Original article
The experience of paediatric residents participating in a child protection rotation: A qualitative study Laura Lewington MD1, Anita Unruh PhD MSW OTC RegNS2, Amy Ornstein MDCM FRCPC FAAP1 L Lewington, A Unruh, A Ornstein. The experience of paediatric residents participating in a child protection rotation: A qualitative study. Paediatr Child Health 2013;18(3):e10-e14.
L’expérience de résidents en pédiatrie qui ont participé à une rotation en protection de l’enfance : une étude qualitative
BACkgrOUnd: Practitioners working in the field of child maltreat-
HisTOriQUe : Les praticiens qui exercent dans le domaine de la maltraitance des enfants sont vulnérables aux traumatismes transmis par personne interposée. Les résidents en pédiatrie canadiens sont peu exposés à la maltraitance d’enfants pendant leur formation. OBjeCTiF : Explorer comment des résidents en pédiatrie ont vécu leur rotation obligatoire au sein d’une équipe de protection de l’enfance en milieu hospitalier (PEH) sur le plan affectif et professionnel. MÉTHOdOLOgie : Huit résidents en pédiatrie ont subi une entrevue après leur rotation en PEH. Les chercheurs en ont analysé la transcription au moyen d’une démarche phénoménologique. Ils ont ensuite fait ressortir des citations exemplaires. rÉsULTATs : Quatre grands thèmes ont été dégagés : expériences de base, facteurs propres à chaque résident, facteurs intrinsèques à la rotation en PEH et évaluation globale de la rotation. Les chercheurs ont utilisé les thèmes et les sous-thèmes pour étayer un modèle conceptuel des expériences des résidents. COnCLUsiOns : Les connaissances acquises grâce aux comptes rendus des résidents peuvent servir à renforcer les futures possibilités de formation dans le domaine de la maltraitance d’enfants et offrent un aperçu pour orienter l’élaboration de systèmes de soutien et les processus de retour sur les événements importants dans ce milieu difficile.
ment are at risk for vicarious traumatization. For Canadian paediatric residents, exposure to child abuse during training is limited. OBjeCTive: To explore how paediatric residents experience a mandatory rotation within a hospital-based child protection team (CPT) from an emotional and professional development standpoint. MeTHOd: Eight paediatric residents were interviewed following their CPT rotation and transcripts were analyzed using a phenomenological approach. Exemplar quotes were then highlighted. resULTs: Four major themes were identified: baseline experiences; individual resident factors; intrinsic CPT rotation factors; and overall rotation assessment. The themes and their subthemes were used to inform a conceptual model of residents’ experiences. COnCLUsiOns: The knowledge provided through residents’ accounts can be applied to strengthen future educational opportunities in the field of child maltreatment and offer insight to help guide the development of support systems and debriefing processes that are important in this challenging field. key Words: Child abuse; Child advocacy; Medical education; Paediatrics; Qualitative research
C
hild maltreatment is a widespread social and public health problem. All paediatricians should be familiar with the recognition, reporting and long-term effects of child maltreatment regardless of their ultimate focus of practice (1). Specific exposure to the field of child maltreatment is an important component of postgraduate training for paediatric residents. It is important to determine the qualities of a positive training experience. Providing health care to possible victims of child maltreatment is particularly stressful. First, doubt may exist about whether a child has been abused. This uncertainty can be a source of stress for clinicians (2). Second, the history in suspected maltreatment cases may be falsified or intentionally misrepresented (3). Trainees may find it difficult to accept this potential dishonesty, because paediatric training generally emphasizes the importance of listening to caregivers. Third, interactions with caregivers in suspected maltreatment cases may be less transparent than usual, because all parties may not be working toward the best interests of the child. Furthermore, interviewing and examining children for the purpose of a maltreatment work-up, as well as court appearances, are unique and stressful aspects of child maltreatment work (4). Shared management with other professionals (ie, social workers, police) can also impose stress, because physicians may experience a loss of control over child maltreatment cases and uncertainty
about their role (2). For the inexperienced learner, this paradigm may prove to be especially difficult. Negative experiences in reporting suspected child maltreatment to a child welfare agency can affect physicians’ future reporting behaviour (5). Additionally, practitioners who had left the field of child maltreatment have indicated that burnout and high levels of job stress were most responsible for their decision to leave (6). Little is known about the long-term effectiveness of child protection training with regard to how it influences clinician behaviour or whether it can be provided in such a way that training-related stress is minimized (1). For Canadian and American paediatric residents, exposure to child maltreatment during training is limited and there are inconsistencies in the requirements of individual programs. Published literature regarding residency training in child maltreatment has focused primarily on required core competencies, perceived adequacy of training programs and the knowledge of residents (7,8). These studies described residents’ ‘experience’ in child maltreatment objectively in terms of the number of cases the resident saw during training rather than subjectively in terms of the emotional impact of the experiences. The aim of the present qualitative study is to explore how senior paediatric resident trainees experience a one-month mandatory rotation with a hospital-based child protection team (CPT) from an emotional and professional development standpoint.
1IWK Health Centre; 2Dalhousie University, Halifax, Nova Scotia Correspondence: Amy Ornstein, IWK Health Centre, 5850/5980 University Avenue, Halifax, Nova Scotia B3K 6R8. Telephone 902-470-8222, e-mail [email protected]. Accepted for publication November 29, 2012
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©2013 Pulsus Group Inc. All rights reserved
Paediatr Child Health Vol 18 No 3 March 2013
Experience of paediatric residents on a child protection team
TablE 1 Semistructured interview questions
TablE 2 Emergent themes and subthemes
Opening question:
Themes
Subthemes
Baseline experience
Work/volunteer positions
1) Prior to your CPT rotation, what experiences did you have in the area of child protection?
