assist in actively changing their nursing practice to measure a positive correlation of implementation of TIC principals in the perinatal setting. Background of the Problem TIC is a newer concept for organizing the public mental health and human services. TIC changes the opening question for those seeking services from “what is wrong with you?” to “what has happened to you?”. TIC was initiated with the assumption 3 that every person seeking services is a trauma survivor who designs his or her own path to healing, facilitated by support and mentoring from the healthcare provider (SAMHSA, 2014). For many existing organizations or programs, healthcare support requires movement from a traditional hierarchical clinical model to a psychosocial empowerment partnership that embraces all possible tools and paths to healing. Healing and support are a partnership with the patient at the center of the healthcare team and a collaboration between nursing, social services, physicians, and all members of the organization. Healing from traumatic events involves a multi-faceted approach including emotional and physical care. A TIC nursing approach incorporates core principals; realization of trauma and how it can affect people and groups, recognizing the signs of trauma, having a team capable to respond to trauma and providers that actively resist in re-traumatization to the patient. In a public health system with many levels and types of services and treatment, TIC is grounded in a patient-centered framework. According to SAMHSA (2014), the social revolution that began in the 1960’s combined with the women’s movement the call for more attention to diverse groups set the stage for an increase in the acknowledgement and treatment of victims of interpersonal violence and crime-related trauma. The introduction of rape trauma syndrome as a condition is highlighted in the psychological consequences of sexual assault and lacks the support from society and the social services system. Research had begun to focus more on interpersonal violence, thus leading to the identification of risk factors and treatment approaches unique to this form of violence and trauma. As these patients were growing in need, federal agencies such as the Substance Abuse and Mental 4 Health Services Administration promoted the need for trauma-informed policies and care. This recognition led national studies to begin to demonstrate the prevalence of traumatic experiences. SAMHSA stated research including the Adverse Childhood Experiences and Women Co-Occurring and Violence studies clearly demonstrated the pervasive long-term impact of trauma through discovery of long-term chronic mental and physical effects of traumatic experiences, reinforcing the call for trauma-informed policies. TIC is a framework that considers the effects that past trauma can have on current behavior, the ability to cope, and can assist to minimize re-traumatization during health care encounters. In the article by Hall et al. (2021), researchers suggested that the next inevitable pandemic in the United States will be a mental health pandemic. These concerns regarding an impending mental health pandemic creates an imperative need for perinatal clinicians to use TIC to support the mental health of pregnant women. Using TIC practices are best done by educating perinatal clinicians to assess and assist pregnant women with their psychosocial concerns in settings where they deliver perinatal care. Education about TIC may increase clinicians’ knowledge, attitudes, and confidence in providing psychosocial support and achieve decreasing the rate of patient retraumatization from childbirth. Statement of the Problem The aim of this project is implementing TIC practices to a perinatal birthing center in rural Northwestern Pennsylvania to increase their knowledge, attitudes, and nursing practices in perinatal TIC. The micro-level population of this project are the Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) who provide care in a birthing center in northwestern Pennsylvania (PA). There are approximately 30 to 35 5 licensed nurses who are employed in this birthing center. The nurses who are employed in the perinatal unit are all females, are Caucasian, speak English and ages range from 20 to 67 years old. This birthing center is part of a non-profit organization in Northwestern Pennsylvania. The project examined the lack of knowledge, attitude towards perinatal trauma and the use of TIC practices of the RNs and LPNs in the perinatal setting. The education and use of TIC practices is to create an increased in quality of the healthcare experience for each patient who may have been exposed to trauma in their past or if the current situation has been traumatic. The healthcare team is trained to know how to treat the patient and avoid re-traumatization that influences their healthcare experience. The project is meant to influence the practice of women’s healthcare and improve the care the nurses provide to this population. Currently, a gap in standardized TIC exists in current nursing practice (Moran, Burson, & Conrad, 2020). In implementing this program, the nurse’s knowledge, attitudes, and practices (KAP) will be evaluated on a scale from prior to and after implementation to measure effectiveness in implementing TIC practices with perinatal nurses. Minimizing psychological effects of the maternal patient subsequently decreases psychological and physical determinants while increase their patient specific outcomes. PICO Question This project is a quantitively focused approach to RNs and LPNs KAP in the perinatal setting. The objective was to assess the perinatal nurses’ KAP on TIC, educate the staff on TIC in the perinatal setting, and then reassess the implementation of TIC on the nursing staff’s attitude, knowledge, and practices after implementation of an 6 educational session. The question posed is: “Does implementing trauma-informed care practices education to perinatal nurses increase their knowledge, attitudes, and practices of trauma-informed care after educational implementation?” Definition of Terms- Conceptual To improve perinatal outcomes and long-term health for women and their infants, an emphasis on psychosocial care that is informed by knowledge about trauma is imperative. Seng and Taylor (2015), noted that professionals who work toward optimizing child welfare development, and health know that preventing trauma is crucial both for individual outcomes and for society. Professionals who care for childbearing women in perinatal settings also realize that it is important to get the mother-infant dyad off to the best possible start. Utilizing TIC, increased positive patient outcomes depends on making specific links between trauma history and current concerns (Seng & Taylor, 2015). The proposed project will use the following terms and definitions: Trauma-Informed Care - This concept can refer to either evidence-based trauma interventions or to a broader systems-level approach that integrates trauma-informed practices throughout a service delivery system (SAMHSA, 2014). Perinatal Nursing - Perinatal nursing is the care and support of women and their families before, during, and after childbirth. Perinatal nurses provide education and resources about pregnancy and childbirth, and help oversee the mother and child during pregnancy, childbirth, and postpartum to ensure the health of both (Petiprin, 2020). Post-Traumatic Stress Disorder (PTSD) - Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very stressful, frightening, or distressing events that causes a dysfunction and impairment in activities of daily living (NHS, 2022). 7 Adverse Childhood Experiences (ACEs) - Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years) such as experiencing violence, abuse, or neglect. ACEs include aspects of the child’s environment that can undermine their sense of safety, stability, and bonding (CDC, 2022). Patient-Centered Care - The Institute of Medicine describes patient-centered care as including qualities of compassion, empathy, respect and responsiveness to the needs, values, and expressed desires of each individual patient. It is inclusive of care that ensures that patient values guide clinical decisions (AACN, 2022). Need for the Project One out of every six women will be a victim of attempted or completed rape by the age of 13 (AHRQ, 2016). Exposure to traumatic events in the lives of women such as rape, intimate partner violence, military sexual trauma, and other forms of sexual assault, child abuse and neglect, terrorism, natural disasters, and street violence, all predispose affected individuals to poor health outcomes. Healthcare teams need to be aware that an individual’s reactions to trauma are normal reactions to abnormal situations. These stated reactions to the trauma remain poorly understood, even by many of the people who are in the best positions to offer support and treatment to trauma victims. To improve perinatal outcomes and long-term health for women and their infants an emphasis on psychosocial care that is informed by some knowledge about trauma is needed. Perinatal nurses who work toward optimizing child welfare, their health, and development need to know that preventing trauma or re-traumatization is a key component in providing patient-centered care in this setting. 8 A rural community-based perinatal setting often transfers high-risk patients to higher levels of care to tertiary centers. Mothers or newborns, who are critical, are separated from each other to receive a higher level of care coordination. Rural community-based hospitals are at a higher risk for patients to endure a traumatic birth and face re-traumatization. The patient not having or being offered the proper resources or support post-events is also considered re-traumatizing. The setting for this project has had traumatic births and, in their wake, resources and support from the nursing staff could have offered more by implementing TIC practices. The nursing staff is patient-centered, but not trained in TIC nursing practices. TIC could increase their nursing practice and improve their quality of patient care. Significance of the Problem According to Carlisle (2018), approximately 70% of people will be exposed to at least one traumatic event during their life and from that 8% will develop Post Traumatic Stress Disorder (PTSD). While most people who experience traumatic events do not develop PTSD, women are two times more likely than men to experience a traumatic stress response, and approximately one in ten women will be diagnosed with PTSD in their lifetime (Carlisle, 2018). Additionally, Carlisle states, one quarter of women will experience physical or sexual abuse or neglect over the course of their life. A woman with a history of trauma or a traumatic childbirth increases the risk that a woman will develop complications during pregnancy or postpartum. Three percent of pregnant women and four percent of postpartum women are diagnosed with PTSD, though many more experience the emotional, psychological, and behavioral impact of traumatic events (Carlisle, 2018). The effects of any trauma can be worse at times of 9 transition and change, and the perinatal period is a time of profound emotional, physical, social, and interpersonal transformation for a woman. The fear of the unknown or the inability to have control over a situation can create feelings that match their previous trauma. Carlisle noted, while it is difficult to differentiate whether previous experiences or a traumatic birth contributes to the development of PTSD in the postpartum period, it nevertheless requires attention because of the vulnerability of mom and baby during this time. TIC begins with knowledge about trauma, the ability to recognize signs of a trauma response, responding to patients effectively, and resisting re-traumatization (Kuzma, Pardee, & Morgan, 2020). As holistic providers, perinatal nurses can create safe care environments, establish collaborative patient relationships based on trust, demonstrate compassion, offer patients options 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. Assumptions The proposed project will be educational and descriptive by design. The honest and truthfulness by the participants will be assumed in answering their pre-survey and post-surveys. The staff will answer questions regarding their knowledge, attitudes, and current practice on TIC individually via an electronic source to provide time and confidentiality. Assumptions that may alter the study results are that the participants may not have any prior experience or knowledge of TIC or any prior trauma-related events. Participants may not pay attention to the educational presentation, and this could directly affect their post-survey results. 