The CHILD study: a Co-designed cHild-centered Interprofessional simulation course to foster Learning through safeguarding Dialogue

doi:10.21203/rs.3.rs-7857922/v1

Background

Globally, in excess of one billion children experience violence and abuse every year, leading to upwards of 40,000 deaths. Child safeguarding education typically occurs in professional silos across healthcare, often focusing on specific undergraduate competencies. In practice, however, child safeguarding requires a multi-professional approach, necessitating effective communication in emotionally charged contexts. To address these needs, we designed an interprofessional course using simulation-based education for experienced healthcare professionals working in the emergency department.

Methods

On three occasions, we delivered an in-person, two-day course with 32 healthcare professionals from medicine, nursing, an in-person two-day course on three occasions with 34 healthcare professionals from medicine, nursing and social work. We collected data using multiple methods including pre and post training surveys (n = 32), observational field notes, individual semi-structured interviews (n = 14) and focus groups (n = 4). We analyzed the data using landscapes of practice theory as a sensitizing concept.

Results

We integrated the insights gained from the open-ended survey responses with our interview and focus group data to generate three key themes 1) collaborative learning, 2) the medium of language and 3) establishing a safe environment. These themes encapsulate our participants' experiences in navigating interprofessional learning within newly established teams during simulated child safety scenarios in the emergency department. Findings also detail participants’ knowledge gains and confidence in reporting child safeguarding concerns.

Conclusions

Child safeguarding involves emotional interactions, ambiguity, and multi-professional coordination. Interprofessional simulation-based child safety training enhances knowledge, communication skills, and teamwork. Simulation educators should emphasize psychological safety, flatten hierarchy, and expose participants to the language and perspectives of other professions and simulated parents to make safeguarding a shared, interdependent responsibility. Integrating authentic, psychologically secure, and child-centered simulations into health and social care curricula and reinforcing these lessons in workplace cultures can improve workforce preparedness and child protection outcomes.

child safeguarding

child protection

interprofessional education

interprofessional simulation

post-registration/postgraduate learning

co-design

simulation-based education

experiential learning

Worldwide, over 1 billion children per year experience violence and abuse, causing long-term emotional, social, and economic consequences, including over 40,000 deaths (1). When healthcare professionals (HCPs) suspect child protection concerns, they must communicate these concerns with parents/caregivers empathetically and unambiguously. Within safeguarding frameworks, child abuse is conceptualized through four distinct yet interconnected categories (2): neglect, emotional abuse, physical abuse, and sexual abuse (see Fig. 1). This categorization provides necessary structure for identification and intervention, also accounting for the stark reality that children often face multiple, overlapping forms of maltreatment. However, these sensitive situations challenge professionals as well as parents and caregivers, leading to additional anxiety in an already stressful situation. Evidence indicates that HCPs may not possess the requisite communication skills to effectively address concerns about potential signs of child abuse with parents (2–5). These “difficult conversations” (4) present emotional difficulties for HCPs (6) and parents alike (7).

Insert Fig. 1: Four categories of child abuse (Tusla, 2017)

Child-safeguarding concerns also place unique demands on communication among multi-disciplinary and interprofessional teams. Indeed, even after children at-risk for abuse are identified, nearly all failures of child protection involve communication breakdowns between professionals (8). These communication barriers contribute to underreporting of suspected child abuse concerns (2, 5). Additionally, parents in these situations may be psychologically and physically exhausted; they may reject professional support and develop negative biases towards child welfare agencies, making effective social support even more important (9). Thus, HCPs require not only training to improve the detection and prevention of child abuse (2) they must also communicate effectively with parents and caregivers of children at risk of abuse or neglect, all while sensitively managing difficult emotions and feelings. Further, these HCPs must communicate in ways that foster cooperation and engagement with both the HCPs and child welfare services.

The remit for child protection does not reside in one single agency. The scope of the problem places the onus on professionals across sectors and agencies to work together not only to recognize signs of potential abuse, but to ensure that individual cases traverse the various points within the system without falling through the cracks. At all stages in the process, high levels of professional awareness, sensitive and empathetic practice must be combined with effective communication skills and multi-agency working (10). Only then will the system, meant to ensure child safety, both identify and deal with these difficult situations effectively, thus preventing additional harm and even preventable deaths.

Unfortunately, current child protection training is referred as “atomistic” (11), typically occurring in professional silos (12), viewing collaboration as a technical problem rectified through “best practice” guidelines or online modules (2). These modules may provide the necessary knowledge related to child safety, yet they do not address the considerable team and communication skills required to ensure that children-at-risk and families successfully navigate a highly complex system. This siloed approach also neglects unpredictable contextual situations, which may trigger conflict and mistrust within interprofessional teams and highlight the highly social nature of team-based clinical practice. In child safeguarding, this team-based practice is essential for the interprofessional collaboration required for effective child safeguarding, highlighting the need for integrated approaches to interprofessional education (IPE) (8, 13–15). An extensive literature base emphasizes the role of IPE in prelicensure health professionals (16); unfortunately, this work often highlights approaches that bring together learners with little to no lived clinical experience and does not address the needs of practicing health professionals.

Multidisciplinary simulation-based education (SBE) curriculum design offers a potential approach to embed complex cases of child abuse into an interprofessional learning experience that fosters contextual collaborative skills in unpredictable environments. IPE creates positive interaction, encourages interprofessional collaboration and improves client care (17). How to effectively design such interprofessional courses for a postgraduate audience remains less clear. Such a course would require the alignment of ‘language, learning approaches and curriculum timetables and …people’ (18).