Vicarious exposure
Introductory questions:
Previous medical exposure
2) Can you tell us about your CPT rotation?
Individual resident factors
3) Do any experiences or events stand out in particular?
Cognitive synthesis
4) Were you able to leave “work at work” during this month?
Personal coping strategies
5) How did you feel during this rotation? …At the beginning of the rotation? …At the end?
Factors related to learning and organization
6) Paediatric medical practice often involves components of child protection. How do you feel about this?
Overall assessment of rotation
7) How could this experience have been made better for you?
Expressed emotion
The team The learning environment Team coping Future work Role of formal debriefing
Transition question: 8) How did your previous experience in issues of child protection influence your experience with the CPT rotation? Key questions: 9) Did the CPT rotation affect you? How so? Can you think of particular examples? 10) Do you think this rotation will influence your interest to become involved in child protection issues in the future? 11) Did the CPT rotation differ from your experience with other paediatric subspecialties? How so? Why? Ending questions: 12) Is there anything else you would like to share about your experience with the CPT? 13) Are there any previous discussion points you would like elaborate on further? 14) Do you think there would be a benefit to more of a formalized debriefing process as a part of the rotation? CPT Child protection team
MeTHOd design A qualitative phenomenological approach (9,10) was used to understand the depth and detail of paediatric residents’ experiences. A 14-question interview guide was created (Table 1) to explore both the emotional experiences (questions 3, 4, 5, 7 and 9) and professional development (questions 6 and 10) of trainees. The guide was used to direct open-ended, semi-structured individual interviews. The project received approval through the Izaac Walton Killam (IWK) Health Centre’s Research Ethics Board (Halifax, Nova Scotia). setting The study was conducted at the IWK Health Centre, a training site for paediatric residents (Dalhousie University, Halifax, Nova Scotia), between May 2009 and May 2010. The CPT is a hospital-based multidisciplinary team that offers medical consultation, assessment, support and therapy to children who have or may have been maltreated. The disciplines represented on the team include medicine, nursing and social work. A month-long rotation with the CPT has been mandatory for senior paediatric residents since 2005. Trainees spend four weeks with the team, during which time the resident responds to all referrals with a social worker, nurse or staff paediatrician. In addition to participating in inpatient and outpatient consultations, the trainee has the opportunity to visit community agencies involved in responding to child maltreatment (eg, law enforcement, Department of Community Services). Residents also perform chart and photo reviews, examine teaching slide sets, attend court proceedings, pursue self-directed learning and receive oneon-one teaching with team members. Paediatr Child Health Vol 18 No 3 March 2013
Participants Paediatric residents who completed the CPT rotation during the study period, or in the preceding 24 months and were still at the centre, were invited to participate. Twelve potential participants were identified and contacted. Four residents were unable to participate because they relocated before an interview time could be scheduled. All participants were contacted after the completion of their CPT rotation and submission of their evaluation. Participants were offered an opportunity to debrief following their interview, on a separate occasion, in case they suffered emotional harm from recounting stressful or traumatic events. The study period was concluded when theoretical saturation of emerging themes in the data was obtained. data collection The principal investigator, who had no involvement with the rotation, conducted interviews with each of the eight participants. Before beginning an interview, consent was obtained and participants were informed that they could elaborate on any discussion point. The interviews lasted 30 min to 45 min and were audiotaped and transcribed verbatim with the exclusion of any identifying data. One interview was only partially transcribed, due to a technical difficulty; analysis of that interview was based on the transcribed portion alone. Analysis Transcripts were independently read and analyzed by all three investigators. Each reviewer identified themes in the transcripts. As thematic categories emerged, sections of text were classified into major themes and subthemes. Themes and subthemes were developed on a consensus basis by the investigators. Ultimately, the main themes formed a conceptual picture reflective of the experience of the participants. Exemplar quotes to illustrate major themes and subthemes were highlighted. When new themes failed to emerge, theoretical saturation was achieved.
