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what is the Independent variable in this article Introduction: At our inpatient psychiatric hospital, which cares for children and adolescents, internal data of use of seclusions and holds as crisis interventions for immediate behavioral health issues demonstrated that we were using these too often. Aims: Benchmarking indicated that we were at the 75% in use of these measures, and it became an organizational goal to reduce the use of these strategies in order to reduce the risk of retraumatization to an already traumatized child. Methods: We used the Iowa Model for Evidence Based Practice-Revised to initiate an evidence-based practice project introducing and hardwiring Trauma Informed Care to the staff and institution. This involved implementing six core strategies specifically designed to reduce the use of crisis interventions. Results: Data obtained at 6 months revealed a 40% reduction in the use of holds and seclusions, and at 12 months, this change was sustained and even improved, reducing the use of these approaches by another 9%. Furthermore, the culture in the institution was changed, and Trauma Informed Care became the norm. Conclusions: Evidence-based practice is a viable approach to change the culture and improve patient outcomes in inpatient psychiatric care of children and adolescents. Further investigation is warranted to determine the specific patient and staff experiences of being cared for, and caring within, the context of trauma-informed care. In the field of child and adolescent psychiatry, it is imperative to understand how the patient’s past may affect their current mental health (Hammer et al., 2011). During hospitalization, children may exhibit behavior that poses a risk to themselves or someone else, and mental health personnel are trained to administer interventions that protect them; these may include placing the child in a physical restraint or seclusion (De Hert et al., 2011). However, these routine interventions may, in fact, retraumatize the child/adolescent (Hammer et al., 2011), which adds to their psychological burden (Lewis-O’Connor et al., 2019). However, there are alternatives to this routine care, and evidence-based practice can provide a template for changing health care personnel’s response to decompensating behavior to a more holistic approach. The purpose of this article is to report evidence-based practice-informed implementation of trauma-informed care (TIC; Substance Abuse and Mental Health Services Administration, 2014) for children and adolescents being cared for in the inpatient psychiatric setting. Background Trauma-Informed Care TIC is defined as the profound understanding of how a patient’s past trauma can affect their current behaviors and future mental health (Muskett, 2014). TIC is ensuring that all other options to crisis intervention have been exhausted and forceful crisis interventions such as physical restraint and seclusion events are used as a last resort (Oster et al., 2016). When each individual patient is before a clinician during an event of imminent risk of harm to self and others, it is critical to keep mindfulness about that patient’s individual trauma in the forefront when formulating a deescalation intervention (Muskett, 2014). The trauma is what the patient says it is and cannot be generalized to others (Lewis-O’Connor et al., 2019). When a child is exposed to trauma, the brain overcompensates in the limbic system in a way that is conductive to surviving a traumatic event or environment. Changes within the brain due to traumatic exposure can lead to dysregulation of cortisol, which inhibits appropriate social behaviors and induces aggressive behaviors (Black et al., 2012). Evidence-Based Practice: Iowa Model-Revised Evidence-based practice (EBP) is a theoretical approach to managing, infusing, and hard-wiring change in the clinical practice environment. The foundation of EBP lies at the convergence of best scientific evidence, clinician expertise, and patient values and is embedded in a context of professional caring (Melnyk & Fineout-Overholt, 2017). This project report is informed by the Iowa Model of Evidence Based Practice-Revised (Iowa Model-Revised; Iowa Model Collaborative, 2017), which appears as Figure 1. This theoretical framework provides a template for reporting activities related to the TIC implementation and evaluation project, which occurred at a large, Midwestern inpatient child (ages 4-11 years) and adolescent (ages 12-17 years) psychiatric hospital, which routinely used traditional approaches (physical holds and seclusion but not mechanical or chemical holds) to protect patients when they could not or would not protect themselves from their own behavior. Open in Viewer Figure 1. The Iowa Model-Revised: Evidence-based practice to promote excellence in health care. Note. Used/reprinted with permission from the University of Iowa Hospitals and Clinics, copyright 2015. Methods: Implementation and Evaluation of the Project Beginning Steps: Finding Clarity The first phase of the EBP process is to identify that a problem exists. For the Iowa Model-Revised (Iowa Model Collaborative, 2017), there is a triggering event of some kind. In this case, the Medical Executive Committee of a 97-bed inpatient for-profit psychiatric hospital specializing in the care of children