Journal of Pediatric Nursing (2015) 30, 478–484

Nurses' Views and Current Practice of

Trauma-Informed Pediatric Nursing Care
Nancy Kassam-Adams PhD a,b,⁎, Susan Rzucidlo MSN, RN c ,
Marie Campbell RN, MSEd, MS, CPC, CPHQ a , Grace Good RN, BSN, MA a ,
Erin Bonifacio MSN, MBA, RN a , Kimberly Slouf MPH, CHES a ,
Stephanie Schneider MS, LPC d , Christine McKenna RN, MSN, CRNP e ,
Carol A. Hanson MSN, RN, CCRN f , Donna Grather MSN, NP-C g
a
Children's Hospital of Philadelphia
b
University of Pennsylvania
c
Penn State Hershey Children's Hospital
d
Nemours Child Health System
e
Children's Hospital of Pittsburgh
f
Geisinger Health System
g
Lehigh Valley Health Network

Received 17 July 2014; revised 16 October 2014; accepted 18 November 2014

Key words:
Grounded in research on posttraumatic stress etiology, “trauma-informed pediatric care” integrates
Psycho-social aspects
understanding of posttraumatic stress, and specific practices to reduce posttraumatic stress, into clinical
of care;
care of ill or injured children. Across five level I or II pediatric trauma centers, 232 nurses completed a
Nursing practice;
survey of knowledge, opinions, self-rated competence, and current practice with regard to trauma-
Trauma care
informed nursing care. Participants were knowledgeable and generally held favorable opinions about
trauma-informed care. The majority considered themselves moderately competent in a range of relevant
skills; their recent practice showed most variability with regard to teaching patients and parents how to
cope with upsetting experiences.
© 2015 Elsevier Inc. All rights reserved.

Background crashes (Kassam-Adams & Winston, 2004; Stallard, Salter,

WHILE THE VAST majority of injured children
experience full physical recovery post-injury, a significant
subset experience negative psychological sequelae (Gold,
Kant, & Kim, 2008; Kassam-Adams, Marsac, Hildenbrand,
& Winston, 2013). In a meta-analysis, the proportion of
injured children experiencing significant symptoms of
posttraumatic stress (PTS) was 19% (Kahana, Feeny,
Youngstrom, & Drotar, 2006). PTS symptoms have been
observed across injury mechanisms and types; e.g., traffic
⁎ Corresponding author: Nancy Kassam-Adams, PhD.
E-mail address: nlkaphd@mail.med.upenn.edu.
& Velleman, 2004), violent injury (Fein et al., 2002), burns
(Saxe, Stoddard, & Sheridan, 1998; Saxe et al., 2005), and
orthopedic injuries (Stancin et al., 2001). Research consis-
tently shows that objective injury severity does not predict
PTS symptoms, but that a child's subjective sense of life
threat is a risk factor for PTS symptom development. (See a
recent review for a comprehensive summary of the research
literature to date (Kassam-Adams et al., 2013)). PTS
symptoms include re-experiencing a psychologically trau-
matic event via intrusive thoughts or images, avoidance of
reminders of the event, cognitive and emotional changes, and
hyperarousal symptoms such as an exaggerated startle