Child safeguarding is not a uni-professional area of knowledge (14). This system involves a chain of professional practices including health and social care, education, and law. The whole system learns from the interplay between the knowledge and practices as professionals cross sectoral boundaries and interact with different professions (19). To truly harness the collective expertise across these diverse professional boundaries, a co-design approach becomes essential; one that brings together professionals from all relevant disciplines as equal partners in the design process (20), ensuring that safeguarding systems are built upon integrated knowledge rather than aggregated individual perspectives (21). Such an approach recognizes that effective child protection emerges not from the sum of separate professional contributions, but from the collaborative creation of shared understanding and coordinated practice (13). By facilitating collaborative learning environments, professionals from different disciplines can explore their own and others' roles and contributions to child safeguarding (22). This cross-disciplinary perspective helps organizations understand how learning happens not just within communities, but across the boundaries between them, revealing opportunities for knowledge sharing and collaboration that might not be obvious when looking at individual communities in isolation (22).

This study describes the implementation of a co-designed interprofessional simulation-based child safeguarding course (CHILD), created in partnership with experienced child protection professionals. We sought to establish design principles to create educational conditions conducive to interprofessional learning in this specialized practice domain. The research explores how interprofessional learning mechanisms operate within the context of simulation-based child safeguarding education for health professionals in practice.

2.1 Study context

The study was conducted at the Royal College of Surgeons Ireland (RCSI), University of Medicine and Health Sciences, and received ethical approval from the RCSI research ethics committee (REC 202206004). Three iterations of the co-designed simulation-based curriculum for interprofessional collaborative practice in the context of child safeguarding were delivered and evaluated.

2.2 Theoretical framing

A sociocultural perspective, namely landscapes of practice (LoP) theory, served as our theoretical framework for understanding learning within the child safeguarding course. This theoretical lens highlights social and cultural aspects of learning and collaborative knowledge creation in specific contexts (23,24). LoP acknowledges that learning is more than an individual process; learning is influenced by social and cultural practices of a particular community or group. Learning and knowledge creation are dynamic processes as individuals and communities interact. In the child safeguarding context, the care of these at-risk children demands collaboration and coordination between hospital-based practitioners and those in outpatient jurisdiction. These health providers come from a variety of professions and disciplines, such as pre-hospital providers, physicians, nurses and social workers to name a few. All of these practice locations and professional groups represent distinct communities of practice (CoP). LoP builds on Lave and Wenger's 1991 CoP model (25) and better addresses the complexities of learning in diverse and interdisciplinary contexts, such as the practice of child safeguarding. Ideally, the boundaries between CoP within a LoP are fluid and permeable, enabling the sharing of knowledge and resources across communities. The conditions that promote boundary spanning behaviors in child safeguarding are essential given the interprofessional nature and complexity of healthcare.

2.3 Course Design/Description

We implemented and evaluated three iterations of the two-day, in person simulation-based interprofessional child safeguarding course. The course was situated within the specific context of an emergency department setting, where instances of child abuse and neglect often become apparent and demand an immediate interprofessional response.

The course had two aims: (a) to prepare emergency professionals to contribute to the care of children-at-risk through effective interprofessional teamwork and collaboration, and (b) to advance the science of IPE by understanding how to create conditions that foster cross-professional learning.

Through an iterative and collaborative co-design approach, we recruited three pediatric professionals (doctor, nurse, and social worker) who served as co-faculty throughout the implementation. These individuals were experienced professionals from the national children's hospital group in Ireland, Children’s Health Ireland, and the national child protection agency, Tusla. Prior to course implementation, we facilitated faculty development workshops, centred on the PEARLS model for debriefing (26), to prepare co-faculty and provide opportunities for practice. During the course, all simulation scenarios were debriefed by pairs of debriefers from different professions to ensure multi-professional perspectives were represented.

Seven simulated participants (SPs) were recruited from a pool of trained SPs involved in simulation-based education at RCSI to participate in the course. These SPs (members of a professional acting group with extensive experience in the RCSI teaching activities) portrayed simulated parents across the three course iterations. The group comprised one male and six females, aged between 26 and 55 years, with professional experience ranging from 5 to 30 years. All SPs had completed a structured training program provided by RCSI SP educators, following the Association of SP Educators' Standards of Best Practice (27). This training encompassed simulated role portrayal, healthcare consultations, and feedback provision. For this course, SPs received scenario-specific training, including access to scenario scripts and pre-briefing materials one week prior to each iteration (See Appendix). On course days, faculty conducted practice runs of the three scenarios, enabling SPs to clarify questions and refine their performances to align with the learning objectives.

Due to the sensitive and emotionally challenging nature of the course content, children and young people were not directly involved in the course development process. Instead, we partnered with Empowering People in Care (EPIC), an advocacy service supporting children and young people (up to age 26) with care experience, to ensure that the crucial perspective and voice of the child was represented throughout the course design and implementation. Participants undertook activities, guided by EPIC facilitators, that reinforced the importance of child-centred care.

The course utilized three immersive simulation scenarios that required an interprofessional and multidisciplinary approach. Detailed descriptions of the simulated scenarios, including learning outcomes, SP role portrayal guidance, and debriefing scripts for co-debriefers, are provided in Appendix A.

The intervention is reported using the TIDier checklist (Appendix B) as well as healthcare simulation research reporting guidance (28).