and adolescents (ages 3-17 years) was responsible for leading the organization through The Joint Commission accreditation process. During periodic reviews, reviewers would ask the staff what plans were in development that would reduce physical restraint and seclusion use for patients (Martin et al., 2008). Furthermore, corporate visitors with expertise in deescalation practices would provide consultation and asked the same questions. Routine care still resulted in a rate of seclusion and restraint use that, when benchmarked with similar organizations was exceeded by 75%. The Joint Commission requires having an ongoing process for reduction of use of seclusion and physical holds (The Joint Commission, 2019); this hospital’s rates of use of seclusions and physical holds were consistently above expected benchmarks. At baseline, it was also observed that, if a staff member chose to use a physical hold as a crisis intervention, it was almost always followed by a seclusion event; other follow-up options would not be considered. These patterns of data alarmed the leadership team, and this became the triggering event (Iowa Model Collaborative, 2017) providing a sense of urgency to attend to the issue. An initial review of the pertinent literature revealed there was ample evidence that other alternative approaches to behavioral management of youth inpatients needed to be considered to provide the wholistic and caring environment that the staff asserted they wanted to create. Crisis events while hospitalized, defined as either a physical hold or seclusion. Seclusion is an involuntary confinement of a person in a room or area (Azeem et al., 2017). Physical hold is a manual technique restricting a person’s movement (Azeem et al., 2017). The potential for patients to become aggressive to themselves or others is generally high during an inpatient stay. The use of physical hold and seclusion are interventions used to keep the patient and others safe when all other interventions have failed (Oster et al., 2016). However, a much more holistic and caring approach is TIC. In addition to a review of the literature, networking with other Chief Nursing Officers (CNO) in similar organizations revealed that, although our organization had the philosophy of TIC, the core approaches were not infused into the culture and environment. It became apparent that a reinvigoration of the principles of TIC as a lived experience for staff and children/adolescents in their care be embraced, helping seasoned and novice nurses and staff to learn new ways of being present with the patient, and focusing on creating a caring and compassionate response and not just moving to a default position of seclusion and restraint. In the Iowa Model-Revised, the next phase is to state the question or focus of the project (Iowa Model Collaborative, 2017). The PICO(T) question (Melnyk & Fineout-Overholt, 2017) for this project was: (P), For children and adolescents (ages 3-17), what is the impact of (I) implementation of the TIC program in an inpatient psychiatric setting versus (C) routine care on (O) rates of use of physical holds and seclusion (T) at 6 and 12 months postimplementation? Decision Point One: Is the Problem a Priority? The first author (RH), the Chief Nursing Officer for this organization, brought the institution’s triggering event data, plus a brief review of the literature, to the Governing Board overseeing the institution. Because reducing holds and seclusions was a priority for the overarching health system and with the understanding that high use of physical holds and holds at this institution were well above the national benchmark, reducing the use of these approaches was a very high priority. Leadership buy-in was obtained and infusion of all interventions comprising TIC were approved for implementation, identifying this as a priority issue and appropriate for organizational change efforts. The CNO served as change agent for the project and became the in-house expert and champion for trauma-informed care. Intermediate Steps Forming a Team Once a clinician, leader, team, or organization determines that the problem is a priority, the next phase is to identify a team. Identification of stakeholders is a critically important step when considering forming the team. In this case, the most important stakeholder is the patient and the patient’s family; prevention of retraumatization has a direct, long-lasting effect on their health and well-being (Azeem et al., 2017). For the purpose of this project, designed to reduce retraumatization in children and adolescents, stakeholders included patients, mental health professionals and support personnel (physicians, nurses, social workers, mental health technicians, among others), as well as administrators. In a broader sense, other stakeholders include insurance companies and the government/society, by reducing long-term costs associated with retraumatization. The group responsible for implementing and evaluating this quality improvement project based on the evidence was the Restraint and Seclusion Performance Improvement Team (R&S-PIT), formed with clinical experts and front-line workers, including the CNO of the facility, the Chief Executive Officer (CEO), the Chief Operating Officer (COO), director of social work, nurse managers from each of three floors, the staff educator, occupational