Many individuals experience a traumatic event during childhood, such as abuse, neglect, parental substance abuse, mental illness, divorce, or incarceration of parent(s) (Centers for Disease Control and Prevention, 2022). These are called adverse childhood experiences (ACEs) and are traumatic experiences that increase the risk of changes in brain development of children; Conn et al., 2018; Felitti et al., 1998). The neurological changes increase the risk of adverse mental, physical, and behavioral outcomes that affect individuals in childhood and across the lifespan (Conn et al., 2018; Felitti et al., 1998; Kerker et al., 2016; Quizhpi et al., 2019), requiring tertiary care (Kerker et al., 2016).
Increased risk of chronic conditions, such as depression and anxiety, heart disease, diabetes, substance abuse, and suicide, are examples of negative health outcomes associated with ACEs (Conn et al., 2018; Felitti et al., 1998). Although no direct correlation has been shown between specific ACEs and poor health outcomes, a strong relationship has been shown between the exposure of stress related to ACEs and behavioral risk factors for chronic conditions and even premature death (Felitti et al., 1998). Despite the critical nature of ACEs , few primary providers screen patients; therefore, intervention is not received. Using a review of the current literature, this project created, implemented, and evaluated an education program to address the gap in knowledge attributed to this lack of screening.
Early detection of traumatic events through routine screening allows appropriate interventions to prevent neurological changes and the risk of subsequent chronic conditions (Centers for Disease Control and Prevention, 2022). Although ACEs have an overwhelming impact on the health care system and individual health outcomes, few pediatric providers report being familiar with the ACEs screening tool and even fewer complete screening during routine examinations (Kerker et al., 2016; Quizhpi et al., 2019). Most providers feel childhood trauma leaves lasting effects on children and adults and report a lack of knowledge and competence as the primary reason for not screening patients (Quizhpi et al., 2019). Without ACE screenings, potential neurological changes go undetected, preventative services underused, and long-term effects continue to occur (Kerker et al., 2016).
As a potential change agent for increasing frequency of ACE screenings, pediatric providers who see ACE screening and intervention as an integral part of client care are more likely to ask about ACEs during routine well-checks (Conn et al., 2018; Kerker et al., 2016). Family nurse practitioners (FNPs) can initiate this change through implementation of routine screenings and subsequent risk reduction and health promotion interventions (Pardee et al., 2017). Most FNPs practice in primary care and see patients across the lifespan (American Association of Nurse Practitioners, n.d.). Thus, it is critical to educate FNP students on ACEs and the overall health effects on children to promote knowledge, skills, and attitudes (KSAs) toward screening. Providing education to FNP students on ACEs, screening techniques, and communication with parents may establish a foundation for increased awareness of ACEs and likelihood to routinely screen children.
The ACE Pyramid is the framework used as the foundation for research completed on ACEs and childhood trauma (Centers for Disease Control and Prevention, 2021). The base of this pyramid includes historical trauma and negative social conditions, which create the foundation leading to adverse effects. Once this foundation has been set, neurological development may be disrupted, which is associated with impaired development, increased rates of risky behaviors, and chronic illness, disabilities, and even premature death. At conception, the fetus has not yet had direct exposure to any traumatic events, although it may still be vulnerable to effects from stress responses of the mother. The foundation of fetal, infant, and childhood trauma then increases the risk of neurological changes and adverse effects throughout life until the time of death, as seen at the top of this pyramid (Centers for Disease Control and Prevention, 2021).
The question guiding this quality improvement project was, “Will FNP students who have received formal training on the effects of ACEs report increased preparedness to screen children during routine exams?”. The purpose was to determine whether FNP student education on ACEs would increase preparedness to screen pediatric clients for ACEs during routine appointments. The outcomes for this project were (1) increase FNP student knowledge of ACEs, (2) enhance FNP student understanding of the skill of screening for ACEs, and (3) improve attitudes toward ACEs and willingness to screen.
Participants included students at two colleges who were enrolled in the FNP track of a Doctor of Nursing Practice (DNP) program. One campus was a private nursing and health care college in an urban midwest city, and the other was a private Seventh-day Adventist college in the rural southeast. Exclusion criteria include anyone not enrolled in the FNP track within the DNP program. Participation was blinded, and no information was gathered on sex, gender, age, or current placement within the program's curriculum. The project was determined by an independent local institutional review board not to need approval.
The intervention involved a stand-alone, asynchronous educational presentation using the Microsoft PowerPoint platform. (See Appendix A, Supplemental Digital Content, https://links.lww.com/JAANP/A174 for presentation outline). It was written and presented by the corresponding author using the voiceover feature and reviewed for content appropriateness and teaching effectiveness by both authors. Content included an overview of ACEs to provide knowledge, interventions to provide information on screening and intervention skills, the impact of ACEs to improve the participants' willingness to screen patients in practice (attitudes). The presentation lasted approximately 45 minutes and was based on evidence and research with appropriate supporting resources provided for participants. Interactive links to preeducation and posteducation surveys were included in the slide presentation (See Appendix B, Supplemental Digital Content, https://links.lww.com/JAANP/A175).