resULTs
Four major themes were identified in the transcripts: baseline experiences in child protection before the CPT rotation; individual resident factors; factors related to learning on and organization of the rotation; and overall assessment of the CPT rotation. Major themes were further divided into subthemes and are presented (Table 2) and discussed below. Theme 1: Baseline experiences in the area of child protection Before beginning their CPT rotation, all residents had at least some exposure to the field of child maltreatment, but the amount and type of experience varied widely. Previous experiences fell within three main areas. First, work or volunteer positions that e11
lewington et al
involved providing leadership to children, such as camp counselling or teaching. Second, vicarious experience via family members who worked with children. Third, previous medical experiences during medical school or junior residency, such as inpatient or outpatient clinical rotations or in the emergency department. While some residents had no previous experience in the first two areas, all residents mentioned some degree of previous medical involvement in maltreatment cases. The amount and intensity of previous medical involvement varied among residents. While some residents had only peripheral involvement in cases, other residents had either seen many cases, or had played a central role in a case such that it left a significant impact on them. The variation in previous experience is highlighted by the following comments: A couple of kids were admitted for work-up and I was on teams (inpatient unit) so it was kind of happening parallel and I wasn’t involved. We see lots of head trauma cases and they’re all horrific, but they all start to seem a bit familiar in some ways. They really were, like they were my patients. I did the admission, I followed them, and I initiated a lot of things for them. Like, it sounds possessive, but I really felt like they were my patients. So they stuck with me. Theme 2: individual resident factors Residents brought to the CPT rotation their own personal ways of expressing emotions, cognitively synthesizing their experiences and coping with stressful encounters. expressed emotions: Many residents were forthcoming with expressing emotional responses to their CPT experiences. Examples of positive emotions and examples of grappling with difficult emotions were abundant. The main categories of positive emotions were empathy toward children and families; confidence about improved skills; excitement about learning; and motivation to protect children. One resident described empathy toward the parents of an allegedly abused child by saying: It just happens that you picture yourself in the other person’s shoes or imagine what your feelings would be. You don’t even ask yourself the question. It just happens. Other positive emotions are exemplified in the following statements: It actually gives you the courage to speak up, and lets you know what you’re supposed to do. (The CPT rotation is) very focused on being good for your learning; those types of things I thought were awesome! I’ve always found these cases are just so motivating, and you really want to do as much as you can. The main categories of difficult emotions were anger toward alleged perpetrators; anxiety about future abilities; frustration toward the investigation process; and sadness about situations encountered. When speaking about a distressing case, one resident said: It makes you angry I think. It made me angry anyways, and all I wanted to do was just go in and yell at the perpetrator and beat them and sink to violence. e12
Additional difficult emotions are illustrated below: I worry that I haven’t gained enough skills. As physicians we can only give information and we don’t get much back in terms of what other information the other services had. So that is what I found really frustrating. It’s always sad when a child has to leave their family and then when you learn more about the family it becomes all the more sad, because often times it’s a family who never got the support they needed during their life and it’s not hard to imagine why parenting is really difficult for them. Cognitive synthesis: In addition to their emotional responses, residents identified numerous cognitive efforts to make sense of how they were feeling or reacting. For example, one resident commented about the lack of closure regarding CPT case outcomes: It would be nice to get the information back, but that’s not a role, that’s just human nature I think, wanting to know more. And perhaps having more information may be helpful in making a decision or it might cloud things – hard to know. Ruminating about cases, consciously and subconsciously, was also common. One resident said: …it lingers there. You think about it. Even if you don’t think about it you are somehow preoccupied with feelings. Yet another thought pattern was attempted synthesis of how child maltreatment fits within the broader scope of societal and worldly issues. One resident exemplified this by saying: We don’t know how to prevent cancer, so it happens, but you accept it. But we know how to prevent shaking a baby. You don’t shake them. It’s like we don’t know how to prevent it, but we know that if you don’t shake the baby it won’t happen, right? Personal coping strategies: Residents identified individual ways to cope with or distract themselves from their CPT experiences. One common strategy was debriefing with people in their support network, such as coworkers, spouses or family members. One resident commented: Whether you have formal or informal debriefing, I’m sure everybody at some point debriefs about it, just to talk about it theoretically or talk about a specific case with (the CPT staff). Theme 3: Factors related to learning on and the organization of the rotation Three subthemes related to inherent supportive elements of the CPT rotation: the nature of the team; the unique learning environment; and the ways in which coping were modelled and conducted by team members. The team: Residents identified the CPT staff as especially warm and receptive to trainees and acutely focused on optimizing residents’ learning experience. These features are highlighted by the following statements: Paediatr Child Health Vol 18 No 3 March 2013
Experience of paediatric residents on a child protection team
Team coping: The assimilation of residents into the ongoing and informal debriefing processes of the team was frequently recognized and appreciated by the residents. This is exemplified by one resident who said:
Baseline Experience
I think the team here really recognizes the emotional side of it. And really, that really came up in almost all the conversations. Not so much asking how you are, but the recognition of the, how heavy the topic matter is.
Case Examples
Resident
Learning
Overall Rotation Assessment
Figure 1) Conceptual model of residents’ experience during a child protection team rotation What makes the rotation work is the personality of the doctors. I think if they weren’t warm and receptive to residents it just wouldn’t work. They always, always, always thought to involve me. Residents also highlighted the supportive and collegial nature of the multidisciplinary team: They (team members) each had a really important role to play. While most paediatric training rotations involve working in a traditional medical model, the CPT rotation involves working directly with community-based organizations as well as the multidisciplinary hospital-based team. This feature was recognized as a strength of the rotation: It sort of provided you with a huge context to, like, the ivory tower type situation that you see here, so it was nice to see people work in their own environments. The learning environment: Residents identified that the rotation involved considerable self-directed learning, because the number of cases seen in a month could be quite variable. It was also identified that, although having more learning opportunities was useful, more cases meant that more maltreatment might have occurred. This paradox is identified in the following statement: They’re very focused on teaching you here, which is fabulous, but often a great case involves a terrible outcome for a child. I found that hard. Residents found that the maltreatment investigation process itself was complex and held the potential for practitioners to misdiagnose the problem. One resident identified this possibility by saying: I don’t know that any four-week rotation will ever completely prepare you for going out in the real world and I’m sure I’m going to miss this kind of presentation…but I think it laid a foundation for helping think about a more reasonable approach.