therapist, and the Milieu Coordinator. Staff caregivers were always welcome and invited to every meeting. The R&S-PIT met monthly, which reviewed data and effectiveness of interventions as they rolled out. Reviewing the Literature When using the Iowa Model-Revised process (Iowa Model Collaborative, 2017), as the team begins to meet, the first order of business is to review the literature, using a systematic search strategy. This was accomplished by using the Cumulative Index to Nursing and Allied Health Literature, ProQuest Nursing, Allied Health Source, Medline, ProQuest Health, and Medical Collection and PubMed. Key search terms used with the search engines were trauma-informed care, trauma, child and adolescent psychiatry, physical hold and seclusions, reduction of physical hold and seclusions, and NASMHPD. This evidence-based project needed to contain specific key terms that discussed reduction of physical holds and seclusions and content was specific to child and adolescent psychiatric population; information regarding trauma; and the impact of trauma on mental health. Also needed was an explanation of TIC, including strategies created by the National Association of State Mental Health Program Directors (NASMHPD https://www.nasmhpd.org/; Azeem et al., 2011) TIC, developed by NASMHPD (Azeem et al., 2011), is a comprehensive and holistic approach to management of behavioral health issues that includes six core strategies for prevention of retraumatization within the behavioral health setting. These core strategies include the following: a leadership team committed to organizational change, the use of data (internal and external) to inform the practice change, development of the workforce/staff, the use of specific tools (such as deescalation) to reduce the use of physical holds and seclusion, ensuring that patients/family members have input, and the use of debriefing techniques as a learning tool when crisis interventions are used. Although each of these strategies may be implemented in different ways in organizations, the core strategies remain the same. The underlying philosophy of TIC assumes that earlier trauma can predict and influence future trauma (Nizum et al., 2020), and that the process of hospitalization for acute behavioral health issues can be a trauma, which then may be magnified by the use of physical holds and seclusion event (Golubchik et al., 2013). TIC substitutes crisis interventions with deescalation, debriefing, staff education (Azeem et al., 2017) and a culture of caring with the goal to support patient safety, promote behavioral change, and improve patient outcomes. Positive changes that can occur include reduction of recidivism, development of positive coping skills, and improved patient and staff interactions (LeBel et al., 2010). TIC provides mental health staff the ability to be informed about and sensitive to issues present in survivors of trauma (Regan, 2010). In a landmark study, Delaney (2006) discovered that 25% to 61% of children and adolescents in the United States had been exposed to some sort of trauma. In the United States, an average of 4.5 children died every day due to abuse and neglect (Saxe et al., 2016). This high prevalence of childhood exposure to trauma and neglect provided compelling evidence for inpatient mental health nurses to become educated in the prevention of secondary trauma during psychiatric hospitalizations and to engage in the organizational change process. Advanced in neurosciences have identified the structure and function of a child’s developing brain, which is physically altered in the presence of trauma and neglect and is irreversible (Saxe et al., 2016). Repeated exposure to significant childhood trauma determines how well parts of the brain integrate and function together (Muskett, 2014). Understanding the effects of trauma and how it can affect a person is especially important when caring for children and adolescents with acute behavioral health problems (ValenKamp et al., 2014). It is estimated that one in four youths will experience some form of trauma during their developmental years (Black et al., 2012). In instances where trauma and behavioral health challenges meet, implementation of a TIC program may improve outcomes (Nizum et al., 2020) and ultimately providing knowledge of the effects of trauma on children and adolescents with behavioral health challenges. Bryson et al. (2017) assert that trauma has consequential implications to a developing brain involving executive functioning and adaptive stress responsivity. Trauma reduces the brain volume structures that are responsible for learning, memory, and emotional regulation. Regulating the emotional stress response may reduce the effects of childhood trauma that ultimately would result in maladaptive behaviors. Long-term maladaptive effects of trauma exposure can result in major depression, suicide, substance use and disruption to their ability to interact socially with peers (Bryson et al., 2017) To qualify for admission to an inpatient behavioral health hospital, a patient must be declared harmful to themselves or someone else. Thus, the potential for patients to become aggressive to themselves or others in generally high during an inpatient stay. If patients become aggressive, or self-harm, it is the responsibility of the staff to keep them safe if they are not