A Logic Model Approach to Trauma-Informed Care

The experience of childhood trauma is common,1,2 and the possible detrimental effects on health extending through adulthood have been well studied. Trauma is a response to “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.”3 Adverse Childhood Experiences (ACEs) have the potential to be traumatic for children; however, when protective factors are in place, this risk is buffered.2 Recognizing the need to mitigate the high prevalence and impact of trauma, the American Academy of Pediatrics (AAP) published a policy statement in 2021 recommending academic institutions integrate trauma-informed care (TIC) practices into all aspects of pediatric health care.1 A trauma-informed health care system uses a multifaceted approach that realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma (in pediatrics this includes children, families, and health care staff); responds by integrating knowledge about trauma into policies, procedures, and practices; and seeks to actively resist retraumatization (defined as the 4Rs of TIC).3Although the AAP policy statement details the importance of TIC, the planning and implementation of trauma-informed practices can remain logistically and practically challenging for health care systems. Becoming trauma-informed is a four-staged process for an organization – beginning with the stage of trauma-aware, to trauma-sensitive, then trauma-responsive, before reaching trauma-informed.4 We suggest health care organizations build on the AAP Policy Statement by utilizing a logic model to better navigate the stages of becoming trauma-informed, and to allow for alignment with organization-specific mission and vision. A multidisciplinary workgroup within the health care channel of a local collective impact organization developed a logic model to help our institution (Fig 1) outline key strategies to translate the AAP Policy Statement into specific and measurable change.The first key strategy outlined in the logic model, workforce development, begins with a readiness assessment for specific clinical sites (eg, division, department, team). This includes evaluating team capacity, identifying key leads to champion TIC within clinical sites, and establishing leadership commitment. The next step is providing TIC education across all staff roles – including triage or admitting staff, clinicians, nurses, and support staff (eg, child life, pastoral care, environmental services). A portfolio of universal TIC education that is developed and delivered over time should include: a broad definition of trauma including medical trauma, historical trauma, secondary traumatic stress, and burnout,1,2 as well as the range of impact on patients, families, and staff; the definition and prevalence of ACEs; and the role of protective factors, particularly safe, stable, and nurturing relationships, in mitigating the potential detrimental health effects of trauma and ACEs.2 This foundational knowledge should include awareness of the 4Rs of TIC to inform staff interactions with patients, families, and colleagues, and to guide best practices and organizational priorities. For example, an institution can adopt a section on TIC within a system-wide required annual safety training, accomplishing the short-term goal of increased knowledge.Specific, measurable outcomes can help track an organization’s progress toward becoming trauma-informed. When possible, existing measures should be leveraged, and additional measures may be added where important gaps remain. For example, employee satisfaction surveys can be used to identify needs related to psychological safety and power dynamics. Some evidence suggests connections between burnout and secondary traumatic stress,5 which may be of particular interest to organizational leadership. This potential role of TIC in supporting staff retention warrants further study. As specific staff TIC education rolls out, in the short-term an institution can track the number of employees receiving it and in the medium-term assess the number of employees who report the application of the 4Rs of TIC during clinical interactions. Long-term evaluation can be completed by tracking the successful expansion of TIC activities.Adopting trauma-informed practices not only has the potential to improve staff experience and reduce retraumatization but also to prevent additional trauma to patients and families. Workforce development is the foundation of the logic model’s second key strategy, prevention and intervention. This strategy serves to decrease retraumatization, improve the physical and emotional hospital environment, and support clinician-patient partnership to improve patient outcomes, enhance trust in the health care system, and support consistent engagement. For example, clinicians caring for hospitalized patients can lift the voice of the patient and family by setting shared expectations, explaining team roles and practices, and offering established hospital support services (eg, child life pastoral care). Family-centered rounds can support protective factors and foster inclusion, collaboration, and trust if they are flexible in ways that enhance relational health, such as accommodating family preferences for reducing staff present or including specific family or community members for support. Policies and resources specific to the clinical site can be established to reduce family stress, such as standardized admission protocols, trauma-informed accessible resources that center the voice of patients and families, and initiatives that promote empowerment by increasing self-efficacy.6 Existing patient satisfaction surveys can be used as a measurement tool, with the inclusion and analysis of open field comments that provide insight into health care trust and engagement.The third key strategy, hospital policies and procedures, systematically integrates TIC across the hospital environment and system. For example, an institution’s process for addressing challenging interactions between patients or families and staff can be replaced with an explicitly trauma-informed process that realizes trauma is widespread and recognizes the role of trauma in healthcare delivery as well as its signs and symptoms influencing challenging interactions. The process should be designed to respond to trauma and resist retraumatization in its approach to identifying mutually acceptable solutions for patients, families, and staff.7Organizations can transition from trauma-aware to trauma-informed using a logic model approach to develop their own short, medium, to long-term goals, with measurable and achievable benchmarks at each stage. The integration of TIC should be complementary to the organizational mission, and as such, the key strategies can and should align with existing organizational initiatives. These identified key strategies ultimately assist organizations in meeting their larger institutional goals (eg, improved patient and family satisfaction, increased employee engagement and retention), while also promoting optimal health and well-being in patients, families, and professionals to potentially interrupt the cycle of trauma.This work would not have been possible without the dedicated members of Joining Forces for Children and our multi-disciplinary Trauma-Informed Care Task Force at Cincinnati Children’s Hospital Medical Center.