http://dx.doi.org/10.1016/j.pedn.2014.11.008
0882-5963/© 2015 Elsevier Inc. All rights reserved.
Trauma-Informed Pediatric Nursing Care
response or hyper-vigilance for danger (American Psychiatric
Association, 2014). Acute stress disorder (ASD) refers to
significant PTS symptoms that occur within 1 month of a
traumatic event. Posttraumatic stress disorder (PTSD) is
diagnosed when significant symptoms persist for more than
1 month and create ongoing impairment in functioning. PTS
symptoms are prospectively associated with lower health-related
quality of life as much as two years post-injury (Holbrook et al.,
2005; Landolt, Buehlmann, Maag, & Schiestl, 2009; Landolt,
Vollrath, Gnehm, & Sennhauser, 2009; Zatzick et al., 2008).
The connection between PTS symptoms and poorer health and
functional outcomes highlights the importance of identifying
and treating these symptoms as part of comprehensive medical
and nursing care of the injured child.
The concept of “trauma-informed pediatric care” has been
defined as incorporating an understanding of posttraumatic
stress in each clinical encounter with ill or injured children
and their families (Kazak et al., 2006; Ko et al., 2008).1
Trauma-informed care shares many of the goals of
family-centered care (Committee on Hospital Care, 2003;
O'Malley, Brown, & Krug, 2008) and “atraumatic care”
(Hockenberry et al., 2013), but incorporates specific
practices to reduce the impact of potentially traumatic
medical events and treatment and the risk of ongoing PTS
symptoms following these events (Stuber, Schneider,
Kassam-Adams, Kazak, & Saxe, 2006). Research on the
etiology of PTS symptoms indicates a number of risk factors
in the peri-trauma period: the child's level of acute pain,
more severe emotional distress, separation from parents,
poor social support for the child, child coping strategies of
avoidance or social withdrawal, and parental emotional
distress (Kassam-Adams et al., 2013). Thus, grounded in this
empirical literature, key elements of trauma-informed
pediatric care include: 1) minimizing potentially traumatic
aspects of medical care and procedures; 2) providing the
child and family with basic support and information;
3) addressing immediate child distress (pain, fear, loss);
4) promoting emotional support (helping parents and
family help their child); 5) remembering family needs
(and identifying family strengths); 6) screening to determine
which children and families might need more support;
and 7) providing anticipatory guidance to those targeted
children about adaptive ways of coping. (See www.
healthcaretoolbox.org; Center for Pediatric Traumatic Stress,
2009). Systematic incorporation of these elements of
trauma-informed care in pediatric trauma care is far from
the norm. For example, a recent national survey of pediatric
and adult level I trauma centers in the US found that only
1
In this intersection between psychosocial and medical/nursing fields,
the terminology of “trauma” can be confusing. We thus use the terms
“traumatic event” and “posttraumatic stress” to refer to extremely stressful
experiences (including but not limited to injury) and to individuals'
psychological reactions to those experiences; “trauma” to refer to physical
trauma/injury, and “trauma-informed care” to refer to health care delivery
which takes psychological trauma into account.
479
20% routinely screened for PTS symptoms in injured
children or adolescents (Zatzick, Jurkovich, Wang, &
Rivara, 2011).
Most pediatric nurses and physicians are aware that
injuries from motor vehicle crashes, burns, interpersonal
violence, and other acute injuries requiring emergency or
inpatient care are extremely stressful for children and their
families. Many of the elements of trauma-informed pediatric
care are part of the clinical skill repertoire of experienced
pediatric nurses (Hockenberry et al., 2013). However,
training in providing trauma-informed care is not routinely
incorporated in nursing or medical education, and clinicians
vary in their knowledge and comfort about this area of
practice. A few studies have examined the range of
knowledge and practice in this area among primary care
pediatricians (Banh, Saxe, Mangione, & Horton, 2008;
Laraque et al., 2004) and emergency physicians and nurses
caring for children (Alisic, Conroy, Magyar, Babl, &
O’Donnell; Ward-Begnoche et al., 2006; Ziegler, Green-
wald, DeGuzman, & Simon, 2005). No prior study to our
knowledge has addressed the attitudes or experiences of
nurses in pediatric trauma units. The current study addresses
this gap in the literature by examining trauma nurses'
knowledge, opinions, self-rated competence, current prac-
tice, and perceived implementation barriers with regard to
trauma-informed nursing care for acutely injured children.
Methods
A survey of staff knowledge, practice, and attitudes with
regard to trauma-informed pediatric care was undertaken as
the initial step in a larger nurse-led project that explored
methods for implementing screening of pediatric trauma
patients and their parents by nurses in trauma centers. The
study was conducted at five of the six pediatric trauma
centers in a large mid-Atlantic state in the US, and was
approved by the IRB in each institution. Each of the five
study sites is designated as a level I or level II pediatric
trauma center. All nursing staff assigned to the acute care
trauma unit at each site were eligible to participate and were
given information sheets that described the research project
and invited their participation (there were no exclusion
criteria). In an IRB-approved protocol, nurses were informed
that their consent to participate was implied if they chose to
complete the trauma provider survey.
Measures
The trauma provider survey was developed to incorporate
key elements and practices involved in trauma-informed
pediatric care based on research findings regarding the
development of posttraumatic stress in children after poten-
