Core Competencies in Trauma-Informed Care for Emergency Medicine: A Modified Delphi Consensus
ABSTRACT
Background Trauma-informed care (TIC) is a framework to recognize and respond to all types of trauma, prevent re-traumatization, and promote resilience. Trauma includes any event that is physically or emotionally harmful and has lasting adverse effects. While TIC strategies are increasingly emphasized in medical education, thus far no core competencies exist to guide competency-based education in postgraduate education.
Objective To build consensus on core competencies in TIC for emergency medicine (EM).
Methods We recruited experts in TIC via snowball sampling to participate in a modified Delphi process. Panelists ranked competencies on a 5-point Likert scale through electronic survey. Threshold for consensus was defined as a mean of 3.75. Thematic analysis was performed on survey free-text responses and transcripts of virtual discussions using inductive and in vivo codes.
Results Sixteen panelists across 12 institutions participated in the modified Delphi, and 49 initial competencies were proposed. During round 1, 100% of the competencies exceeded the consensus level, but many panelists offered suggestions and changes. Thus, we conducted 2 virtual discussions and reorganized the proposed competencies into 19 competencies in round 2. We further narrowed to 16 competencies in round 3. Thematic analyses were used between rounds to organize panelists’ comments for revisions. There were no major changes proposed by panelists after round 3, and all competencies exceeded the consensus level. Examples of the final competencies include “define trauma,” and “describe the widespread impact of trauma on health.”
Conclusions We achieved consensus on 16 core competencies for EM physicians in training.
Introduction
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma as “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.”1 About 20% of survivors of traumatic injury are ultimately diagnosed with post-traumatic stress disorder (PTSD) after an acute inpatient hospitalization.2 Estimates of the lifetime prevalence of PTSD in the United States range from 3.4% to 26.9%.3
Trauma-informed care (TIC) is defined by SAMHSA as “an organizational structure and treatment framework that involves understanding, recognizing, and responding to the effects of all types of trauma.”1 It is based on 6 principles: (1) safety, (2) trustworthiness and transparency, (3) peer support, (4) collaboration and mutuality, (5) empowerment, voice, and choice, and (6) culture, historical, and gender issues.1 TIC considers both the trauma of the patient and the clinician within this framework. Studies within TIC are divided into 2 topics: universal precautions and trauma-specific care.4 Within universal precautions, knowledge of trauma history is not required; rather clinicians are expected to treat all patients with the presumption of past traumatic experiences with the goal of avoiding re-traumatization.4,5 This differs from trauma specific strategies, which are employed when a clinician knows a patient has undergone a traumatic experience, such as sexual assault or traumatic injury.4
Despite the widespread prevalence of trauma and existing literature on TIC, many physicians lack appropriate training. While core competencies have been developed for undergraduate medical education,6 and some specialties, such as pediatrics, have incorporated TIC into their postgraduate medical education standard curriculum,7 currently no defined educational competencies exist for TIC in any medical specialty. A deficit, therefore, exists in which physicians are expected to care for substantial numbers of victims of trauma, without appropriate postgraduate training in TIC. It is therefore critical to develop competencies in TIC to inform education interventions that have measurable and actionable outcomes on clinician behavior and, ultimately, patient care.
Thus, using a competency-based medical education framework, informed by the Accreditation Council of Graduate Medical Education (ACGME) 6 content areas, our objective was to develop educational competencies for universal precautions of TIC for use in emergency medicine (EM) resident physician training.
KEY POINTS
Methods
Study Design
We used a modified Delphi technique to build consensus of core competencies in TIC for EM postgraduate education. The study was conducted between October 2023 and July 2024. This study was directed by a steering committee of 5 individuals (K.J., M. Montano, M. Moreira, A.W., D.M.) across 3 institutions with dedicated expertise in TIC (A.W., M. Montano), competency based medical education (D.M., M. Moreira), and medical education simulation (A.W., M. Moreira). K.J. was responsible for communication between the steering committee and panelists and performing qualitative analysis. All members of the steering committee are authors of this study.
