Evaluating an online trauma-informed care training module for exercise oncology professionals: A mixed-method study of acceptability and potential for effective behaviour change
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AshaGatland
BA, GDipPsych(Adv)
1TamaraJones
Ph.D
1MichaelMarthick
Ph.D
2SarahStratulate
DPT
1BSc-Kin1
JessicaLees
Ph.D
3SelinaParry
Ph.D
3CamilleEShort
Ph.D
1,3✉EmailCamille.short@unimelb.edu.au1Melbourne Centre for Behaviour Change, Melbourne School of Psychological SciencesUniversity of MelbourneParkvilleVICAustralia
2Valion HealthSydneyNSWAustralia
3Department of Physiotherapy, Melbourne School of Health SciencesUniversity of MelbourneParkvilleVICAustralia
Asha Gatland, BA, GDipPsych(Adv)1, Tamara Jones, Ph.D1*, Michael Marthick, Ph.D2, Sarah Stratulate, DPT, BSc-Kin3, Jessica Lees Ph.D3, Selina Parry, Ph.D 3, Camille E Short, Ph.D1,3*
*Equal senior author
Affiliations
1. Melbourne Centre for Behaviour Change, Melbourne School of Psychological Sciences, University of Melbourne, Parkville, VIC, Australia.
2. Valion Health, Sydney, NSW, Australia
3. Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Parkville, VIC, Australia
Corresponding author: Camille E Short
Camille.short@unimelb.edu.au
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Funding Sources:
This research was conducted as part of a Victorian Cancer Agency (VCA) Fellowship awarded to A/Prof Camille E. Short (MCRF19028).
Role of the Funder: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.
https://orcid.org/0000-0002-4177-4251
Conflicts of interest: All authors declare that they have no conflicts of interest
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Author Contribution
AG, TJ and CES conceived of the study, develop study methodology and handled project administration. CES obtained study funding. MM assisted with recruitment to the study and sourcing experts for the development of the intervention under study. CES led development of the intervention, with review provided by TJ, JL and SP among others (see acknowledgments). AG conducted data analysis, under supervision by CES and TJ. AG wrote the first draft of the manuscript, under supervision of CES and TJ. All author reviewed and edited the draft manuscript.
Abstract
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Research highlights the importance of exercise in holistic cancer care, yet the prevalence of trauma among cancer patients underscores the need to integrate trauma-informed approaches into exercise oncology practice. This study explored the acceptability and potential efficacy of an online trauma-informed care training module designed for exercise oncology professionals. Fifty-five Australian exercise professionals with experience in oncology completed the module and evaluated it through an online survey, with a subset of 22 also participating in semi-structured interviews. Survey findings indicated high acceptability and strong potential for efficacy. Interviews revealed that the engaging design and perceived value of the module supported its acceptability, while its role as a formalising framework, its influence on intention toward trauma-informed care, and its guidance for practical implementation shaped perceptions of efficacy. Overall, findings suggest that brief online training can consolidate existing knowledge and foster intentions to integrate trauma-informed care into exercise oncology services. Future development should prioritise scaffolding opportunities that support the transition from intention to practice.Keywords:
trauma-informed care
exercise
neoplasms, online training
education, evaluation
Evaluating an online trauma-informed care training module for exercise oncology professionals: A mixed-method study of acceptability and potential for effective behaviour change
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Introduction
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Research has consistently highlighted the benefits of incorporating exercise as part of cancer care [1, 2]. To increase equitable access among a growing population of oncology patients, there is a need for exercise services to become more trauma-informed [3, 4]. People with a lived experience of cancer are particularly at risk of trauma [5], which can impede treatment engagement and clinical outcomes [6, 7]. Increasingly, trauma-informed care (TIC) is being integrated into exercise interventions for survivors of domestic abuse and sexual assault, and suggests promising benefits for participant engagement [8, 9]. However, there is a noticeable gap in the extension of these services to oncology care.Up to 40% of cancer patients experience post-traumatic stress symptoms as a direct result of diagnosis and treatment, while closer to 70% of people will experience at least one traumatic event throughout their lifetime [5].A key advantage of TIC is that it does not require an in-depth knowledge of various traumas; rather, it outlines key principles through which healthcare providers can proactively accommodate and protect against a (re)traumatising experience. These include prioritising the physical and psychological safety of clients, supporting empowerment and choice in care settings and being receptive to cultural, historical and gender diversities [10, 11].
