Nurse Education in Practice 72 (2023) 103752

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Nurse Education in Practice

journal homepage: www.elsevier.com/locate/issn/14715953

In-service education in trauma care for intensive care unit nurses: An

exploratory multiple case study
Maha Almarhabi a, b, *, 1, Jocelyn Cornish a, Mary Raleigh a, Julia Philippou a
a
Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, James Clerk Maxwell Building, 57 Waterloo Road, London SE1 8WA,
UK
b
Faculty of Nursing, King Abdulaziz University, Jeddah, Saudi Arabia

A R T I C L E I N F O A B S T R A C T

Keywords: Aim: This study explores the perceptions of intensive care units (ICUs) nurses with different educational back­
Intensive care unit grounds regarding their abilities in trauma care and the in-service education they receive to support it.
Trauma care Background: The advanced care of patients with traumatic injuries in ICU environments requires skilled and
Injury
knowledgeable nurses, who need continuing and in-service education to provide the best care. Therefore, it is
Nursing
Continuing education
essential to understand the competencies and educational support these nurses may need in the ICUs to ensure
In-service education safe and effective care delivery.
Design: An exploratory multiple case study design was used, comprising three hospitals located in two different
regions of Saudi Arabia.
Methods: The study was conducted between October 2021 and March 2022. A total of forty ICU clinical staff,
twelve managers, nine leaders and seven clinical educators participated in semi-structured interviews, which
were complemented by a review of available documents on the trauma care in-service education syllabi, com­
petencies and protocols. Interview data were analysed according to the Framework analysis approach, while
documents were reviewed using qualitative content analysis.
Findings: The data analysis revealed two interrelated categories relevant to trauma care: (i) care practice and (ii)
education practice. The trauma care practice category highlighted the limited competencies and education in
trauma care, as well as the perceived challenges and educational needs of nurses. The education practice cate­
gory described the staff learning behaviours, supervision practices and in-service education systems in the
participants’ settings.
Conclusions: The study concludes that there is a lack of trauma care education at the examined sites. It suggests
the need for further research to develop a theoretical foundation for trauma care education that can meet ICU
nurses’ educational needs while this being feasible to implement in the specific ICU context and practice.

1. Introduction
Traumatic injuries are among the top ten leading causes of death and
disability, (World Health Organisation [WHO], 2018a) resulting in more
than 5.8 million deaths annually (approximately 10% of global mor­
tality) (Franklin and Sleet, 2018). The WHO (2018b) reports that deaths
from injuries are predicted to rise by 28% in 2030, with a similar esti­
mate for 2060, due largely to increased economic growth and traffic
injuries (Adeloye et al., 2016). However, the extent of such injuries
varies between countries (Alanazi et al., 2015). In Saudi Arabia (SA),
trauma injuries are the main cause of death in adults under forty, with
Road Traffic Collisions (RTCs) being the primary cause of
trauma-related deaths and causing over 19% of deaths in Saudi Ministry
of Health (MoH) hospitals (Abolfotouh et al., 2018; Alharbi et al., 2020).
Recent changes, including accelerated socioeconomic development,
population growth and changes in driving legislation and culture (e.g.,
women being allowed to drive from 2018) have led to an increase in
trauma-related fatalities, from 17.4 to 28 per 100,000 capita, compared
with 10 per 100,000 capita in the USA and 5 in the UK (Alharbi et al.,
2020).

* Corresponding author at: Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, James Clerk Maxwell Building, 57
Waterloo Road, London SE1 8WA, UK.
E-mail address: maha.almarhabi@kcl.ac.uk (M. Almarhabi).
1
ORCID: 0000-0002-8109-9545