able to themselves (Golubchik et al., 2013). The use of physical holds and seclusions are interventions used to keep patients safe only when all other interventions have been exhausted (Oster et al., 2016; emphasis, the authors’). The use of physical holds and within mental health institutions have a long history of being an acceptable intervention for patients who are at imminent risk of harming themselves or someone else (Cusack et al., 2018). However, the risk of injury increases for both staff and patients when these are used (Ross et al., 2014). Using such approaches is now understood to retraumatize youth, creating further long-term damage to the still developing brain (Hammer et al., 2011) and affecting mental health (Bryson et al., 2017). Crisis interventions are still common, approved, but highly regulated, practices (De Hert et al., 2011) within the behavioral health inpatient setting (Oster et al., 2016). It has only been in the past decade that emerging research (Ross et al., 2014) has identified the importance of creating a culture of safety in behavioral health that, by reducing crisis intervention use, retraumatization is also reduced (Nizum et al., 2020). Implementation of a TIC program for children and adolescents may provide patients and caregivers a heightened understanding of this risk and may promote trust between caregivers and patients (Azeem et al., 2011). TIC allows patients the ability to heal and feel safe (Bryson et al., 2017) and provides less traumatic interventions in order to reduce this risk of retraumatization (Muskett, 2014). Decision Point 2: Determining if There is Sufficient Evidence to Change Practice In this phase of EBP (Iowa Model Collaborative, 2017), the team reviews the evidence and decides about whether or not to implement a change in practice. In this case, the R&S PIT professional group reviewed the literature and the baseline physical hold and seclusion rate from the Risk Management Director who was responsible for gathering internal evidence and the R&S PIT team determined that a change in practice house-wise was appropriate. The decision to pursue this change was approved by the Governing Board of the facility and support for the change within the R&S PIT group was strong, and the R&S PIT was charged to design this change, based on the literature review, the clinicians’ experiences, and patient preferences (Melnyk & Fineout Overholt, 2017). Critical Implementation Point: Designing and Implementing a Change in Practice The most complex activity of EBP is designing and developing a planned change project to test if a change in practice is a good change. There are numerous aspects to consider (see Figure 1). In this example, a test of change was implemented on all three units. Implementing a TIC program that was age specific for the pediatric versus adolescent population was initiated from the beginning of the planned change. The six core processes that comprise TIC served as the foundation for specific organizational interventions that were developed for the project. These approaches were bundled; that is to say, the activities nested together and were to be implemented in full as one program in all areas. None of the chosen interventions were extraneous or optional In this institution, the approaches used included the following: staff education, staff use of deescalation techniques, completed needed administrative updates, enhanced communication, patient education, and, most important, culture change. Staff Education Education to reflect the TIC philosophy and expected outcomes were given to new and seasoned staff; this was reiterated during annual competencies for all employees. Group therapy personnel were also updated to include trauma awareness and education, which included self-awareness and mindfulness techniques. Debriefings were a crucial aspect of staff education that moved the information into practice; much learning took place within this structure. If an employee used a crisis intervention, three debriefings were held. The first debriefing included employees involved and was an effort to get data before the end of the shift, while the occurrence was fresh on everyone’s mind. The second debriefing took place between the patient and a staff member who was identified as having the best rapport with the patient within 24 hours; patient input from this debriefing was included in the development of subsequent care plans. The goal was to record the patient’s perspectives on the experience, after they had had an opportunity to process and reflect on what had happened. These debriefings were routine prior to implementation of TIC at the facility. What was new was the final debriefing, which occurred within 48 hours of the incident, and included a reviewal of video documentation of the incident, before, during and after it occurred. This debriefing was led by the R&S PIT team and included as well, the employees involved in the crisis intervention and the social worker assigned to the patient. Psychological safety of staff members was addressed by the R&S PIT team as each individual could themselves experience a traumatizing reaction when reviewing the video. Psychological safety was assured as each debriefing began with a supportive statement identifying possible reactions on reviewing the incident and during debriefing. One member from the