Access to trauma-informed care may also be especially important for cancer patients with existing history of trauma or marginalisation. Currently, sexual and gender minority patients report receiving varying levels of care quality in oncology settings, as well as specific identity-related traumas of being ‘outed’ by medical professionals [12, 13]. There is also disproportionately lower screening uptake for breast, colorectal and cervical cancers among women who have experienced adverse life events such as homelessness, serious mental illness and sexual abuse [14, 15]. While trauma is unlikely to significantly reduce uptake of treatment perceived as immutable (e.g. chemotherapy), it may reduce the uptake of services perceived as non-urgent or invasive [7]. This is important considering exercise supports bear a risk of bodily (re)traumatisation, and because patients with trauma history may perceive this secondary treatment as an unnecessary burden given the risk of triggers.
Qualitatively, cancer patients undergoing treatment consistently report fear and trepidation surrounding physical activity, as well as a lack of confidence in their current capabilities [16, 17]. Fear of adverse effects, the need for flexible support and decisional input into exercise regimens have also been identified as key barriers to uptake. Reflectively, a meta-analysis of exercise trials among cancer patients showed high drop-out rates when exercise is unsupervised, suggesting informed professional support may drive engagement. [18]. With knowledge of TIC, exercise professionals can provide support appropriate for a range of patient experiences and protect against distress. This may enhance engagement, especially among those with prior trauma.
To the authors' knowledge, no trauma-informed care exercise interventions currently exist for oncology populations, however evidence from interventions in other groups underscores the critical role of provider knowledge of TIC principles. This includes the importance of clear, respectful communication and collaborative engagement with trauma survivors to support autonomy and shared decision-making [19, 20]. Despite the pivotal role of the facilitator, professionals across exercise and oncology care sectors report varying levels of self-efficacy to provide TIC [20, 21]. Encouragingly, other health professionals, including paediatricians and mental health clinicians, have reported increased self-efficacy following trauma-informed training interventions, suggesting this can be an effective tool to build professional competence [22–24]. To this end, a short TIC online training module has been developed for exercise oncology professionals. The choice to deliver the training module online is also consistent with growing evidence showing e-learn modules as equally effective as face-to-face approaches [25], while also providing greater flexibility for busy health professionals.
Mixed-method pilot testing is proposed to provide preliminary insights into how the intervention influences its users and to inform suitability for scaled evaluation [26]. When approaching early evaluation, users’ initial perception, termed acceptability, is a critical step that informs all other implementation outcomes (e.g. fidelity, feasibility, scalability) [27]. Gauging acceptability alongside a measure of potential efficacy can extend beyond initial perception to explore intervention impact [28]. In this study, potential efficacy was conceptualised using the COM-B model (Michie et al., 2011), which proposes that behaviour change occurs when individuals have the Capability, Opportunity, and Motivation to act [29]. Examining changes across these domains offers a theoretically grounded indication of whether the module may support professionals to deliver TIC in practice. Finally, given the absence of trauma-informed interventions in exercise oncology, in-depth qualitative interviews can provide the necessary penetration to explore unidentified consumer needs early in the implementation process.
This study comprises two primary aims: (1) to comprehensively evaluate the acceptability, and (2) to explore the potential efficacy of a trauma-informed intervention designed for exercise oncology professionals, with the goal of informing future implementation.
Methods
Recruitment and participants
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The recruitment of exercise professionals to participate in this study occurred primarily through a convenient sampling method via emails to exercise professionals listed on Exercise and Sports Science Australia (ESSA) and Australian Physiotherapy Association (APA) websites. Potential participants were eligible to participate if they were a qualified physiotherapist or exercise physiologist, had reliable internet access, worked and resided in Australia and if they were able to read and write in English. A
Further participants were recruited via snowballing techniques and word of mouth. Those who expressed interest were sent a brief online REDCap survey to confirm their eligibility.Registered participants received access to a secure learning management system (LMS) hosted by the University of Melbourne where they could complete the module in their own time, complete an evaluative survey, and provide contact details if they were willing to participate in a qualitative interview.