Paediatr Child Health Vol 18 No 3 March 2013
Theme 4: Overall rotation assessment The overall assessment of their CPT rotation was unanimously positive. Residents expressed an increased sense of confidence and awareness toward future work in the area of child maltreatment, as in this comment: I think that before I started I had a hard time imagining, like when kids come through emerg you always have a hard time putting child abuse on your list of differentials because you don’t want to think that people are bad innately. The residents had a mixed view of the value or need for a more formal debriefing process. All residents noted the benefit of the ongoing and informal team debriefing and many residents identified supportive people with whom they already debriefed. Some residents felt that a formal opportunity for debriefing would add to the already useful mechanisms in place, but others saw it as unnecessary. This resident illustrated the more common view: Knowing that there is someone interested in how you feel is probably more practical at the time instead of trying to dredge things up a month later when you may not remember the emotions and thoughts or details of a case.
disCUssiOn
The findings of the present study offer an in-depth understanding about how a CPT rotation is experienced by paediatric resident trainees. A conceptual model of the four major themes (baseline experience before a CPT rotation, individual resident factors, factors related to learning on and organization of the rotation, and overall assessment of the CPT rotation) is given in Figure 1 to illustrate residents’ experience of the rotation. This model illustrates that residents begin their rotation with a certain level of previous experience. This background informs the ensuing experience residents have on the rotation, how the resident synthesizes the rotation, and how the learning process is perceived. Ultimately, these two aspects of the rotation (resident and learning factors) and the pre-existing experiences combine and interact to create the residents’ impression of the rotation. Further, the specific child protection case examples noted by the residents were central to each resident’s overall experience. The conceptual model can be used to inform future approaches to resident training in this area. First, the background experience provides the foundation and variably shapes the initial impression residents have about child protection work. By acknowledging a resident’s starting point it may be easier to map an optimal path of where the resident will emerge after completion of the rotation from both an internal (ie, emotional/cognitive) and external (ie, learning/team) perspective. Second, by recognizing residents’ emotional and cognitive responses to child protection cases, staff members may choose to model coping strategies that specifically e13
lewington et al
address both positive and negative emotions, as well as cognitive efforts to make sense of a particular case. For example, by acknowledging residents’ anger and sadness toward societal injustices, staff could initiate a discussion about channelling this emotional energy toward productive outcomes. Third, the positive role of the multidisciplinary team, as noted by the residents, suggests that exposure to the work and roles of nonmedical professionals is important and highlights the merit of fostering interprofessional learning. The positive multidisciplinary exposure during residents’ CPT rotation provided excellent opportunity to foster professional development within the Canadian Medical Education Directions for Specialists (CanMEDS) roles of collaborator, health advocate and communicator (11). In centres without multidisciplinary teams, consideration should be given to exposing paediatric residents to other professionals involved in child welfare work such as social workers, therapists, psychologists and law enforcement. Finally, trainees identified the benefit of informal debriefing. We propose that ongoing debriefing in a team environment is an effective method, although it should not preclude more formal debriefing at the end of a rotation. Limitations of the present study include the small sample size and the potential for researcher bias in the data analysis. While small, the sample size was acceptable for a qualitative study. A final focus group of participants, at the end of the study period, to review the conceptual model was planned; however, this was not logistically possible. Strengths of the study include independent review of reFerenCes
1. Bannon MJ, Carter YH. Paediatricians and child protection: The need for effective education and training. Arch Dis Child 2003;88;560-2. 2. Hall DM. Is protecting children bad for your health? Arch Dis Child 2005;90:1105-6. 3. Reece RM, Ludwig S, eds. Child Abuse: Medical Diagnosis and Management, 2nd edn. Philadelphia: Lippincott Williams & Wilkins, 2001. 4. Johnson, CF. Child abuse as a stressor of pediatricians. Pediatr Emerg Care 1999;15:84-9. 5. Flaherty EG, Jones R, Sege R. Telling their stories: Primary care practitioners’ experience evaluating and reporting injuries caused by child abuse. Child Abuse Negl 2004;28:939-45. 6. Bennett S, Plint A, Clifford TJ. Burnout, psychological morbidity, job satisfaction, and stress: A survey of Canadian hospital based child protection professionals. Arch Dis Child 2005:90:1112-6.
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transcripts by three investigators to reduce bias in data interpretation and achievement of theoretical saturation of identified themes. Additional research into the experience of trainees in child protection work is required. In our centre, the positive influence of a supportive team was clearly identified. Previous research has demonstrated considerable variability in child protection training among different residency programs (7,8), thus, raising the question of whether residents in other training sites feel as supported within their teams. Interviews with residents who have trained at different sites may identify additional factors that would ensure a positive training experience. Additionally, interviews with professionals in other fields, whose work involves child protection, would identify whether other professionals feel supported within their teams. For example, a study conducted with family court judges found that many judges felt their professional environment was not accepting or supportive of discussing emotions or difficulties among coworkers (12). The findings from the present study can be applied to strengthen the educational experience of all residents completing a child maltreatment rotation. They highlight the importance of maintaining open dialogue and of debriefing with trainees about their current and previous experiences in the field. As a result of supportive and emotionally informed training, trainees may be willing to engage in the reporting and assessment of potentially abused and neglected children in their future careers. 7. Ward MGK, Bennett S, Plint AC, King WJ, Jabbour M, Gaboury I. Child protection: A neglected area of pediatric residency training. Child Abuse Negl 2004;28:1113-22. 8. Narayan AP, Socolar RR, St Claire K. Pediatric residency training in child abuse and neglect in the United States. Pediatrics 2006;117:2215-21. 9. Strauss A, Corbin J. Basics of Qualitative Research. London: Sage, 1990. 10. Van Manen, M. Researching lived experience: Human science for an action sensitive pedagogy. London: Althouse Press, 1990. 11. Frank, JR, Jabbour M, Fréchette D, Marks M, Valk N, Bourgeois G, eds. Report of the CanMEDS phase IV working groups. Ottawa: The Royal College of Physicians and Surgeons of Canada, 2005. 12. Osofsky JD, Putnam FW, Lederman CS. How to maintain emotional health when working with trauma. Juv Fam Court J 2008;59:91-102.