10 Limitations There are limitations that must be considered for this project: the small sample size of one perinatal unit that consists of 30 to 35 Registered Nurses (RN) and Licensed Practical Nurses (LPN). A small sample size could affect the study’s representation and distribution in this focused population and create generalized and hinder transferable results across many perinatal units. A lack in prior research can be cause for a decrease in validating the research results. This is due to only a recent change in cultural awareness to TIC in the perinatal population. Eastern culture has historically been known for avoiding uncomfortable subjects such as miscarriages, stillbirths, and or traumatic births. The recent change and interest in trauma and how it will affect this population is a limitation of limited previous data. A growing need to impact trauma affected individuals and how to support those who have experienced perinatal trauma is a valid reason for this research. Summary of the Problem Trauma is a concept that encompasses different emotions, responses, and outcomes for everyone individually. Traumatic experiences and traumatic births are not rare, they are common around the globe. Prior trauma such as adverse childhood experiences can shape and affect the woman during the perinatal period. Trauma and traumatic birthing experiences can affect the women’s health, their mental status, family structure, bonding ability, and infant mortality rates. To provide patient-centered care, RN’s and LPN’s will need to perform competent TIC. Without implementing traumainformed practices in the perinatal setting, the staff will not advance in evidence-based care practices resulting in negatively affecting women, infant, and children in a cycle that 11 reduces community and individual health. New research is stating the need and shift in culture to support empathic critical thinking skills such as, “what happened to you” instead of “what is wrong with you”. The research that is available provides a strong support for TIC in the perinatal period and a need for further research. 12 Chapter 2 Review of Related Literature Perinatal Trauma-Informed Care In the perinatal period, nurses will encounter patients who have a history of trauma and patients that have experienced a traumatic birthing experience. Women who experience a traumatic birth without the proper support may exhibit physical and psychological manifestations. Traumatic experiences may hinder their feelings of having more children, create relationship problems, negatively affect bonding with their newborn, and may cause avoidance of medical interventions that are like their birthing experience such as pap smears. Trauma survivors can develop both long-term and shortterm effects from trauma. Short-term effects can be seen and felt by the patient as normal responses in the mind and body to an abnormal situation. The human brain is wired to react quickly in situations that threaten survival. The sympathetic nervous system then signals a cascade of events that cause the body to react such as fight, run, freeze, or faint (Kuzma et al., 2020). Long-term effects associated with trauma can create maladaptive responses to stress. These individuals may develop hyperreactive responses to stress. These effects from trauma can affect overall health, pregnancy, and outcomes for themselves and their infants. TIC is an approach to caring for patients who have a history or have experienced trauma. This approach recognizes the signs and symptoms of trauma and acknowledges the impact trauma has had on the patients’ life. According to the SAMHSA, 2014, the TIC approach is based in the four R concept. The first R is realizing the widespread impact of trauma and the potential paths for recovery. This approach to patient care then 13 recognizes the signs and symptoms of trauma in patients, family, and staff within the healthcare system. TIC providers then respond by fully integrating their knowledge about trauma into policies, procedures, and practices to always avoid re-traumatization of the patient (Figure 1). A comprehensive literature search was conducted using CINAHL Complete and Medline Complete. The key terms used consisted of trauma, trauma-informed care, and patient-centered care; the database yielded over 1,600 results. The search was then modified to use more specific terms: perinatal, articles that were within six years, English language, and peer-reviewed; this resulted in 66 results. The open term of TIC resulted in articles open from different and vague organizations not relating to women’s healthcare. The specification of adding the key word perinatal provided articles that yielded evidence-based results in maternity settings. There was a reoccurring theme such as perinatal TIC is a new education program and that more research was needed to increase the reliability of these findings. The resulted perinatal articles did find that increasing the perinatal staff’s knowledge on trauma and TIC practices has shown to increase the confidence of the perinatal staff to provide trauma-informed patient-centered care and meet the needs of trauma survivors. Assessing Knowledge, Attitudes, and Practices of Nurses on TIC In reviewing the available literature, several studies mentioned a positive correlation between pre- and post-education on the nursing staff’s knowledge, attitudes, and practices of TIC (King, Chun, Chokski, Choi, & Seng, 2019). In a study conducted by King et al., the authors researched the “Knowledge, Attitude, and Practice related to Trauma-Informed Practice” tool. The analysis indicated that the 21-item version could 14 reliably assess knowledge, attitudes, and practices (KAP) related to TIC among healthcare professionals in a pediatric institution. The implementation of assessing the staff’s knowledge, attitudes, and practices provided quantifiable evidence of the understanding of the healthcare professionals nursing practices. The nursing staff quantified an increase in KAP impact regarding Adverse Childhood Experiences (ACE’s), and trauma post-education. The results of the study did identify the additional need for healthcare organizations to effectively assess the learning needs of their staff to address gaps in KAP to implement a TIC approach that meets the needs of their patients and staff. In a study by Choi and Seng (2015), an educational session was completed with perinatal staff members and their knowledge, attitudes, and skills were assessed pre and post the educational meeting. The authors used an 11-item questionnaire developed using a knowledge, attitudes, and skills standard format. The questionnaire asked questions about level of knowledge, type of attitude, and level of skills for providing TIC. The first ten items used a five-point Likert agree and disagree scale. The total score range was 10 to 50, where a higher score indicated better KSAs for TIC. The post-survey also included one open-ended question for participants to provide comments about their learning needs for this topic and the program. The program lasted for one hour, was interactive, discussion-based, and was designed for perinatal health care professionals. The results showed qualitatively that many participants found the training program to be useful and relevant to their practice settings. A statistical increase in the quantitative data was noted in the post-educational session survey results. Educating Nurses in Trauma-Informed Care 15 To change practices, one must first know the value of what needs to change. Negative feelings associated with childbirth can lead to increased postpartum depression, lower patient satisfaction scores, and elective changes in providers–birthing centers for future pregnancies (Gilbert & Burke, 2022). Many obstetric clinicians are unaware of the negative effect that a history of sexual assault can have on a woman’s perinatal experience. These clinicians, including nurses, are not always aware of the benefits of asking these types of questions or even how to ask patients about past experiences with sexual assault or past trauma. When not asked, patients may feel it is irrelevant or that no one cares, thus leaving them unprepared for how the intimacy of child- birth can affect them. According to Gilbert and Burke (2022), currently there is no standard of care that addresses the special needs that survivors of trauma may require during childbirth. Educating perinatal nurses on perinatal trauma at the time of delivery is crucial to impacting trauma in the perinatal period. Negative outcomes associated with perinatal trauma while in the care of the healthcare team can occur when the mother has a negative perception of their birth, the mother feels that her emotional and physical experiences are not met from her healthcare team, they experience a real or threat to their or infants’ life, injury during birth, and emergency c-sections. A review of literature found a study conducted by Salameh and Polivka (2020), developed an educational module about the elements, principles, and clinical application of TIC. Topics included the types of traumas, the impact trauma has on lives of individuals, recognizing trauma, and strategies for implementing TIC principles. All fulland part-time neonatal team members completed the educational module and an 16 evaluation survey. The project team also developed an evaluation survey to be completed following the education module by neonatal team members. The survey included five Likert-style questions about participant’s perception of their understanding of TIC, their ability to use TIC principles and elements in practice, the ability to recognize trauma in new mothers, the ability to provide the appropriate referrals, and current use of TIC principles and elements (Linn & et. al., 2021). The study’s clinical implications from the results supported the education in TIC increased collaboration between the patient and their healthcare team. Due to a limited amount of research in the specific area of perinatal care, Hall, et. al. (2016) did implement a study on TIC education to Emergency Room nursing staff. An education session was completed along with a pre and post education survey. After the TIC education, ED nurses reported more confidence in their ability to talk to patients about traumatic experiences and understand how their current nursing practice is trauma informed. New Program for Perinatal Nursing As previously noted, perinatal TIC practices are a new or limited researched area of nursing care. The assessment tool of assessing the nurse’s knowledge, attitudes, and practices of TIC is also a new assessment tool with limited available research validation. Large-scale change in the standard of care takes time to accomplish, however, it is not necessary to wait. In the absence of systematic reviewed evidence, nurses can look to established routines such as the process of mutual collaboration in care planning and informed consent (Sperlich & et al., 2017). To successfully move this area of nursing forward, assessment of the trauma specific interventions must be evaluated for effectiveness. Assessing the nurse’s pre-educational session knowledge of TIC practices, 17 attitude towards trauma, and their current active practices of TIC and post knowledge, attitude, and practices guides program and outcome effectiveness. This area of practice may shape patient outcomes, satisfaction, and overall health. Identifying professionals’ areas of weakness in a novel perinatal program allows the educator to include more information as needed to meet the participants needs. A study conducted by McNamara & et. al., (2021), presented a novel curriculum introducing TIC practices to healthcare professionals. There was no prior TIC training in place. This model was developed in partnership with former patients and nationally recognized resources on TIC. Analysis of patient referral data from before and during the study period shows a change in provider practice patterns, such that physicians facilitated more connections to resources over time. In the short term, all professional groups experienced an improvement in comfort levels of TIC by reaching the set outcome goal of a level five of comfortability. This was measured by performing a pre- and postworkshop surveys. Implementing TIC practices in a perinatal setting can produce shortand long-term positive patient-centered outcomes. The Conceptual and Theoretical Framework Perinatal TIC is conceptualized as an organizational change framework centered on principles intended to promote healing and reduce the risk of re-traumatization for vulnerable individuals. These principals are shifting care practices by using the four Rs concept (Appendix A: Perinatal Trauma-Informed Care). The four Rs include: realizing the impact of trauma, recognizing the signs and symptoms in individual patients, families, and peers, integrating their knowledge of trauma into policies, procedures, and practices, and seeking to actively resist re-traumatization (Menschner & Maul, 2016). 