Developing an Evidence-Based Educational Framework to Support the Trauma Care Competencies of Intensive Care Unit Nurses in Saudi Arabia

Abstract

Background The management of trauma patients in intensive care units (ICU) has a significant impact on patients’ survival and outcomes. Trauma care during this phase is complex, and care management requires skilled and knowledgeable nurses to deliver competent care and improve patient safety and outcomes. To ensure the delivery of competent care within the high-tech and constantly changing ICU practice, continuous and in-service education/training are needed. Research on trauma care education beyond emergency in critical care environments is scarce, especially in contexts that have a workforce with diverse educational backgrounds.

Overarching aim To develop an educational framework that informs the basis of and/or theoretically drives interventions for supporting ICU nurses' trauma care competencies, meeting the needs of a mixed-culture workforce context in Saudi Arabia.

Design and Methods The study was guided by the Medical Research Council (MRC) framework for developing complex interventions and consisted of three phases, drawing upon the development stage of this framework: Phase 1 involved a systematic review and meta-analysis that examined the effect of educational interventions on trauma ICU nurses' competence. Additionally, a review of educational learning theories was also completed to base the educational framework development on established theoretical ground. Phase 2 consisted of the main study, which was an exploratory multiple embedded case study design that incorporated three hospitals from two different regions within the Kingdom of Saudi Arabia. Key informants or stakeholders were members of the nursing workforce recruited from the adult intensive care units (ICUs). Data were collected through semi-structured interviews complemented by documentary reviews of trauma-related education syllabi, competencies, and care protocols. This was to provide an in-depth understanding of the local context, practice, and education needs in ICU trauma care and to explore the factors influencing nurses’ in-service education in Saudi Arabia. This followed by, Phase 3 involved stakeholders' focus groups aimed at refining the initially developed education framework based on interview data and reaching an agreement on the optimal implementation of in-service education across various ICU settings in Saudi Arabia. The datasets from interviews and focus groups were analysed according to the Framework analysis approach, while documents were reviewed using qualitative content analysis.

Findings In phase 1, the systematic review demonstrated the positive effect of trauma care education interventions on nurses’ competence. However, this review identified limited interventions primarily focused on managing traumatic brain injury (TBI) patients. Additionally, the findings are weakened by the absence of theoretical frameworks that go beyond simply delivering and measuring the impact of interventions. Such frameworks should encompass a deeper understanding of context, practice, educational needs, and components, including education format and delivery methods. The absence of these elements limits their generalisability. (Published paper 1) In phase 2, sixty-eight multinational nursing key informants—clinical staff, clinical educators, nurse managers and leaders—were included from the three hospitals. The findings were conceptualised into main categories comprising a number of major themes and subthemes. The first category provides an extensive contextual exploration of trauma care and education in Saudi Arabia. Two interrelated themes relevant to trauma emerged from the data analysis: (i) care practice and (ii) education practice. The trauma care practice highlighted the limited competencies and education support in trauma care, as well as the perceived challenges and educational needs of nurses. The trauma education practice described the staff learning behaviours, supervision practices and in-service education systems in the participants’ settings. These findings were also supported by reviewing the relevant documents. (Published paper 2) In phase 3, the focus groups agreed with the insights provided by the interviewees and suggested a number of ways in which they could help create a favourable environment for nurse training and sustain nurses’ motivations. Based on findings from phases 2 and 3, a main category presented the education content that ICU nurses need to form the trauma ICU education framework. Stakeholders wanted in-service education by subject experts characterised by: (i) relevant educational content; (ii) a range of educational techniques; and (iii) flexible delivery and format. Moreover, a category addresses the factors that enable and inhabit the successful implementation of the education framework in the studied context. Nurses identified factors that encouraged them to participate in this in-service education, including adequate planning, sufficient resources, and a supportive work environment, whilst heavy workloads, scheduling issues, cost, and low-quality training and educators, balancing of life and wellbeing hindered their participation. (Published paper 3)

Conclusion The PhD study presented in this thesis systematically developed a novel and evidence-based in-service education framework that has not been investigated before in the Saudi Arabian context or globally. It constitutes a unique and significant contribution to the body of knowledge regarding the understanding of theory and practice in multicultural nursing workforce education within complex clinical environments. It is anticipated that the framework will yield positive benefits in staff educational training due to its novel methodological approach, combining an exploratory multiple-case study and an empowering education model, underpinned by the MRC development stage, which was successful in developing this context- specific framework. The developed in-service education framework is set to undergo feasibility testing at the post-doctoral level. The use of multiple cases can enhance the transferability of the developed education framework; however, it is necessary for researchers in other contexts to evaluate its adaptability, feasibility and effectiveness. The engagement of key clinical stakeholders in the ICUs, along with thorough consideration of context and practice, is a significant element for the development of the educational framework. Therefore, to enhance the quality, efficiency and feasibility of trauma care in-service education, it is essential to ensure that educational content is highly relevant and motivating for individuals, while also considering the impact of various organisational factors operating in local clinical settings that can influence nurses' in-service and continuing education.