2.4 Participant Recruitment

Participants included postgraduate HCPs who were actively working with children within the care pathway for at-risk populations in the Republic of Ireland. The course recruited professionals from four specific groups: pediatric nurses, pediatric doctors (Dr), pediatric medical social workers (MSW), and child protection/community social workers. All participants were required to have completed their undergraduate training and be working in teams that manage children's care, with proficiency in reading and writing English. Eligible participants were professionally employed in health or social care disciplines that designated them as mandated persons for child safeguarding reporting, requiring them to previously complete the HSE online training in child protection. The study excluded individuals under 18 years of age, undergraduate health profession students, those unable to communicate in English, professionals not working in mandated reporting roles, and individuals serving in voluntary capacities. Participants were identified via the research team’s professional networks and invited to participate via email. The Participant Information Leaflet and consent form were provided: (a) by email at recruitment, allowing participants time to consider their participation, and (b) on the day of the intervention. Purposeful sampling ensured a balance from various professional groups. Researchers recruiting participants and collecting data were not involved in their employment or professional evaluation.

2.5 Data Collection

We used multiple methods for collecting data for this study, including pre and post intervention surveys, observational field notes during the intervention, followed by post-intervention semi-structured interviews and focus groups. The overarching research programme was informed by co-design workshops with multiple professionals involved in the chain of child safeguarding in Ireland.

2.5.1 Participant Demographics

Prior to the training intervention, participants completed a survey to gather demographic information: gender, age, years of professional experience, professional background.

2.5.2 Interprofessional Experience

Participants were invited to provide information relating to their interprofessional child safeguarding experience, including other professions with whom they have liaised for child safeguarding concerns in the past three months, and the number of reports they have made of child safeguarding concerns in the past three months.

2.5.3 Interprofessional Child Safeguarding Cases Tool

Cases from the HSE Children First Training (Tusla, 2017) were adapted to a 10-item case-based tool, to assess participants' ability to evaluate child safeguarding concerns and their self-reported confidence in their assessments. The activity included 10 case-based scenarios involving potential child safeguarding concerns, that alluded to one or more of the four classifications of child abuse Neglect, Sexual Abuse, Emotional Abuse and Physical Abuse (see Figure 1). A detailed summary of the 10 cases is provided in Table 1. For each case, participants were asked to state if they would report a child safeguarding concern (Report/Not report), and how confident they were with their decision (Likert scale 1 = Very certain to 5 = Doubtful). Additionally, participants were provided with a free text box to include their rationale for their decision and reported confidence in the decision. Participants were asked to complete this activity before and after the training intervention to examine the potential impact of the training intervention.

Insert Table 1 Summary of the ten cases adapted from the HSE Children First Training

2.5.4 Post course interviews and focus groups

Qualitative data was collected through multiple methods to capture participants' learning experiences and decision-making processes. Semi-structured interviews (n=14) and focus groups (n=4, with 12 participants in total) were conducted following course completion to explore participants' perspectives on interprofessional collaboration, learning outcomes, and the application of knowledge gained through the simulation-based training (see Appendix C for the interview guide). The interviews and focus groups occurred online, two to four weeks post course. The interviews lasted on average 30 minutes in duration, while focus groups took 45-60 minutes. Interview or focus group choice was determined by participant availability and logistical considerations. Additionally, free-text responses from the Interprofessional Child Safeguarding Cases Tool offered rich qualitative insights into participants' thought processes, professional knowledge application, and the evolution of their decision-making frameworks, related to child safeguarding concerns, before and after the educational intervention.

2.6 Data analysis

2.6.1 Quantitative Data

Independent sample t-tests, at the significance level of p < 0.05, were used to compare participant confidence in their decision to report or not report a child safeguarding concern in the Interprofessional Child Safeguarding Cases Tool, pre- and post- simulation training. Quantitative data analysis was carried out using STATA v13.

2.6.2 Qualitative Data

We used theoretical thematic analysis to analyse qualitative data from interviews supplemented by field observations (29). The LoP framework served as a sensitizing concept to guide the deductive analysis, providing theoretical lenses through which interprofessional learning and boundary-crossing behaviors within the child safeguarding context could be examined. We used Nvivo to support data analysis.

Reflexivity

Our team comprised various professional backgrounds, which contributed to our analytic framing. Five members of the research team had ‘insider status’ in the studied professional domains, so we reflected on our individual positionality during analytical team meetings (30). MOT is a former first responder with responsibility for child safeguarding, and a health professions educator. WJE and DH are both pediatric emergency physicians, health professions educators with simulation expertise. AW is a pediatric nurse specialist with vast experience in child safeguarding in sexual assault treatment centers. MW is a social worker with a background in the national child protection agency. CS is a simulation researcher, with expertise in SP methodology. NC is a former primary school teacher, simulation researcher and lecturer in game design. CM is a geologist, a lecturer in simulation with SP methodology expertise and AJD is a medical physicist, health professions educator with SP methodology expertise.

We now report the results of the study, first highlighting the quantitative survey responses and subsequently integrating the qualitative data from both the open-ended survey responses (Table 3), with interview and focus group data.

3.1 Participant Demographics

Thirty-two participants (25 female, 7 male) participated across the three course iterations: 12 (iteration one), 10 (iteration two), and 10 (iteration three). Participants included medical doctors and nurses working in pediatric context, as well as social workers from both the clinical context and the child protective agency in Ireland, Tusla. Participants reported varying levels of experience in their professional role, from one year up to more than 20 years’ experience (Figure 2).

Insert Figure 2 Participant experience in their professional role

To understand participants' familiarity with the process of reporting suspected child safeguarding concerns, participants were asked to disclose the number of cases they reported in the three months prior to taking part in the training intervention, see figure 3. Participants on average reported up to five cases, however, one nurse reported 24 suspected cases of child abuse in the months prior to the training.