18 According to Menschner and Maul (2016), these are successfully implemented by patient empowerment, informing patients of their choices, maximizing collaboration among healthcare staff, patients, and families, ensuring settings that are mentally and physically safe, and portraying trustworthiness through complete transparency. Organizations include patient-centered care in their mission statement and or their core values. Patient-centered care is viewed as holistic, individualized, respectful, and empowering. The Institute of Medicine (IOM) defines patient-centered care as, “including qualities of compassion, empathy, respect, and responsiveness to the needs, values, and expressed desires of each individual patient” (para. 2, 2022). Implementing TIC practices to healthcare professionals will support the organization’s goal and values to provide patient-centered care by providing care that is compassionate and responsive to this populations needs. A patient’s mental health is just as important as their physical health. Avoiding re-traumatization or supporting an individual through a traumatic situation is tailored to the patient’s concerns as well as meeting their holistic needs. Jean Watson’s theory of human caring is a theory in nursing that the patient not only needs medicine but also providers need to care to heal (Ozen & Okumus, 2017). It asserts that a human beings cannot be healed like an object to be repaired. Trauma survivors need a holistic approach to care to avoid negative patient outcomes and medical re-traumatization. Ozen and Okumus (2017) stated the conceptual elements of the Watson’s theory include the caritas process, the transpersonal caring relationship, caring moments, and caring occasions, and caring–healing modalities. Various studies have established that the theory of human caring can make nursing care more efficient, aware, 19 and improve care outcomes. TIC establish caring into nursing practices and can improve outcomes for the perinatal population. Summary of the Review of Related Literature A review of evidence-based literature supports implementing TIC in the perinatal population setting. The needs of patients who have a history of prior trauma, a traumatic birthing experience, or to avoid re-traumatization is essential in providing quality holistic healthcare. TIC has core principals such as realization of how trauma affects others, recognizing the signs and symptoms of trauma, implementing a system that responds to trauma, and resisting re-traumatization. These principals are implemented throughout the organization by compassion, empathy, trustworthiness, and respect for the patient. Multiple research studies have found that implementing TIC to perinatal nurses does increase some knowledge in trauma, a positive change in their attitudes towards trauma, and a positive change in their nursing practice by an increase in post-surveys from preeducation surveys. More research is needed to validate the effectiveness of the program across organizational cultures. However, this shouldn’t delay educating and implementing TIC practices in the perinatal setting. Patient-centered care implemented with Jean Watson’s theory of caring supports organizational values and holistic nursing care. Educating those who care for others is the concrete foundation for positive results in quality improvement outcomes. 20 Chapter 3 Methodology TIC is a patient-centered approach to healthcare that calls on health professionals to provide care in a way that prevents re-traumatization of patients and staff (Fleishman, Kamsky, & Sundborg, 2019). Traumatic exposures are based on the patient’s subjective perception of the event. Trauma occurs to any age, gender, socioeconomic status, race, and sexual orientation (Fleishman et al., 2019). According to AHRQ (2016), individual trauma results from an event, series of events, or set of circumstances that an individual experiences as physically or emotionally harmful or life-threatening. AHRQ states one out of every six American women have been the victim of attempted or completed rape in her lifetime. These events can have lasting adverse effects on the individual's functioning and mental, physical, social, or emotional wellness. The ability for perinatal registered nurses to recognize the prevalence of traumatic exposure, the effects of hospital retraumatization, and that the impact of TIC has on the health and well-being of the maternity patient can improve maternal and neonatal outcomes through advanced nursing practice (Sperlich, Li, & et al., 2017). Purpose The purpose for the project is to implement TIC to the obstetrical perinatal RNs and LPNs in a rural community inpatient nursing department. It is vital that perinatal nurses recognize the effects of trauma on the individual, how to approach perinatal clients in a TIC manner improving their nursing practice and understand the impact that TIC can have on the patient’s current and future encounters with healthcare. 21 Approval from Pennsylvania Western University and the University of Pittsburgh Medical Center (UPMC) was granted (Appendix B) this writer will analyze the nursing staff's pre-implementation surveys (Appendix A) on their KAP scores to post-survey scores on TIC. The educational session was offered over a one-hour timeframe. The interactive session educated the perinatal staff on the definition of trauma, the effects of trauma on the individual, and TIC nursing practices. The presentation consisted of a PowerPoint (Appendix F) presented by the writer including a role play dialog session on traumatic perinatal experiences and their appropriate TIC responses (Appendix E). This writer also quantitatively measured the assigned numbers from the Likert scale associated with the KAP questions on the pre-and post-surveys (Appendix A). The same KAP survey was administered in the same online format after the educational session on the perinatal trauma-informed nursing care program. Through data analysis, the project aimed to determine if there is a positive correlation in providing education to the perinatal nursing staff and an increase of their KAP in TIC. Increasing the perinatal nursing staff’s KAP in TIC increases the quality and safety of care provided during the perinatal experience. Through avoiding re-traumatization and providing acknowledgement and support this increases mothers and infants’ health outcomes. The analysis of data information will prospectively show a need for this proposed project by analyzing a lack in TIC KAP. Project Method and Design The question for this study is, “Does implementing trauma-informed care education to perinatal nurses increase their attitudes, knowledge, and practices of traumainformed care after implementation?” 22 The project design is to measure the outcomes which includes the implementation of a one-hour in-person TIC for perinatal nurses' presentation developed by this writer. This was created as a PowerPoint presentation reviewing the definition of trauma, the four Rs of TIC (Figure 1), implementing TIC in the perinatal nursing practice, and how trauma affects the individual’s healthcare (Appendix F). The educational PowerPoint also included an interactive session that allows the nurses to role play situations of perinatal trauma and how the nurse approaches the individuals in a TIC manner (Appendix E). The project used a quasi-experimental research design, to identify if the intervention of the educational session has or has not created a difference in the staff's knowledge, attitudes, and clinical practices. A pre-educational and post-educational survey (Appendix A) were conducted with the participants. This survey was adapted from a prior study from Oliver & Mahon (2005). The pre-and post-surveys are included in the quantitative data analysis review and nominal data. The KAP survey consisted of a series of thirty questions assessing the participants knowledge of TIC, their attitudes toward TIC practices, and current practices involving TIC (Appendix A). The data collection is ordinal data and is analyzed by a five-point Likert scale for answers demonstrating the nurses KAP. This writer assigned a 5-point Likert Scale such as: 1 for “No Knowledge, 2 for “Very Poor”, 3 for “Average”, 4 for “Good”, and 5 for Very Good”. The measure of improvement is a positive correlation between TIC education and an increase in the numeral values assigned to the nurses’ KAP. According to Andrade et al. (2020), KAP surveys are now widely accepted for investigating health-related behaviors and health-seeking practices. A KAP survey is 23 meant to be a representative survey of a target population. This project is introducing TIC to perinatal nurses. The survey aims to elicit what is known (knowledge), believed (attitude), and done (practiced) in the context of the topic of TIC in perinatal nursing. Staff may feel uncertain or not confident in how to respond to individuals who disclose a trauma history; understanding the KAP in the nursing staff can increase professional confidence by providing education in knowledge and practice gaps. An increase in professional confidence in TIC practices can assist in their readiness for change and ultimately an increase in quality patient care. Another study implemented a knowledge and attitude survey pre and post an educational session. The study by Marvin and Robinson (2018), used a 12-question survey that rated their knowledge of trauma, attitudes about TIC, and the participants readiness for change in practice. The survey rated the questions from one “not ready” to ten “ready”. This survey was able to show a positive correlation between the increase in knowledge of the participants and a readiness to implement change by tailoring their preimplementation of TIC as a needs assessment and assessing the education through a post survey indicating staff readiness and a change in nursing practices. Data was collected using a structured questionnaire that is self-administered through UPMC REDCap. The KAP questionnaire chosen has been modified from the KAP questionnaire by researchers Abdoh, Bernardi, and McCarthy (2017) (Appendix A). The modified questionnaire underwent face validation, which is the process of whether the instrument is likely to do what it is intended to do. The questionnaire was also reviewed under content validation that will examine whether the instrument is appropriate for what the survey is attempting to answer and does it have included all the 24 necessary questions. The questionnaire was reviewed by individuals who are familiar in obstetrical and the psychology content of the survey, in evaluating the questions as unsatisfactory or satisfactory. The mentors of this proposed project offered feedback to the writer for improvement during a project overview, and no survey corrections were noted as necessary. The review of this KAP survey was completed and reviewed by the chair and committee of this proposed project. Each member meets the experience requirement noted