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Throughout the interview process, the research team monitored participant demographics and thematic saturation through weekly discussions. Male participants and physiotherapists were purposively recruited in the later stages of data collection to ensure balanced representation. Semi-structured interviews were conducted (approx. 15–30 mins) until data saturation was achieved at the consensus of the researchers. A
This study was approved by the University of Melbourne Human Research Ethics Committee (ID: 29603).Materials and Measures
Training module
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The training module was developed as part of a larger program of work focused on optimising an existing prehabilitation service for cancer patients using co-design (trial registration: ACTRN12624000363583). The training module focused on raising staff awareness about patient trauma and teaching skills on how to deliver exercise services in a trauma-informed way (see Fig. 1). It was expected to take 20 minutes to complete and was originally developed using Mitchie and colleagues’ COM-B model [29] to maximise the likelihood of clinical behaviour change among professionals following completion. CES, an experienced psycho-oncology researcher, drafted the original module script, which was then reviewed and refined by consumers (i.e. those with lived experience of exercise oncology services) and oncology health professionals. These included a clinical psychologist, clinical nurse and social worker, as well as other members of the investigator team with clinical exercise experience. See Table 1 for an outline of the training module content. Access to the module is available upon request.Fig. 1
Screenshot showing the first screen of the trauma-informed care training module for exercise oncology professionals.
Module Component | Content Outline | COM-B Target |
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Understanding the Meaning of Trauma | · Outlines key sources of trauma · Describes common effects of trauma · Identifies benefits of implementing trauma-informed care | Motivation increased by influencing outcome expectancies and self-relevancy |
Recognising Signals of Distress | · Lists key indicators of distress for professionals to look out for (e.g. highly agreeable responses) · Indicators are listed with concrete examples (e.g. “whatever you say”) | Capability enhanced by improving knowledge |
Key Principle 1: Trust and Safety | · Provides definition of emotional safety · Presents video demonstration of clinician building trust and safety with patient · Quiz questions prompt learners to evaluate demonstration | Capability and self-efficacy enhanced through modelling, vicarious consequences and feedback |
Key Principle 2: Collaboration | · Outlines tips for collaborating with patients · Presents video demonstration of clinician setting goals collaboratively with patient · Quiz questions prompt learners to evaluate demonstration | Capability and self-efficacy enhanced through modelling, instructions on how to perform the behaviour, and feedback |
Key Principle 3: Empowerment | · Provides practical examples of how to facilitate patient empowerment (e.g. tracking workouts) | Capability and self-efficacy enhanced through instructions on how to perform the behaviour |
Reflective Task | · Summarises key responsibilities of professionals in their role · Mental reflection activity invites professionals to identify one strategy they will implement to make service more trauma-informed | Motivation enhanced by prompting self-reflection and intention formation |
Figure 1. Screenshot showing the first screen of the trauma-informed care training module for exercise oncology professionals.
Table 1. Content outline for trauma-informed care training module
Survey questionnaire
Participants completed the evaluative survey between 26th June and 12th August 2024 (see supplementary file 1). This included an 8-item Acceptability questionnaire adapted from the Theoretical Framework of Acceptability (TFA) [30]. Participants evaluated the training module on a 1–5 Likert scale across seven component constructs and an overall measure, general acceptability. The second part of the survey was a 5-item questionnaire evaluating perceived efficacy of the module adapted from the COM-B questionnaire [31]. This allowed investigators to assess the impact of the module against relevant constructs of the COM-B model (including the additional measure, ‘self-efficacy’), that had informed its development. Participants rated their agreement from 0–10 on items relating to levels of Capability, Motivation and Opportunity to deliver trauma-informed exercise services and could opt to briefly explain their ratings in an open-comment box at the end of the questionnaire. They were also asked to provide relevant demographic and professional information (see Table 2).