Paediatr Child Health Vol 18 No 3 March 2013
The experience of paediatric residents participating in a child protection rotation: A qualitative study Laura Lewington MD1, Anita Unruh PhD MSW OTC RegNS2, Amy Ornstein MDCM FRCPC FAAP1 L Lewington, A Unruh, A Ornstein. The experience of paediatric residents participating in a child protection rotation: A qualitative study. Paediatr Child Health 2013;18(3):e10-e14.
L’expérience de résidents en pédiatrie qui ont participé à une rotation en protection de l’enfance : une étude qualitative
BACkgrOUnd: Practitioners working in the field of child maltreat-
HisTOriQUe : Les praticiens qui exercent dans le domaine de la maltraitance des enfants sont vulnérables aux traumatismes transmis par personne interposée. Les résidents en pédiatrie canadiens sont peu exposés à la maltraitance d’enfants pendant leur formation. OBjeCTiF : Explorer comment des résidents en pédiatrie ont vécu leur rotation obligatoire au sein d’une équipe de protection de l’enfance en milieu hospitalier (PEH) sur le plan affectif et professionnel. MÉTHOdOLOgie : Huit résidents en pédiatrie ont subi une entrevue après leur rotation en PEH. Les chercheurs en ont analysé la transcription au moyen d’une démarche phénoménologique. Ils ont ensuite fait ressortir des citations exemplaires. rÉsULTATs : Quatre grands thèmes ont été dégagés : expériences de base, facteurs propres à chaque résident, facteurs intrinsèques à la rotation en PEH et évaluation globale de la rotation. Les chercheurs ont utilisé les thèmes et les sous-thèmes pour étayer un modèle conceptuel des expériences des résidents. COnCLUsiOns : Les connaissances acquises grâce aux comptes rendus des résidents peuvent servir à renforcer les futures possibilités de formation dans le domaine de la maltraitance d’enfants et offrent un aperçu pour orienter l’élaboration de systèmes de soutien et les processus de retour sur les événements importants dans ce milieu difficile.
ment are at risk for vicarious traumatization. For Canadian paediatric residents, exposure to child abuse during training is limited. OBjeCTive: To explore how paediatric residents experience a mandatory rotation within a hospital-based child protection team (CPT) from an emotional and professional development standpoint. MeTHOd: Eight paediatric residents were interviewed following their CPT rotation and transcripts were analyzed using a phenomenological approach. Exemplar quotes were then highlighted. resULTs: Four major themes were identified: baseline experiences; individual resident factors; intrinsic CPT rotation factors; and overall rotation assessment. The themes and their subthemes were used to inform a conceptual model of residents’ experiences. COnCLUsiOns: The knowledge provided through residents’ accounts can be applied to strengthen future educational opportunities in the field of child maltreatment and offer insight to help guide the development of support systems and debriefing processes that are important in this challenging field. key Words: Child abuse; Child advocacy; Medical education; Paediatrics; Qualitative research
C
hild maltreatment is a widespread social and public health problem. All paediatricians should be familiar with the recognition, reporting and long-term effects of child maltreatment regardless of their ultimate focus of practice (1). Specific exposure to the field of child maltreatment is an important component of postgraduate training for paediatric residents. It is important to determine the qualities of a positive training experience. Providing health care to possible victims of child maltreatment is particularly stressful. First, doubt may exist about whether a child has been abused. This uncertainty can be a source of stress for clinicians (2). Second, the history in suspected maltreatment cases may be falsified or intentionally misrepresented (3). Trainees may find it difficult to accept this potential dishonesty, because paediatric training generally emphasizes the importance of listening to caregivers. Third, interactions with caregivers in suspected maltreatment cases may be less transparent than usual, because all parties may not be working toward the best interests of the child. Furthermore, interviewing and examining children for the purpose of a maltreatment work-up, as well as court appearances, are unique and stressful aspects of child maltreatment work (4). Shared management with other professionals (ie, social workers, police) can also impose stress, because physicians may experience a loss of control over child maltreatment cases and uncertainty
about their role (2). For the inexperienced learner, this paradigm may prove to be especially difficult. Negative experiences in reporting suspected child maltreatment to a child welfare agency can affect physicians’ future reporting behaviour (5). Additionally, practitioners who had left the field of child maltreatment have indicated that burnout and high levels of job stress were most responsible for their decision to leave (6). Little is known about the long-term effectiveness of child protection training with regard to how it influences clinician behaviour or whether it can be provided in such a way that training-related stress is minimized (1). For Canadian and American paediatric residents, exposure to child maltreatment during training is limited and there are inconsistencies in the requirements of individual programs. Published literature regarding residency training in child maltreatment has focused primarily on required core competencies, perceived adequacy of training programs and the knowledge of residents (7,8). These studies described residents’ ‘experience’ in child maltreatment objectively in terms of the number of cases the resident saw during training rather than subjectively in terms of the emotional impact of the experiences. The aim of the present qualitative study is to explore how senior paediatric resident trainees experience a one-month mandatory rotation with a hospital-based child protection team (CPT) from an emotional and professional development standpoint.
1IWK Health Centre; 2Dalhousie University, Halifax, Nova Scotia Correspondence: Amy Ornstein, IWK Health Centre, 5850/5980 University Avenue, Halifax, Nova Scotia B3K 6R8. Telephone 902-470-8222, e-mail [email protected]. Accepted for publication November 29, 2012
e10
©2013 Pulsus Group Inc. All rights reserved
Paediatr Child Health Vol 18 No 3 March 2013
Experience of paediatric residents on a child protection team
TablE 1 Semistructured interview questions
TablE 2 Emergent themes and subthemes
Opening question:
Themes
Subthemes
Baseline experience
Work/volunteer positions
1) Prior to your CPT rotation, what experiences did you have in the area of child protection?