Insert Figure 3: Number of cases reported by participants three months prior to training intervention

Additionally, participants were asked to list the number of other HCPs they engaged or collaborated with while managing suspected child safeguarding cases in the three months prior to taking part in the training intervention (Figure 4). The social workers from Tusla, the national child protection agency and the pediatric nurses engaged with more professionals than the medical social workers and the medical doctors.

Insert Figure 4: Interprofessional experience three months prior to training intervention

3.2 Interprofessional Child Safeguarding Experience

Table 2 presents the participants' decision to report/not report suspected child abuse concerns based on the 10-item case-based tool, before and after the training intervention. While there was little change across some of the cases, cases 4, 5 and 8 are statistically significant, at the p < 0.05 level, indicating a change in participant responses because of the training intervention. To assess confidence in making a report about possible abuse, there were tendentiously significant quantitative improvements reporting confidence decision (Likert scale 1 = Very certain to 5 = Doubtful). The data are represented as mean pre and post training scores and across all cases the data suggests that participants were more confident in their decision after the intervention- note that lower scores post training indicate higher levels of confidence.

Insert Table 2: Participant decision to report/not report child abuse concerns and their self-reported confidence before and after training

Insert Table 3: Case content qualitative analysis

3.3 Qualitative themes

We used the landscapes of practice principles of engagement, imagination, and alignment as a theoretical lens. We generated three key themes from our participant focus groups and interviews and combined these with our learnings from the open-ended text in the survey responses. These themes include: (1) collaborative learning, (2) the medium of language and (3) creating a safe space. These themes represent our participants’ experiences in navigating interprofessional learning in newly formed teams during simulated child safeguarding scenarios in the emergency department. The themes both facilitated and influenced each other, i.e. creating a safe space enhanced collaborative learning among the interprofessional teams and sharing the nuances of each discipline’s lexicons contributed to both psychological safety and collaborative learning. Combining the learnings from this course resulted in knowledge translation and integration to the workplace, namely enhanced communication skills with both colleagues and patients, and a deeper understanding of the multi-professional approach required for effective child safeguarding practices.

Collaborative learning

Collaborative learning encompassed an array of experiences, where participants became more aware of other professionals’ roles in the collective goal of keeping children safe. They reflected on their own roles and responsibilities and how teamwork is essential in real world situations where child-centered care is the utmost priority. "The reality is that child protection is everyone's responsibility, and it doesn't just happen when the social worker is in the room" (P08, MSW).

Participants noticed a gap in their knowledge regarding the specific roles of other HCPs and realized that they have been working in silos for far too long. “But when you actually open those doors and you get a glimpse inside of what the other service provides and how the other professionals work, I think it kind of breaks down those walls and makes it more of a team and interprofessional effort than just me versus you” (P18, Nurse). Participants realized that this interprofessional training helped to complete the picture of the further care these children would receive, noting: “…how beneficial it is to know what other people's roles are and what they can and cannot do…so I, as a nurse will know what exactly my social worker is going to help with and what Tusla [child protection agency] will do in a case, for example. I probably didn't know that much, If I'm being totally honest…oh, I just handed it over to the social worker, but that’s not the case, you know?” (P11, Nurse).

In terms of reporting cases, a common response from participants before they completed training related to the ambiguity and the need for further information before they could decide to report or not report. For example: “Unless I had further evidence that this type of bruise could be a result of NAI [non-accidental injury] then I do not believe I have enough information to work off of in order to make a report to Tusla [National child protective service agency]” [P31, MSW, “Do not report”, Case 8, Pre-training].

After the training intervention there was a greater sense of confidence and assurance to identify a child safeguarding concern and to develop strategies to support the parents and children described in these cases: “Based off new information I received on this course, I now know that bruises on the neck can be a child protection concern and therefore Tusla may need to monitor the family following initial assessment”[P31, MSW, “Report”, Case 8, Post-training].

These findings demonstrate that through the interprofessional course, participants gained new knowledge from engaging in training and collaborating with others. Additionally, the change in this participant’s decision from “Do not report” to “Report” demonstrated an increased awareness of the nuances of potential child abuse concerns, as well as a deeper understanding of Tusla’s role.

Participants also identified concrete value in the cooperation of hospital-based and community-based teams to achieve their common patient safety goals: “I have the height of respect for the medical teams and trust their judgement completely. And it’s just having it joined up between ourselves, the community-based teams and the medical teams…it’s lovely too, the joint approach, (be)cause it makes it more real…It’s like reading a book and acting out a role- it’s just so much more powerful” (P17, TSW).

Participants also appreciated other professionals’ lived experience in the complex world of child safeguarding and expressed gratitude for the opportunity to talk about their common struggles and normalize their experience: “Actually getting to engage and being on the same course as people from the different disciplines just changed everything cuz you could actually discuss it with them. Things are so much different when you talk to someone with life experience and who's doing the job, than just reading about it in a book or maybe hearing from say one expert, like one lecture, just actually getting to chat things through” (P33, Dr).

Alongside the gap regarding other roles, participants described how they felt burdened by the gravity of these child safeguarding concerns; knowing that other providers are also mandated reporters of suspected abuse somehow eased the heaviness of that load: “So I think that kind of eases things as well in my mind a little bit when, you know that the other professionals on the team are sending off their referrals as well to add to yours and fill the picture” (P24, Dr).