and the instrument was reviewed before the pre-test and educational session implementation. Upon project completion, the answers from participants were anonymous by participant IDs assigned by the REDCap survey program. The data was then exported to an Excel spreadsheet for analysis. Setting The setting took place in a rural community-based hospital in the inpatient obstetrical department. The obstetrical department consists of ten post-partum beds, five labor and delivery rooms, fifteen nursery beds, and three level-two nursery beds. A nursing staff of approximately 30 to 35 nurses ranging from RNs and LPNs are currently active on the unit. This can fluctuate as there are two graduate Registered Nurses and positions available for hire. All the participants are Caucasian, speak the English language, and are female. The site of the educational setting was on the inpatient obstetrical unit and recorded live for those at home. The live video was provided using the private Microsoft Teams application that is encrypted through the organization. The permission to record the presentation and voice of the writer was obtained from the nurse unit director before implementation (Appendix G). The option for recording made this educational session 25 available to all staff members regardless of day availability but had a time restriction of active participation at the time offered live for inclusion of this project. This location is handicap accessible, has ample parking, and an elevator for those who may need accommodations. The room will accommodate approximately 30-40 participants in the room at one time. Participants Criteria for inclusion in the sample consists of all hired RN’s and LPN’s who volunteer to attend the one-hour education session and complete the surveys. The methods to measure the stated outcome is implementation of a one-hour in person TIC for perinatal nurses’ presentation. This will be recorded for review and presented on the facilities unit and on Microsoft Teams platform. Exclusion criteria are obstetrical patient care technician’s, physicians on staff, and patients as this project was produced for nursing practice and cannot include the vulnerable population of pregnant women directly. The names of the participants were kept confidential. When the participants arrived for the in-person education session they were provided with a packet that contains a consent form (Appendix D), pre-survey access, a PowerPoint slide packet for notetaking (Appendix F), and a link with directions for completion of the post-survey. The survey link was shared in the Microsoft Teams application chat function for easy access to those who joined online. The use of an online survey did not provide any identifying information and only noted participant IDs one to twenty. For the participants via Microsoft Teams, the writer shared the consent form digitally for review on the Microsoft Teams application prior to starting the education session. 26 Implementation of the Project Before the pre-and post-surveys, there was a consent form that included a statement stating the participant agrees to the terms and conditions of the proposed project (Appendix D). The participants were given approximately 15-20 minutes to complete the consent form and pre-survey prior to the start of the educational series. After an interactive one-hour educational session on implementing TIC in the perinatal setting, the participants were given time for questions to clarify any information presented. The participants were then instructed on how to access the post-survey. Data was excluded if either the pre-survey or post-survey was not obtained. Any surveys excluded from the educational session will be noted in the data results. A Pearson Correlation will be conducted on the pre-survey post-survey results. In using a convenience sampling method, the recommended size with a confidence interval of 95% and a statistical power of 0.20. This participation will be reflective of a rural community-based obstetrical unit and provide valid results with participation. It is important to note that the leader for this project had an active participation throughout the study. There were no other data collectors or data entry persons involved. This writer has access to the data along with the faculty chair; all material will be kept on a flash drive and/or in a locked file cabinet. No other individuals other than the writer and committee will have access to the raw data and no names will be associated with the data or the study with the above stated numbers assigned as participant IDs. Ethical Considerations Approval from the Institutional Review Board from Pennsylvania Western University was obtained (Appendix B). This writer then gained approval of this quality 27 improvement project from the setting site (Appendix B). Notification of the proposed project’s availability for participation via informational flyer (Appendix C) was posted on the obstetrical private website and on the obstetrical unit’s communication board in advance of one week. The information flyer provided the name of the project and participation date and time. A letter of explanation and consent were given to each participant and explained in person at the beginning of the educational session. In the consent letter, the program explanation stated that consent to participate in the proposed project is completely voluntary and if they agree to participate, they were asked to sign the consent form provided in the packets and complete the pre- and post-surveys. For those individuals who are joining via remote Microsoft Teams, the participants were asked by the writer if they are willing to provide their preferred contact email for pre- and post-survey questions via REDCap survey program. This was to insure post-implementation data collection and confidentiality. Participants were informed of the risks or benefits and compensations to individuals participating in this project. The results will be dispersed in the analysis of the data. Numbers assigned via participant ID and the use of online surveys will permit anonymity and privacy of the participants. Instrumentation The pre-and post-surveys were conducted using an electronic survey form consisting of a five-point Likert scale for each question with a total of thirty questions. The first page included a consent statement, explaining the terms the participant is agreeing to by completing the pre- and post-survey. The statement will be followed by a series of questions and possible answer options such as, “No Knowledge”, “Very Poor”, 28 “Average”, and “Very Good”. The “no knowledge” answer is provided in hopes the participants provided honest answers. Instructions were given asking participants to answer all the questions to the best of their ability. The responses from the KAP survey scores pre-and post-survey were exported from the REDCap program to Microsoft Excel for data analysis. This program will assist in performing bivariate statistical tests. A Pearson correlation was used to test the data in the same individuals as is in the pre-survey, post-survey designs where measures are obtained at two different times in one sample. Accurate predictions enhance accurate findings to reduce errors in the data analysis. The participants could have a bias or distortion in the interpretation of the questions or scoring of the surveys. Per Lund Research (2018), The Pearson correlation coefficient is a measure of the strength of a linear association between two variables and is denoted by r. A Pearson product-moment correlation attempts to draw a line of best fit through the data of two variables, the Pearson correlation coefficient, r, indicates how far away all these data points are to this line of best fit. The Pearson correlation coefficient, r, can take a range of values from +1 to -1 a value of zero indicates there is no association between the two variables. A value greater than 0 positive association; that is, as the value of one variable increases, so does the value of the other variable. A value less than 0 indicates a negative association; that is, as a value of one variable increases, the value of the other variable decreases. The use of open REDCap links was used to decrease biases and create anonymous participation. At the completion of the pre and post survey’s, the results were evaluated for missing data. Managing the missing data will occur after the survey data has been 29 cleaned and double-checked for input errors into the REDCap system. The first step was to review the survey data for missing answers to survey questions. There was not a high percentage of respondents failed to answer any survey questions, it is important to determine whether there was a problem in the design. This can be due to the survey questions are confusing, unclear in what it is asking. There were three respondents who did not complete the post-surveys. In this project the question or questions that are omitted were determined whether the participant should be omitted from further analysis. To be kept in the analysis, the participant must have completed data on all the variables or questions. Question-wise deletion is only appropriate for data missing completely at random. Due to the reduced sample size this could create the understanding that the validity needs to be unbiased and if confusion occurs, the project lead did provide contact information for clarity. This project lead provided their contact information at the beginning of the education session and was available for clarification. Each question on the survey determines the interpretation of the nurse's KAP regarding TIC. The use of regression or imputation methods for missing data would skew the data and invalidate whether the implementation of TIC to perinatal nurses improved their KAP. Perinatal Trauma-Informed Care Presentation The educational series will be provided via PowerPoint presentation (Appendix A) in person and via the online Microsoft Teams application. It was presented in a conference room with tables and chairs available for the participants. The presentation was approximately 40 minutes in length and allowed time for consent form signatures, survey completion, and questions. 30 Included in the presentation was learning outcomes which included a) what TIC is, b) the core principals of TIC which include “Realize, Recognize, Respond, and Resist re-traumatization”, c) factors that affect women in perinatal period, d) impact trauma has on women in the perinatal period, and e) resources available for trauma survivors. This presentation was interactive with a breakout session which required the participants to pair, one reading a traumatic birthing experience card while the other nurse read back a trauma-informed response card (Appendix E). Those who are online will only participate through listening and the presenter read each card aloud. The breakout session was to provide a kinesthetics method of learning to cover TIC nursing interventions. The cards simulated recognizing traumatic situations and how to respond to the trauma survivors in an empathetic and supportive manner. At the end of the presentation the participants were reminded of the post-survey. Data Collection Both the Internal Review Boards (IRB) (UPMC and Pennsylvania Western University) approved this project, the project lead explained the purpose of the project during nursing team huddles. The lead then, one weekd prior, provided the flyer to the staff to indicate possible staff participation. The day of the presentation the lead provided packets that included the writers contact information and PowerPoint slides, collect signed consent forms, and provided the link for the pre and post implementation surveys. The project implementation day included the implementation of perinatal TIC. At its conclusion, the participants were reminded of the post-survey link that was provided on their handouts and in the chat. The data from the pre and post surveys were reviewed, exported from the REDCap instrumentation, and then analyzed by utilizing the Microsoft 31 Excel system. The results will be kept for five years on a confidential computer drive. The results will be sent for publication and shared with the UPMC Wolf Center. Data Analysis For