Vicarious exposure
Introductory questions:
Previous medical exposure
2) Can you tell us about your CPT rotation?
Individual resident factors
3) Do any experiences or events stand out in particular?
Cognitive synthesis
4) Were you able to leave “work at work” during this month?
Personal coping strategies
5) How did you feel during this rotation? …At the beginning of the rotation? …At the end?
Factors related to learning and organization
6) Paediatric medical practice often involves components of child protection. How do you feel about this?
Overall assessment of rotation
7) How could this experience have been made better for you?
Expressed emotion
The team The learning environment Team coping Future work Role of formal debriefing
Transition question: 8) How did your previous experience in issues of child protection influence your experience with the CPT rotation? Key questions: 9) Did the CPT rotation affect you? How so? Can you think of particular examples? 10) Do you think this rotation will influence your interest to become involved in child protection issues in the future? 11) Did the CPT rotation differ from your experience with other paediatric subspecialties? How so? Why? Ending questions: 12) Is there anything else you would like to share about your experience with the CPT? 13) Are there any previous discussion points you would like elaborate on further? 14) Do you think there would be a benefit to more of a formalized debriefing process as a part of the rotation? CPT Child protection team
MeTHOd design A qualitative phenomenological approach (9,10) was used to understand the depth and detail of paediatric residents’ experiences. A 14-question interview guide was created (Table 1) to explore both the emotional experiences (questions 3, 4, 5, 7 and 9) and professional development (questions 6 and 10) of trainees. The guide was used to direct open-ended, semi-structured individual interviews. The project received approval through the Izaac Walton Killam (IWK) Health Centre’s Research Ethics Board (Halifax, Nova Scotia). setting The study was conducted at the IWK Health Centre, a training site for paediatric residents (Dalhousie University, Halifax, Nova Scotia), between May 2009 and May 2010. The CPT is a hospital-based multidisciplinary team that offers medical consultation, assessment, support and therapy to children who have or may have been maltreated. The disciplines represented on the team include medicine, nursing and social work. A month-long rotation with the CPT has been mandatory for senior paediatric residents since 2005. Trainees spend four weeks with the team, during which time the resident responds to all referrals with a social worker, nurse or staff paediatrician. In addition to participating in inpatient and outpatient consultations, the trainee has the opportunity to visit community agencies involved in responding to child maltreatment (eg, law enforcement, Department of Community Services). Residents also perform chart and photo reviews, examine teaching slide sets, attend court proceedings, pursue self-directed learning and receive oneon-one teaching with team members. Paediatr Child Health Vol 18 No 3 March 2013
Participants Paediatric residents who completed the CPT rotation during the study period, or in the preceding 24 months and were still at the centre, were invited to participate. Twelve potential participants were identified and contacted. Four residents were unable to participate because they relocated before an interview time could be scheduled. All participants were contacted after the completion of their CPT rotation and submission of their evaluation. Participants were offered an opportunity to debrief following their interview, on a separate occasion, in case they suffered emotional harm from recounting stressful or traumatic events. The study period was concluded when theoretical saturation of emerging themes in the data was obtained. data collection The principal investigator, who had no involvement with the rotation, conducted interviews with each of the eight participants. Before beginning an interview, consent was obtained and participants were informed that they could elaborate on any discussion point. The interviews lasted 30 min to 45 min and were audiotaped and transcribed verbatim with the exclusion of any identifying data. One interview was only partially transcribed, due to a technical difficulty; analysis of that interview was based on the transcribed portion alone. Analysis Transcripts were independently read and analyzed by all three investigators. Each reviewer identified themes in the transcripts. As thematic categories emerged, sections of text were classified into major themes and subthemes. Themes and subthemes were developed on a consensus basis by the investigators. Ultimately, the main themes formed a conceptual picture reflective of the experience of the participants. Exemplar quotes to illustrate major themes and subthemes were highlighted. When new themes failed to emerge, theoretical saturation was achieved.