tially traumatic medical events. Earlier versions of the survey
were employed and refined in several quality improvement
projects undertaken by members of our team. The survey
includes 38 items in five categories, assessing: 1) knowledge
about trauma-informed pediatric care (11 items); 2) opinions
about trauma-informed pediatric care (6 items); 3) self-rated
480
competence (10 items); 4) recent practice (7 items); and 5)
perceived barriers to implementation of trauma informed care
(4 items). Each item for knowledge, opinions, self-rated
competence, and perceived barriers is rated on a 3- or 4-point
Likert-type scale with anchors appropriate for the category,
e.g., potential barriers were rated as “not a barrier”, “somewhat
of a barrier”, or “significant barrier”. Internal consistency
(Cronbach's alpha) ranged from fair to excellent in the current
sample for item subsets assessing knowledge (.66), opinions
(.60), self-rated competence (.90), recent practice (.80) and
barriers (.69). For the current study, we created summary
scores for each of three item categories (knowledge,
opinions favorable to trauma-informed care, and self-rated
competence) by summing survey item ratings (1 to 3, or 1 to
4) for each of these sets of items, such that higher scores
indicate greater knowledge, more favorable opinions, and
greater self-rated competence.
Data Analysis
We examined demographic variables and survey items with
descriptive analyses, primarily proportion of respondents
endorsing survey items. In terms of the precision of our estimates,
an N of 232 allows a 95% confidence interval of +/−6.4%
for an observed proportion of 50%, or +/−3.9% for an observed
proportion of 90%. We derived summed scores of item
ratings for three item categories (knowledge, opinions, self-rated
competence). We then examined potential associations
among demographic variables and survey items or summary
scores, using chi square analyses or logistic regression. We
compared participants above vs. below the sample median for
years of pediatric nursing experience and years of acute care
trauma unit experience.
Results
All nurses working in the acute care trauma unit at each
site were invited to participate in the survey via information
sheets and announcements. Approximately 355 nurses across
all sites were eligible to participate in the survey; 238 nurses
(approximately 67% of those eligible) completed question-
naires. Demographic and descriptive information is not
available for nurses who did not choose to participate. Six
surveys were excluded from these analyses because data
were missing for more than 10% of survey items; thus the
current paper reports on a sample of 232 nurses. Nearly all
participants were female (97%). Participants were generally
young, with 42% under age 30. With regard to professional
training, 215 (93%) were RN's, 5 (2%) LPN's, and 6 (3%)
did not report their status. Participants varied widely in their
number of years of experience providing pediatric nursing
care (range b 1 year to 38 years; median = 6 years) and in
their number of years working on the acute care trauma unit
(range b 1 year to 36 years; median = 5 years).
Knowledge of Injury-Related Posttraumatic Stress
For most knowledge items, a very high percentage of
nurse participants responded correctly (Table 1). The two
N. Kassam-Adams et al.
items with the lowest proportion of correct responses
concerned the lack of association of objective injury/illness
severity with risk for PTS symptoms and the expectation
that most injured children and families will cope well.
About half of participants responded incorrectly to each of
these items.
Opinions About Trauma-Informed Care
Participants' rating of opinion items indicate that nearly
all hold opinions favorable to trauma-informed care, with
each item rated in a favorable direction by more than 90% of
participants (Table 2).
Self-Rated Competence in Providing Trauma-
Informed Pediatric Care
The majority of participants rated their skills in providing
trauma-informed pediatric care as “somewhat competent”
(Table 3). Almost universally, nurses reported feeling very or
somewhat competent in responding calmly and without
judgment to a child's or a family's strong emotional distress
(99%) and in engaging with families so that they feel
comfortable talking with the nurse (97%). Fewer than 1 in 5
nurses rated themselves as very competent eliciting details of
a traumatic event without re-traumatizing the child and
family, educating children and families about common PTS
reactions, or responding to a child's or a parent's questions
about whether a child would die.
Which Trauma-Informed Practices are Nurses
Already Implementing?
When asked about their own nursing practice with
pediatric patients in the past 6 months, the most frequently
endorsed trauma-informed practices were encouraging
parents of pediatric patients to get support for themselves
and teaching patients or parents about managing procedur-
e-related pain or anxiety (Table 4). About half of participants
reported asking children or parents directly about symptoms
of emotional distress. Fewer than half reported teaching
parents or children about specific ways to help manage
emotional aspects of medical experiences.
Potential Barriers to Implementing Trauma-Informed
Care
The survey also asked nurses to rate four factors which
might be barriers to integration of trauma-informed care
within pediatric trauma units: time constraints, worry about
further upsetting or re-traumatizing children and families, lack
of training, and confusing information/evidence on trauma-in-
formed practices. Very few nurses rated any of these factors as
a “significant” barrier, but each was rated as “somewhat of a
barrier” by more than half (55% to 66%) of the participants.
Exploring Associations Among Key Variables
Nurses' age, pediatric experience, and acute care trauma
unit experience were not associated with summed scores for
Trauma-Informed Pediatric Nursing Care 481