Panelist Selection
Panelists were invited to participate in the modified Delphi if they had expertise in TIC as demonstrated by peer-reviewed publications on TIC or related topic areas, were identified as an expert by academic medical associations, or had meaningful professional experience in the fields of TIC, violence intervention, or medical education. Additional potential panelists were recruited through professional connections of steering committee members. Potential panelists were contacted by electronic mail. Panelist invitees were further asked to suggest other individuals whom they considered suitable to participate. No compensation for participation was offered. A panel of 11 to 30 members was targeted based on prior literature on modified Delphi methods.10,11
Stage 1: Building an Initial Set of Core Competencies
In July 2023, members of the steering committee performed a search of existing trauma-informed care education studies and competencies to inform the initial draft of proposed competencies. The steering committee searched peer-reviewed literature, medical education resources (eg, MedEd Portal, white papers), and non-peer-reviewed reports through an online search of Google, Google Scholar, and PubMed utilizing key terms including “trauma informed care,” “emergency medicine,” “emergency department,” and “education.” The primary author reviewed abstracts, and a selection of relevant full-text articles were subsequently reviewed by the steering committee. Through this search, the steering committee created an initial set of proposed core competencies. The proposed core competencies specifically relied heavily on a consensus document by Ashworth et al8 and the American Psychological Association 2015 guidelines on TIC9 and were framed within 6 content areas defined by the ACGME. Due to similarities, the areas of Interpersonal and Communication Skills and Professionalism were combined into a single topic. Patient Care was divided into 2 subsections, history taking and physical examination, to assist with the development of future education interventions that frequently use these subsections to identify critical actions.
Stage 2: Consensus-Building Process to Select and Refine Core Competencies
Modified Delphi Round 1:
During the first round, panelists were sent a list of potential core competencies created by the steering committee (online supplementary data Table 1) within an online questionnaire, made with Google Forms. Panelists were asked to rank the importance of including each statement as a core competency on a 5-point Likert scale (not important to critical). For each proposed competency, panelists were invited to offer comments, suggest edits, and suggest additional competencies. A mean score and standard deviation (SD) for each competency was calculated. Consensus was defined as a mean score ≥3.75, which corresponds to 75% raw agreement.11 We planned to remove any statements that did not meet the minimum requirement for consensus from subsequent rounds. Following each round, free-text responses were analyzed using thematic analysis, with the goal of organizing panelists’ comments and suggestions when revising proposed competencies. Coding was performed by a single member of the steering committee (K.J.) using inductive and in vivo codes and memo writing within Microsoft Word. Key themes were identified through discussion by the steering committee during a virtual meeting following each round. The steering committee sought to incorporate as many suggestions and comments offered by panelists as possible after each round. However, in the case of contradictory suggestions from different panelists (eg, disagreement between panelists on whether “chaperone” referred to a staff member or guest) or suggestions that steering committee members thought could not feasibly be incorporated (eg, a specific online resource), the omission or inclusion of panelists suggestions were decided by steering committee majority vote.
Virtual Panelist Discussion:
Following the first-round questionnaire, panelists were asked to review anonymized free-text responses and scores for each proposed competency. We then hosted 2 virtual, 1-hour panelist discussions (Zoom Video Communications Inc). All panelists were invited to participate. The discussions were facilitated by the primary author and were audio recorded and transcribed after obtaining consent from all participants. Transcriptions were analyzed using thematic analysis as described above. Identifying information was subsequently manually extracted from transcripts, and anonymized transcripts were disseminated to all panelists for review.
Modified Delphi Round 2:
Proposed competencies were revised based on results of the panelist discussion and first round questionnaire. The second questionnaire used the same scoring system and free-text response opportunities as described in round 1. Results were analyzed using the same process as round 1.
Modified Delphi Round 3:
Panelists were asked to review anonymized free-text responses and scores for each proposed competency from round 2. A third questionnaire was distributed to panelists with the same scoring system and free-text comment opportunities. The analysis process was repeated. Utilizing Student’s t tests, mean scores were compared between rounds 2 and 3.