https://doi.org/10.1016/j.nepr.2023.103752
Received 17 May 2023; Received in revised form 25 July 2023; Accepted 17 August 2023
Available online 20 August 2023
1471-5953/© 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
M. Almarhabi et al.
The number of trauma-related fatalities in the hospital is also sub­
stantial, presenting a challenge for healthcare professionals involved in
trauma management. In particular, trauma patients who have survived
emergency resuscitation and have been admitted to the Intensive Care
Unit (ICU) have unique clinical conditions, such as multiple injuries
resulting in haemodynamic instability, recurrent bleeding, missed or
incomplete injury identification and a risk of systematic and secondary
injuries following admission (Mondello et al., 2014; Prin and Li, 2016;
Chiang et al., 2021). These high-risk factors can prolong the patients’
ICU stay and therefore make their management complex, requiring close
observation and an advanced and specialised level of care. Care de­
ficiencies during in-hospital critical care management increase trauma
patient mortality and worsen patient outcomes (Mondello et al., 2014;
Prin and Li, 2016). The WHO (2023) considers that at least two million
worldwide fatalities could be prevented by improvements in
trauma-care services, where highly competent healthcare professionals
make an impact on patient mortality. Competent in-hospital manage­
ment during the critical care phase in the ICU significantly correlates
with survival and outcomes for these patients (Tang et al., 2020;
Chowdhury et al., 2022).
1.1. Background
ICU nurses are the mainstay of the ICU Multidisciplinary Team
(MDT), working closely with trauma patients and making a significant
contribution to care safety (Limbu et al., 2019) through early identifi­
cation of missed injuries and complications, coordinating effective
teamwork and thus safeguarding patient outcomes (Jennings and
Mitchell, 2017; Nogueira and Domingues, 2018). To deliver safe and
effective care, ICU nurses require a specialised set of clinical compe­
tencies beyond those of core critical care (Osman et al., 2019). A review
of literature suggests the need to clarify these clinical specialised com­
petencies for ICU nurses (Egerod et al., 2021). Furthermore, the Critical
Care Network National Nurse Leads in the UK have proposed specific
adult critical care services and skill sets for specialised areas, such as
trauma, burns and neurology (Critical Care Network, 2015; Deacon
et al., 2017) to ensure the required skills and maintain clarity and
consistency in daily practice (Good and Kirkwood, 2017; DeGrande
et al., 2018).
In the trauma field, the National Major Trauma Nursing Group in the
UK (National Major Trauma Nursing Group (NMTNG), 2017) has
established a trauma competency framework for ICU nurses, in addition
to fundamental critical care competencies drawn from a nationwide
study (Whiting and Cole, 2016). Furthermore, the World Federation of
Critical Care Nurses (World Federation of Critical Care Nurses
[WFCCN], 2020) has recommended that ICU professional and educa­
tional bodies recognise the importance of specialised preparation and
training for nurses in advanced critical care domains, which is not
covered by basic nursing programmes.
In light of this need for specialised skills, several studies have
emphasised that caring for trauma ICU patients involves complex de­
mands that concern ICU nurses. Such demands arise from the severity of
injuries and associated complications, including physiological insta­
bility, ongoing resuscitation through Damage Control Surgery (DCS) and
the presence of the lethal triad consisting of hypothermia, acidosis and
coagulopathy (Boström et al., 2012; Crossan and Cole, 2013; Carter and
Cumming, 2014; Sandström et al., 2016; Whiting and Cole, 2016; Jen­
nings and Mitchell, 2017; Oyesanya et al., 2018). The literature un­
derscores that trauma patients benefit from specialised care from
competent staff and thus supports the need for enhanced education and
recognition of appropriate skills and knowledge in this dynamic and
high-tech environment (Silva and Whalen, 2014; Heydari et al., 2019).
However, there remains limited research in this area, particularly in the
Saudi context, considering the characteristics of international nurse
recruitment and diverse nursing educational preparation (Alsadaan
et al., 2021). Additionally, there is an absence of studies that delineate
2
Nurse Education in Practice 72 (2023) 103752
the existing context and practice status of trauma ICU nursing and the
support provided through in-service education programmes. Therefore,
this study seeks to address this gap by exploring the current status of
care practices and educational support for ICU nurses in trauma care in
SA, aiming to contribute to the future advancement of trauma care and
education in this critical care setting.
1.2. Aim
This study explores the perceptions of ICU nurses with different
educational backgrounds regarding their abilities in trauma care and the
in-service education they receive to support it in the context of Saudi
ICUs.
2. Methods
2.1. Design
An exploratory multiple-case study design was used to examine the
phenomenon of nurses’ trauma care and education within their bounded
system and context. This approach captured multiple perspectives and
generated an in-depth understanding of this phenomenon (Cope, 2015).
Further, the purposive sampling approach was used, as particular in­
dividuals provided relevant perspectives to meet the study’s aim. The
consolidated criteria for reporting qualitative research (COREQ)
informed the reporting of this study (Tong et al., 2007).
2.2. Context description
This study comprised three sites of major Ministry of Health (MoH)
hospitals, located in Jeddah (Western region) and Riyadh (Central re­
gion). These provinces are the largest in SA and report high rates of
injuries, mainly from RTCs, of which Riyadh demonstrates the highest
(21.4%) with the Western region following with 15.2% (Alslamah et al.,
2021). The selected hospitals serve as referral centres for trauma cases
from nearby provinces and were included to maximise sample variance
and produce a broad pattern of data reflecting the nurses’ experiences
(Yin, 2009). The hospitals under the MoH follow a unified framework
that covers staff training, patient safety measures and quality assurance
processes. This helps to ensure that patients receive the best possible
healthcare, although the way each hospital implements the framework
may vary depending on their leadership approaches and practices. The
inclusion of three sites was to draw data from a setting recognised as the
first and largest designated Level 1 Trauma Centre belonging to the
MoH, as well as two other settings designed with their own in­
frastructures and resources to receive trauma cases. Therefore, the data
were drawn to allow a comprehensive investigation of the phenomenon
from the perspective of nurses who may have varying levels of access to
different resources. Table 1 further describes the three sites.
2.3. Population and sample
This study involved national and expatriate ICU nursing staff in
various roles: Clinical Staff (CS), Clinical Educators (CE), managers
(units’ head nurse (HN), assistant head nurse (AHN) and unit manager)
and nursing leaders, e.g., Charge Nurses (CN). Expatriate nurses are
recruited from overseas to work in SA on a contractual basis. The study
used purposive sampling to draw on a wide range of perspectives con­
cerning trauma ICU care and education to ensure the representativeness
of settings and richness of data, (Maxwell, 2012) consistent with
case-study sampling, which employs types of cases or/and individuals to
gain a deeper understanding (Ishak and AbuBakar, 2014). Participants
were invited to take part via hospitals’ nursing administrations and
research centres, which were requested to distribute the study’s infor­
mation and rationale for the research using printed posters and emails. It
was the responsibility of interested participants to contact the
M. Almarhabi et al. Nurse Education in Practice 72 (2023) 103752