resULTs
Four major themes were identified in the transcripts: baseline experiences in child protection before the CPT rotation; individual resident factors; factors related to learning on and organization of the rotation; and overall assessment of the CPT rotation. Major themes were further divided into subthemes and are presented (Table 2) and discussed below. Theme 1: Baseline experiences in the area of child protection Before beginning their CPT rotation, all residents had at least some exposure to the field of child maltreatment, but the amount and type of experience varied widely. Previous experiences fell within three main areas. First, work or volunteer positions that e11
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involved providing leadership to children, such as camp counselling or teaching. Second, vicarious experience via family members who worked with children. Third, previous medical experiences during medical school or junior residency, such as inpatient or outpatient clinical rotations or in the emergency department. While some residents had no previous experience in the first two areas, all residents mentioned some degree of previous medical involvement in maltreatment cases. The amount and intensity of previous medical involvement varied among residents. While some residents had only peripheral involvement in cases, other residents had either seen many cases, or had played a central role in a case such that it left a significant impact on them. The variation in previous experience is highlighted by the following comments: A couple of kids were admitted for work-up and I was on teams (inpatient unit) so it was kind of happening parallel and I wasn’t involved. We see lots of head trauma cases and they’re all horrific, but they all start to seem a bit familiar in some ways. They really were, like they were my patients. I did the admission, I followed them, and I initiated a lot of things for them. Like, it sounds possessive, but I really felt like they were my patients. So they stuck with me. Theme 2: individual resident factors Residents brought to the CPT rotation their own personal ways of expressing emotions, cognitively synthesizing their experiences and coping with stressful encounters. expressed emotions: Many residents were forthcoming with expressing emotional responses to their CPT experiences. Examples of positive emotions and examples of grappling with difficult emotions were abundant. The main categories of positive emotions were empathy toward children and families; confidence about improved skills; excitement about learning; and motivation to protect children. One resident described empathy toward the parents of an allegedly abused child by saying: It just happens that you picture yourself in the other person’s shoes or imagine what your feelings would be. You don’t even ask yourself the question. It just happens. Other positive emotions are exemplified in the following statements: It actually gives you the courage to speak up, and lets you know what you’re supposed to do. (The CPT rotation is) very focused on being good for your learning; those types of things I thought were awesome! I’ve always found these cases are just so motivating, and you really want to do as much as you can. The main categories of difficult emotions were anger toward alleged perpetrators; anxiety about future abilities; frustration toward the investigation process; and sadness about situations encountered. When speaking about a distressing case, one resident said: It makes you angry I think. It made me angry anyways, and all I wanted to do was just go in and yell at the perpetrator and beat them and sink to violence. e12
Additional difficult emotions are illustrated below: I worry that I haven’t gained enough skills. As physicians we can only give information and we don’t get much back in terms of what other information the other services had. So that is what I found really frustrating. It’s always sad when a child has to leave their family and then when you learn more about the family it becomes all the more sad, because often times it’s a family who never got the support they needed during their life and it’s not hard to imagine why parenting is really difficult for them. Cognitive synthesis: In addition to their emotional responses, residents identified numerous cognitive efforts to make sense of how they were feeling or reacting. For example, one resident commented about the lack of closure regarding CPT case outcomes: It would be nice to get the information back, but that’s not a role, that’s just human nature I think, wanting to know more. And perhaps having more information may be helpful in making a decision or it might cloud things – hard to know. Ruminating about cases, consciously and subconsciously, was also common. One resident said: …it lingers there. You think about it. Even if you don’t think about it you are somehow preoccupied with feelings. Yet another thought pattern was attempted synthesis of how child maltreatment fits within the broader scope of societal and worldly issues. One resident exemplified this by saying: We don’t know how to prevent cancer, so it happens, but you accept it. But we know how to prevent shaking a baby. You don’t shake them. It’s like we don’t know how to prevent it, but we know that if you don’t shake the baby it won’t happen, right? Personal coping strategies: Residents identified individual ways to cope with or distract themselves from their CPT experiences. One common strategy was debriefing with people in their support network, such as coworkers, spouses or family members. One resident commented: Whether you have formal or informal debriefing, I’m sure everybody at some point debriefs about it, just to talk about it theoretically or talk about a specific case with (the CPT staff). Theme 3: Factors related to learning on and the organization of the rotation Three subthemes related to inherent supportive elements of the CPT rotation: the nature of the team; the unique learning environment; and the ways in which coping were modelled and conducted by team members. The team: Residents identified the CPT staff as especially warm and receptive to trainees and acutely focused on optimizing residents’ learning experience. These features are highlighted by the following statements: Paediatr Child Health Vol 18 No 3 March 2013
Experience of paediatric residents on a child protection team
Team coping: The assimilation of residents into the ongoing and informal debriefing processes of the team was frequently recognized and appreciated by the residents. This is exemplified by one resident who said:
Baseline Experience
I think the team here really recognizes the emotional side of it. And really, that really came up in almost all the conversations. Not so much asking how you are, but the recognition of the, how heavy the topic matter is.
Case Examples
Resident
Learning
Overall Rotation Assessment
Figure 1) Conceptual model of residents’ experience during a child protection team rotation What makes the rotation work is the personality of the doctors. I think if they weren’t warm and receptive to residents it just wouldn’t work. They always, always, always thought to involve me. Residents also highlighted the supportive and collegial nature of the multidisciplinary team: They (team members) each had a really important role to play. While most paediatric training rotations involve working in a traditional medical model, the CPT rotation involves working directly with community-based organizations as well as the multidisciplinary hospital-based team. This feature was recognized as a strength of the rotation: It sort of provided you with a huge context to, like, the ivory tower type situation that you see here, so it was nice to see people work in their own environments. The learning environment: Residents identified that the rotation involved considerable self-directed learning, because the number of cases seen in a month could be quite variable. It was also identified that, although having more learning opportunities was useful, more cases meant that more maltreatment might have occurred. This paradox is identified in the following statement: They’re very focused on teaching you here, which is fabulous, but often a great case involves a terrible outcome for a child. I found that hard. Residents found that the maltreatment investigation process itself was complex and held the potential for practitioners to misdiagnose the problem. One resident identified this possibility by saying: I don’t know that any four-week rotation will ever completely prepare you for going out in the real world and I’m sure I’m going to miss this kind of presentation…but I think it laid a foundation for helping think about a more reasonable approach.