This study was approved by the Colorado Multiple Institutional Review Board through the global educational studies exemption application.
Results
A total of 24 expert panelists were identified by both steering committee members and panelist invitees. Ultimately, 16 panelists from 12 institutions were recruited and consented to participate (Figure). The majority of panelists were female (81%, 13 of 16), affiliated with an academic medical center (63%, 10 of 16), and located in the western region of the United States (56%, 9 of 16) (Table 1). Panelists had a wide array of expertise across medical specialties and subspecialty areas, including, but not limited to, resident education, intimate partner violence, community violence intervention, persons experiencing homelessness, and physician wellness. The panel included 3 (of 16, 19%) professional TIC coaches, co-chairs of the Massachusetts General Brigham Trauma-Informed Care Initiative, the medical director of a forensic nursing program, the medical director of a community violence intervention program, and a state chief health officer.
Citation: Journal of Graduate Medical Education 17, 5; 10.4300/JGME-D-24-00915.1
Modified Delphi Round 1
The first questionnaire, which was administered between October 2023 and January 2024, had a total of 49 proposed core competencies. All 16 panelists responded to the questionnaire. Mean scores for each proposed competency ranged from 3.94 to 5 on a 5-point Likert scale (online supplementary data Table 2). No core competencies fell below the consensus threshold of 3.75. Nine new competencies were suggested by panelists. Online supplementary data Table 3 describes examples of free-text quotes from panelists, codes, codebook definitions, and associated themes. Key themes from panelist comments included: (1) need for clarification of terms, removal of redundancies, and incorporation of more practical and measurable skills within the context of EM education; (2) increased incorporation of opportunities for patient autonomy; and (3) increased consideration of staff safety and mental health. Although none of the competencies fell below the consensus threshold, the panelists and steering committee agreed that a shorter list of competencies was necessary for the development of practical trainings and simulations, although we did not have a preset limit on the maximum number of competencies.
Virtual Panelist Discussions
Panel discussions were not originally planned as part of the Delphi process; however, given the unexpected results of the first round of the Delphi, virtual panel discussions were convened to further understand panelists perspectives, incorporate panelist edits, and narrow the overall number of core competencies. The virtual panels occurred over 2 weeks in March 2024. Five panelist members and all members of the steering committee participated in 2 virtual discussions between rounds 1 and 2. Four of the panelists were female (80%) and included co-chairs of the Massachusetts General Brigham Trauma-Informed Care Initiative, the medical director of a community violence intervention program, and a professional TIC coach. Additional characteristics for these panelists can be found in online supplementary data Table 4. During the discussions, panelists and steering committee members collaborated to revise the list of proposed competencies to several broad core competencies with associated specific sub-competencies. Additionally, multiple proposed competencies were consolidated to avoid redundancies. Key themes of the virtual panelist discussions included: (1) the need for consolidation, removal of redundancies, and clarification of content areas; and (2) clarifying expectations for resident roles, knowledge base, and systems level thinking. These discussions were utilized by the steering committee to revise proposed competencies and decrease the number of proposed core competencies between rounds 1 and 2 (Table 2).
Modified Delphi Round 2
The second questionnaire had a total of 19 proposed core competencies with associated sub-competencies. Of the original 16 panelists, 13 (81%) responded to the questionnaire between April 2024 and May 2024. Mean scores for each of the proposed competencies ranged from 4.36 to 5 on a 5-point Likert scale (online supplementary data Table 5). No core competencies fell below the consensus threshold. The panelists suggested one new competency. Key themes from round 2 included: (1) ensuring core competencies and sub-competencies are sufficiently generalizable and demonstrable; (2) narrowing definitions and content to be more specific to EM and TIC; and (3) separating teaching point and educational content from core competencies. Based on panelist comments, additional edits to competency and sub-competency wording and reorganization of competencies within content areas were made by the steering committee.