They also recognized differing priorities among the professionals which seemed to mitigate some preconceived tensions that they previously experienced in similar workplace situations. One social worker described a lightbulb moment: “Seeing what the doctors are having to deal with… I can understand why they’re focused on the medical bit...it was a bit of a reality check…This is a sick kid and needs a doctor to look after them” (P04, MSW).

Interestingly a physician made the same observation from her perspective: “… The social worker was like, wow, I didn't realise you done that much work or you spent that much time… then we were explaining, myself and the nurse, [how] a case would often take a few hours in A and E [Emergency Department] before you'd be contacting Tusla. And they were very surprised at that” (P33, Dr). This interaction shows how working together ensures deeper understanding and awareness of what each profession is trying to achieve.

The Medium of Language

Shared learnings incorporated various terminologies and communication strategies across the different professions of medicine, nursing and social work. Of note, the use of shared language was considered a key take-away, both while working across professional boundaries and also through professional interactions with parents. During a simple telephone exercise, participants discovered for the first time the relevant communication checklists and mnemonics that were used in different disciplines. For example, the “Signs of Safety” is a child protection tool used in social work referrals and SBAR (Situation Background Assessment Recommendation) is regularly used as a handover protocol in medicine. These tools helped to increase understanding of both the specific situation at hand, and of the wider contextual nature of the non-accidental injuries: “We do a lot of referrals to Tusla but we don't have Signs of Safety that they use as their checklist, you know, from the referrals they are getting from us so then it's difficult. There's a loophole there for not putting the correct information in that they're looking for, because we don't have that piece of the jigsaw, that they are using as their tool” (P09, MSW).

Providing opportunities to reflect and discuss the relevance of these discipline specific tools in a safe learning environment, gave professionals the confidence to ask more relevant questions when they returned to the workplace: “I had a phone conversation the other day with a doctor who said something that I didn't know, but I just asked him about it and he was like, oh, sorry. And explained it. And it's just nice when you have that respect for each other. And it's very easy to just be open and be aware that, we may not know the same terms and things like that. And so I felt like that was highlighted in that simulation” (P31, MSW).

This interprofessional training provided both the clarity and the permission to be honest in sharing knowledge gaps. While watching others in the simulated scenarios, participants acquired new ways of communicating, which inspired reflection on how they would communicate in similar situations: “Certain words, certain things that I would have picked up on from maybe two people in particular, a nurse and a social worker in that scenario and it was the way that they brought the information to the client’s attention but in a very non-threatening way… it was lovely to observe” (P14, TSW).

Participants realised that more experienced colleagues had diverse styles of communicating to help parents feel reassured, depending on the context: “I learned a few very crisp lines from that discussion.... We try to stay empathic, but their tone and everything well that was a big learning point for me, to learn from others that do it every day. I learned a few new words that I should say to parents to make them more comfortable” (P13, Dr).

Sometimes these moments of clarity occurred across different professions, which participants found very helpful for practice: “During the break after my simulation, I talked to the social worker… and what they would do is sit down and give a warning shot…they would just lay down everything on the table without jargon and tell them ‘this is what is happening’. And the greatest insight that I got from that was that yes, you're telling the parent that ‘this is what is happening and we are not blaming you, but if this continues, this is what will happen to your child’…And I will be using that now in my profession” (P24, Dr).

Whilst the simulated scenarios were helpful for improving communication skills and developing specific language, other elements of the curriculum also proved beneficial. Participants learned clear and concise communication from experienced faculty members during the post-simulation debriefing sessions: “So ‘the main thing is to say the main thing’, is what he said. And I think that really resonated with me… that it's important to make sure that you keep your message concise and that everyone can pick up what you are saying, ‘cuz what you say and how people perceive it can be two different things” (34, Dr).

The child’s perspective was also enlightening. Whilst this curriculum did not engage child actors as simulated patients, an external agency from EPIC (Empowering Children In Care) facilitated mini role play activities to ensure the child’s voice was included. “I thought it was really good to have the representative from EPIC…. [It made us] think about how we talk to children, how we talk to them about what’s happening. And even when we try not to use jargon, we probably are. So I think it was really powerful to just hear that voice” (P08, MSW).

Creating a safe space

Participants came to this training from various professional backgrounds but also with mixed levels of professional experience, both in their day-to-day practice and with their child safeguarding content expertise. While the course was promoted as simulation-based, some had more practice with this educational technique than others. Most had already completed the purely didactic and mandatory online Children First child safeguarding training. Therefore, establishing psychological safety was a critical element to the success of our interprofessional training sessions, which all participants acknowledged: “We're all professionals that were coming into something new that none of us had actually, I suppose, been aware of or done anything like this previously. So we were all on the same level” (P31, MSW).

A number of deliberate strategies helped to create a safe learning environment in which participants felt relaxed and comfortable enough to speak up and share their experiences, regardless of their differences:

"In some courses they will say so who's interested to speak... you have to put your hand up. And for me, I think it's intimidating, especially I'm from [country] so English is not actually my first language... So I liked being addressed by name, it was very encouraging" (P01, Dr).

Alluding to the challenges of power dynamics in healthcare, participants felt that the learning environment addressed this effectively: “There’s a total flattening of hierarchy, which for me is not an issue…but I remember working in [setting] and there was very much an issue between different professions but there’s none of that [here]. It’s a total focus on the child and the presentation. And it’s really nice to see the respect people have for each other” (P17, TSW).