R&S PIT team was designated to meet with individual staff members as needed based on staff’s responses during the final debriefing. Private support meetings would occur as needed. Staff who may have been triggered by the debriefing would also be encouraged to contact Employee Assistance Program as needed. This final debriefing became a powerful educational tool for all; the open discussion of the situation and results facilitated learning about how to infuse TIC into practice consistently; this opportunity to use the language and philosophy of TIC facilitated culture change as well. Use of Deescalation as a Tool to Reduce Seclusion and Restraint Use The Joint Commission (2019) identifies deescalation as “a combination of strategies, techniques and methods intended to reduce a patient’s agitation and aggression” (p. 1). Deescalation techniques that were included in the educational intervention provided to employees and used as needed by staff included communicating caring with empathy in a calm manner; repeating simple messages as needed until they were heard; intentional use of body language that was nonthreatening, and approaching the patient one-to-one (as opposed to multiple people hovering nearby); listening, and responding, to the expressed needs of the patient; and setting clear limits that were simple (The Joint Commission, 2019). A major component of deescalation in this population is the therapeutic use of self. This includes monitoring one’s own body language, speaking in a low and calm voice, using eye contact, and most important, expressing a comportment of empathy. These techniques were evaluated when the debriefings occurred, and if opportunities to substitute deescalation for a physical hold or seclusion intervention was seen, it was used as a teaching point during the final crisis intervention debriefing. Administrative Updates Policies and procedures related to the use of physical holds and seclusions were updated to reflect the processes and expected outcomes of infusion of TIC philosophy. Job descriptions were updated to include requirements to use TIC whenever appropriate; employees were held to these standards during their annual performance appraisals. Recognition of excellent employee use of TIC actions were recognized with an award, selected by R&S PIT committee members. All patient documentation from admission to discharge was updated and/or created to uphold the principles and practices of TIC. Enhanced Communication Along with debriefings, as care unfolded, if a particular patient would require three or more of the following interventions (a PRN medication for aggressive behaviors; physical hold, and or seclusion within 3 days), this would trigger a multidisciplinary discussion of the overall plan of care for the patient. Included in this discussion was the physician, the social worker/therapist, the nurse, and the CNO. A deep discussion about the patient’s treatment plan; medication management; milieu management and family dynamics. At the end of this meeting, the care plan was updated to reflect the new interventions or new/current medications changes. In this way, individual patient data were used to inform practice and next steps. Change in the Culture of Care Implementing a TIC program did not eliminate the need for crisis interventions as each crisis situation is unique. Once each staff member was educated in the philosophy and practical approaches used when implementing TIC, the culture for utilizing physical hold and seclusions gradually changed. Staff went from quickly utilizing a crisis intervention to avoiding these approaches until all other recommended TIC interventions had been exhausted. As well, staff learned that a crisis intervention involving a patient restraint episode did not necessarily required the patient to be placed, automatically, in seclusion. Staff began to see that other alternatives, such as having a patient go in their own room where they remained unrestricted could also be effective and was in congruence with TIC. Thus, the hold event was separated from the seclusion event and the culture of TIC deepened. Having a TIC program provided alternative interventions but, more important, brought a heightened level of staff self-awareness when interacting with an aggressive child. Staff began to see the aggressive child in a different way that allowed them to not take the patient’s behavior as personal or as a reflection of poor care. Staff began to use deescalation techniques learned during education and following debriefings and were able to see that this approach was successful in maintaining the dignity and care of the child, while keeping staff safe. Staff began using TIC language and approaches consistently during crisis incidents, using deescalation, and debriefings; these, in turn, illuminated the emerging trauma-informed culture. A consensus of understanding developed with the staff that using crisis interventions increased a patient’s risk for retraumatization; and began approaching each patient situation as if the patient, indeed, had a history of trauma, whether or not they did. This became an underlying assumption of the TIC culture. This culture change process did not occur overnight; it took several months to see the change. However, as employees saw the results of their changed culture, there was more and more consistent use