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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.

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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

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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

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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

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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

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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

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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

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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).

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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.

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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

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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.

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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.

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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

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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

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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).

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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,

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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.

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Figure 2.
Question One Results Exposure to Trauma

TIC Question 1
6
5
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Pre survey Q 1

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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.

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Figure 3
Question 2 Effects of Trauma

TIC Question 2
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Pre Survey Q2

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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
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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
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Pre Survey Q 9

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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.

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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
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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
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Pre Survey Q 18

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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.

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Figure 8
Question 22 Resources for Implementation of TIC

TIC Question 22
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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.

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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
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Pre Survey Q 26

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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.

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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
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Pre survey Q 28

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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.

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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

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results may have shown a greater need for education. A need for future research would be
noted to confirm a greater positive correlation.

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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

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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

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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
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American Association of Colleges of Nursing (AACN). (2022). Person-centered care.
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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
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Fleishman, J., Kamsky, H., and Sundborg, S., (2019). Trauma-informed nursing practice.
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Gilbert, P. and Burke, D. (2022). Is there a need for trauma-informed care in the perinatal
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Hall, A., McKenna, B., Dearie, V., Maquire, T., Charleston, R., and Furness, T. (2016).
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King, S., Chen, K-L., and Chokski, B. (2019). Becoming trauma-informed: Validating a
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Kuzma, E. K., Pardee, M., and Morgan, A. (2020). Implementing patient-centered
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Linn, N., Stephens, K., Swanson-Biearman, B., Lewis, D., and Whiteman, K. (2021).
Implementing trauma-informed care strategies for mothers of infants with
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Lund Research. (2018). Pearson product-moment correlation. Retrieved from:
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Marvin, A. F., and Robinson, R. V. (2018). Implementing trauma-informed care at a nonprofit human service agency in Alaska: Assessing knowledge, attitudes, and
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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
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10.1188/05.CJON.110-112
Ozen, Y. D., and Okumus, H. (2017). Effects of nursing care based on watson’s theory of
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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
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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

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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
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Figure 3. Pre- and post-survey data question two.

TIC Question 2
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Pre Survey Q2

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Post Survey Q2

Figure 4. Pre- and post-survey data question seven.

TIC Question 7
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Pre Survey Q 7

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Figure 5. Pre- and post-survey data question nine.

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TIC Question 9
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Pre Survey Q 9

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Post Survey Q 9

Figure 6. Pre- and post-survey data question sixteen.

TIC. Question 16
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Pre Survey Q 16

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Post Survey Q 16

Figure 7. Pre- and post-survey data question eighteen.

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TIC Question 18
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Pre Survey Q 18

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Post Survey Q 18

Figure 8. Pre- and post-survey data question twenty-two.

TIC Question 22
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Figure 9. Pre- and post-survey data question twenty-six.

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TIC Question 26
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Figure 10. Pre- and post-survey data question twenty-eight.

TIC Question 28
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14

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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.

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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

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Appendix C
The education invite flyer for the staff to participate in the study

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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.

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Appendix E

The breakout session with role-play interactive cards

72

73

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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

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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)

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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)

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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)

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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

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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”

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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/

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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.

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Appendix G
Recording Approval Letter from Unit Director