There was a sense of feeling valued and included, regardless of role or experience, and this created comfort in sharing and learning together: “…Inclusion is one of the pillars of psychological safety and I really saw that shine throughout the simulations, and where everybody was given a chance to talk, to bring their ideas onto the table. Everybody had a chance to input, and to get something out of it. So that was really good. And it was psychologically safe. Everybody felt that they could do that” (P24, Dr)

This perspective was supported by some of the rationale provided in reporting the cases after the training intervention. In addition to heightened awareness, about child abuse, participants often felt comfortable enough to express their uncertainty and describe the ambiguity more fully: “Unsure if she [the mother] doesn’t want to press charges [against the perpetrator], are we limited? But in terms of the welfare of the unborn child I presume we still need to [report]” [P18, Nurse, “Report”, Case 2, post training].

Building relationships and connections among newly assigned teams during the course proved successful through icebreakers and layering up task complexity: “I really liked the comic thing [teambuilding exercise] because everyone was having fun and we managed to break the ice with everyone. So when we went into smaller groups, it was easier. Like you could ease into it” (P01, Dr).

Participants enjoyed their small group allocations, and this was important for collaborative learning as well as psychological safety. “Breaking off into small groups for tasks as well as being in the same group the first day, and the second day was probably beneficial because I found on the second day we were all chatting about what we were doing at the weekend. And you’ve only met these people! Do you know what I mean?” (P3, Nurse).

Curating the space for people to make their own connections was also remarked upon, as participants felt they could network for future learning opportunities: “But I think the breakout, the lunch and just having that informal 15 minutes with someone, again, just builds up that relationship and that trust and that ability to be able to say, oh actually if you ever wanted more information on that, give me a call or vice versa” (P08, MSW).

4.1 Results summary

In summary, our simulation-based child safeguarding intervention impacted participants’ learning and professional practice in various ways. First, our findings suggest that the course experience catalyzed a shift from uncertainty towards greater clarity in terms of increasing recognition that child safeguarding is a shared endeavor rather than an individual burden. Participants gained confidence in their decision-making to both report and recognize child safeguarding concerns, despite complex clinical presentations and challenging conversations. Multiple quotes from our dataset demonstrate how interprofessional dialogue was not only valued but also transformative in broadening professional perspectives and aligning child-centered needs across different sectors. The course also promoted an enhanced child safeguarding lexicon, supporting interprofessional communications and shared vocabulary for future practice. Psychological safety was not only a feature of the training environment but also a facilitating factor, enabling learners to practice challenging decisions, learn from each others’ mistakes, all while developing trust across professions.

4.2 Integration with the literature

IPE benefits from explicit theoretical underpinning rather than relying solely on pragmatic or experiential accounts (18). Using the three principles of LoP theory (23) to guide our analysis, framed our most important findings as established mechanisms of IPE, rather than incidental experiences.

1) Engagement- Our participants actively engaged with each other’s perspectives, breaking down siloes and recognizing shared responsibility for safeguarding.

2) Imagination- Simulated cases afforded participants opportunities to imagine themselves in other roles, developing empathy for colleagues and adopting new approaches to communicate with parents and children.

3) Alignment- Shared language, clarified roles and collaborative decision-making helped participants reach a collective child-centered goal.

We can further interpret our findings through the theoretical lens proposed by Hean et al. (18). Participants described breaking down professional silos that hampered communication, recognizing safeguarding as a collective responsibility. These findings resonate with social capital theory, in which IPE fosters trusting relationships across professional boundaries (18). The sense of psychological safety, equality, and mutual respect reported by course participants in our study reflects the conditions outlined in contact theory, where equal-status interaction under a shared goal (child safeguarding) flattens hierarchy and encourages honesty. Finally, the simulated scenarios, in which participants observed and adopted colleagues’ language, tools, and communication strategies, illustrated the principles of CoP, with learners moving from passive observation to active participation in authentic interprofessional practice. Taken together, these theoretical insights provide a robust explanation of why the training not only enhanced knowledge and confidence, but also transformed how participants collaborated, communicated, and aligned around the shared goal of safeguarding children.

Ambiguity or uncertainty related to reporting potential cases of child abuse was a common experience among our participants, especially in their pre-intervention responses to case reporting. Participants hesitated to report without “enough evidence”. Post-training, they grew more confident to take action even in the face of uncertainty, recognizing that ambiguity is expected in child safeguarding and that collaboration reduces this potential fear of making difficult decisions that have significant impacts for both children and parents. Clinically, this uncertainty also exists, and cases of child abuse and neglect are not always obvious, with a recent Irish study showing that over 90% of clinical examinations often appear normal (31). These ‘normal’ examinations can cause delayed disclosures and systemic issues with accessing support, further adding to the emotional burden on staff (31). Our interprofessional simulation-based course gave professionals the tools and opportunities to apply them in exactly these conditions, reinforcing psychological safety as a prerequisite for full interprofessional participation. Effective psychologically safe learning environments consist of three elements: a) mistakes are welcomed, b) facilitators role model integrity, honesty, curiosity etc. to facilitate positive learning experiences, and c) foundational activities are layered into the training to build expectations and trust before high-stakes simulation is expected (32).

While the main focus of our study was post-registration professionals, our findings align well with a realist review that highlights interprofessional learning for undergraduate healthcare students. Maddock et al. (33) outline that interdependence and embodiment are essential elements for achieving effective IPE outcomes. Interdependence means that learners must genuinely need one another’s contributions, especially in sensitive contexts. Merely being present is insufficient; the tasks must require skills and knowledge from more than one profession to succeed (33). Our participants valued and relied upon one another’s contributions, reframing child safeguarding as a shared interdependent process, often requiring different pieces of information from police, paramedics, medical and social work professionals. Embodiment then refers to creating immersive, authentic scenarios to help learners feel the realities of interprofessional practice (33). Engaging trained SPs to act as parents in our course reinforced the emotional aspects of the simulated scenarios, creating an immersive experience for our participants dealing with challenging cases. This helped learners empathize with both colleagues and parents, adopt new communication practices, and rehearse responses to sensitive safeguarding scenarios in a safe, supportive environment. Maddock et al. (33) also recognized the importance of involving skilled facilitators in sensitive IPE contexts, as well as building in time for reflection, which were key strengths of our study.