statistical analysis, the writer will consult a statistician for review. The sample size will at most include the inpatient obstetrical perinatal nurses on staff, making the sample size 30 to 35 participants for the reliability of the proposed project. Data collection will be initially completed via REDCap electronic link. The collection will be electronic format so that the pre-implementation KAP assessment is non-bias or influenced by a group discussion. The objective is honest and reliable answers to assess gaps in knowledge and to provide a valid analysis from the post-surveys. The responses the KAP scores pre-and post-survey will be then organized into an excel spreadsheet. For this project, it is noted that Appendix A data collection is in Microsoft Excel format. The Microsoft Excel program is to aid in statistical analysis. This program will assist in performing bivariate statistical tests. Bivariate statistical testing is defined as the study of the relationship between two variables (Syvia & Terhaar, 2018). The use of individualized REDCap links will decrease biases by providing privacy and will then allow an analysis of differences between participants for the validity of the results. Time Schedule Implementing TIC in the perinatal setting through an educational session was offered in one day and one session but with two formats online and in person. The writer attained pre-implementation data and post-implementation data from participants on the same day as the intervention. Following IRB approval, the participation flyer and notification of the educational presentation was placed on the settings unit. This allowed 32 time for the presentation to occur with proper notification to the voluntary participants. This session occurred at 5:30 pm allowing flexibility for more participants. Following the program presentations, the data was exported from the REDCap survey system into Microsoft Excel spreadsheet, and then the accuracy of data was examined as previously described. The projected time frame to enter and validate the data’s accuracy was approximately one week. The data and statistical analysis were compiled, evaluated, summarized and conclusions were developed within one month following the program presentation. Summary of Methodology In conclusion, this project will determine the statistical significance of the implementation of TIC to perinatal nurses. The educational session to the staff aims to create a change in the standard of perinatal nursing care to increase the quality of care provided to patients in the perinatal setting. Although, this is focused on perinatal nurses, the education and implementation of TIC practices is universal and may improve the quality of nursing care in every healthcare setting. The data was planned, presented, collected, and analyzed to avoid error or biases as described in detail. The project was implemented to a rural group of perinatal nurses that provided a small but adequate sample size for statistical analysis. Participants were given an online link to the REDCap survey instrument that included a thirty question KAP five-category Likert scoring survey pre-TIC program. This data was inputted into the Microsoft Excel statistical program and reviewed. After the presentation, the same post-survey was given via the same online link. The post-survey was given post-presentation to avoid biases or skewed responses to reflect an accurate reflection of changed KAP. This data was then placed in 33 the Microsoft Excel program and reviewed by the writer for input error and data cleaning. A Pearson Correlation was then used to analyze the data to determine the statistical correlation of KAP in perinatal nursing staff. Missing data was then reevaluated and deleted to increase the validity and statistics with no bias of the study's results. 34 CHAPTER 4 Results and Discussion Pregnant women and infants are two of the most vulnerable populations that may be impacted by past or present trauma, impacting the individual and future generations over a lifetime. The need for TIC has been discussed in the literature due to the many of adverse health effects associated with trauma. TIC can guide the nurse’s approach to patient-centered care as TIC is fundamentally grounded in the understanding of trauma, and its impact on the women’s behaviors, psychological, and physical health. Nurses are central to healthcare and have an impact on the outcome and quality of patient care. Assessing the frontline nursing staff’s KAP on TIC and then educating them on perinatal TIC directly impacted their knowledge, their attitudes, and how they practice nursing. This project included a pre-survey (Appendix A), an educational session on perinatal TIC, (Appendix F) and administered a post-survey (Appendix A) upon completion of the session. The results from participation were completed by analyzing the frontline nursing staff’s KAP on TIC by UPMC REDCap instrumentation and utilizing the Microsoft Excel system in completing data analysis. The UPMC REDCap was a requirement of the UPMC Healthcare System. Results There was a total of 20 voluntary participants who participated in this project. Of the 20 participants, 20 completed the pre-survey. However, only 17 (85%) participants completed the post-survey. The three (15%) participants who did not meet the criteria of the study by not completing the post-survey were excluded by data removal. The participants were notified via private Facebook Family Birthing Center page post and by 35 a physical informational flyer (Appendix C) that was posted on the nursing unit one week prior to implementation. Each participant was assigned a random participant identification number. Each participant identification number was organized by completion of a pre-survey and postsurvey found in the record status dashboard. Participants numbered six, fourteen, and seventeen were removed because of the missing post-survey data. This was accomplished by utilizing the REDCap system participant record status dashboard function and clicking remove participant data. The results were evaluated by completing a Pearson correlation, coefficient of two independent variables utilizing the 2019 Microsoft Excel program. The nurses preand post-surveys were divided into Knowledge, Attitude, and Nursing Practice (KAP). Evaluating their knowledge their results were as follows: exposure to trauma is common (0.4) p = 0.002, trauma effects the persons physical, emotional, and wellbeing (0.6) p = 0.002, trauma-informed care requires providers to recognize, understand, and respond to the effects of trauma (0.1) p = 0.002, and trauma-informed care includes the understanding the physical, psychological, and emotional safety of the patient and provider (0.1) p = 0.002. The nursing staff’s attitude regarding trauma and TIC were evaluated and their results were, informed choice is essential in healing/recovery from trauma (0.4) p = 0.002, trauma-informed care is essential when working with ante-, intra-, and postpartum patients (0.18) p = 0.002, and “I have all the resources I need to engage in trauma-informed care” (0.1) p =.0002. Lastly, their nursing practice was evaluated, and the results were, “I help clients and peers to recognize their own strengths” (0.5) p = 36 0.002 and “my interaction with each client is unique and tailored to their specific needs” (0.3) p = 0.002. Discussion of Results The results were obtained by completing a Pearson correlation test using the 2019 Microsoft Excel program which evaluated the statistical significance of the participants pre-education KAP and post-education KAP. A Pearson correlation coefficient was computed to assess the positive relationship between the variable of presurvey KAP scores and the variable of post-education session post-survey on the nurses KAP scores. The results identified results from -1 to 1, -1 indicating a negative relationship between the variables and one indicating a positive relationship. The survey scales utilized a Likert scale ranging from one to five, one indicating very poor KAP to five indicating very good KAP. Knowledge The RNs and LPNs knowledge were evaluated in questions one, two, seven, and nine (Appendix A). These questions were designed to assess their knowledge of trauma and TIC. In this sample, the participants showed an increase in all areas of their knowledge such as exposure to trauma is common, trauma effects the persons physical, emotional, and wellbeing. 37 Figure 2. Question One Results Exposure to Trauma TIC Question 1 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre survey Q 1 9 10 11 12 13 14 15 16 17 Post Survey Q 1 Question one Figure 2 asks, “Exposure to trauma is common”. This pre-survey to postsurvey reflected a p= 0.4 positive Pearson coefficient indicating an increase in the nursing staff’s knowledge that exposure to trauma is common and not a rare obscure event in women’s lives around the world. Subjectively, the staff post-presentation was shocked at how common trauma is and verbally noted that the projects presentation left a lasting impression by instructing them on the prevalence of trauma. 38 Figure 3 Question 2 Effects of Trauma TIC Question 2 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre Survey Q2 9 10 11 12 13 14 15 16 17 Post Survey Q2 Question two Figure 3 asks, “Trauma effects the persons physical, emotional, and wellbeing”. The understanding of this question pre-and post-knowledge survey indicated that increasing the nursing staff’s knowledge that trauma is an event that alters the person not just emotionally. The knowledge gained was evident in a p= 0.6. The education session provided knowledge to the nursing staff’s understanding that trauma effects the person physically and their well-being affecting the mother and infant dyad. 39 Figure 4 TIC Question 7 Recognize and Respond to Trauma TIC Question 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre Survey Q 7 9 10 11 12 13 14 15 16 17 Post Survey Q 7 Figure 4 question seven asks, “Trauma Informed Care (TIC) requires providers to recognize, understand, and respond to the effects of trauma”. The increase in knowledge from the pre-survey to post-survey’s was a positive correlation indicated of p= 0.1. This understanding that it is the nursing staff who provide care that need to recognize trauma, have the knowledge to understand its effects on the women in their care, and respond to its effects is an essential to perinatal TIC. The pre-survey results show that this is a knowledge gap that was addressed in the presentation by post-survey data. 40 Figure 5 Question 9 Safety of the Client and the Provider TIC Question 9 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre Survey Q 9 9 10 11 12 13 14 15 16 17 Post Survey Q 9 Figure 5 question nine asks, “TIC includes understanding the physical, psychological, and emotional safety of both the client and the provider”. This knowledge question assesses whether the nursing staff understand that TIC includes the understanding of safety of the provider and the patient. The pre- to post-survey data showed drastic increases in knowledge post-project implementation with a Pearson correlation result of p= 0.1. Regarding the project’s hypothesis,” Does implementing trauma-informed care practices education to perinatal nurses increase their knowledge, attitudes, and practices of trauma-informed care after educational implementation?” The evaluation of these questions does support the projects intent, providing TIC education to perinatal nurses did provide an increase in their knowledge. 