of TIC interventions, until this became the norm. Summary of Program Implementation Timeline Awareness of the problem of too many uses of physical restraint and seclusion interventions led to a sense of urgency and buy-in from leadership escalated the need for change. This was communicated to staff over a period of about 2 months before the educational interventions focusing on TIC with an emphasis on deescalation techniques were rolled out. During this time, all needed administrative updates were completed. Multidisciplinary discussions and retooling of patient treatment and care plans began following the educational interventions as well. Implementation of the debriefings with video review followed approximately 2 months later. This entire process took about 6 months; culture change was in place by the end of 12 months. Results Post Implementation Data The last phase of designing and piloting a practice change is to report postimplementation data (Iowa Model Collaborative, 2017). In this case, data were analyzed weekly and reported to staff monthly during the change process. Formal evaluation of the project occurred at 6 months and again at 12 months; see Figure 2 for project timeline. These data appear in Table 1 and demonstrate an overall reduction in crisis interventions of holds and seclusions of more than 41%. The administrative decision was made (Decision Point 3) to continue using TIC philosophy and interventions throughout the organization. Open in Viewer Figure 2. Number of uses of crisis interventions (restraint and seclusion events) 6 months before and after implementation. Open in ViewerTable 1. Number of Uses of Crisis Interventions (Restraint and Seclusion Events) 6 Months Before and After Implementation. Events Before After Difference Seclusion 215 125 −41.86% Restraint 225 134 40.44% Total 440 259 −41.14% Integrating and Sustaining the Change In this phase of the Iowa Model-Revised (Iowa Model Collaborative, 2017), identifying ways to hardwire this change is emphasized. At this organization, the three different floors of the inpatient psychiatric hospital with children and youth, key stakeholders continued to be front-line staff. Administrators engaged key personnel by creating a friendly competition among floor staff to identify each month, which area has used the least number of crisis interventions. Success in this endeavor became a point of pride and further embedded these behaviors into the culture. Reinfusion of information occurred systematically during new employee orientation and through yearly competencies. As a result of these continued efforts, the changes have been sustained, and crisis interventions have continued to decline marginally, with about a 4% lessening at 12 months’ follow-up. Dissemination of these results remains the final step. Discussion Reducing the numbers of physical holds and seclusions for aggressive or disruptive behavior in pediatric inpatients may have impact on the patients’ quality of life while hospitalized. By identifying and implementing a TIC culture, with an atmosphere of caring, empathy and concern there was a notable decrease in the overall tension on the units. The staff anecdotally expressed pride in successfully implementing and establishing these changes. Because of key stakeholder buy-in, the changes were sustained, with data at 12 months demonstrating a further reduction of holds and seclusions by 9.3%. The EBP framework of the Iowa Model-Revised (Iowa Model Collaborative, 2017) provided a strong foundation for describing this important work. The model itself provided consistent input into the iterative steps of evidence-based practice change and strengthened the reporting of the project and outcomes. It serves as a useful tool for similar work. Limitations of the project include a lack of staff participation at the outset of the project; however, their engagement grew as the project unfolded. There was no formal assessment of staff or patient satisfaction and impact on staff turnover was also a gap. Staff data to support culture change was lacking and would have been useful to evaluate the current culture. Another gap was the lack of patient input (Azeem et al., 2015) in the processes, especially the debriefings that included video review. Much powerful learning was missing because of this: The patient could have had the opportunity to see their own behavior on video and through the eyes of the caregivers; likewise, caregivers could have queried patients about their feelings and thoughts at the time. Adult role-modeling of learning to change behavior through reflection was another opportunity missed. Further research is needed to determine the impact of a TIC culture on specific patient and staff outcomes. Implications for Nursing Trauma-informed care in nursing practice decreases the use of crisis interventions and the risk of retraumatization (Hammer et al., 2011). Implementation of a TIC program fosters an environment that sustains a culture that thoughtfully considers a patient’s past trauma to facilitate patient care in a context of current and future mental health needs (Bartlett et al., 2016). Patient care is positively affected by a decrease in crisis interventions; staff are now aware of the patient’s trauma and provide multiple approaches to manage a pending

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