4.3 Strengths and limitations

To the best of our knowledge, few if any studies have explored interprofessional simulation-based education with child safeguarding professionals in the emergency department context. By including professionals from medicine, nursing, and social work with varying levels of experience mirrors the real-world composition of safeguarding teams, making our findings directly relevant to practice. We captured multiple methods of data, pre and post intervention, and used theory driven frameworks to guide our data analysis for added methodological rigor. Using simulation-based education was innovative, as most post-registration child safeguarding education in Ireland consists of asynchronous self-paced e-learning modules. In addition, the broad perspectives and expertise within our research team also added to the robustness of this study, as many members of the research team experienced these child safeguarding issues firsthand. We considered these personal experiences in our reflexivity throughout.

We recognize that our study was conducted on a single site and our sample was both purposive and relatively small. Participants did not represent all professionals working in the chain of child safeguarding meaning we may have missed some important perspectives, although the multiple course iterations, multi-method approach, and rich data help counter this limitation. Future course iterations could adapt to different contexts and include different professional perspectives e.g. teachers, lawyers, dentists, community services. Future research should study health professionals engaging in interprofessional training within their usual teams.

4.4 Implications and future directions

Child safeguarding demands continuous interprofessional collaboration and teamwork to ensure children at risk of abuse and neglect don’t fall through the cracks of a fractured system. Our study contributes important pragmatic learnings as implications for future simulation-based approaches to improve interprofessional collaborative practice in this context. Based on our findings and our knowledge of simulation-based education, we propose several design principles to guide others seeking to develop similar courses:

Design scenarios that reflect authentic nuance and complexity to mirror the real cases professionals encounter in practice, by fostering cross-professional interdependence and creating genuine opportunities for interprofessional learning through participation, observation and facilitated debriefings.
Recruit course participants with diverse experience levels whenever possible to foster cross-professional learning.
Embed psychological safety from the beginning of healthcare professional training and attend to it through all course phases.
Foster the use common safeguarding vocabulary throughout the course, since developing a common language to communicate across professional boundaries was transformative for our participants.
Integrate the child’s voice to anchor the safeguarding focus on the child.

These learnings about interprofessional course design also have relevance for the workplace. Workplace teams should ideally replicate these safe learning principles in team-based training. Continuous professional development could include follow-up case-based reviews or team reflective huddles to reinforce the skills learned during the simulations and feed into systems level or quality improvement initiatives.

Child safeguarding practice is characterized by emotionally charged conversations, uncertainty, and multi-agency collaboration. Interprofessional simulation-based training in child safeguarding not only improves participants’ knowledge but also shapes their behavior, communication styles, and collaboration. To establish conditions in which safeguarding becomes a shared, interdependent responsibility, simulation educators should emphasize establishing psychological safety, flattening hierarchy, and exposing participants to the language and perspectives of other professions, as well as simulated parents. Our findings demonstrate potential to enhance workforce readiness and ultimately improve child protection outcomes by integrating authentic, psychologically safe, and child-centred simulations into health and social care curricula and reinforcing these lessons within workplace cultures.

Ethics approval

The study was conducted at the Royal College of Surgeons Ireland (RCSI), University of Medicine and Health Sciences, and received ethical approval from the RCSI research ethics committee (REC 202206004)

Consent for publication

Consent from participants was gathered using RCSI-approved consent forms.

Availability of data

The datasets generated and/or analysed during the current study are not publicly available but are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding:

This work was supported by the Irish Higher Education Authority Innovation and Transformation Program under grant agreement 19032A01.

Author contributions

The International Committee of Medical Journal Editors (ICMJE) provides criteria for authorship:

Conceptualization: Ideas; formulation or evolution of overarching research goals MOT, WE, AD, NC, CS, CM
Methodology: Development or design of methodology MOT, AD, NC, CS
Validation: Verification of results- all authors
Formal analysis: MOT, AD, CS, NC
Investigation: Conducting experiments or data collection MOT, NC, CS, AD
Data curation: Management and preservation of data MOT, NC, CS, AD
Writing – original draft: Writing the initial draft MOT, AD
Writing – review & editing: Critical review, commentary, and revision- all authors
Visualization: Data presentation, figures AD, CS
Supervision: Oversight and leadership responsibility AD, WE
Project administration: Management and coordination AD, MOT, CS, NC
Funding acquisition: Obtaining financial support for the project- RCSI Consortium

Acknowledgements

The authors would like to acknowledge Anastasija Simiceva, Angeline Traynor, Eileen O’Brien, Brian Doyle, Rachael Lee and the RCSI SIM technical team for their assistance in this study. We gratefully acknowledge all participants, including HCPs and simulated participants, for their valuable time, insights, and active engagement throughout this research. We also extend our appreciation to Suzanne O’Brien and EPIC for representing the essential voice of the child in this research.