A link to the presentation was sent to potential participants who met inclusion criteria through the schools' email system and was open for participation for two weeks. The potential participants for each implementation site were ultimately determined by leadership at each site. Leadership representatives for each site were given the inclusion criteria and then decided how to best disseminate the presentation for their respective institution. One school sent the link to all enrolled DNP FNP students (approximately 100 students), and the other chose to only include students currently enrolled in a specific pediatric course (19 students). At both institutions, the presentation and surveys were available for a specified 2-week period, chosen independently for and by each school.
The online preeducation and posteducation survey was used to assess KSAs toward ACE screening, and links to these were embedded in the presentation at appropriate points. These surveys were written by the corresponding author and reviewed by both authors based on the content presented. There were four questions to assess both knowledge and skills, which consisted of a combination of true/false and multiple-choice questions. Two questions to assess attitudes and likelihood to screen future patients were asked and based on 5-point Likert scales. The same questions were asked for both the preeducation and posteducation surveys. Data were compared from the pre and post surveys to evaluate the impact of the education. Because the presurvey, education, and postsurvey were completed in this order and in a single time frame, the intervention education was the only variable.
Study of the intervention
The preeducation and posteducation surveys were created to assess participants' KSAs about ACEs. As a quality-improvement project, Quality and Safety Education for Nurses concepts were used as a foundation for the education and surveys (Cronenwett et al., 2007). Knowledge questions in the surveys assessed the learners' understanding of the effects of ACEs; skill questions assessed the knowledge of screening tools available and recommendations of how and when to screen patients, and attitude questions assessed the learners' beliefs of the importance of routinely screening for ACEs. Because the 10-question survey was created specifically for this project, there are no reliability and validity measures for this survey.
Measures and analysis
Quantitative data were collected and analyzed from the online survey links. Knowledge and skill questions were graded for correct answers, and attitude questions were assessed using a 5-point Likert scale. A paired t-test was used to compare accuracy of answers to knowledge and skills questions pre and post surveys. The improvement in attitudes or likelihood to screen were also compared using paired t-tests for analysis. The results were designed to be compared for both statistical and clinical significance.
Because ACEs are nondiscriminatory and occur in such prevalence, the probability of some participants having experienced one or more ACEs was high. An agreement for participation was provided and discussed on the first slide of the presentation. It stated that each potential participant had a choice to participate and could choose to leave the project at any time. Links or phone numbers to respective school counseling services were provided at the end of the presentation for participants to contact if needed. Individual or organizational participants were voluntary. An email introducing the project included the agreement to participate. Data were anonymous and reported as aggregate data with no identifying information. Collaborative Institutional Training Initiative education was completed. There were no conflicts of interest in this study.
Paired t tests compared the mean score of the preeducation surveys to the mean score of the posteducation surveys for each of the three sections—knowledge, skill, and attitude—for each of the implementation sites and for the combined results of both sites. Posteducation survey mean scores higher than the preeducation survey mean scores shows positive impact. Improvement was noted in each category for both individual sites and the combined aggregate but did not reach the level of statistical significance in every category. The aggregate data were collected from two sites with a total of 33 responses on the preeducation survey (n = 33) and 30 responses on the posteducation survey (n = 30). Statistical significance was also seen in the skills section for both implementation sites and in the knowledge questions for one of the sites.
In the knowledge section, each participant answered four questions. With 33 participants in the preeducation survey, a total of 132 questions were answered, and with 30 participants in the posteducation survey, 120 questions were answered. Because the information collected was anonymous, the three participants who did not complete both surveys could not be excluded from the study. No statistical significance was found (t(2) = −2.09, p > .05) in knowledge. The mean score of the preeducation knowledge questions (M = 0.70, variance = 0.07) was not significantly different from the mean score of the posteducation knowledge questions (M = 0.88, variance = 0.01). However, an improvement in correctly answered questions was seen with 92 of 132 questions answered correctly in the preeducation survey and 105 of 120 questions answered correctly in the posteducation survey for an increase of 18% (Figure 1).
Results from each individual site had similar clinical findings, with implementation site 1 showing statistical significance (t(2) = −3.08, p < .05). Site one had 19 preeducation survey participants (n = 19) and 16 posteducation survey participants (n = 16). The mean score of the preeducation skills questions for site 1 (M = 0.66, variance = 0.05) was significantly lower than the mean score of the posteducation skills questions for this site (M = 0.84, variance = 0.01), which showed an 18% increase from the preeducation to posteducation survey. Site two data (n = 14) did not show statistical significance (t(2) = −1.32, p > .05). The mean score of the preeducation questions (M = 0.75, variance = 0.13) was not statistically significant from the mean score of the posteducation knowledge questions (M = 0.91, variance = 0.02) but still showed clinical improvement of 16% accuracy in the questions answered (Figure 2).