41 Attitude Their attitudes were assessed on questions sixteen, eighteen, and twenty-two (Appendix A). In evaluating the nurse’s attitude, this project noted an increase in correlation between providing education and their attitudes in all areas of TIC. Figure 6 TIC question 16 Informed Choice TIC. Question 16 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre Survey Q 16 9 10 11 12 13 14 15 16 17 Post Survey Q 16 Figure 6 question sixteen asks, “Informed choice is essential in healing/recovery from trauma”. The nurse’s attitude toward understanding that the patient should always have informed choices is fundamental to their healing of trauma and recovery phases. Informed consent is a concept that is not new. However, how it is presented and carried out from providers matters to those who have endured trauma. A nurse who carries the understanding that informed choice is needed in every patient encounter is embodying 42 perinatal TIC. An increase was indicated in data analysis with a positive correlation of p=0.4 from providing education to the perinatal staff from pre-to post-surveys. Figure 7 Question 18 Ante, Intra, and Postpartum Patients TIC Question 18 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre Survey Q 18 9 10 11 12 13 14 15 16 17 Post Survey Q 18 Figure 7 question 18 asks, “TIC is essential to working effectively with ante, intra, and postpartum patients.” The positive correlation of 0.18 from pre- to post-surveys indicated an increase in the nursing staff’s attitude toward incorporating TIC with all patients and not just intrapartum patients where they are screened for post-partum depression. The TIC practices are universal guidelines and should be used in every encounter and with every patient population. 43 Figure 8 Question 22 Resources for Implementation of TIC TIC Question 22 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre Survey Q 22 9 10 11 12 13 14 15 16 17 Post Survey Q 22 Figure 8 question twenty-two asks, “I have all the resources I need to engage in TIC”. When implementing an improvement in quality of patient care or providing care to patients it’s important to have the attitude that the staff has the resources they need to carry out TIC practices. The pre-surveys indicate the staff believing they did not have the resources by noting a positive correlation of p= 0.1 in comparison with the post-surveys. After educating the staff on what trauma is, how common they will encounter it in this patient population, how they can approach patients, and the available resources for patients and staff the post-surveys indicate a more confidence and attitude in engaging in TIC practices. 44 This project’s sample showing an increase in attitude toward perinatal TIC is a direct measurement of the future quality of patient care. Without buy in from the participants, a change in culture will never occur. Quantifying a change in frontline staff’s attitude correlates to better patient outcomes and answers the hypothesis that implementing a perinatal TIC education does increase the nursing staff’s attitude toward TIC. Nursing Practice The RNs and LPNs nursing practice were evaluated in questions twenty-six and twenty-seven (Appendix A). The data analysis of the pre- and post-surveys indicated an increase in the nursing staff’s TIC nursing practice post-education implementation. Figure 9 Question 26 Recognition of Strengths TIC Question 26 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre Survey Q 26 9 10 11 12 13 14 15 16 17 Post Survey Q 26 Figure 9 question twenty-six asked, “I help clients and peers to recognize their own strengths”. In supporting individuals through a traumatic experience TIC encourages the nursing staff to assist the patient in finding strengths, coping mechanisms, and support. 45 Providing education to the staff in this critical action increases their implementation into their nursing practice with the highest positive correlation of p= 0.5. Figure 10 Question 28 Unique Needs of the Client TIC Question 28 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre survey Q 28 9 10 11 12 13 14 15 16 17 Post Survey Q 28 Figure 10 question twenty-eight asks, “My interaction with each client is unique and tailored to their specific needs.” Providing education to the perinatal nursing staff on the unique reactions, emotions, needs, and resources available in TIC guidelines increased the staff’s understanding and ability to provide quality nursing care. The nurses’ nursing practice is improved by gaining the knowledge of TIC and the needs of this vulnerable patient population was evidenced by a positive correlation of p= 0.3. Increasing a nurse’s knowledge by providing education has the potential to improve perinatal care. Improving their nursing practice grounded in TIC principals, has the potential to create an impact on future mother baby dyads that will last generations. 46 Limitations There are limitations that must be considered for this project: the small sample size of one perinatal unit that consisted of 30 to 35 RNs and LPNs could have affected the study’s representation and distribution of this focused population as a generalized or transferable results across many perinatal units. The fact that there were 20 participants and from that 20, three were excluded due to missing data which made this an even smaller sample. Additional reasons that could have affected the sample size included, vacations of the staff, availability of the staff, and the time the education session was offered. A lack in prior research can be cause for a decrease in validating the research results. This is due to only a recent change and interest of the culture in the perinatal population. Eastern culture has historically been known for avoiding uncomfortable subjects such as miscarriages, stillbirths, and or traumatic births. The recent change and interest in trauma and how it will affect this population is a limitation of limited previous data. A growing need to impact trauma affected individuals and how to support those who have experienced perinatal trauma is a valid reason for this research Summary The pre- and post-survey results were exported to a Microsoft Excel program and then evaluated by completing a Pearson correlation of two independent variables a presurvey and a post-survey. This project’s aim was to implement TIC to perinatal nurses and improve their KAP. The nurses KAP were evaluated and overwhelmingly found a positive correlation between providing education and improving the nurses KAP. The small sample size is a project limitation and consideration that in a larger sample size 47 results may have shown a greater need for education. A need for future research would be noted to confirm a greater positive correlation. 48 Chapter 5 Summary, Conclusions, and Recommendations Summary of Findings For some women, the events experienced during childbirth or pregnancy are enough to be perceived as traumatic; for other women it doesn’t have to be a dramatic event to be considered traumatic. Factors such as the loss of control, loss of their dignity, the unfriendly attitude of those around them, and feelings of not being heard or the absence of informed consent to procedures all are common experiences by those expressed to have had a traumatic birth. A lack of support and understanding by healthcare professionals can contribute to cascading events in the quality of their patients, newborns, and communities’ lives from experiencing birth trauma. Women who experience a traumatic birthing experience without support can hinder their feelings of having more children, create relationship problems, negatively affect the bonding with their newborn, and they may avoid medical interventions that are similar to their birthing experience such as pap smears. A trauma-informed approach to nursing care is inclusive to trauma-specific interventions; whether it includes assessment, treatment or recovery supports, it also incorporates key trauma principles into the targeted organizational culture (Substance Abuse and Mental Health Services [SAMHS], 2014). Perinatal nurses care for patients during the antepartum, intrapartum, and postpartum periods when unanticipated events or unwanted feelings may occur. Adopting the TIC into practice can create positive outcomes and avoid re-traumatization of the patients in their care. This project enhanced current nursing practice by incorporating the understanding of TIC to perinatal LPNs and 49 RNs. The project provided education to the nursing staff by an online and in person presentation and administered a pre-survey and post-survey to assist in their knowledge of perinatal TIC, reevaluate their attitudes towards TIC, and assist in actively changing their nursing practice to measure a positive correlation of implementation of TIC principals in the perinatal setting. Through data analysis, the results of the surveys were analyzed by using the 2019 Microsoft Excel program and completing a Pearson Correlation test. After project implementation, the nurses’ responses in KAP toward perinatal TIC resulted noting a positive correlation range of p= 0.1 to 0.6 between educating the staff and an increase in their KAP. The positive correlation answers the question posed, “Does implementing trauma-informed care practices education to perinatal nurses increase their knowledge, attitudes, and practices of trauma-informed care after educational implementation?” Providing education and hands on application of TIC practices allows the nurses to apply common situations of trauma and learn how to provide support, empathy, and quality of care that can ripple through generations. Implications for Nursing Patients who are in ante, intra, or postpartum are in a vulnerable and profound transitional period of their lives. These transitions can be re-traumatizing to individuals who have a history of a traumatic experience or be trauma-inducing for the first time. As healthcare providers, nurses are the frontline staff that shape the perceptions, provide support, and deliver resources to their patients. In the perinatal setting, nurses can avoid re-traumatization and minimalize feelings of powerlessness. Although this project population was centered around perinatal nurses, the implementation of TIC practices are 50 universal to any nursing practice. The project provided education to perinatal nursing staff. The education provided understanding of what trauma is, examples of traumatic experiences including birth trauma, prevalence of trauma in women, how trauma affects the psychological, physical, and emotional wellbeing of the woman and newborn dyad, what birth trauma is, TIC practices, empathetic understanding, coping in labor, and patient and provider resources. Administering a pre-and post-survey allowed the project lead to assess the effectiveness of the nursing staff’s KAP post-implementation. The results indicating a positive correlation projected the need for this education to nurses. Specifically, nurses are the healthcare providers who at the bedside that provide the support trauma survivors require. Educating nursing staff on changing their attitude toward recovery is possible, trauma survivors aren’t faking it or being dramatic impacts their quality of patient care. When nurses implement TIC practices such as empathetic understanding, providing informed consent, explaining details before administering care, and recognizing signs of trauma all provide a patient with support and avoids retraumatization. Implementing the research findings provides a quality improvement to nursing and a sense of safety to patients and their families. TIC nurses carry out their interactions following their patients’ unique needs with the understanding that each patient is unique. This safe environment ensures a culture of safety and provides a ripple for generations. How a woman perceives her birthing experience shapes how she encounters healthcare for her family and herself in the future. TIC implements nurses to rise to the patients’ needs to provide trust in their most vulnerable transition into motherhood. The methods of TIC implemented transitions can assist in positive newborn 51 outcomes through positive mother-baby bonding and lowers rates of depression. Nurses being educated on what resources are available and using them can increase positive outcomes in mother-baby dyads and decrease nursing burnout or moral injury. Recommendations for Further Research The recommendations for future research are to continue to offer education to perinatal nurses on TIC practices and to provide TIC education universally to all nurses. A nursing cultural change does not occur after one presentation. However, presenting the prevalence of trauma and the understanding that women are in a state of vulnerability are key factors in supporting the need for further implementation of perinatal TIC practices research. The implementation of the pre-surveys shows that there is a gap in TIC knowledge, attitude, and in