Evaluating Take 5: Virtual Learning Sessions on Trauma Informed Care for Healthcare Staff During COVID-19

Trauma disproportionately impacts people with HIV. To mitigate these adverse impacts, primary care providers can identify and address trauma with clients using a trauma informed care (TIC) approach. In 2018, an organization that provides national level training and capacity-building, Cicatelli Associates, Inc. (CAI), developed a TIC implementation model, now delivered in HIV and primary care agencies throughout the United States to integrate TIC into their culture, environment, and service delivery. To respond to the complex challenges of the COVID-19 pandemic, we developed a webinar series, Take 5, to leverage and expand upon the existing knowledge and skills of providers across 15 agencies part of the New Jersey Trauma Informed Care (NJTIC) project.

This article describes the series’ purpose, to support staff and sustain their TIC competencies during this unprecedented reality. Results of our evaluation indicated the reaction, satisfaction, and impact described by staff, who enhanced their TIC knowledge and utilized new skills with clients and also in caring for themselves. These promising practices can be applied broadly during crises to bolster knowledge, skills, collaboration, and self-care.

Background of Take 5 and Trauma Informed Care

The role of trauma informed care cannot be understated when engaging with and providing supportive services...The role of trauma informed care (TIC) cannot be understated when engaging with and providing supportive services to people with HIV (PWH). In the United States, up to 74% of PWH have post-traumatic stress disorder (PTSD) related to adverse childhood experiences in comparison to 8% of adults in the general population (Applebaum et al., 2015). Studies have shown that along with PTSD, PWH are also four times more likely to have at least one co-morbid mental health diagnosis, including depression, anxiety, bipolar disorder, and schizophrenia, all of which have been found to be associated with childhood trauma (Marshall, 2017). The experience of trauma can influence health behaviors and subsequent health outcomes (Galvin, 2019). PWH who have experienced trauma are 58% less likely to adhere to their anti-retroviral treatment compared to PHW who have not experienced trauma (Brown, Harrison, & Li, 2019).

The motivation for this model is based on the understanding that primary care providers play a critical role in identifying and addressing past trauma with clients...Since 2018, CAI, a national training and technical assistance organization, has developed and implemented a TIC implementation model to build the capacity of primary care agencies and their healthcare staff to integrate TIC throughout their cultures, environments, and service delivery. The motivation for this model is based on the understanding that primary care providers play a critical role in identifying and addressing past trauma with clients, as opposed to simply relying on referrals to external mental health services to support these needs.

The CAI implementation model consists of organizational assessments. To identify areas for environmental and cultural change; leadership engagement; robust training for staff on trauma prevalence and TIC service delivery; and coaching on how to integrate delivery of TIC services for clients. Services may include screening for trauma symptoms coupled with a brief education session on the impacts of trauma; and agency level skills-building psychoeducational classes for those identified as needing more support. CAI technical assistance providers offer capacity building and training to staff at these agencies to implement components of the model to ensure successful integration of TIC into agency culture, environment, and service delivery.

The CAI model of TIC implementation has been adapted in a variety of settings across the United States. The first and largest implementation of the model was in HIV care agencies throughout the state of New Jersey (CAI, 2022b). To guide the TIC implementation model and its implementation and integration across diverse agencies, we leveraged the four phase Exploration, Planning and Preparation, Implementation, and Sustainability (EPIS) framework from the field of Implementation Science (Aarons, et al., 2011). We have designed key implementation activities in each EPIS phase to build the capacity of agencies integrating TIC by engaging leadership, providing focused technical assistance, delivering training for staff and supervisors, and utilizing a performance improvement approach to implementation of TIC services.