Variable | All participants (N = 55) N (%) | Interview participants (n = 22) n (%) |
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Age (years), mean (SD) | 35 (8.0) | 34.3 (6.4) |
Sex | ||
Female | 45 (81.8) | 15 (68.2) |
Male | 10 (18.2) | 7 (31.8) |
Occupation | ||
Exercise physiologist | 29 (52.7) | 13 (59.1) |
Physiotherapist | 26 (47.3) | 9 (40.9) |
Experience in profession (years), mean (SD) | 12.2 (6.8) | 11.7 (6.1) |
Experience in oncology | ||
A little | 2 (3.6) | |
Moderate | 28 (50.9) | 9 (40.9) |
Extensive | 25 (45.5) | 13 (59.1) |
Work setting(s) | ||
Public hospital | 18 (32.7) | 8 (36.4) |
Private hospital | 11 (20.0) | 5 (22.7) |
Private practice | 26 (47.3) | 8 (36.4) |
Research | 6 (10.9) | 3 (13.6) |
Community and not-for-profit | 2 (3.6) | 1 (4.5) |
Prior training in TIC | ||
Yes | 10 (18.2) | 3 (13.6) |
No | 45 (81.8) | 19 (86.3) |
TIC already in practice | ||
Somewhat | 4 (7.3) | 2 (9.1) |
Moderately | 7 (12.7) | 3 (13.6) |
Quite a bit | 26 (47.3) | 10 (45.5) |
Extremely so | 18 (32.7) | 7 (31.8) |
Semi-structured interview
Semi-structured interviews (15–33 minutes; median = 18 minutes) were conducted by AG between July and August 2024 using a question guide developed by the research team (see supplementary file 2). Rather than being mapped to specific constructs within the TFA and COM-B frameworks, the interview guide was designed to explore acceptability and potential for efficacy more broadly (e.g., overall acceptability). The aim was to capture more nuanced, context-specific insights and emergent themes to complement quantitative analysis. Participants were also invited to consider any adjustments that might support future implementation.
Data analysis
All quantitative measurements were analysed descriptively using JASP Version 0.17.3. Demographic information was analysed using counts and proportions, while open-comment data from the survey was analysed separately as part of the study’s qualitative dataset.
Interview and open-comment data collected from the survey questionnaire were analysed both inductively and deductively as part of a reflexive-thematic approach [32]. This allowed the research team to identify unforeseen patterns in the data, while also framing analysis around the study’s evaluative aims. Interview audio was transcribed automatically using the Zoom Pro AI Companion transcription tool and checked for accuracy by AG as part of data familiarisation. Transcripts from early interviews were initially coded without pre-defined categories and with attention to semantic content as part of an inductive approach. A closer deductive lens was then applied to analyse the data for material identified by the researchers as relevant to the constructs under investigation (i.e. pertaining to acceptability and potential efficacy). Once 75% of all qualitative data had been closely coded using this second deductive approach, researchers (CES, TJ, AG) began to search for themes in line with the study aims. To ensure a rigorous thematic interpretation, codes and themes were discussed iteratively by the research team at weekly meetings and thematic maps generated to encourage reflection and (re)organisation.
Results
Participant characteristics
Of the 92 eligible participants who consented to participate, 55 (60%) completed the module and evaluative survey, and 45 (49%) provided contact details to be contacted for interview. A subset of these participants were invited to participate in a semi-structured interview, (n = 25) and 22 went on to take part. Figure 2 provides a summary of study participation.
Fig. 2
Participant flow chart for survey questionnaire and interview.
Figure 2. Participant flow chart for survey questionnaire and interview.
Participant characteristics, including demographic and professional information, are provided in Table 2.
Table 2. Participant characteristics
Quantitative results
Due to the negative skew of the distributions observed, medians, interquartile ranges, minimum and maximum values were reported for each Acceptability and Efficacy domain in Figs. 3 and 4.
Fig. 3
Boxplots for Theoretical Framework of Acceptability (TFA) domains (scale 1–5; a higher score equals a more positive response). Medians for each item are represented by black lines. Boxes represent the quartile range for each item, with whiskers extending to include minimum values. Dots represent outlier ratings. General = General Acceptability. Opportunity = Opportunity Costs. Burden and Opportunity Cost domains are reverse scored so that higher scores = greater acceptability.
Fig. 4
Boxplots for efficacy domains (scale 0–10, with higher scores indicating a more positive response). Medians for each item are represented by black lines. Boxes represent the quartile range for each item, with whiskers extending to include minimum values. Dots represent outlier ratings.
Acceptability
As shown in Fig. 3, participants rated the module positively across all TFA domains, indicating a high level of overall acceptability. Of the seven component domains, the highest median values were observed for self-efficacy and ethicality, suggesting participants felt very confident completing the module, and that it fit their value system. The presence of outliers showed a small minority of participants disagreed with the ethicality of the module.
Positive median values (> 3) were observed for attitude, perceived effectiveness and opportunity cost, indicating participants generally liked the module, felt it achieved its intended purpose and did not interfere with other priorities. The absence of an interquartile range altogether across intervention coherence and burden domains suggests perception was unanimous regarding the module’s coherence and minimal required effort. Most participants held positive or highly positive perceptions of general acceptability, with scores confined to the upper end of the TFA scale.