In the skills section, each participant answered four questions. The number of participants and questions answered were the same as the knowledge section. The t tests comparing the mean scores of the preeducation and posteducation survey results for the skills questions found a significant difference between the mean scores of the two groups (t(2) = −2.82, p < .05). The mean score of the preeducation knowledge questions was significantly lower (M = 0.96, variance = 0.04) than the mean score of the posteducation knowledge questions for the combined implementation sites (M = 0.96, variance = 0.004). Clinical improvement was seen with 99 of 132 questions answered correctly in the preeducation survey and 115 of 120 questions answered correctly in the posteducation survey for an increase of 21% (Figures 1 and 3). Clinical and statistical significance were the same for each individual site.
The attitude section was composed of two questions based on a 5-point Likert scale with one being “not important” or “not likely” and five being “very important” or “very likely.” Responses were averaged for comparison. The first attitude question assessed the participants' perception of the importance of screening for ACEs. The second question assessed the participants' likelihood to screen patients in practice. The number of participants were consistent with knowledge and skills sections. For the combined site attitude questions, no significant difference was found (t(2) = −1.28, p > .05). The mean score of the preeducation attitude questions (M = 4.41, variance = 0.33) was not significantly different from the mean score of the posteducation attitude questions (M = 4.78, variance = 0.03) based on a 5-point Likert scale (Figure 4). Clinical and statistical significance were the same for each individual site.
Although there was no significant increase in the first attitude question, there was a significant difference found (t(2) = 12.71, p < .05) for the likelihood of participants to screen patients in practice. For this question, the mean of the scores from the preeducation survey (M = 4, variance = 0) was significantly different from the mean of the scores from the posteducation results (M = 4.67, variance = 5.56) based on the 5-point Likert scale (Figure 5).
Summary and interpretation
Although not all the pretest and posttest differences were statistically significant, there was improvement in all questions. This study demonstrated overall increase in KSAs after education related to the importance of early screening and intervention of ACES. The improvement in the survey results and the reported primary reason for the current lack of screening being a lack of knowledge and competence (Kerker et al., 2016) support the need for ACE education in DNP programs. Before the education provided in this project for FNP students, 70% showed accurate knowledge of ACEs and the effects, and 75% showed knowledge of how to accurately screen pediatric patients, which correlated with four out of five stating a willingness to screen patients in practice. After the education was provided, participant scores showed an 18% increase in knowledge, a 20% increase in skills, and a 0.67 improvement on a 5-point Likert scale for likelihood to screen patients in practice. Because the pediatric providers who are not familiar with ACEs do not screen due to the lack of knowledge and skills, education for providers would improve the frequency of screening. Although this study did not directly measure actual frequency of screening, it did measure and show an increase in likelihood to screen their future patients.
This study, however, is subject to limitations. Limitations in this study include the sample size (presurvey n = 33; post-survey n = 30), the inability to identify and compare answers from presurvey to postsurvey for individual participants, and the potential for variability related to where participating students were in the DNP curriculum. The small sample size for this project makes it difficult to identify significant data results. There were also three participants who completed the presurvey but not the postsurvey. However, because all results were deidentified, it was not possible to exclude these individuals from the data sample. The variability of previous knowledge related to this information based on the point in the DNP program for each student and individual clinical experiences offer room for limitations in the significance of these data.
In conclusion, this project used current knowledge available to address the gap in knowledge and skills to routinely screen patients in primary care for ACEs through an education presentation for FNP students. Increasing knowledge of and skills to screen patients among FNP students also increased the reported willingness to screen patients in primary care settings. The lack of statistical significance in knowledge and attitudes toward ACE screenings may be attributed to the small sample size, inclusion of incomplete participating results, and variance of the placement of the education based on current curriculum. However, the improvements in all areas and the significance of early screening and intervention for ACEs do show the need for continued research on the incorporation of education on ACEs in DNP programs. Continued research to address limitations and determine the most effective forms of pedagogy used and placement of the education within existing curriculum would be critical to increasing the frequency of ACE screening in primary care settings by FNPs. This increase in screening will allow for early intervention and overall improved outcomes in pediatric patients across their lifespan.
Acknowledgments:The authors acknowledge Tara Whitmire, DNP, APRN-NP, CHFN, Holly Gadd, PhD, APRN, FNP-BC, and Mitzie D. Perry MSN, FNP-BC, for their support and contributions to this project and manuscript.
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