nursing practices. A larger sample may have provided a more drastic positive correlation. Presenting this education to multiple perinatal units and opening it to the Obstetricians is another recommendation in future research. TIC practices are universal. Continued nursing research and organizational support can create a positive catalyst for change throughout women and children’s lives for generations to come. 52 References Agency on Healthcare and Research (AHRQ), (2016). Trauma-informed care. Retrieved from: https://www.ahrq.gov/ncepcr/tools/healthier-pregnancy/factsheets/trauma.html American Association of Colleges of Nursing (AACN). (2022). Person-centered care. Retrieved from: https://www.aacnnursing.org/5B-Tool-Kit/Themes/PersonCentered-Care Andrade, C., Menon, V., Ameen, S., and Praharaj, S. K. (2020). Designing and conducting knowledge, attitude, and practice surveys in psychiatry: Practical guidance. Indian Journal of Psychological Medicine, 42(5). DOI: 10.1177/0253717620946111 Birth Trauma Association. (2018). What is birth trauma? Retrieved from: https://www.birthtraumaassociation.org.uk/for-parents/what-is-birth-trauma Bremmer, J. D. (2022). Traumatic stress: Effects on the brain. Dialogues in Clinical Neuroscience, 8(4). https://doi.org/10.31887/DCNS.2006.8.4/jbremner Carlisle, M. (2018). Trauma-Informed care in the perinatal period. Retrieved from: https://www.themotherhoodcenter.com/blogindex/2018/8/9/trauma-informedcare-in-the-perinatal-period Center for Disease Control and Prevention (CDC). (2022). Fast facts: Preventing adverse childhood experiences. Retrieved from: https://www.cdc.gov/ violence prevention/aces/fastfact.html 53 Fleishman, J., Kamsky, H., and Sundborg, S., (2019). Trauma-informed nursing practice. The Online Journal of Issues in Nursing, 24(2). DOI: 10.3912/OJIN.Vol24No02Man03 Gilbert, P. and Burke, D. (2022). Is there a need for trauma-informed care in the perinatal population? Journal of Obstetrics Gynecology and Neonatal Nursing, 51(4S). doi: 10.1016/j.jogn.2022.05.122 Hall, A., McKenna, B., Dearie, V., Maquire, T., Charleston, R., and Furness, T. (2016). Education emergency room nurses about trauma-informed care for people presenting with mental health crisis: A pilot study. BMC Nurse, 15(21). Doi: 10.1186/s12912-016-0141-y Institute of Medicine. (2022). Person-centered care. Retrieved from: https://www.aacnnursing.org/5B-Tool-Kit/Themes/Person-Centered-Care King, S., Chen, K-L., and Chokski, B. (2019). Becoming trauma-informed: Validating a tool to assess health professional’s knowledge, attitude, and practice. Pediatric Quality and Safety, 5(4). DOI: 10.1097/pq9.0000000000000215 Kuzma, E. K., Pardee, M., and Morgan, A. (2020). Implementing patient-centered trauma-informed care for the perinatal nurse. The Journal of Perinatal & Neonatal Nursing, 34(4). doi: 10.1097/JPN.0000000000000520 Linn, N., Stephens, K., Swanson-Biearman, B., Lewis, D., and Whiteman, K. (2021). Implementing trauma-informed care strategies for mothers of infants with neonatal abstinence syndrome. Wolters Kluwer Health, 46(4). Doi: 10.1097/NMC.0000000000000728 54 Lund Research. (2018). Pearson product-moment correlation. Retrieved from: https://statistics.laerd.com/statistical-guides/pearson-correlation-coefficientstatistical-guide.php Marvin, A. F., and Robinson, R. V. (2018). Implementing trauma-informed care at a nonprofit human service agency in Alaska: Assessing knowledge, attitudes, and readiness for change. Journal of Evidence-Informed Social Work, 15(5). doi: 10.1080/23761407.2018.1489324 Menschner, C., Maul, A. (2016). Key ingredients for successful trauma-informed care implementation. Retrieved from: https://www.samhsa.gov/sites/defaul t/files/ programs_campaigns/childrens_mental_health/atc-whitepaper-040616.pdf McNamara, M., Cane, R., Hoffman, Y., Reese, C., Schwartz, A., and Stolbach, B. (2021). Training hospital personnel in trauma-informed care: Assessing an interprofessional workshop with patients as teachers. Academic Pediatrics, 21(1). Oliver, D., and Mahon, S. M. (2005). Reading a research article part I: Types of variables. Clinical Journal of Oncology Nursing, 9(1). DOI: 10.1188/05.CJON.110-112 Ozen, Y. D., and Okumus, H. (2017). Effects of nursing care based on watson’s theory of human caring on anxiety, distress, and coping when infertility treatment fails: A randomized control trial. Journal of Caring Sciences, 6(2). doi:10.15171/jcs.2017.010 55 Rutberg, S., and Bouikidis, C. D. (2018). Focusing on the fundamentals: A simplistic differentiation between qualitative and quantitative research. Nephrology Nursing Journal, 45(2), 209- 212. Sperlich, M., Li, Y., Seng, J. S., Taylor, J. and Bradbury-Jones, C., (2017). Integrating trauma-informed care into maternity care practice: Conceptual and practical issues. Journal of Midwifery and Women's Health. Doi:10.1111/jmwh.12674 Sylvia, M. L., and Tehaar, M. F. (2018). Clinical analytics and data management for the DNP. Springer Publishing Company. Squires, M. E. and Tourangeau, A. (2009). Research rounds the missing data dilemma. Canadian Journal of Cardiovascular Nursing, 19(4). Retrieved from: https:// pubmed.ncbi.nlm.nih.gov/19947309/ Substance Abuse Mental Health Services Administration (SAMHSA). (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Retrieved from: https://store.samhsa.gov/product/SAMHSA-s-Concept-ofTrauma-and-Guidance-for-a-Trauma-Informed-Approach/SMA14-4884 56 Figures Figure 1. The four assumption Rs in TIC. Perinatal Trauma-Informed Care Realization Resist Respond Recognize Recognize Respond Realization Resist Figure 2. Pre- and post-survey data question one. TIC Question 1 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre survey Q 1 9 10 11 12 Post Survey Q 1 13 14 15 16 17 57 Figure 3. Pre- and post-survey data question two. TIC Question 2 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 Pre Survey Q2 10 11 12 13 14 15 16 17 13 14 15 16 17 Post Survey Q2 Figure 4. Pre- and post-survey data question seven. TIC Question 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre Survey Q 7 9 10 11 12 Post Survey Q 7 Figure 5. Pre- and post-survey data question nine. 58 TIC Question 9 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 Pre Survey Q 9 10 11 12 13 14 15 16 17 13 14 15 16 17 Post Survey Q 9 Figure 6. Pre- and post-survey data question sixteen. TIC. Question 16 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre Survey Q 16 9 10 11 12 Post Survey Q 16 Figure 7. Pre- and post-survey data question eighteen. 59 TIC Question 18 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 Pre Survey Q 18 10 11 12 13 14 15 16 17 14 15 16 17 Post Survey Q 18 Figure 8. Pre- and post-survey data question twenty-two. TIC Question 22 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre Survey Q 22 9 10 11 12 13 Post Survey Q 22 Figure 9. Pre- and post-survey data question twenty-six. 60 TIC Question 26 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 Pre Survey Q 26 10 11 12 13 14 15 16 17 15 16 17 Post Survey Q 26 Figure 10. Pre- and post-survey data question twenty-eight. TIC Question 28 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 Pre survey Q 28 9 10 11 12 Post Survey Q 28 13 14 61 Appendices Appendix A This is the pre-test and post-test evaluation survey questions. This is the information via confidence levels on the nurse’s knowledge, attitude, and practices on TIC using a 5point Likert Scale ranging from no knowledge or use to very good knowledge or use of. 62 Appendix B The site UPMC approval letter and Pennsylvania Western University IRB approval letter for the conduction of this project From: QualityReviewCommittee Sent: Monday, December 19, 2022 10:26 AM To: Lewis, Randilyn Subject: 4212 -- QI Project Submission Approved: -- Implementing Perinatal Trauma-Informed Nursing Care Project Sponsor, The Quality Improvement Review Committee is pleased to inform you that your QI project has been approved. We have also notified your local quality department of this approval and encourage you to share updates on the project’s progress. Please note that results of QI projects must be reviewed by local quality directors and approved by the Chief Quality Officer prior to dissemination (via presentation or publication) outside of UPMC. UPMC has adopted the Standards for Quality Improvement Reporting Excellence guidelines, SQUIRE 2.0 as the suggested reporting format. For multi-center projects, the QRC approval refers only to that part of the project being performed at UPMC facilities and the sponsors are responsible for obtaining approval from other non UPMC facilities participating in the project. We suggest that you share your findings on this project with the QRC. When your project is complete, please navigate to the Quality Improvement Project Portal and go to “My Projects.” Select the project and go to the “Project Summary” tab, add the findings in the “Project Results” field, and click “Submit Project Results to QRC.” 63 Projects reviewed and approved by the UPMC Quality Improvement Review Committee do not meet the federal definition of research according to 45 CFR 46.102(l) and do not require additional IRB oversight. Project Submission Details: Project ID: 4212 Project Title: Implementing Perinatal Trauma-Informed Nursing Care Project Sponsor: Randilyn Lewis ** Professional Staff Nurse, BSN, Expert ** NW Obstetrics / Nursery Project Co-Sponsor(s): Cheryl Siverling ** Unit Director ** NW Obstetrics - Nursery Michelle Wright ** Physician - UPP ** UPP13-MAGEE SRVCS AT NORTHWEST Submitted By: Randilyn Lewis ** Professional Staff Nurse, BSN, Expert ** NW Obstetrics / Nursery Additional Information from the QRC: To view the full project, log in to the Quality Improvement Project Portal, click on “My QI Projects,” and select project. Thank you for submitting your project for our review Eric J. Dueweke, MD, MBA, FACC 64 Cardiologist and Clinical Lecturer Medical Advisor, UPMC Quality Improvement Review Committee (QRC) UPMC Heart and Vascular Institute E-mail: duewekeej@upmc.edu 65 Institutional Review Board 250 University Avenue California, PA 15419 instreviewboard@calu.edu Melissa Sovak, Ph.D. Dear Randilyn, Please consider this email as official notification that your proposal titled “The Implementation of Perinatal Trauma-Informed Nursing Care” (Proposal #PW22-082) has been approved by the Pennsylvania Western University Institutional Review Board as submitted. The effective date of approval is 12/14/2022 and the expiration date is 12/13/2023. These dates must appear on the consent form. Please note that Federal Policy requires that you notify the IRB promptly regarding any of the following: (1) Any additions or changes in procedures you might wish for your study (additions or changes must be approved by the IRB before they are implemented) 66 (2) Any events that affect the safety or well-being of subjects (3) Any modifications of your study or other responses that are necessitated by any events reported in (2). (4) To continue your research beyond the approval expiration date of 12/13/2023, you must file additional information to be considered for continuing review. Please contact instreviewboard@calu.edu Please notify the Board when data collection is complete. Regards, Melissa Sovak, PhD. Chair, Institutional Review Board 67 Appendix C The education invite flyer for the staff to participate in the study 68 Appendix D The participants consent form PARTICIPANT CONSENT FORM University Affiliation: Pennsylvania Western University Clarion Administrative Office 108 Carrier Administration Building Clarion, PA 16214 814-393-2337 Project Title: Implementing Perinatal Trauma-Informed Care Project Lead: Randilyn Lewis MSN, CBC 1593 Baker Rd. Franklin, PA 16323, (814)516-6498, rlewis@pennwest.edu Faculty Advisor: Dr. Mary Terwilliger PhD, RN 1801 West First Street Oil City, PA 16301, (814)564-2057, mterwilliger@pennwest.edu You are invited to participate in a project being conducted through Pennsylvania Western University. We ask that you read this form and ask any questions you may have before you decide whether or not you want to participate in the project. Please feel free to ask the project lead any questions you may have. The university requires that you give your signed agreement if you choose to