Training maternal and child health nurses in early relational trauma: An evaluation of the MERTIL workforce training

Abstract

Background

Parents who experience relational trauma may inadvertently create contexts of care that undermine secure beginnings to life for their young children. Universal health services such as Maternal and Child Health (MCH) services offer a unique whole-of-population platform for prevention through early detection and intervention. To date however, relevant workforce training has been minimal.

Objectives

We report on an evaluation of state-wide workforce training to support MCH nurses to identify and respond to early relational trauma within parent-child dyads.

Design

Process and learning evaluation data were obtained at baseline (N = 1450), exit (n = 734) and follow-up (n = 651).

Settings and participants

Specialist training was developed and delivered to 1513 MCH staff in Victoria, Australia, via a 20-hour program of online learning and clinical skills workshops.

Results

At baseline, across eight measures of confidence in recognizing and responding to relational trauma, 30–49% of nurses rated their confidence as low. Significant increases in all areas of self-rated learning were found post-training. Three months post-training, gains in confidence and capability were sustained, with no significant variations by participant role or setting. Overall program satisfaction was >90%. Continuing concerns at follow-up focused on pragmatic concerns about inadequacy of referral networks and appropriate intervention pathways.

Conclusions

In this evaluation of a state-wide training program for nurses working with early relational trauma, we found excellent uptake and program satisfaction, and results support learning impact and retention. Findings are discussed with regard to translation potential across early childhood settings.

Introduction

Family trauma and related disturbances of early care in the neonatal through pre-school periods are key determinants of social and emotional development across the life-course (Schore, 2003; Schore and McIntosh, 2011). Single incident trauma may occur through isolated, unpredictable experiences such as sudden loss or severe accidents (van der Kolk et al., 2005). In contrast, relational trauma represents a cascading pattern of risks occurring in the context of early care relationships (Norman et al., 2012). Developmental ramifications of early relational trauma exposures during critical periods of brain and psychological development are marked, and provide clear impetus for interventions aimed at improving the mental health of parents and young children.

The common umbrella for all forms of trauma occurring in the early years is its relational context. Experiences including maltreatment, neglect, or other distortions of emotional care have in common the infant's experience of anxiety, uncertainty or fear in the context of primary attachment relationships (Forbes et al., 2012). This in turn may disrupt or distort core developmental processes (Scarborough et al., 2009), increasing risk for exposure of the infant to repeated or unpredictable threat or fear during critical periods of immune, cardio-vascular, and neuro-biological development (Glaser, 2000; Levendosky et al., 2011). The specific developmental needs in this period for attuned interactions renders the infant extremely sensitive to factors that disturb care-giving responsiveness, including parents' own unresolved trauma experiences (Newman, 2012) and personality and mood disorders (Newman, 2008; Newman and O'Shaughnessy, 2015) which can result in neglectful and anxiety-producing interactions.

The healing mirror to relational trauma, and the vehicle for prevention of further risk is relational repair, which can be cultivated through approaches that support vulnerable parents in providing sensitive care (Australian Centre for Posttraumatic Mental Health and Parenting Research Centre, 2014; Bernard et al., 2012; Thomas and Zimmer-Gembeck, 2011). Effective recognition of trauma symptoms in parent and/or infant, supported by validated screening and response frameworks (McIntosh et al., 2016), is critical. The emphasis is on effective recognition of traumatized states within the parent-infant dyad to enable early support for repair. Frontline nursing services are well placed to achieve this via the establishment of relationships with the parent in the peri-natal period, and the opportunity for repeated observations, supportive conversations, and targeted practical responses. These integrated activities, possible even in the context of brief encounters (Duggan et al., 2004; Eckenrode et al., 2000; LeCroy and Krysik, 2011; Moss et al., 2011), provide the ground for psychological safety in the parent-infant relationship.

MCH services in Victoria, Australia provide developmental surveillance and offer support to every child born in the state during the birth to school-age window. The service saw >80,000 children aged 0–1 years in the 2017–18 financial year (Department of Education and Training, 2018). Population coverage is excellent, with over 99% coverage at an initial home visit, and 83% coverage retention at 12 months in 2016–17 (Department of Education and Training, 2017). As such, the MCH service is uniquely positioned at the public health level for global detection of risk. The primary focus of this service has been to ensure optimal physical health and development of children, but attention is increasingly extending to the emotional wellbeing of the broader family and the detection of relational risk.

