Sustained Clinical Training and Capacity Building through International Collaboration: The Safe Children Vietnam Project

Purpose: Frontline Paediatric Emergency Department (ED) staff are charged with the responsibility of managing injury and trauma presentations and making complex care decisions around the clock. An ongoing international collaboration between Sydney Nursing School at the University of Sydney and Children’s Hospital 2 in Ho Chi Minh City, Vietnam was initiated in 2013. The purpose was to provide sustained clinical training and build research capacity to improve recognition and response to child injury through maltreatment in the ED.   Following initiation of the study and clinical training program implementation, relationships were established with UNICEF and the Ministry of Health (Vietnam). The ability to translate research outcomes into wider practice relies on influencing policy and legislation surrounding the reporting and management of child maltreatment cases. These key relationships are an important element of translation of the research findings. Ideally, it is intended that the Safe Children Vietnam (SCV) program will eventually be replicated throughout rural and urban provinces in Vietnam. There is scope for the clinical training program to be implemented in other countries and regions where child protection training and research capacity has been identified as a priority.

Methods:

Action research was used to initiate, implement, and evaluate a suite of clinical training strategies. Following an initial needs analysis, the participating units identified as those with highest impact and ability to disseminate knowledge and skills to other departments included ED, Outpatient Department (OPD) and the Burns Reception Unit (BRU). Staff from each of these departments participated in train the trainer and research workshops. The Chief Investigator conducted a site visit immediately upon the award of grant funding, to establish key relationships, and secure support. Following input from stakeholders within the hospital, a needs analysis was then conducted to establish current practice, knowledge, and protocols regarding child maltreatment presentations, and what kind of intervention would be most appropriate and have the best uptake. At this point, the Project Manager resided in-country for a 6-month period to strengthen relationships and develop the training intervention. Findings from the needs analysis were used to inform the development of the training program. Additional input was sought from senior staff in the participating departments.

A multi-mode approach was used, and all training was conducted in Vietnamese. This included use of a workbook, lectures, workshops, short-film, and posters. Key components of the training intervention included specific training regarding the recognition and response to abusive head trauma presentations, and the implementation of a Child Injury Screening Tool (CIST). A train the trainer model was employed to encourage sustainability of the intervention. Quantitative surveys were conducted amongst nurses and doctors prior to the training intervention, immediately following, and repeated at 3-months post-intervention. Focus group interviews were conducted at the 3-month follow-up.

The Project Manager employed in-country support staff to assist with translating documents, facilitating meetings with hospital stakeholders and community organisations, development and implementation of the training intervention, learning the Vietnamese language, and understanding cultural norms and expectations. In particular, the CIST, developed at the request of senior nursing and medical staff, underwent a thorough process of consultation and revision to ensure appropriate content and format for use in the ED.

Achieving high-quality translation of materials was a key priority of the project. All materials, including participant information statements, consent forms, quantitative surveys, training materials and the CIST were fully back-translated to ensure consistency of content. In addition to back-translation, feedback was sought from a variety of stakeholders regarding the suitability of the materials for use in the clinical setting to ensure cultural and procedural validity. In-depth interviews and focus groups were conducted in Vietnamese and English, with transcriptions provided in full in English for analysis. A selection of focus groups were also transcribed and analysed in Vietnamese to ensure consistency of meaning and thematic analysis.

Results:

Needs analysis was conducted via in-depth interviews and focus groups with nursing and medical staff from the ED and OPD. Clinicians reported low levels of personal confidence and professional self-efficacy in their capacity to recognise and respond to child maltreatment presentations; an urgent need for training and the development of protocols to assist in the recognition of and response to child maltreatment presentations; and an apparent conflict between the professional role (obligation to medically treat the child and discharge from hospital) and the ethical role (the need to protect the child from further harm, yet not having a framework to do this); and child maltreatment legislation in Vietnam. 

Participating clinicians reported difficulty in attending the training sessions due to time pressures within their workplace. In spite of these barriers, participation rates were excellent. Recruitment to the training intervention was highly successful, with staff participation greater than 50% across participating departments. Completion rates of the training workbook were higher than expected, with 72% (n=74) of staff having partly or completely finished the workbook at the time of initial follow-up; and senior medical staff assumed responsibility for designing and conducting further staff training in November 2014, under supervision of the Safe Children Vietnam team.

Results showed a statistically significant improvement in professional self-efficacy for the recognition and response to child maltreatment presentations, as well as knowledge of abusive head trauma. Some barriers were encountered in the implementation phase of the CIST. With high patient ratios, staff struggle to complete detailed documentation. Implementation of the screening tool was seen to add to that burden.

Conclusion:

The SCV project was successfully implemented largely thanks to high levels of support and cooperation from stakeholders in Vietnam. Both evaluative and intervention stages of the project experienced high levels of participation, and clinicians reported positively on their experiences of the program during evaluation. Clinician knowledge and professional self-efficacy regarding child maltreatment and abusive head trauma improved significantly following the training intervention. Further work on successful implementation of the CIST is needed. An action research approach ensured fluidity in training intervention development and implementation, and was a core component to ensuring the intervention was relevant to clinical need.

In summary, this collaborative relationship was able to thrive due to a number of factors, including: project staff living in-country for sustained periods of time, communication occurring in a timely and respectful manner, participants embracing one another’s cultural differences, and a sincere openness to suggestions and input from all stakeholders. As a direct result of this successful collaboration, further relationships were developed with NGOs in Vietnam, the Ministry of Health (Vietnam), academics at a local university in Vietnam, and independent research groups. These relationships are essential to ensure the sustainability of SCV as a tool to improve clinician recognition and response to child maltreatment in the present, and towards the future.