Table 1 Table 2
Description of the three sites context. A contextual description of the nursing workforce, the competency framework
Setting Description
and the in-service education system.
Contextual element Description
Site 1 One of the largest MoH hospitals, located in Riyadh, has recently been
designated a Level − 1 Trauma Centre in cooperation with the Australian The nature of the nursing The nursing workforce in Saudi Arabia (SA) is
Alfred Hospital. It has several specialised centres and units. ICUs bed workforce multicultural, with diverse nationality, ethnic,
capacity has increased to 200 beds, across six units: General ICU for educational and experiential backgrounds.
medical and surgical cases; Cardiac, Isolation, Neuro, Burns and Trauma Approximately 60% of the workforce is made up of
ICU. The total ICU nursing workforce at the time of data collection was 513 expatriates (e.g., Indians, Filipinos and Malaysians).
(73 Saudi and 440 expatriates). The infrastructure of this trauma centre Expatriates have different educational backgrounds
was different from the other two sites and data were collected from and skill sets in nursing developed through the
different ICUs that received trauma cases. This was to ensure the relevance nursing education system in their country of origin.
of the sample and approach nurses who handled different trauma cases. When in SA, they are given access to training
The data were collected mainly from the Trauma ICU, which had a total programmes that aim to improve their
staff of 100 (13 Saudis and 87 expatriates) at the time of data collection, understanding of the SA culture and address
then from the neuro ICU, which receives head injury patients and some language barriers, enabling them to provide care
participants were also recruited from the general ICU, which receives that is culturally sensitive and patient-centred.
trauma patients after they have completed their treatment plans. Staff
work 12-hour shifts. Competency framework used The nursing competency framework in the Saudi
in MoH hospitals MoH is applied to all nursing departments
Site 2 A large tertiary hospital, located in the north of Jeddah city. The hospital employees across the country. This framework
has different adult ICU specialties. The data were collected from the main consists of four competencies:
ICU, which has a bed capacity of 26 and receives trauma cases mainly from -Mandatory competencies include core nursing
RTCs and falls. The total ICU staff at the time of data collection was 110 (40 activities (e.g., infection control, emergency
Saudis and 70 expatriates). Staff work 12-hour shifts. response and environmental safety).
-General competencies include common nursing
Site 3 The largest MoH tertiary hospital is located in central Jeddah city. It is a
activities that are applicable to nurses working in
key reference hospital and has a wide range of specialised centres. There
different settings (e.g., patient assessment,
are different adult ICUs (General, Burn, Cardiac, Isolation). The data were
medication administration and formulation of a
gathered from a general ICU with a bed capacity of 36, which receives
nursing care plan).
trauma cases caused by RTCs and falls. During the time of data collection,
-Unit-specific competencies include a variety of
the total staff was 155 (60 Saudis and 95 expatriates). Staff work 8-hour
competencies tailored to each nursing specialty (e.
shifts.
g., medical, surgical, paediatric, obstetrics, ICUs,
mental health and so on). ICU-specific competencies
include the domains specific to ICU care, such as
researcher. Data saturation was achieved after interviews with forty advanced airway management (e.g., invasive/non-
clinical staff, twelve managers, nine leaders and seven educators, at invasive ventilation), haemodynamic management
which point no further themes were generated through the data analysis (e.g., cardiac, renal and neuro systems) and the
process. A preliminary description of the context relevant to the nursing administration of vasoactive substances.
-Annual competencies include the assessment of
workforce, the competency framework in use and the in-service edu­
mandatory competencies as well as selected
cation in Saudi MoH hospitals (Saudi Commission for Health Specialties competencies from general and unit-specific groups
[SCFHS], 2014; Aljohani, 2020; Alsadaan et al., 2021) is provided in to ensure the process of assessing, maintaining and
Table 2. monitoring nurses’ knowledge and skills, improving
competent performance to provide quality and safe
care for each specialty.
2.4. Data collection
Workforce’s in-service The Saudi Commission for Health Specialties
education system (SCFHS) is the national body regulating
The data were collected from October 2021 to March 2022 by means
professionals’ registration and approving all
of face-to-face, semi-structured interviews, along with a review of healthcare practitioners’ continuing professional
available trauma ICU in-service and continuing education documents development (CPD) activities for competency
and requirements (syllabi, competencies and/or care protocols). Access development to provide quality care in accordance
with national standards. The key requirements for
to these documents was obtained with permission following a formal
the workforce’s in-service education system
request from the nursing education and quality departments, while the include:
units’ senior staff facilitated electronic access to them. The interview -CPD activities and mandatory education topics (e.
topic guide was informed by an in-service education model for nursing g., patient safety) that require specific numbers of
staff (Chaghari et al., 2017) identified from a theoretical review of hours per year to maintain their licensure. These
educational activities include courses, workshops
learning theories used in nursing education practice, as well as the
and conferences.
relevant literature (Almarhabi et al., 2021). Interview questions were -Preceptorship, mentoring and supervision
piloted with five members from the categories of ICU staff, educators, programmes for new staff/ trainees are necessary to
managers and leaders, who commented on clarity and relevance and no ensure their smooth integration into the healthcare
workforce. These programmes provide guidance,
revision to the interview guide was required. The pilot interviews were
support and supervision from experienced
not included in the final dataset. The primary researcher (MA) is a professionals.
qualified nurse with prior experience in the ICU and has received pro­ -Evaluation and documentation involve periodic
fessional training in qualitative research methods. All interviews were assessments of staff competencies and performance
conducted by the primary researcher. There was no pre-established to evaluate the effectiveness of the in-service
education programmes, as well as maintaining
relationship between the interviewer and participants prior to study
accurate records of the nurses’ certifications or
commencement. Interviews took place in a confidential space in the participation in in-service education activities and
ICUs and lasted from thirty to sixty minutes. They were conducted in their competence evaluations.
English, digitally recorded and transcribed verbatim by a professional
transcription service. Participant demographic data were collected prior
to the interviews by questionnaire. In accordance with qualitative
studies, the primary researcher kept notes about context and
self-reflection on the potential impact of her previous experience on the

3
M. Almarhabi et al. Nurse Education in Practice 72 (2023) 103752

research to minimise the influence of researcher bias and enhance the
study’s credibility (Lincoln and Guba, 1985).
2.5. Data analysis
The study employed Framework analysis, (Ritchie et al., 2014)
alongside within-case and cross-case comparison (Gale et al., 2013).
Steps of analysis included: a) reading, re-reading and noting down initial
thoughts; b) coding of the first transcripts sets independently by the
researcher (MA) and the team (JP, JC and MR), primarily using a table
matrix, where cross-case comparisons were maintained and then using
N-Vivo (QSR International Ltd.) for a comparison view and data man­
agement; c) an analytic framework, agreed by all members, was then
applied by indexing to subsequent transcripts; d) data were charted into
the framework, summarised using quotes from each transcript; and e)
interpretation of the data, allowing for theoretical concepts to be
interrogated and connections/differences made between sites. The
identification of anomalies was considered throughout the analysis and
the framework was constantly refined. The primary researcher reviewed
seven trauma care in-service education syllabi, as well as twelve com­
petencies and nineteen protocols relevant to trauma cases in ICUs,
collected from all sites, dated within the three years of data collection,
which concluded in March 2022 (supplementary file 1). Qualitative
content analysis was used in reviewing these documents (Elo and
Kyngäs, 2008). By becoming familiar with and thoroughly examining
the documents, an overall grasp of the covered areas in trauma care and
education was obtained. Then, a table matrix was used to systematically
review and extract data from the documents for further understanding
and interpretation. The generated themes were organised into categories
and reported to describe the key findings resulting from the reviewed
documents. The data from interviews were further compared with and
validated by a review of these education syllabi, ICU competencies and
protocols pertinent to trauma care. Throughout the data collection and
analysis, the study team had regular discussions to ensure process ac­
curacy and data saturation.
2.6. Ethical considerations
3. Findings
3.1. Demographic data
Table 3 presents the demographic characteristics of the ICU nurses.
3.2. Interview findings
Two distinct but interrelated categories – ‘care practice’ and ‘edu­
cation practice’ – arose from the dataset describing the context relevant
to trauma ICU care and the education of nurses from diverse back­
grounds. Nurses’ perceptions regarding their trauma care competencies
and education support were found to be influenced by both practice and
education characteristics in the context, as illustrated by the generated
themes, supported by quotations and evidence from reviewing available
documents from all sites. A summary of the reviewed documents is
found in supplementary file 1.
3.3. Care practice
Nurses’ perceptions of their trauma care competence were shaped
largely by the unit’s core competencies, protocols and available edu­
cation opportunities, described as follows.
3.3.1. Limited trauma-specialist-competencies
Nurses, across the sites, identified competencies related to advanced
organ support that apply to all critical care cases in ICUs, including
trauma care, such as massive blood/fluid transfusions, inotropes,
External Ventricular Drainage (EVD) and Intracranial Pressure (ICP).
However, the unit-specific nurse competencies assessment does not
cover trauma-related procedures such as ICP. Nurses also identified a
lack of specialised competencies for other types of injuries and care
protocols, although participants from Site 1 stated that they use Trau­
matic Brain Injury (TBI) protocols, in Trauma and Neuro ICUs to care for
TBI patients. The review of competency documents further revealed no
specialised set of competencies/protocols beyond those specified by
nurses:

Ethical approval was granted from King’s College London Research “There are no specific competencies regarding trauma- but some com­
Ethics Panel (LRS-20/21–20933) and the Institutional Review Board petencies can be relevant and applicable, like massive blood transfusion,
from Saudi Health Affairs Directorates in two regions (H-02-J-002 and central venous catheter, as most of our patients need inotropes, also chest
H-01-R-053). Participants were provided with information sheets tube and drains care because some will have haemothorax and pneu­
explaining the purpose of the study and assured of the confidentiality of mothorax…” [Site 2, CS-5]
their information. Participants’ informed consents were obtained before
the interviews began. Table 3
Participants’ demographics.
2.7. Study rigour Characteristics N %

Position Clinical nurse 40 58.82

The trustworthiness criteria of Lincoln and Guba (Lincoln and Guba, Nurse educator 7 10.29
1985) were used to ensure rigour. Credibility was ensured through the Nurse manager 12 17.64
recording of the interviews, listening to audios, the transcription of each Nurse leaders 9 13.23

interview and constantly reading the data to ensure that it reflected the Participants Site 1 30 44.12
participants’ views. The generated codes and categories from the initial (by site) Site 2 19 27.94
Site 3 19 27.94
transcripts analysis were read independently by the researchers to
validate the analytical framework. Dependability was ensured through Gender Male 11 16.18
Female 57 83.82
transparent documentation of the study process and justifications of
methodological and analytical choices. An audit trail was kept Age (years) < 24 3 4.41
throughout to record the research process and all decisions made. 25–29 15 22.06
30 + 50 73.52
Transferability was enhanced through a detailed description of the
studied phenomena, context, methodologies and findings. Confirm­ Nationality Saudi 24 35.29
Expatriates 44 64.71
ability was achieved through the description of the themes and the use of
verbatim quotations in the presentation of the findings. Qualification Diploma degree 6 8.82
Bachelor’s degree 50 73.53
Master’s degree 12 17.65