Along with service delivery, there has also been broad concern for the mental health and well-being of healthcare workers throughout the pandemic.The onset of the COVID-19 pandemic brought about tremendous disruption to implementation across the healthcare landscape, and leaders in the field had to rapidly adapt and identify new ways to support staff and clients. The quick transition to telehealth provided its own set of difficulties. For example, interviews with the leadership of HIV care organizations in South Carolina revealed several challenges associated with the provision of telehealth services: technical challenges related to equipment, internet access, digital literacy, Health Insurance Portability and Accountability Act (HIPAA) compliance, perceived client discomfort in the virtual setting, increased rates of no-shows, and an impact on the client-provider relationship (Yelverton et al., 2021). Along with service delivery, there has also been broad concern for the mental health and well-being of healthcare workers throughout the pandemic. A national survey of healthcare workers in the United States between May-October 2020 found that 61% of respondents reported fear of COVID-19 exposure or transmission, 38% reported anxiety and/or depression, and 49% reported feelings of burnout (Prasad et al., 2021).

Similarly, agencies we had been working with in New Jersey to implement TIC prior to the pandemic also experienced widespread challenges, including agencies that closed to in-person client services, shifting service delivery models, and lack of access to technology to support patient care. As a training organization, CAI was immediately concerned with identifying the best approaches to continue to provide professional development and support to staff and agencies. To mitigate these challenges and respond accordingly, we launched a new virtual webinar series, Take 5, at the start of the pandemic (in April 2020) which aimed: 1) to increase the capacity of staff to apply trauma informed concepts and skills that adapt to new realities and challenges of their work, and 2) for staff in the field to stay connected among a supportive TIC community while working in modified/remote environments.

...with staff operating in crisis, sessions needed to be brief with concrete information that was easy to digest and implementInitially, Take 5 offerings were designed to last 20 minutes; with staff operating in crisis, sessions needed to be brief with concrete information that was easy to digest and implement. Eventually, the series offered webinars approximately 45 minutes in length as we heard from staff that they would like additional time to cover topics more in-depth. Topics discussed during the Take 5 series addressed pressing needs for clinical and direct service staff working with people with HIV, such as: de-escalation and self-talk strategies to use during COVID-19, social isolation, providing client-centered care in remote environments, and case studies to showcase skills in action. The full list of offerings may be found in Table 1; recordings of many of the webinars may be viewed on the New Jersey HIV Trauma-Informed Care Project (CAI, 2022a) website.

Table 1. Take 5 Series Attendance and Polling Results

¹Polling questions were incorporated into Take 5s in February 2021. For Take 5s that occurred in 2021, percentages represent the sum of attendees who responded “Yes, but only a little” and “Yes, 100%.” For Take 5s that occurred in 2022, percentages represent the sum of attendees who responded “Yes” and “Partially.”

Methods

Results informed real-time development and/or adjustment of the training series to best meet their individual needs and those of their clients.CAI offered the Take 5 series with the New Jersey Trauma Informed Care (NJTIC) Project weekly between the months of April and August 2020, and then shifted to monthly and every two months from August 2020 onwards. To evaluate the satisfaction, reaction, and impact of the series, we utilized a mixed methods approach similar to how we approach evaluation of other NJTIC trainings and technical assistance offerings. This data additionally provided opportunities for us to conduct continuous quality improvement to understand experiences of staff who participated in the series, and the extent to which the series met its stated goals, as well as collect their suggestions for future sessions. Results informed real-time development and/or adjustment of the training series to best meet their individual needs and those of their clients.

Data Sources and Participants
Data sources draw from over two years of quantitative and qualitative data collected from April 2020 through August 2022 including: administrative data on series attendance, participant feedback to the series collected via an online survey, Take 5 webinar feedback collected via Zoom polling, and qualitative feedback to the series collected during technical assistance sessions.

As part of its routine training management, CAI collects attendance data from each training or event offered by the NJTIC Project using its registration system, Learning Stream. Additionally, we launched the Take 5 Series Impact Survey in October 2020 as a retrospective 6-month survey to see how participants had retained information from the series and the impact the series had on their work. The survey included eight questions with response options on a 5-point Likert scale to assess increases in knowledge and skills gained from the series, practical applications of trauma informed skills and the use of case studies, and the usefulness of supplementary materials such as handouts. We distributed the survey to all participants who joined a Take 5 webinar since April 2020 (n = 204); the response rate was 24%.