Figure 3. Boxplots for Theoretical Framework of Acceptability (TFA) domains (scale 1–5; a higher score equals a more positive response). Medians for each item are represented by black lines. Boxes represent the quartile range for each item, with whiskers extending to include minimum values. Dots represent outlier ratings. General = General Acceptability. Opportunity = Opportunity Costs. Burden and Opportunity Cost domains are reverse scored so that higher scores = greater acceptability.
Potential Efficacy
As outlined by the boxplots in Fig. 4, participants tended to rate the module positively across capability (knowledge and skills), opportunity, motivation and self-efficacy domains, indicating good potential for efficacy. Equal median ratings suggest the training module had the highest perceived impact on participants’ motivation to implement TIC, as well as their self-efficacy to do so. A slight decrease in median rating was observed across skills and knowledge domains, despite higher self-efficacy.
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This suggests that while the module influenced motivation more than capability, it nonetheless boosted participants’ confidence in implementing TIC.Figure 4. Boxplots for efficacy domains (scale 0–10, with higher scores indicating a more positive response). Medians for each item are represented by black lines. Boxes represent the quartile range for each item, with whiskers extending to include minimum values. Dots represent outlier ratings.
Qualitative results
A summary of qualitative findings is presented below, with themes, sub-themes and additional illustrative quotes provided in Tables 3 and 4. Quotes have been edited for grammar and punctuation to maximise clarity.
Theme | Sub-theme | Description | Illustrative quotes |
|---|---|---|---|
Engaging design | Ease of use | User experience contributed positively to participants’ perception of the module, or else interfered with their capacity to complete it | “I think it was really smooth in terms of the way it was delivered. It's all nicely put together. It was kind of easy to work with.” (P8) “I like training that's quite straightforward and easy to use. So I think the way that it was done was good.” “Sometimes I felt like the audio at the start of the slide was different to the text. And so I found myself sort of yeah, getting a bit like not sure whether to listen or read.” (P17) |
Use of multimedia | Varying use of modalities (e.g. text, video, interactive quiz) helped maintain engagement with the module. | “I appreciated the mixture of content delivery methods. I find too many videos frustrating in online training, these were a good length, not too frequent and very useful. The different panels of text and types of content were nice to help break up the text content.” (P41) “I appreciated the mix between text, audio, video, questions etc. I liked that there was a spoken intro for various parts. It limited how much reading was involved.” (P9) | |
Concise presentation | Participants appreciated the succinct summarisation of content to support clarity and engagement | “I liked to see the information presented the way that it was - it was just very succinct. There weren't heaps of words, it was just dot points.” (P19) “I thought it was very clear and concise, which is sometimes rare for training modules. So I thought it was the perfect length, a good mixture of kind of slides which were quite straight to the point, didn't have a lot of heavy text.” (P3) “The information in it was easy to follow and kind of pretty easy. It wasn't too in depth which makes it easy to follow along with.” (P48) | |
Interactive | Participants liked how the interactive components of the module facilitated active engagement with the module. | “I liked how you click through it, and you like you got to learn more about each bit like each of the bits and pieces. I thought that it was, yeah, it was really good and interactive.” (P14) “I like how it's interactive. It wasn't just you know, here's a text and you read it, that's all that's really out there at the moment…and you're like, cool. How do I implement that into my profession?” (P1) “I liked the fact that it had you know, bits to click on. So it kind of - you had to stay engaged in that regard.” (P15) | |
Perceived value | Alignment with personal values | Participants generally reported strong value alignments with trauma-informed care, likely influencing perception of the module. | “Certainly, I think that considering and you know acting on the key points that are in the training needs to be part of your job, anyway.” (P19) “I think it's obvious that you know that you need to have some sensitivities around people with a cancer diagnosis, but maybe it's not obvious to some people. But I think it is always very easy to forget how traumatic these experiences can be, particularly, I suppose, once you're familiar with working with this population.” (P17) “[T]he part in it that was talking about, you know, being considerate of people's pronouns and you know, not assuming that someone has a male or a female partner… I don't know if that would - if someone who was against it came up to that in the module they might just kind of disregard the entire module.” (P15) “[U]sing a very strong terminology - and trauma to me is a very strong terminology - like a significant life event, maybe, some people might consider it's a significant life event rather than trauma, I don't know...[it] just got me thinking about the actual terminology. I wish they’d call it something different, because it's - yes, because every patient with cancer you could then put them under trauma.” (P27) |