Table 1 Nurses' knowledge regarding injury-related posttraumatic stress and trauma-informed care (N = 232).
Knowledge items Correct responses
(N; %)
Prevalence, risk factors, and course
1. Almost everyone who is seriously injured or ill has at least one traumatic stress reaction in the immediate aftermath 201 (87%)
of the event.
2. It is inevitable that most children and families who experience a life-threatening illness or injury will go on to 157 (68%)
develop significant posttraumatic stress or PTSD. (Disagree)
3. Children who are more severely injured or ill generally have more serious traumatic stress reactions than those 119 (51%)
who are less severely injured or ill. (Disagree)
4. Children who, at some point during the traumatic event, believe that they might die are at greater risk for 193 (84%)
posttraumatic stress reactions.
5. Many children and families cope well on their own after experiencing serious illness or injury. 114 (49%)
6. The psychological effects of an injury or illness often last longer than the physical symptoms. 223 (96%)

Signs and symptoms

7. Children and families with significant posttraumatic stress reactions usually show obvious signs 160 (70%)
of distress. (Disagree)
8. I know the common signs and symptoms of traumatic stress in children and families. 175 (87%)
9. Some early traumatic stress reactions in children and families can be part of a healthy emotional recovery process. 222 (96%)

Effectiveness of screening and intervention

10. There are things that providers can do to help prevent longer-term posttraumatic stress in ill and injured children 227 (98%)
and families.
11. There are effective screening measures for assessing traumatic stress that providers can use in practice. 206 (89%)
Note. For items 2, 3, and 7, “disagree/strongly disagree” represents a correct response.

knowledge, self-rated competence, or favorable opinions
about trauma-informed care. Comparing participants below
the sample median to those at or above the median,
participants with 5 or more years' trauma unit experience
were more likely to report teaching parents what to say to a
child after a difficult, painful, or scary experience (46% vs.
28%; χ2 = 7.06, df = 1, p = .008), as were participants with
6 or more years' pediatric care experience (46% vs. 30%;
χ2 = 5.54, df = 1, p = .02). Those with 6 or more years'
pediatric experience were also more likely to report teaching
a parent or child specific ways to cope with upsetting
experiences (53% vs. 38%; χ2 = 4.52, df = 1, p = .03).
Length of pediatric or trauma unit experience was not
associated with reported use of any other trauma-informed
practice. In logistic regression analyses, knowledge and
favorable opinions of trauma-informed care were not
associated with use of any of the trauma-informed practices
included in the survey, but self-rated competence was
modestly associated with each of these practices, with odds
ratios ranging from 1.12 to 1.20. Based on these results, we
conducted an exploratory analysis of the independent
contribution of experience and self-rated competence to the
likelihood of reporting one specific practice (teaching parents
what to say after a difficult experience). In a multiple logistic

Table 2 Nurses' opinions regarding trauma-informed care (N = 232).