We implemented interviews in Fall 2020 with agency supervisors to better understand how their staff used the knowledge and skills from the Take 5 series in their work, and to explore the ways in which the series supported staff by providing an opportunity to engage with peers and stay connected on TIC topics. Interviews were completed with seven supervisors from four agencies using a semi-structured interview guide. Participants provided informed verbal consent prior to each interview. Virtual interviews were conducted by technical assistance providers and recorded and transcribed.

Lastly, beginning in February 2021, we used a virtual polling feature at the end of each Take 5 webinar to assess participant learning. We asked 3 questions in the poll. When the series launched in April 2020, we did not anticipate the gravity of the COVID-19 pandemic and that the series would continue for so long. To help us collect valuable continuous quality improvement (CQI) data, therefore, we decided to introduce this polling approach at the end of each offering to learn the extent to which participants gained new knowledge, learned new skills, and planned to use the day’s content in their work. Response rates to the twenty polls conducted since February 2021 ranged from 53-100%. The NJTIC Project received IRB exemption through WCG IRB.

Analysis
We conducted descriptive analyses on Take 5 participation, participant experience, and satisfaction data. During analysis for the Take 5 Series Impact Survey, responses of “strongly agree” and “agree” were combined into “strongly agree/agree.” Analysis of the virtual polling data for webinars that took place in 2021 combined the responses “Yes, 100%” and “Yes, but only a little” into “Yes.” Additionally, for webinars that took place in 2022, responses of “Yes” and “Partially” were combined into “Yes.” Excel was used for all quantitative analyses.

To analyze the qualitative data, two researchers (S.B., A.C.) read the transcripts and created a codebook with the major themes. The researchers each coded one transcript and met to discuss application of codes and finalize the codebook. The de-identified transcripts were uploaded to MAXQDA 2020, a qualitative analysis software, to complete coding. Both researchers coded all four transcripts. When coding discrepancies arose, they were discussed and resolved until the inter-coder agreement was above 80%. The researchers used thematic content analysis to identify the main themes from the transcripts.

Findings

Take 5 Series Offerings and Attendance
On average, Take 5 participants attended four sessions within the series...From April 2020 through August 2022, the NJTIC Project offered 42 Take 5 webinars; 27 webinar offerings were new content, and 15 webinar sessions included content the series previously covered as a way to repeat and reinforce concepts, and also ensure any new staff received content. On average, Take 5 participants attended four sessions within the series; 351 unique participants were reached with a total attendance of 1,466. The number of participants at each session ranged from 8 to 64, with an average of 35 participants per session.

Increasing TIC Knowledge
...the webinars helped their staff to learn more about TIC.Overall, participants of the series reported that the Take 5 series increased their knowledge of TIC both immediately following the offering as well as six months later. For webinars where virtual polling was conducted, 99% of participants’ knowledge of TIC had increased at the conclusion of the webinar; and after 6 months of offerings, the Take 5 Series Impact Survey found 94% of respondents reported the Take 5 series increased their knowledge of TIC. Supervisors echoed this finding, stating that the webinars helped their staff to learn more about TIC. Table 2 summarizes the themes that emerged from this data with examples of supporting quotes.

Table 2. Summary of Qualitative Themes and Supporting Quotes

Take 5 Series’ Impact on Staff Skills and Application

...90% reported the series provided them with practical ways to apply trauma informed skills with themselves.The Take 5 series provided new skills for participants to use in their work with clients and for their own self-care. Reported immediately following the webinars through virtual polling, an average of 98% of participants across the offerings reported that they learned trauma informed skills during the day’s Take 5 and 100% said they would use and apply their learnings in their work.