In Victoria, MCH services are delivered via local government authorities (LGAs) and community health services, and provided through three interrelated programs: the Universal and Enhanced programs and a 24-hour telephone service, the MCH Line. Staff are registered as both Division 1 nurses and midwives, with post-graduate qualifications in child and community nursing. Families can access the Universal service for ten free 30–60-minute appointments at intervals from birth to pre-school. Appointments focus on monitoring physical and mental health of both infants and parents and providing health promotion and interventions as required. The Enhanced service provides additional support for families experiencing challenges including family violence, child protection concerns, drug and alcohol misuse, mental illness, disability, medical risk, homelessness, lack of social support, youth pregnancies, or parent–baby bonding and attachment problems. In addition to the nursing workforce, the Enhanced program also employs some allied health staff, including social workers, occupational therapists and family support workers. The telephone-based service, staffed by nurses, provides 24-hour support to parents regarding expressed and often urgent needs, including nutrition, breastfeeding, child, maternal and family health, parenting, mental health support, and referrals as needed.

State and federal level legislative reform and policy contexts now explicitly prioritize investment in the early years, to reduce the effects of disadvantage on childhood development. These evidence-based policy directions recognize that access to health services and participation in learning and care programs directly influence a child's development, and that for children experiencing disadvantage, active participation in programs such as the MCH service may mitigate the effects of disadvantage. The Victorian Royal Commission into Family Violence (State of Victoria, 2016) set a firm imperative for the development of universal trauma-informed practice in frontline services including the MCH service. The MCH Service Practice Guidelines and Standards (State of Victoria, 2009b), revised Key Ages and Stages Activity Framework (State of Victoria, 2009a) and the introduction of additional hours of service through the Enhanced MCH program render the MCH system a ready holding environment for new directions in trauma-informed practice. Collectively, these state and federal initiatives buttress the national Early Childhood Development Strategy (COAG, 2009) which articulated that “by 2020 all children have the best start in life to create a better future for themselves and for the nation”.

MCH nurses are a well-qualified profession, having completed nursing, midwifery, and child, family and community health degrees. They are well trained in behavioural indicators of physical, sexual, and emotional abuse and neglect. Nevertheless, recent workforce reviews (Australian Centre for Posttraumatic Mental Health and Parenting Research Centre, 2014; Taft et al., 2018) have identified a workforce demand for trauma-informed training, yet identified none of adequate rigor, efficacy or translational value for universal application to the 0–5 population. This training gap has also been noted internationally as a challenge for nurse education (Yang et al., 2019). Barriers to integration of trauma-informed approaches in the paediatric sector include limited training opportunities and unclear practice principles (Marsac et al., 2016). The current training project, delivered in response to a state government request in 2018, was a timely opportunity to address a noted gap. Through an enhanced and consistent understanding of early development in a relational frame, the program aimed to build universal capacity and confidence in the MCH service for earliest detection of relational trauma, and better position MCH nurses to respond in ways that would minimize complex sequelae for parents and infant over time.

Program pedagogical design reflected current best practice in healthcare reform, and trauma-informed curriculum, aiming to foster knowledge of the prevalence and diversity of vulnerabilities in both clients and practitioners (Marsac et al., 2016; Rother and Lavizzo-Mourey, 2009), using mixed training modalities including case vignettes and facilitation of problem-based learning (Layne et al., 2011). The use of pedagogical frameworks that incorporate both theoretical principles and case-based learning modules is linked to increases in practitioner self-efficacy and a better understanding of the underlying principles of risk and protective factors in the family context (Layne et al., 2011).

In this light, the ‘My Early Relational Trauma Informed Learning’ (MERTIL) program comprised an online learning process, followed by face-to-face clinical skill workshop. Flexible online training was delivered over three themes, spanning eight chapters each 1–1.5 h, as indicated in Table 1, with supporting resources provided in the online library.

Following completion of the online modules (13 hours including supporting reading and listening materials), nurses attended a 7-hour clinical skills workshop, led by infant mental health specialists. Here they reviewed filmed case studies, focusing on dyadic observation skills, case formulation and practicing effective relationally based trauma conversations in the moment, and meta-cognitive strategies for managing potentially traumatizing material, for both the nurse and parent.

The current study aimed to evaluate the efficacy of this 20-hour program. Immediate and medium term impacts on confidence in and capacity for early trauma detection and response were the principle focus.