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Theme 4: Overall rotation assessment The overall assessment of their CPT rotation was unanimously positive. Residents expressed an increased sense of confidence and awareness toward future work in the area of child maltreatment, as in this comment: I think that before I started I had a hard time imagining, like when kids come through emerg you always have a hard time putting child abuse on your list of differentials because you don’t want to think that people are bad innately. The residents had a mixed view of the value or need for a more formal debriefing process. All residents noted the benefit of the ongoing and informal team debriefing and many residents identified supportive people with whom they already debriefed. Some residents felt that a formal opportunity for debriefing would add to the already useful mechanisms in place, but others saw it as unnecessary. This resident illustrated the more common view: Knowing that there is someone interested in how you feel is probably more practical at the time instead of trying to dredge things up a month later when you may not remember the emotions and thoughts or details of a case.
disCUssiOn
The findings of the present study offer an in-depth understanding about how a CPT rotation is experienced by paediatric resident trainees. A conceptual model of the four major themes (baseline experience before a CPT rotation, individual resident factors, factors related to learning on and organization of the rotation, and overall assessment of the CPT rotation) is given in Figure 1 to illustrate residents’ experience of the rotation. This model illustrates that residents begin their rotation with a certain level of previous experience. This background informs the ensuing experience residents have on the rotation, how the resident synthesizes the rotation, and how the learning process is perceived. Ultimately, these two aspects of the rotation (resident and learning factors) and the pre-existing experiences combine and interact to create the residents’ impression of the rotation. Further, the specific child protection case examples noted by the residents were central to each resident’s overall experience. The conceptual model can be used to inform future approaches to resident training in this area. First, the background experience provides the foundation and variably shapes the initial impression residents have about child protection work. By acknowledging a resident’s starting point it may be easier to map an optimal path of where the resident will emerge after completion of the rotation from both an internal (ie, emotional/cognitive) and external (ie, learning/team) perspective. Second, by recognizing residents’ emotional and cognitive responses to child protection cases, staff members may choose to model coping strategies that specifically e13
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address both positive and negative emotions, as well as cognitive efforts to make sense of a particular case. For example, by acknowledging residents’ anger and sadness toward societal injustices, staff could initiate a discussion about channelling this emotional energy toward productive outcomes. Third, the positive role of the multidisciplinary team, as noted by the residents, suggests that exposure to the work and roles of nonmedical professionals is important and highlights the merit of fostering interprofessional learning. The positive multidisciplinary exposure during residents’ CPT rotation provided excellent opportunity to foster professional development within the Canadian Medical Education Directions for Specialists (CanMEDS) roles of collaborator, health advocate and communicator (11). In centres without multidisciplinary teams, consideration should be given to exposing paediatric residents to other professionals involved in child welfare work such as social workers, therapists, psychologists and law enforcement. Finally, trainees identified the benefit of informal debriefing. We propose that ongoing debriefing in a team environment is an effective method, although it should not preclude more formal debriefing at the end of a rotation. Limitations of the present study include the small sample size and the potential for researcher bias in the data analysis. While small, the sample size was acceptable for a qualitative study. A final focus group of participants, at the end of the study period, to review the conceptual model was planned; however, this was not logistically possible. Strengths of the study include independent review of reFerenCes
1. Bannon MJ, Carter YH. Paediatricians and child protection: The need for effective education and training. Arch Dis Child 2003;88;560-2. 2. Hall DM. Is protecting children bad for your health? Arch Dis Child 2005;90:1105-6. 3. Reece RM, Ludwig S, eds. Child Abuse: Medical Diagnosis and Management, 2nd edn. Philadelphia: Lippincott Williams & Wilkins, 2001. 4. Johnson, CF. Child abuse as a stressor of pediatricians. Pediatr Emerg Care 1999;15:84-9. 5. Flaherty EG, Jones R, Sege R. Telling their stories: Primary care practitioners’ experience evaluating and reporting injuries caused by child abuse. Child Abuse Negl 2004;28:939-45. 6. Bennett S, Plint A, Clifford TJ. Burnout, psychological morbidity, job satisfaction, and stress: A survey of Canadian hospital based child protection professionals. Arch Dis Child 2005:90:1112-6.
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transcripts by three investigators to reduce bias in data interpretation and achievement of theoretical saturation of identified themes. Additional research into the experience of trainees in child protection work is required. In our centre, the positive influence of a supportive team was clearly identified. Previous research has demonstrated considerable variability in child protection training among different residency programs (7,8), thus, raising the question of whether residents in other training sites feel as supported within their teams. Interviews with residents who have trained at different sites may identify additional factors that would ensure a positive training experience. Additionally, interviews with professionals in other fields, whose work involves child protection, would identify whether other professionals feel supported within their teams. For example, a study conducted with family court judges found that many judges felt their professional environment was not accepting or supportive of discussing emotions or difficulties among coworkers (12). The findings from the present study can be applied to strengthen the educational experience of all residents completing a child maltreatment rotation. They highlight the importance of maintaining open dialogue and of debriefing with trainees about their current and previous experiences in the field. As a result of supportive and emotionally informed training, trainees may be willing to engage in the reporting and assessment of potentially abused and neglected children in their future careers. 7. Ward MGK, Bennett S, Plint AC, King WJ, Jabbour M, Gaboury I. Child protection: A neglected area of pediatric residency training. Child Abuse Negl 2004;28:1113-22. 8. Narayan AP, Socolar RR, St Claire K. Pediatric residency training in child abuse and neglect in the United States. Pediatrics 2006;117:2215-21. 9. Strauss A, Corbin J. Basics of Qualitative Research. London: Sage, 1990. 10. Van Manen, M. Researching lived experience: Human science for an action sensitive pedagogy. London: Althouse Press, 1990. 11. Frank, JR, Jabbour M, Fréchette D, Marks M, Valk N, Bourgeois G, eds. Report of the CanMEDS phase IV working groups. Ottawa: The Royal College of Physicians and Surgeons of Canada, 2005. 12. Osofsky JD, Putnam FW, Lederman CS. How to maintain emotional health when working with trauma. Juv Fam Court J 2008;59:91-102.
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