In the Take 5 Series Impact Survey which asked respondents to consider the offerings they had attended in the past 6 months, 92% of respondents reported learning new trauma informed skills, 94% reported the series provided practical ways to apply trauma informed skills with their clients, and 90% reported the series provided them with practical ways to apply trauma informed skills with themselves (see Table 3). Eighty-seven percent of respondents reported using trauma informed skills presented in the series in their work.

Table 3. Take 5 Series Impact Survey Results

¹ Responses of “strongly agree” and “agree” were combined into “Strongly Agree/Agree”

The webinars facilitated skills practice through role play and case studies...To increase staff TIC skills and capacity, the series integrated time for staff to practice new skills and those with which they were already familiar. The webinars facilitated skills practice through role play and case studies to showcase examples of how staff can utilize their TIC skills in practice. The Take 5 series covered a variety of applications of TIC but some of the skills that staff learned included de-escalation strategies, skills for leading grounding exercises, as well as how to discuss a variety of topics related to COVID-19 with clients such as substance use, safer sex, universal grief, coping strategies, and social isolation.

Across multiple agencies, supervisors expressed that they had seen their staff implement TIC skills...One of the most prominent themes that appeared throughout the qualitative interviews with the supervisors was the discussion of how staff were utilizing their trauma informed care skills with clients. Across multiple agencies, supervisors expressed that they had seen their staff implement TIC skills such as de-escalation, re-framing, and employing TIC language (see Table 3).

Staff members’ TIC skills were enhanced not only for interactions with clients, but also for use with themselves. Supervisors recognized that staff members increasingly used their TIC skills personally, utilizing practices such as positive self-talk, self-care, calming methods, and knowing when to take a break.

Supporting Staff During COVID-19
While the Take 5 series received overwhelmingly positive feedback from both supervisors and staff regarding the topics and information presented, the “sense of normalcy” and consistency that the series provided to agency staff throughout the COVID-19 pandemic was not unnoticed. One participant noted:

I think one of the – one of the best things that the Take 5 series accomplished was in a time where everything was kind of unsettled, and we weren’t having the face-to-face interaction with, with staff, with patients. It was something consistent, and something that we could depend on, and something in most cases was presenting relevant topics to our day-to-day challenges as, as the COVID pandemic was unfolding, and we were kind of trying to adapt with all the changes. So that was helpful, that it was consistent and it was relevant. (See other examples of this theme in Table 2)

The series was also helpful in providing staff with skills related to COVID-19; in particular, how to discuss the pandemic and its effects with clients. As staff and clients alike navigated the pandemic, Take 5 gave staff highly relevant tools to support clients in the most pressing concerns that emerged during COVID-19. Staff were able to address client questions and concerns while continuing to provide regularly offered services.

Staff and Supervisor Experience with the Take 5 Series
Supervisors shared positive feedback about the Take 5 series regarding the time commitment, schedule, variety of topics, and activities included in the webinars. Staff also appreciated the applicability and timeliness to the topics which they could apply with their clients and for themselves. A supervisor stated:

My staff actually likes to Take 5; they get excited when they're available because I think it's because it's two things. It's one, because it's something that they can personally use themselves and also because their clients are going through very stressful experiences right now. So they really can use the trauma informed techniques. [...] It just reminds them to use [their skills]. And also to help them with the other thing like grounding, breathing, and stuff like that.

Throughout the pandemic, the Take 5 series helped to refresh TIC topics for staff and reinforce the trauma informed skills that they already knew. Supervisors commented that the webinars helped them stay up to date on TIC and were “a good reminder of the skills they’ve used in the past,” noting that they would continue recommending the series to their staff. While being viewed as a helpful refresher course for some who had taken prior TIC training courses, other supervisors appreciated that the Take 5 webinars allowed anyone to attend, regardless of prior TIC training.