participate. Purpose of the Project: Trauma-informed care begins with knowledge about trauma, the ability to recognize signs of a trauma response, responding to patients effectively, and resisting re-traumatization. As holistic providers, perinatal nurses can create safe care environments, establish collaborative patient relationships based on trust, demonstrate compassion, offer patients options 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. Procedures: If you agree to participate in this project, we will ask you to do the following: attend one of two offered educational sessions whether online on Microsoft Teams or in person at UPMC Northwest in the provided conference room. You will be handed a packet or sent 69 via email a packet that contains this consent form, directions with how to access the Pre and Post REDCap survey link, and PowerPoint slides. You will then be instructed to sign the consent form voluntarily and be given approximately 15 minutes to complete the preeducation session survey. Your directions for the survey will be assigned a number in which you will indicate the number as your name for confidentiality reasons. The lead will then start the educational session followed by answering questions. The postimplementation survey will consist of the same questions as the pre implementation survey you will be asked to complete the post-survey via REDCap. “The Implementation of Perinatal Trauma-Informed Nursing Care” (Proposal #PW22-082) has been approved by the Pennsylvania Western University Institutional Review Board as submitted. The effective date of approval is 12/14/2022 and the expiration date is 12/13/2023. Risks and Benefits of Being in the Project: The project has no risks with an educational quality improvement project. The benefits to participation are to potentially increase knowledge in this content area for your nursing practice. Compensation: No compensation is offered for participation in this project. Privacy and Confidentiality: The data from the pre-and post-survey’s will be reviewed by numbers listed on the packets, placed in an excel spreadsheet, and then analyzed by utilizing the REDCap data analysis program. The results will be kept for five years on a confidential computer drive. The results will be sent for publication and shared in person at a hospital-wide nursing convention. The recordings will be kept for one year on an encrypted organizational Microsoft Teams page and used for educational purposes only. An exception to confidentiality is information on child abuse and neglect that is obtained during research. The information will be reported to the appropriate local or state agency in accordance with Pennsylvania law. Right to Refuse or End Participation: I understand that I may refuse to participate in this project or withdraw at any time. I also understand that I may be withdrawn from the project at any time by the project lead(s). 70 Contact Information: If you have concerns or questions about this project, please contact the project lead(s). Project Lead: Randilyn Lewis MSN, CBC 1593 Baker Rd. Franklin, PA 16323, (814)516-6498, rlewis@pennwest.edu Faculty Advisor: Dr. Mary Terwilliger PhD, RN 1801 West First Street Oil City, PA 16301, (814)564-2057, mterwilliger@pennwest.edu If you have questions or concerns about your rights as a project participant or would like to register a complaint about this project, you may contact the Pennsylvania Western University Clarion IRB by calling 814-393-2337, or emailing irb@pennwest.edu, or mailing the IRB using the following address: Pennwest University Clarion Administrative Office, 108 Carrier Administration Building, Clarion, PA 16214. Statement of Consent: I have read the information described above and have received a copy of this information. I have asked questions I had regarding the project and have received answers to my satisfaction. I am 18 years of age or older and voluntarily consent to participate in this project. ________________________________________________________________________ _____ Signature of Participant / Date ________________________________________________________________________ _____ Signature of Lead Thank you for your participation. 71 Appendix E The breakout session with role-play interactive cards 72 73 74 Appendix F The PowerPoint presentation on Perinatal Trauma-Informed Nursing Practice I M PL EM EN T I N G T R A U M A - I N FO R M ED CAR E I N TO N U R SI N G PR A C T I C E Presented by: Randilyn Lewis MSN, RNC PennsylvaniaWestern University 75 W hat isTrauma? Defined as resulting from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. Image from Family Psych, (SAMHSA, 2014) Traumatic Experiences Traumatic experiences may be current and ongoing or associated with more remote events of childhood and early life. These experiences may include: Intimate partner violence Sexual assault and rape Violence perpetrated based on race or sexual orientation Neglect during childhood Combat and service trauma Natural or occurring disasters such as weather or car accidents Repeated exposure to community violence Refugee and immigration status; or family separation Birth Trauma (ACOG,2021) 76 Perinatal or Birth Trauma Birth trauma is a phrase for PostTraumatic Stress Disorder (PTSD) after childbirth. Birth trauma also includes women who experience symptoms of PTSD after childbirth without a full diagnosis. Image from MyBaBa, (Birth Trauma Association, 2018) 77 Birth Trauma The term “obstetric violence”-In the perinatal setting this may include Unexpected outcomes Procedures Obstetric emergencies A nonmedical term that has been used to refer to situations in which a pregnant or postpartum individual experiences disrespect, indignity, or abuse from health care practitioners or systems that can stem from and lead to loss of autonomy These situations may include,--Repeated and unnecessary vaginal examinations, unindicated episiotomy, activity and food restrictions during labor, and forced cesarean delivery. More subtle manifestations may -- Neonatal complications include minimization of patient symptoms and differential treatment based on race, substance use, or other characteristics (ACOG, 2021) 70% of people will be exposed to at least one traumatic event during their life and from that 8% will develop Post Traumatic Stress Disorder (PTSD). ”Tr aum a” is it rare or are we just not aware? While most people who experience traumatic events don’t develop PTSD, women are two times more likely than men to experience a traumatic stress response, and approximately one in ten women will be diagnosed with PTSD in their lifetime One out of every six women will be a victim of attempted or completed rape by the age of thirteen One quarter of women will experience physical or sexual abuse or neglect over the course of their life Three percent of pregnant women and four percent of postpartum women are diagnosed with PTSD, though many more experience the emotional, psychological, and behavioral impact of traumatic events Image from Peach Tree (Carlisle, 2018) 78 The Effects of Trauma Mental Physical Views on Healthcare Institutions Image from Edward Ma Emotional Effects of Birth Trauma Anxiety Depression Feelings of hopelessness, powerlessness, shame, guilt, or disconnection with infant PTSD 79 PH Y SI C A L EFFEC T S O F B I RT H T R AU M A Thinking and Actions Chronic Diseases Self-Harm Avoidance of Healthcare Providers Image from Trauma Recovery Trauma-Informed Care A trauma-informed approach to care has been defined as: “A strengths-based service delivery approach that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both practitioners and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment” 80 FO U R PR I N C I PA L S O F T R AU M A - I N FO R M ED CAR E 81 Trauma-Informed Care into Nursing Practice Staff and clinicians should work to create an environment that is safe, calm, comfortable, and clean. Interactions should be compassionate, with expression of genuine concern and support, and survivors of trauma should be treated with respect and without judgment It is important to understand that trauma is experienced uniquely by each individual; therefore, the ways in which individuals react to and recover from trauma also will be unique Educating patients about the health effects of trauma and offering patients opportunities to disclose their traumatic events should be common practice. Screening for specific types of trauma is either required or recommended by multiple agencies and organizations (ACOG, 2021) Trauma-Informed Care Into Nursing Practice Offering options during care that can lessen anxiety, such as seeking permission before initiating contact, providing descriptions before and during examinations and procedures, allowing clothing to be shifted rather than removed, and agreeing to halt the examination at any time upon request, are all beneficial practices At every opportunity, patients should be offered the choice to be actively involved in all decision-making regarding their care. A practice should assess what services they are and are not equipped to provide. For services not provided, a robust resource list and educational materials should be available to assist with appropriate referrals, recovery, and healing. Understand and inform that Recovery is possible (ACOG,2021) 82 Three conditions that promote growth and change in patients Accurate Empathy • • Unconditional Positive Regard • Empathetic Understanding Genuineness Accurate Empathy is the ability to listen to your patients and accurately reflect to them the essence and meaning of what they said • When people explore their real experiences in the company of someone who continues to regard them with unconditional acceptance, they can begin to heal from the trauma they have experienced. Ask: “ How are you coping with your labor?” Clues she may not be coping: States she is not coping Crying Coping In Labor Sweating TremulousVoice Panicked activity during contraction Tense Inability to focus or concentrate 83 Provide Support To Their Physical-EmotionalNatural Birth Process IV pain medication Epidural Offer Shower, Hot or Cold Packs, Massage or Pressure, Movement and Ambulation, Birthing Balls, Focus points, Breathing Techniques Coping In Labor Mood, Lighting, Music, Fragrance,TV, Temperature One-on-One support, Doula,You should consider the patients: Life experiences, Sexual Abuse, Stressors, and Fears CMQCC Toolkit, 2016 B R EA K O U T SESSI O N 84 References American College of Obstetricians and Gynecology (ACOG), 2021. Caring for patients who have experienced trauma. Retrieved from: https://www.acog.org/clinical/clinical-guidance/committeeopinion/articles/2021/04/caring-for-patients-who-have-experienced-trauma Birth Trauma Association. (2018). What is birth trauma? Retrieved from: https://www.birthtraumaassociation.org.uk/for-parents/what-is-birth-trauma California Maternal Quality Care Collaborative (CMQCC). (2016). Coping with labor algorithm. Retrieved from: https://www.cmqcc.org/content/appendix-f-coping-laboralgorithm Carlisle, M. (2018). Trauma-Informed care in the perinatal period. Retrieved from: https://www.themotherhoodcenter.com/blogindex/2018/8/9/trauma-informed-care-in-theperinatal-period Edward Ma. (2021). Retrieved from: https://twitter.com/Maahokgit/status/1391822919018418187/photo/1 Family Psychiatry and Therapy. The nature of trauma and its effect on the PTSD brain. Retrieved from: https://familypsychnj.com/2019/02/the-nature-of-trauma-and-its-effecton-the-ptsd-brain/ MyBaBa. Understanding birth trauma: The signs, symptoms, and when to get help. Retrieved from: https://www.mybaba.com/understanding-birth-trauma/ 85 References Substance Abuse and Mental Health Service Association (SAMHSA), (2014). Concept of trauma and guidance for a trauma-informed approach. Retrieved from: https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4884.pdf Peach Tree Perinatal Wellness. (2022). Retrieved from: https://peachtree.org.au/definitions/ The Trauma Recovery Institute. Trauma recovery. Retrieved from: https://psychosocialsomatic.com/trauma-recovery/ Unfold Your Wings. Retrieved from: https://www.facebook.com/photo/?fbid=3139354736325795&set=pb.100063485953446.2207520000. 86 Appendix G Recording Approval Letter from Unit Director