Statements about trauma-informed care Nurse ratings (N, %)
Strongly Agree Disagree Strongly
agree disagree
1. Providers should focus on medical care for hospitalized children as opposed to 6 (3%) 14 (6%) 137 (59%) 75 (32%)
children's mental health.*
2. The way that medical care is provided can be changed to make it less stressful for 60 (26%) 160 (69%) 8 (3%) 3 (1%)
children and families.
3. Providers can teach families how to cope with trauma. 59 (25%) 169 (73%) 2 (1%) 2 (1%)
4. Health care professionals should regularly assess for symptoms of traumatic stress. 81 (35%) 148 (64%) 1 (b 1%) 1 (b 1%)
5. It is necessary for providers to have mental health information about their pediatric 76 (33%) 143 (62%) 11 (5%) 2 (1%)
patients in order to provide appropriate medical care.
6. I have colleagues I can turn to for help with a child or family experiencing significant 75 (32%) 144 (62%) 8 (3%) 4 (2%)
traumatic stress.
Note. For item 1, “disagree/strongly disagree” represents an opinion favorable to trauma-informed care.
482 N. Kassam-Adams et al.

Table 3 Nurses' self-rated competence in specific aspects of trauma-informed care (N = 232).

Specific aspects of trauma-informed care Nurse ratings (N, %)
Very Somewhat Not
competent competent competent
1. Engaging with traumatized children/families so that they feel comfortable talking to you/ 97 (42%) 127 (55%) 7 (3%)
comforted by you
2. Responding calmly and without judgment to a child's or family's strong emotional distress 124 (53%) 106 (46%) 1 (b 1%)
3. Eliciting details of a traumatic event from a child or family without re-traumatizing them 38 (16%) 147 (63%) 45 (19%)
4. Educating children and families about common traumatic stress reactions and symptoms 43 (19%) 140 (60%) 47 (20%)
5. Avoiding or altering situations within the hospital that a child or family might experience 66 (28%) 149 (64%) 16 (7%)
as traumatic
6. Responding to a child's (or parent's) question about whether the child will die 37 (16%) 139 (60%) 50 (22%)
7. Assessing a child's or family's distress, emotional needs, and support systems soon after a 77 (33%) 131 (57%) 22 (10%)
traumatic event
8. Providing basic trauma-focused interventions (assessing symptoms, normalizing, providing 76 (33%) 130 (56%) 25 (11%)
anticipatory guidance, coping assistance)
9. Understanding how traumatic stress may present itself differently in younger children, older 64 (28%) 139 (60%) 26 (11%)
children, and teens
10. Understanding the scientific or empirical basis behind assessment and intervention for 36 (16%) 139 (60%) 55 (24%)
traumatic stress

regression analysis, pediatric experience and self-rated
competence were independently associated with reported
use of this practice.
Discussion
In this survey of nurses working in pediatric acute care
trauma units, participants were knowledgeable about many
aspects of trauma-informed care. They generally held
favorable opinions about integrating psychosocial conside-
rations and awareness of potential posttraumatic stress
responses into their practice. Most considered themselves
moderately competent in a range of skills and practices that
are elements of trauma-informed pediatric care. These
findings represent good news for efforts to expand awareness
and skills in trauma-informed pediatric nursing care of
hospitalized children. It appears that nurses are open to this
framework and already comfortable with many of the
component skills.
This study complements and extends two prior studies
which examined the views of emergency nurses regarding
aspects of trauma-informed care (Alisic et al.; Ward-Begnoche
et al., 2006). When emergency nurses were asked to implement
screening for risk of injury-related PTSD in pediatric patients,
they reported that screening was easy to implement although
their comfort with the process varied (Ward-Begnoche et al.,
2006). In a recent qualitative study, emergency nurses and
physicians in Australia described varied degrees of knowledge
about prevalence and risk for psychological sequelae of
pediatric injury, and a range of practices based on experience
and instinct rather than systematic training (Alisic et al.).
Nurses in the current study were at least as knowledgeable
about and comfortable with trauma-informed practice as
physicians in prior studies. For example, Ziegler et al. (2005)
found that 86% of emergency physicians incorrectly believed
injury severity to be a risk factor for PTS symptoms, compared
to about half of the nurses surveyed in this study, and Banh
et al. (2008) reported that 20% of primary care pediatricians
felt able to provide brief interventions to assist patients with
PTS reactions, compared to 33% of nurses in the current study
who felt very competent to do this.