Experience in ICU (years) 1–5 30 44.12

6+ 38 55.88

4
M. Almarhabi et al.
3.3.2. Limited education/training
ICU nurses reported that trauma training courses were available but
were less frequent and tended to be aimed at all hospital staff, with an
emphasis on triaging and initial trauma care with an MDT approach for
Emergency Department (ED) staff and the medical team. Despite the
increasing number of trauma patients moved to the ICU after emergency
care, ICU nurses were given fewer chances to attend training after ED
staff were prioritised:
“We have an annual trauma course…. but is mainly for ED and
mandatory for ED nurses, as these are the groups targeted, followed by
other hospital departments. This leaves limited spaces for ICU nurses.
These courses are not only for nurses but also physicians, specialists
and….” [ Site 2, CE-2]
This was supported by the review of in-service education syllabi,
showing topics such as early resuscitation and haemorrhage control,
relevant to ED management, while others focused on non-nursing care.
Nurses emphasised their need for specialist trauma courses relevant to
the ICU context since they viewed trauma care in the ICU as distinct
from ED:
“In ED, they do the initial care, but here patients stay for longer and are
given different procedures and also different from other critical patients.”
[Site 3, CS-7]
Moreover, the participants stated that trauma courses tended to
focus mainly on TBIs/neurological care. The documents review
confirmed some coverage of neurological care and related procedures
across all sites. In Site 1, nurses admitted high numbers of neuro cases
and an available course on ‘Neurocritical Trauma’, which was also
identified through the document review. However, analysis revealed
limited topics related to other trauma types:
“We have neuro-critical care courses and different ICUs receiving trauma
cases, so ICU nurses are encouraged to attend and do cross-training in
Neuro ICU and trauma ICU.” [Site 1, CN-3]
3.3.3. Trauma ICU care challenges
Perceived challenges for the ICU nurses in managing trauma care
were categorised into physical, psychological and work environment
issues. Physical care issues explain why trauma patients receive different
ICU treatment and their care complexities, such as assessment and
detecting change in intubated, sedated TBI patients, along with sec­
ondary injuries and invisible deteriorations. Trauma patients’ vulnera­
bility, need for several procedures and close monitoring at the same time
presented additional challenges, such as ventilated, agitated trauma
patients with a risk of self-extubation; unanticipated hemodynamic
changes; mobility restrictions (e.g., patients with tractions); the need for
repeated Pan CT (computerised tomography) scans to detect hidden
injuries; the care of patients requiring multiple operations and ensuring
patient stability before surgery or radiological scans:
“We receive more trauma cases and we face care difficulties, like RTC
patients, who are very agitated – the parameters change suddenly, they
are at risk of self-extubation, so need more observation….” [Site 1, CS-7]
Participants mentioned challenges with specific groups, including
young patients with serious injuries, RTCs and comorbidities, e.g.,
COVID-19 or tuberculosis. They considered trauma care more dynamic
compared with other cases with specific diagnoses, owing to the need for
multi-specialists, intensivists and multiple procedures:
“To me, COVID-19 is less challenging than trauma patients. Trauma is
very toxic because sometimes it requires massive blood transfusions; we
will be running here and there. Caring for polytrauma is very difficult,
especially for young patients.” [Site 2, CS-10]
“The issues with trauma patients; they are active cases managed by ICU
physicians and other specialists.” [Site 1, HN]
5
Nurse Education in Practice 72 (2023) 103752
Psychological difficulties experienced by the nurses managing
trauma cases included stress and fear, particularly among new staff. This
includes when they are assigned to patients with severe trauma who
need multiple procedures and are at risk of rapid change, where inad­
equate staffing poses risks for adequate observation of colleagues with
less experience, which may have an impact on patient safety:
“As a new staff member, I was assigned to a patient with multiple injuries.
I was afraid and stressed. I see the same experience with our new staff
now; despite the expert trauma team, we need to be aware of this care.”
[Site 3, CN-1]
Nurses cited work challenges as including staff shortages, nurse-
patient ratios, overtime, additional duties and failure to consider their
qualities/expertise during patient assignments. They were concerned
that simultaneously learning and caring for trauma patients could
compromise safety:
“…other factors make the work more difficult; even if I’m experienced, I
cannot manage; we are handling two critical patients, patient capacity is
increasing, also manpower shortages, they are calling us for overtime and
extra shifts.” [Site 1, CS-14]
3.3.4. Perceived educational needs of ICU nursing staff
The study highlighted various educational needs across settings and
from all nurse categories, as summarised in Table 4. Nurses asserted the
need for education support due to the high level of trauma cases ad­
missions and the importance of developing independent decision skills
as part of the team. They stressed the need for new staff to acquire the
high level of expertise required for advanced trauma care alongside
psychological/emotional support:
“We need to know about head injuries to prevent unintentional harm to
the patient… ICU focused assessment and neurological care are difficult
identifiable parameters when patients experience changes.” [Site 2, CS-
10]
Expatriate nurses cited the advanced haemodynamic interventions,
such as extracorporeal membrane oxygenation (ECMO), available in
Saudi clinical settings and the need to learn about them for their
competence development, experience advancement and future
employment:
"Based on my experience in my home country, we do not have that many
resources and advanced machines like here, provided by the Ministry. I
see for the first time the ECMO machine and it is good I got the opportunity
to work here and learn using such machines.” [Site 1, CS-4]
3.4. Education practice
Education practice represents the context of clinical learning,
including nurses’ learning behaviours, supervision and the in-service
education system.
3.4.1. Clinical learning behaviours
The nurses’ learning behaviours for obtaining knowledge or making
safe decisions are discussed below.
3.4.1.1. Dependency on more experienced staff. Most ICU nurses tended
to depend, for knowledge and support, on more experienced staff (e.g.
HN, AHN, CNs, CE and expert colleagues) and on ICU physicians and
specialists for immediate decision-making. The participants agreed that
exposure to trauma care is beneficial, encouraging them to learn from
their superiors and benefit from more experienced ED and operation
room (OR) staff during patient transfers to the ICU:
M. Almarhabi et al.
Table 4
Education/training needs reported across the sites.
Knowledge/skills needs
Patient assessment
Neurological trauma
Chest trauma
Fracture and musculoskeletal
Other trauma types/cause
Blood/IV fluid and
medications
Mobility and positioning
Sedation and analgesia
Haemodynamic status
Surgical trauma care
Trauma-related care and
research
Examples on the identified needs
Head to toe (focused) assessment on ICU
admission.
ICU survey and recognition of secondary injuries.
Head injuries and traumatic brain injury (TBI)
protocol.
Spinal cord injuries (e.g., spinal and neurologic
shock).
Neurosurgery/neurological cases management.
Glasgow coma scale (GCS) and pupils reaction
assessment.
External ventricular drain (EVD) and intracranial
pressure (ICP) management (e.g., signs and
symptoms of increased ICP).
Haemothorax and pneumothorax management.