Discussion

In March 2020 at the beginning of COVID-19, healthcare agencies were faced with unprecedented challenges and confusion on how to best support clients or pivot service delivery. Many agencies closed their doors to in-person services or provided limited services. In response, CAI rapidly adapted to offer virtual training sessions and capacity building and considered ways to make these virtual offerings easy, digestible, and short to assure effectiveness and a positive reception. By designing a shorter and frequently offered training series online, we responded to new realities and work challenges of the staff during the pandemic. These changes made it convenient to attend the series and allowed staff to stay connected to one another for support, camaraderie, and sharing of best practices.

Now, three years after the start of the pandemic, best practices during this challenging time have emerged on topics such as telehealth delivery and virtual learning platforms and modalities (Wosik, et al., 2020; Thomas et al., 2020; Lingum et al., 2021). Our Take 5 approach and findings presented within further this literature and offer promising new practices and experiences that can inform healthcare organizations seeking to engage staff in both already learned TIC-related knowledge and skills, and new information.

Limitations and Lessons Learned
There are several study limitations to note. The evaluation tools used to assess the satisfaction, reaction and impact of the Take 5 series relied on self-reported information among staff, which may be subject to selection bias. To mitigate these limitations, we sought to triangulate findings through interviews with supervisors to get a 360 degree sense of their observations of staff and characterize the ways in which staff increased their knowledge and skills as a result of the Take 5 series.

As a training and capacity building organization, we have gained many insights about successful adaptation of capacity building to virtual and/or hybrid settings to best meet staff and organizational needs. For example, we aim to create a safe virtual environment; gain and sustain participant interest using a concise curriculum, including material to appeal to multiple learning styles; and provide space and time for participants to share their experiences.

Findings from interviews with supervisors indicated that a short, accessible format aligns with the day-to-day realities of busy healthcare staff...Finally, the findings from this study can inform other programs interested in applying TIC trainings and integration in innovative ways, given that findings from this evaluation indicated that the series helped staff “refresh” the knowledge they already had related to TIC; learn how to apply their TIC knowledge and tools in new contexts (e.g., COVID-19 pandemic, working remotely, modified service delivery environments); and gain new knowledge and skills. Findings from interviews with supervisors indicated that a short, accessible format aligns with the day-to-day realities of busy healthcare staff and that this method supported staff in immediately using the skills and knowledge gained.

Implications for Nursing Education and Practice:

The Take 5 series utilized a brief, frequently implemented, virtual webinar format to enhance existing knowledge and skills related to TIC and supplement new concepts and applications during an incredibly unprecedented and challenging time for agencies, staff, and clients. The series was well-received by both staff and supervisors, ensured a balance of content that reviewed existing knowledge with new content and skills, engaged participants by watching role-plays of skill utilization and making plans to use corresponding skills in their work, and offered short, consistently scheduled sessions (i.e., less than 1 hour, held 1 time per month) that were not burdensome on busy clinic schedules.

...virtual learning offered in short sessions provides a high-quality option for nurses and other staff to stay connected to one another...The Take 5 series was created in response to the COVID-19 pandemic, but these promising practices can be applied to other challenging situations and times of crisis. By consistently staying connected to one another and the NJTIC project throughout the series, staff remained engaged in TIC so that they could continue to support their clients. When meeting in-person or for long periods of time is not feasible, virtual learning offered in short sessions provides a high-quality option for nurses and other staff to stay connected to one another, apply existing skills to new contexts, and gain new knowledge and skills to support their clients and themselves.

Authors

Sabrina Baumgartner, MPH
Email: sbaumgartner@caiglobal.org

Sabrina Baumgartner is the Lead Evaluator for Health Systems Integration Initiatives at Cicatelli Associates, Inc. (CAI) with over 9 years’ experience in the public health field. In her role, she plans and implements program evaluations on trauma informed care, supplemental nutrition programs for families, maternal and child health initiatives, and sexual violence prevention programming. She designs implementation guidance tools, qualitative and quantitative data collection tools, and completes corresponding analyses to inform programming. Ms. Baumgartner holds a Masters of Public Health from the Columbia Mailman School of Public Health.