Table 4 Nurses' report of specific trauma-informed practices performed in the past 6 months (N = 232).
Specific trauma-informed practice Have done this in past
6 months (N, %)
1. Ask the child questions to assess his/her symptoms of distress 127 (55%)
2. Ask parents questions to assess their symptoms of distress 116 (50%)
3. Teach parents what to say to their child after a difficult/painful/scary experience 90 (39%)
4. Provide information to parents about emotional or behavioral reactions that indicate that the child 91 (39%)
may need help
5. Teach parent or child specific ways to cope with upsetting experiences 107 (46%)
6. Teach parent or child ways to manage pain and anxiety during procedures 174 (75%)
7. Encourage parents to make use of their own social support system (family, friends, church, etc.) 185 (80%)
Trauma-Informed Pediatric Nursing Care
Despite an overall picture of self-rated competence with
elements of trauma-informed care, there are several areas in
which survey results suggest room for improvement. Given
the experiences which their patients bring to this episode of
care, it would be valuable for nurses in pediatric acute care
trauma units to have training that increases their sense of
competence in eliciting details of a traumatic event without
re-traumatizing a child or parent, educating patients and
families about common PTS reactions, and responding to
questions about whether a child may die (Kazak et al., 2006).
Nurses' reports of their recent practice showed the most
variability with regard to teaching parents and children
specific skills. Teaching patients or parents how to manage
procedural pain and related anxiety was frequently endorsed
(three quarters of those surveyed), perhaps because this
represents a well-established aspect of pediatric nursing
practice (Fein et al., 2012; Koller & Goldman, 2012). On the
other hand, teaching patients or parents how to cope and
what to say with regard to upsetting experiences, and which
emotional and behavioral reactions might follow such
experiences, was endorsed by fewer than half of those
surveyed. It may be that these latter practices are not
incorporated as systematically in training or ongoing
professional education for nurses.
Strengths of the current study include its high response
rate and inclusion of nurses with a range of levels of
experience in multiple level I and level II pediatric trauma
units across rural, suburban, and urban areas. Because this
study surveyed nurses working in acute care trauma units in
one US state, these results might not be generalizable to
nurses in other types of settings or other regions. Future
research should examine these issues in a larger national
sample of nurses across a variety of settings.
The results of this survey suggest that efforts to improve
trauma-informed nursing care should highlight specific skills
related to helping patients and their parents manage
emotional responses to difficult medical experiences. As
one example, the Medical Trauma Working Group of the
National Child Traumatic Stress Network created the “DEF
Protocol”, which helps health care providers address distress,
emotional support, and family needs in a systematic manner
(Stuber et al., 2006). This protocol is based in the research
evidence and best practice recommendations for professional
responses to children in the early aftermath of traumatic
events (National Institute for Clinical Excellence, 2005).
Information and tools for trauma-informed pediatric care,
including training based on the DEF protocol, and
downloadable patient education materials in English and
Spanish, are available online at www.HealthCareToolbox.
org (Center for Pediatric Traumatic Stress, 2009).
The study also has implications for nursing education and
for continuing professional education for nurses. In addition
to ongoing training regarding managing and supporting
effective parent presence during pediatric procedures, it may
be useful to systematically include content and skills training
for nurses' role in patient/parent teaching regarding the
483
emotional and behavioral reactions that may follow difficult
medical experiences and specific techniques to promote
adaptive coping.
Acknowledgments
This work was funded in part by grants U79SM058139 and
U79SSM061255 from the Substance Abuse and Mental Health
Services Administration, and by a grant from the American
Trauma Society - Pennsylvania Division. The authors gratefully
acknowledge the contributions of the dedicated nurses
and other staff at each institution, without whom this
project would not have been possible, including Margaret
Chorazak, Nonette Clemens, Christopher Coppola, Kelly
Eckrich, Kimberly Fields, Marsha Haack, Brandi Peachey,
Mary Jo Pedicino, and Bonnie Pugliese.
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