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Table 1: Summary of the ten cases adapted from the HSE Children First Training

Case	Summary	Concern
Case 1	13-year-old girl looking after 5-year-old brother	Neglect
		Emotional Abuse
Case 2	Pregnant woman with 3-year-old child, presents with injuries inflicted by husband but doesn’t want to report	Physical Abuse
		Emotional Abuse
Case 3	Woman presents to mental health services with low mood and thoughts of self-harm, woman is a single mother with three children	Neglect
		Emotional Abuse
Case 4	Mother of 6-year-old boy attends services with son and appears drunk. Mother denies drinking but blames behaviour on vertigo.	Neglect
		Emotional Abuse
Case 5	20-month-old baby admitted for gastro-enteritis for 3^rd time in 6 months, family homeless, generally unkempt.	Neglect
		Emotional Abuse
Case 6	Dad attends service with 4-year-old daughter with reports that daughter says older brother has been touching her at night.	Sexual Abuse
Case 7	32-year-old woman reports that when she was 6 she was abused by her uncle	Sexual Abuse (Historical)
Case 8	11-month-old baby attends with bruise on her neck. Mother reports she fell while trying to walk.	Physical Abuse
		Emotional Abuse
Case 9	8-year-old girl attends service with her mom. Mom is very critical of daughter and often presents unhappy and aggressive.	Emotional Abuse
Case 10	15-year-old boy brought into A&E by police, drunk, with cuts on his wrist.	Neglect
		Emotional Abuse

Table 2: Participant decision to report/not report child abuse concerns and their self-reported confidence before and after training intervention

Case	Concern	Pre-training		Post-training		P value	Pre-training	Post-training
		Report (%)	Not report (%)	Report (%)	Not report (%)		Confidence Likert Scale Mean ± Stdev	Confidence Likert Scale Mean ± Stdev
Case 1	Neglect	90	10	100	0	0.39	1.61±0.95	1.45±0.85
	Emotional Abuse
Case 2	Physical Abuse	90	10	97	3	0.45	1.32±0.65	1.23±0.5
	Emotional Abuse
Case 3	Neglect	84	16	71	29	0.41	1.84±1	1.68±0.98
	Emotional Abuse
Case 4	Neglect	87	13	84	16	0.03	1.81±0.91	1.48±1
	Emotional Abuse
Case 5	Neglect	52	48	55	45	0.04	2.23±1.12	1.77±1.02
	Emotional Abuse
Case 6	Sexual Abuse	90	10	100	0	0.41	1.45±0.93	1.55±1.09
Case 7	Sexual Abuse (Historical)	87	13	90	10	0.48	1.47±0.86	1.41±0.86
Case 8	Physical Abuse	52	48	74	26	0.02	2.23±1.12	1.71±0.9
	Emotional Abuse
Case 9	Emotional Abuse	52	48	68	32	0.15	2.27±1.14	2.03±0.98
Case 10	Neglect	65	35	68	32	0.51	1.58±0.72	1.71±1.16
	Emotional Abuse

Table 3: Case content qualitative analysis


Case	Concern	Participant	Pre-training rationale	Post training rationale
Case 1	Neglect	P 13, Doctor	13-year-old can babysit younger children.	Neglect: Insufficient parental/adult supervision.
	Emotional Abuse
Case 2	Physical Abuse	P 6, Doctor	Even though is wrong for her husband to hurt her, if she will not report then I have to follow her permissions. However, I will keep a record of this case.	Report Abuse even though she doesn't want to report, she might be under pressure.
	Emotional Abuse
Case 3	Neglect	P3, Tusla Social Worker	More information needed about network and support system, however, without this information safer to report.	Community support may benefit Mam. Do not report child abuse.
	Emotional Abuse
Case 4	Neglect	P9, Medical Social Worker	Refer for further investigation such as contact with her GP for medical history. Unsure why is Tusla involved? Possible this was a concern for them [Tusla] and needed reports of same.	Report to Tusla, outline to mum that they may need to link with her regarding her medical history or diagnosis. Report concern regarding her behaviour as may be important part of picture in their [Tusla] assessment.
	Emotional Abuse
Case 5	Neglect	P27, Medical Social Worker	No evidence of child protection concerns, parents respond appropriately. Gastro issues/Nappy rash could be underlying medical condition?	Refer to community-based family supports.
	Emotional Abuse
Case 6	Sexual Abuse	P26, Nurse	That is inappropriate touching, but where did her brother learn this behaviour? He too may have been abused.	I am mandated to report a disclosure of CSA [child sexual abuse] and her brother may be at risk too.
Case 7	Sexual Abuse (Historical)	P33, Doctor	Very difficult as if Alison doesn’t want to press charges reporting it could put her in an unsafe position. However, if the uncle is still alive and has access to children they may be at risk, therefore I would report it.	If the uncle is still alive and can pose a risk to other children then there would be grounds for a Tusla report however I'm not sure unless children are currently at risk if you can report to Tusla/police based on a historic case. Would discuss with Tusla for advice.
Case 8	Physical Abuse	P31, Medical Social Worker	Not enough evidence/information to report a child protection concern.	Based off new information I received on this course I know that bruises on the neck can be a child protection concern and therefore Tusla may need to monitor family following initial assessment.
	Emotional Abuse
Case 9	Emotional Abuse	P15, Doctor	Unsure.	Emotional Child abuse.
Case 10	Neglect	P 27, Medical Social Worker	No CP [Child Protection] concerns.	No CP [Child Protection] concerns evident, CAMHS [Child and Adolescent Mental Health Services] out-patient referral more appropriate.
	Emotional Abuse

No competing interests reported.

The CHILD study: a Co-designed cHild-centered Interprofessional simulation course to foster Learning through safeguarding Dialogue

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