Intercostal tube (ICT) drains and care.
Mechanical ventilation and oxygenation.
Multiple fracture management.
Skin and skeletal tractions (e.g., neck and leg
traction).
Mobility restrictions/ proper positioning.
Managing road traffic collisions(RTCs) cases.
ICU management of polytrauma cases (e.g.,
abdominal trauma, ortho, pelvis, maxillofacial,
eyes and ears).
Blunt and penetrating injuries.
Fast and massive blood transfusion.
Fluid replacement therapy and fluid restriction.
Hyperosmolar treatment, crystalloids and colloids,
IV fluid (e.g., mannitol use).
Medications used in trauma cases (e.g.,
pregabalin).
Cervical collar and immobilisation.
Turning and positioning of trauma cases (e.g., C-
spine/cervical fracture).
Turning/positioning and logrolling protocol.
Sedation and muscle relaxation in trauma.
Trauma patients with self-extubating risks (e.g.,
distress, agitated patient).
Pain management.
ABC management (airway management more
commonly reported).
Blood pressure/ mean arterial pressure monitoring
and management.
Haemorrhagic shock.
Trauma patient on extracorporeal membrane
oxygenation (ECMO).
Post damage control surgery (DCS) care.
Post-op care in open abdominal surgeries (e.g.,
exploratory laparotomy).
Management of patients requiring multiple
operations.
Wound care/dressing change in major trauma.
Trauma care protocols/indications and handling
different procedures.
Trauma care continuity in ICU.
Managing secondary trauma insults (e.g., post-
trauma diabetes insipidus (DI); coagulopathy).
Measuring intra-abdominal pressure.
Trauma patient care safety (further injuries and
systematic complications, e.g., aspiration
pneumonia and head elevation according to case
situation).
Managing vulnerable trauma patients (e.g.,
pregnant patients, patients with comorbidities).
Trauma updates and research.
Brain-dead patients and organ donation.
Training of new nurses to a high level of experience
in trauma care.
6
Nurse Education in Practice 72 (2023) 103752
Table 4 (continued )
Knowledge/skills needs Examples on the identified needs
Nurses’ role within the multi- Communicating and cooperating with the
disciplinary team multidisciplinary team (MDT).
Understand the specialists’ orders.
Skills of clinical decision-making in ICU trauma
care (knowing how and why).
Psychological support Psychological preparation to lessen feelings of
panic in dealing with complex and severely injured
cases.
“We have our expert colleagues, our charge nurses, head nurses and
educators; if I face something complex, or I am still not confident, I will
directly ask my superiors…” [Site 3, CS-5]
“When we receive ICP patient, sometimes we approach operation room
(OR) physician and nurses and learn from them.” [Site 2, CS-11]
3.4.1.2. ICU teamwork and interprofessional team. Nurses valued
collaboration with other nurses, diverse interprofessional teamwork,
mutual communication and feedback to support collaborative learning
and prevent repetition of practice failures. Nurses recognised the ben­
efits of assigning nurses based on patient acuity, nurses’ qualities/
seniority and placing new nurses with experienced professionals. They
also consulted intensivists and trauma specialists as part of the team (e.
g., neurosurgeons, orthopaedic specialists):
“We are working as a team. Even though I’m more experienced, I need to
discuss with my colleagues, even new nurses, because every day we learn
new things and our experiences are different; the teamwork here is helpful
for exchanging knowledge….” [Site 3, CS-4]
As confirmed by HNs, CNs and CEs, nurses found that their knowl­
edge and decision-making priorities improved through practice, because
allocating trauma patients by severity and staff seniority ensured that all
nurses gained varied experience and learned from their colleagues:
“I and the CN ensure that all staff have exposure to trauma patients,
assigned according to their experience and patient acuity, because we
want all to develop these skills.” [Site 3, HN]
3.4.1.3. Resource access and use. Nurses recognised the use of online,
physical and human resources as a part of their searching skills and
learning efforts when they needed knowledge or skills about certain care
components. The most frequently reported resources were Google
searches, nursing books, procedural manuals and YouTube videos, along
with medical libraries, the ‘MoH deep knowledge’ website and evidence-
based research. They also identified the benefits of reviewing hospitals
polices/protocols:
“We can access additional knowledge through online like Medscape,
watch YouTube…we can read books, procedures manuals here and refer
to polices/ procedures.” [Site 3, CS-8]
3.4.2. Clinical supervision
This theme outlines supervision practice, performance monitoring
and support for nurses’ learning concerning trauma care.
3.4.2.1. Promoting nurses’ competence and development. Most nurses
reported receiving regular formal and informal supervision and assis­
tance from their superiors. Daily bedside rounds allowed them to
address knowledge gaps, such as new or updated protocols/policies.
Nurses emphasised the benefits of a supportive atmosphere for effective
supervision and learning:
M. Almarhabi et al.
“We have clinical support from educators, charge nurses and head nurses,
e.g., during daily rounds, we check to overcome any difficulties”. [Site 1-
AHN]
HNs, CNs and CEs also received staff development from other de­
partments, such as education, quality and infection control, monitoring
for compliance with protocols and bundles and awareness of policies.
CNs stressed staff monitoring during shifts for identification of poor
practice, performance gaps and development needs. All participants
stated that the annual competency evaluation is part of their formal
supervision and performance monitoring:
“Staff are monitored every day by us and also by nursing quality and
infection control, for their compliance with care bundles and documen­
tation and we will make an action plan to solve any problem…” [Site 1-
HN]
Managers acknowledged the significance of supervision for pro­
moting nurses’ psychological well-being and enabling them to express
their challenges:
“Part of the supervision is giving nurses a lot of support; I’m very sensitive
to their needs, including new staff unable to adjust to the environment.
This helps maintain good mental health” [Site 2-HN]
3.4.2.2. New staff preceptorship/mentoring. Participants indicated that
there was a preceptorship programme, where new nurses were super­
vised by more experienced staff, using ICU-specific competency exami­
nations to assess their ability to manage patients independently. All
nurses (Saudi and expatriates) attended a general nursing orientation
that covered a range of basic ICU competencies but was not specific
enough for trauma specialisation. Saudi graduates and staff without ICU
experience could follow a critical care training programme:
“Both non-Saudi and Saudi newcomers have a preceptorship, with an
orientation programme and specific-unit competencies. Right now, we
have a nine-month critical care programme from the directorate, focusing
on Saudi graduates and staff without ICU backgrounds…” [Site 2, CE-1]
Some new staff felt that, despite being monitored and offered feed­
back, they were not fully proficient in trauma care, particularly due to
the short training period during the COVID-19 pandemic:
“We were trained quickly because they needed more staff in ICUs during
COVID-19. We are not competent in all trauma care aspects, as these
have decreased due to curfews, but staff with more experience still teach
us.” [Site 1, CS-15]
3.4.3. In-service education system
The following subthemes outline the context’s in-service education
system and practice.
3.4.3.1. Needs assessments. The staff highlighted the requirement to
undertake in-service education for their professional development,
annual evaluation and contract renewal:
“Our in-service education is part of our required evaluation and profes­