Modified Delphi Round 3
The third questionnaire had a total of 16 proposed core competencies with associated sub-competencies. Twelve panelists (75%) responded to the questionnaire between June 2024 and July 2024. Mean scores for each proposed competency ranged from 4.5 to 5 (online supplementary data Table 6). No core competencies fell below the consensus threshold. No new competencies were suggested by panelists. We did not identify any new themes during analysis of free-text comments, although separating teaching point and educational content from core competencies was re-identified during round 3. There were no statistically significant differences in mean score between core competencies between rounds 2 and 3 (Table 3).
Following round 3, the steering committee utilized the comments suggested to make minor modifications to the sub-competencies, specifically around word choice and use of footnotes. The only sub-competency to change meaningfully was under the competency, “Demonstrates knowledge of effect of trauma on oneself” within Practice-Based Learning. The proposed sub-competency was: “Demonstrates an openness to reflect on the effects of secondary trauma on oneself and other team members.” One of the panelists was concerned that this required a self-disclosure on the part of the resident and that this level of vulnerability in an educational and professional setting was inappropriate. Upon further review and discussion by the steering committee, this sub-competency was changed to: “Utilizes a structural debrief to process effects of secondary trauma on oneself and other team members.” Panelists had final approval of this change. The final consensus core competencies were distributed to panelists by email and was approved by all panelists (Table 4).
Discussion
In this study, we utilized a modified Delphi process to develop core competencies in universal precautions of TIC for EM residents. We identified 16 TIC competencies that represent core knowledge and observable behaviors within the 6 ACGME content areas. The identified competencies provide guidance for educators for assessment of residents on critical knowledge, attitudes, and skills related to trauma and TIC. To our knowledge, this is the first attempt to couple competency-based medical education and TIC in postgraduate medical education.
Many of the core competencies and sub-competencies apply, with minimal adjustment, across multiple medical specialties. Other specialties, such as pediatrics, where TIC has been incorporated into ACGME requirements,7 could benefit from the increased detail and definition within these competencies. For example, the pediatric ACGME requires, “effective communication strategies with patients and patients’ families consistent with trauma-informed care,” however what qualifies as effective communication through TIC and how this should be assessed is unclear. Yet the competencies defined within the content areas of Professionalism and Interpersonal and Communication Skills directly relate to this requirement. We therefore encourage the use of our initial competencies as a foundation for future development of similar competencies in other specialties.
The primary limitation of this study is the panel selection. We relied on a snowball method to recruit participants who met the criteria for panel expertise. Additionally, although the proposed competencies evolved considerably through the modified Delphi process, no proposed competencies fell below the threshold initially set for inclusion. This may represent a measurement bias, as the Likert scale we selected may not have been sensitive enough to detect differences in importance for inclusion. Furthermore, although the steering committee attempted to incorporate as many panelist suggestions as possible, unconscious biases by steering committee members may have impacted the revisions. Finally, our initial set of competencies was developed from a search of the literature, but we did not perform a formal systematic or scoping review, instead relying heavily on the recent systematic review by Brown et al.10 It is possible that important concepts for competencies were not identified in our search or suggested by panelists.
Future work should emphasize validating these core competencies, as well as defining which competencies and sub-competencies correspond to different educational milestones. Furthermore, these core competencies should be used to develop measurable, evaluable behaviors within both clinical and simulation environments. Prior literature suggests that simulations may improve knowledge, competency, and possibly confidence in TIC following the training in medical students and graduate nurses.11,12 Finally, changes in clinical practice and patient-centered outcomes as a result of TIC training remain critically understudied. In a recent systematic review, only 2 studies described clinical practice change and patient-centered outcomes.10 We anticipate that these clearly defined competencies, mapped to ACGME content areas, will provide greater structure for education, clearer metrics for performance evaluation, and ultimately, will provide the framework to evaluate patient centered outcomes in future studies.
Conclusions
We achieved consensus on 16 core competencies for EM physicians in training.
Flow Diagram of Panel Participation and Core Competency Development
Author Notes