Beth Hurley, MPH
Email: Bhurley@caiglobal.org

Beth Hurley is a Project Director at CAI with over a decade of experience working in HIV. Ms. Hurley serves as the Deputy Director of the Trauma Informed Care Division and Project Director for the CAI NJ Trauma Informed Care Project, which supports 15+ HIV Care and Treatment agencies in integrating TIC into their culture, environment, and delivery of services. Ms. Hurley has supported a number of additional projects including working with RWHAP funded medical providers to contract and be reimbursed by Medicaid and Marketplace insurance plans through targeted training, technical assistance, and customized materials, tools and resources. Ms. Hurley has a background in public health with specific expertise in curriculum development, the development of training tools and job aids, collaborative learning, billing for STD and HIV services, and working with a diverse team of staff and expert consultants.

Allyson Crinklaw, MPH, CHES
Email: acrinklaw@caiglobal.org

Allyson Crinklaw is an Evaluation Analyst at CAI. In this capacity, she develops and implements evaluations on trauma informed care services and disease intervention specialist training. Allyson’s background in public health includes experience in water access, health promotion, disaster preparedness and response, and creative youth development. Ms. Crinklaw holds a Master of Public Health from the Columbia University Mailman School of Public Health, and a BA in Human Biology and Society from the University of California, Los Angeles.

Lindsay Senter, MPH
Email: lsenter@caiglobal.org

Lindsay Senter serves as a Vice President, Research and Evaluation at CAI. She holds a Master’s Degree in Public Health in Epidemiology from the University of Washington, where she was an awardee in the Maternal and Child Health Leadership Program. Ms. Senter has over 15 years’ experience working as an applied public health researcher in diverse settings, including city health departments, hospitals, and non-profit organizations. She has specific expertise in social science research, epidemiology and program evaluation. In this capacity, Ms. Senter provides overall direction and coordination at CAI of multiple research and evaluation projects related to reproductive health, trauma informed care, women’s health, tobacco, and HIV/AIDS. She leads a team of staff members who utilize qualitative and quantitative methods and implementation science frameworks to support adoption of innovative new approaches in healthcare settings and measure effectiveness and impact.

Melanie Steilen, BSN, RN, ACRN
Email: Melanie@caiglobal.org

Melanie Steilen is the Director of Nursing Education at CAI.  Ms. Steilen has over 30 years of clinical, research, administrative, and teaching experience as a Registered Nurse. Throughout her tenure at CAI, Ms. Steilen has been responsible for the development, design, and implementation of a diverse array of training programs for healthcare professionals. Topics of expertise include but are not limited to: reaching the most at risk clients, talking about tough topics, incorporating chronic disease management in HIV care, mental health and HIV, prevention with positives, and behavior change. Ms. Steilen serves as the President of the Board ANAC (Association of Nurses in AIDS Care).

Michelle Hyland, MA [B.Ed. Canadian equivalent]
Email: MHyland@caiglobal.org

Michelle Hyland serves as a Vice President, Curriculum Development at CAI, providing oversight and strategic direction to the curriculum and e-learning departments. Ms. Hyland oversees the planning, development and quality assurance of all training products including face-to-face training curricula (trainer’s manuals, participant handbooks, PowerPoints), training-of-trainer’s curricula, implementation manuals, toolkits, webinars, learning collaboratives, facilitator’s guides for behavioral interventions, technical assistance materials, and online learning modules, including microlearning modules. Ms. Hyland has over twenty years of experience in curriculum development, program management, and distance learning.

Barbara Cicatelli, MA
Email: barbara@caiglobal.org

Barbara Cicatelli, MA, is the President and Founder of CAI, a non-profit educational organization that provides training and technical assistance to health and human service agencies to better meet the needs of marginalized and underserved populations and communities. Ms. Cicatelli’s expertise in adult learning and education has been at the core of the organization’s highly successful and effective approach to capacity building. She has led her organization through extraordinary growth and development, forging relationships with international, federal, state, and local agencies.