sional development to renew our contract.” [Site 2, CS-2]
Across the three sites, nurses’ in-service education plan was based on
a Learning Needs Assessment (LNA) survey and subjects of interest. They
were given a yearly or quarterly plan, determined by the ICU patients’
care needs and relevant procedures:
“Every year we do a needs assessment, which reflects nurses’ education
needs and prepare a plan and topics that need to be repeated more
frequently”. [Site 1, CE-3]
CEs stated that in-service education plans were created using LNA,
feedback from staff assessments, mandatory ICU lectures and any lack of
7
Nurse Education in Practice 72 (2023) 103752
bedside skills identified during observations:
“The unit CE, HN and AHN discuss issues and come up with a list of
needs, in addition to nurses’ need assessments. Also, I check the staff
competence assessments to determine the most prevalent shortcomings as
well as any skills gaps noted during our daily observations, then we will
combine these topics for an in-service plan.” [Site 3, CE-2]
3.4.3.2. In-service education delivery. Data revealed that in-service
topics were regularly presented by groups of nationals and expatriates,
such as lectures or discussions of rare diagnoses/cases. Nurses consid­
ered these beneficial for communication, feedback and accurate infor­
mation, constructively reinforcing learning and preparing for
competency assessments:
“The educators assign the topics to us…we prepare and share them with
our colleagues; this is a chance to discuss, get feedback and improve our
information and competency evaluation…”[Site 1, CS-13]
Other in-service opportunities were offered by medical teams related
to ICU trauma patient care, such as ICP management and knowledge
transfer during handovers:
“…in our ICU, if there is any unfamiliar case, like intracranial pressure
(ICP)/external ventricular drain (EVD), the ICU physicians arrange
group teaching sessions…also while endorsing the next duty colleagues,
we will teach them the procedures”. [Site 1, CN-3]
Managers and educators indicated equity and equality of education,
while both locally and internationally educated nurses tended to share
expertise:
“There is no difference in the education between Saudi and non-Saudi
nurses, they have the same competencies and training here and learn
from each other.” [Site 2, unit manager]
The participants noted the following shortcomings which had an
impact on their current in-service education.
3.4.3.3. In-service education shortcomings. Shortcomings were mostly
related to course topics, content and delivery methods. Educators also
commented on the failure to address real trauma care practice and ex­
pectations, such as how to logroll neurologically injured patients. Nurses
also stressed the significance of training from educators with strong
trauma-related knowledge and abilities, using practical and interactive
learning methods:
“The problem is the topics; the content and the way of teaching are
sometimes boring. I usually ask about issues I face in our trauma practice-
and this is one of the reasons why I left my old institution.” [Site 2, CS-5]
International staff also raised the issue of the language barrier.:
“We learn from the lectures and discussions with physicians. We some­
times cannot follow these, as they speak in Arabic”. [Site 3, CS-5]
Nurses raised the issue of insufficient educators to ensure proper skill
practice due to their other commitments outside the unit, while man­
agers and educators also cited flaws with hospital education resources
and equipment:
“Usually, the clinical educators guide the staff, but there are insufficient
educators available all the time at the bedside….” [Site 1, CN-1]
The nurses compared pre-pandemic and post-pandemic in-service
education, noting the need for trauma education after a long time of
COVID-19 care:
“During COVID, all our courses focused on COVID-19 management. Now
that we are receiving more trauma cases, we need training to update our
knowledge.” [Site 3, CS-12]
M. Almarhabi et al.
4. Discussion
This paper has reported the current perceived inadequacy of trauma-
specialised competencies and training in ICUs across three Saudi tertiary
institutions, which was verified by reviewing the available documents
and was supported by the identified care challenges and educational
needs. Many commonalities in trauma care challenges and educational
needs were identified across all sites and from Saudis and expatriates,
which thereby indicated that the results could reflect trauma care and
education practices in Saudi ICUs. This could also be true in wider
contexts and may rely on the organisation’s structure, policies and
workforce competencies (Endacott et al., 2022). Despite this, certain
site-specific differences were also observed. Site 1, for instance, had care
and education policies for ICU nursing that were limited to traumatic
brain injuries (TBIs), while nurses in Sites 2 and 3 exhibited greater
emphasis on the need for enhanced neurotrauma training, reflecting the
high incidence of TBI cases (Abolfotouh et al., 2018). Differences were
also evident between the roles of the ICU nurses, with more experienced
and senior nurses expressing a stronger desire for advanced training and
acquiring a high level of expertise. There was also emphasis on the need
for less experienced staff to handle complex trauma cases. Furthermore,
expatriate nurses highlighted the need for advanced machine training to
be available in Saudi healthcare settings and for more context-specific
training that considers language or cultural nuances in the Saudi prac­
tice context. These findings reinforce the necessity for trauma ICU
competency-based education, as outlined in the broader literature
(Boström et al., 2012; Crossan and Cole, 2013; Carter and Cumming,
2014; Sandström et al., 2016; Whiting and Cole, 2016; Oyesanya et al.,
2018). Findings further emphasised the significance of advanced care
training in ICUs that extends beyond the core ICU skill set to encompass
specialised critical care competency development, which concurs with
the recommendations by the professional bodies of the UK’s National
Major Trauma Nursing Group and the World Federation of Critical Care
Nurses (NMTNG, 2017; WFCCN, 2020).
Nurses emphasised the specific difficulties of neurotrauma cases,
with TBI patients showing neurophysiological care needs due to lengthy
ICU stay caused by multiple injuries and loss of consciousness and the
risk of systemic complications, such as muscular atrophy (Alimo­
hammadi et al., 2018). Previous studies have outlined the potential to
miss critical changes indicative of a decline, due to inadequate re­
sources, staff and nurse-patient ratios; the findings of the current study
concurred with this and the issue affected the nurses’ ability to master
their skills and provide better care (Varghese et al., 2017; Oyesanya
et al., 2018). Both the interviews and documentary evidence raised the
importance of implementing training in neurological care, due to the
current absence of any focus on ICU, particularly in Sites 2 and 3.
Participants from all sites cited some challenges and educational
needs (as shown in Table 4), which align closely with the trauma care
concerns discussed in the literature. Crossan and Cole’s study explored
the need for ICU nurses to acquire specialist knowledge and skills to
manage spinal-column fractures after initial Damage Control Surgery
(DCS) and in lethal triad conditions (Crossan and Cole, 2013). This was
supported by a study identifying the complexity associated with the care
of trauma patients with open abdominal wounds after Damage Control
Laparotomy and the need for specific abilities concerning patients’
ventilation protocol, intra-abdominal pressure monitoring, surgical
VAC/suction care and complications, such as sepsis (Chipu et al., 2017).
This study also found a lack of care protocols and equipment having an
impact on nurses’ competence to deliver better care and suggested
adding trauma to the critical care curriculum, including the need to
develop evidence-based protocols and post-registration ICU trauma
education programmes.
Moreover, Sandström et al.’s study found that ICU nurses need to be
“prepared for the unexpected” (p 61), due to unpredictable changes to
patients’ condition, (Sandström et al., 2016) supported by further
research highlighting the unique characteristics of trauma patients’
8
Nurse Education in Practice 72 (2023) 103752
physiological symptoms (e.g. bleeding, severely injured body parts)
(Alzghoul, 2014). All studies recommend that ICU nurses require spe­
cialised training to address patients’ needs in a timely manner and
overcome the psychological challenges inherent in handling complex
trauma cases as described in the current study. This is consistent with
studies reporting nurses’ potential for secondary posttraumatic stress
due to trauma care complexity and unpredictable outcomes (Alzghoul,
2014; Missouridou, 2017).
The accounts of ICU nurses and the review of documents retrieved
from all sites showed inconsistencies in terms of compliance with the
broader recommendations for trauma care competencies and education
in ICUs. The in-service education framework, for instance, promotes
regular competency and needs assessments. The findings, nonetheless,
revealed a disparity between the stated policies and their actual
implementation, as exemplified by the limited relevance of the exam­
ined educational syllabi and ICU competencies concerning trauma care
in ICU environments. Hence, the study’s findings reinforce the impor­
tance of prioritising the fulfilment of trauma education requirements
specifically tailored for ICU nurses in Saudi Arabia. It provides a foun­
dation for future discussions among key clinical stakeholders regarding
policies and practices related to in-service education requirements and
support in trauma ICU nursing. Establishing a robust in-service educa­
tion programme for the ICU nursing workforce will enhance their
trauma care competence, have a positive impact on patient care out­
comes and reduce ICU mortality (Prin and Li, 2016; Chowdhury et al.,
2022).
Further, the findings reported in this paper highlighted nurses’
clinical learning behaviours, including their dependence on experts,
with senior managerial and educational staff tending to foster inter­
personal relationships (Gary et al., 2021). A study conducted in a trauma
centre ICU found that supportive relationships were vital for helping
nurses to adapt to this complex environment, alongside collegial support
to promote skills, such as a collaborative ICU nursing team and inter­
professional communication to enable interactive learning (Stewart,
2021). Further, nurses use quickly accessible evidence-based resources
to address knowledge gaps, retrieve up-to-date information and verify
their care decisions (Kleinpell et al., 2011; Ahmad et al., 2018).
Furthermore, the nurses identified the supervision applied in practice
and perceived it as beneficial for improving their competence and
facilitating the transition of new staff. This is supported by evidence
describing effective supervision in fast-paced settings as creating a
supportive environment assisting supervisees to adhere to workplace
polices, enhancing person-centred practice, learning opportunities and
professional development (Snowdon et al., 2017; Rothwell et al., 2021).
In this study, superiors noted that supervision also considered staff
well-being to minimise burnout (Martin and Snowdon, 2020).
Moreover, various forms of learning needs assessment (LNA),
essential for designing in-service programmes tailored for the needs of
ICU nurses and patients, have been used (Khaleghi et al., 2020). This is
to highlight workforce strengths, weaknesses and priority areas,
resulting in effective in-service education programmes (Renning et al.,
2022). The studies also stressed the need to customise ICU training to the
practice reality, different patients’ care needs and requisite competence
(Santana-Padilla et al., 2019, 2022). Nurses, however, highlighted
shortcomings in their current in-service practice, such as inappropriate
content, which was reducing its effectiveness (Yektatalab et al., 2020).
These findings further underscore the necessity for clinical stakeholders
to engage in discussions regarding optimal educational approaches to
ensure the effectiveness of in-service education for trauma care. It
should be noted that the current research was conducted during the
global COVID-19 pandemic, when staff redeployment had an impact on
nurses’ training (San Juan et al., 2022). However, a review of docu­
mentation prior to the pandemic identified similar issues concerning
educational support.
M. Almarhabi et al.
4.1. Strengths and limitations
To the best of the researchers’ knowledge, this is the first qualitative
examination of trauma care and education for ICU nurses with diverse
educational backgrounds across countries. The inclusion of multiple
sites and diverse staff from different roles can expand study’s trans­
ferability to other contexts. However, the study has some limitations.
The educators’ sample was smaller than other groups, so more educa­
tionalist viewpoints would enhance the results. This was due to
departmental educators’ shortages. Moreover, while the researchers
endeavoured to retrieve all pertinent documents for review, some may
have been overlooked.
4.2. Implications for practice
This study suggests that it is essential to provide education to support
ICU nurses’ competence in trauma care. Educational interventions
function because of a solid theoretical grasp of how and why they work
effectively in a particular context (Almarhabi et al., 2021). The study
recommends consulting nurses in clinical, educational, management
and leadership roles to establish a contextually appropriate trauma ed­
ucation paradigm with the best practical components for nurses of
diverse educational backgrounds.
5. Conclusion
This study highlights the deficiencies and essential needs for tailored
trauma care competency-based education specifically designed for
trauma ICUs in Saudi Arabia. It has delineated trauma care and educa­
tion in the ICU context, identifying key aspects for future examination.
Understanding current practice, contexts and nurses’ needs improves
the effectiveness of education outcomes. The study therefore recom­
mends that further research should involve key informants to inform a
theoretical underpinning for educational intervention and additional
evaluation.
Funding sources
This research received no funding source.
CRediT authorship contribution statement
Maha Almarhabi: Project administration, Conceptualization,
Investigation, Methodology, Visualization, Writing - original draft,
Writing - review & editing. Jocelyn Cornish: Methodology, Writing –
review & editing, Supervision. Mary Raleigh: Methodology, Writing –
review & editing, Supervision. Julia Philippou: Conceptualization,
Methodology, Writing – review & editing, Supervision.
Declaration of Competing Interest
There is no known conflict of interest to declare.
Data Availability
The datasets used and analysed during the current study are avail­
able from the corresponding author on reasonable request.
Acknowledgements
The authors would like to thank the ICU nurses who worked at the
forefront during the pandemic for their hard work and dedication and
extend their thanks to the nurses who gave their time to participate in
this study. The corresponding author thanks the research supervision
team for their help and guidance throughout the research journey.
9
Nurse Education in Practice 72 (2023) 103752
Ethics approval statement
Ethical approvals were granted from all study sites affiliated with the
Saudi Ministry of Health.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.nepr.2023.103752.
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