Relevance to profession | Participants widely reported that the module content was relevant to their day-to-day experiences and professional concerns. | “This is a vital piece of education for exercise professionals seeing any patients who have had significant health challenges or trauma. (P52) “I thought that they you know, looked like scenarios that we would typically see. I guess you know, they were on the simpler end, which again, is totally expected and understandable with this sort of first contact module for this kind of concept. But yeah, I thought they were really relevant.” (P24) “I work in oncology and palliative care. So I think it's very relevant in both those areas…And I think not even just, I think for me, what also stood out was - it's great me doing the training but I think it's also as the wider MDT, everyone else needs to have that awareness, too.” (P16) | |
Cost-effective | Participants reported that the module provided good value relative to the time and effort taken to complete it. | “It felt really short for the amount of value that it provided. So I'd say, sort of the balance was really sort of heavily weighted towards yeah, value rather than time.” (P26) “It was quick, easy, low burden and certainly if we were onboarding new team members it'd be the sort of thing that I think, yeah, this would be a great use of 15 minutes.” (P17) “I think the module length you know, it was able to hold your attention…as I said, like you know, whenever there's free education opportunities like, I think, as clinicians, you, you know, it's in your own best interest to [spend] half an hour, 20 min, click on the link and it can just give you that opportunity to stop and reflect.” (P39) |
Theme | Sub-theme | Description | Illustrative quotes |
|---|---|---|---|
Formalising trauma-informed care | Affirms current practices | Module re-affirmed many of participants’ current practices as being trauma-informed | “I think there were things that I already did that I may not have realized were like components of trauma informed care.” (P25) “I probably found it, I guess a little bit reassuring in terms of it's not something I've necessarily had training in per se…but I guess [it] reaffirmed that how I'm going about it in in terms of just being like a little bit more patient centred, and sort of acknowledging of, I guess, the experiences of the individual.” (P26) “The approach of this educational module represents how I practice. Exposure to these formal concepts in an education context gives me confidence to continue the continue the way I work. This supports me to support others.” (P46) |
Clarifies existing knowledge | The module clarified participants’ understanding of TIC or prompted them to consider it in a different way | “I thought it was a helpful module to kind of solidify my understanding of trauma informed care, and how that could change or impact exercise prescription in more palliative patients.” (P5) “I guess what I probably took home was to consider [TIC] even for the patients that might seem simple.” (P3) “I'll always talk about my partner, or whether someone has a partner rather than husband…and I feel like I just always do that. But I never did it from a perspective of I'm being more trauma informed. So I think just thinking about it in that regard and opening my eyes to being like, okay, there is more to it…just considering it from a different perspective”. (P25) | |
Elucidates concept confusion | The module highlighted the need to define TIC in relation to adjacent concepts e.g. patient-centred care, cultural sensitivity | “I guess what would have made it more enjoyable for myself, or kind of helped me to gain a bit more learning satisfaction was, perhaps, if let's say, there was a little kind of section as to maybe how us clinicians could have come across trauma informed care, but maybe in in different terms...and that kind of helps us differentiate actually, how this trauma-informed module is different from maybe you know usual kind of professional development or e-learning that we have at work.” (P31) “I think there's a lot of overlap, you know, with patient centred care principles… it's not a necessarily a new concept to be alerted and heightened awareness of the vulnerabilities of the patients that we can be seeing…I think it would probably be very hard to make a clear distinction.” (P39) “I feel like a bit of it I'm doing already, just being culturally sensitive and having that biopsychosocial model of framework that we learn from physiotherapy. I feel like, oh, that's kind of like overlapping. So how is trauma informed care different to what I'm already doing?” (P27) | |
Shaping intention | Increases motivation | Completing the training module increased participants’ motivation to provide a trauma-informed exercise service for patients | “I will try and consciously implement it during my work from now on. Very simple things can make a big difference to patients.” (P3) “I do feel that the course has inspired me to look into more education in this area.” (P50) “I do assessments in the corridor all the time and will be more aware of patient cues now.” (P54) “I think it's a really great starting point, because what I found at the end of it is, I wanted to know more.” (P7) |
Increases awareness | Completing the training module increased participants’ awareness of the importance of providing a trauma-informed exercise service, as well as the opportunity to reflect on ways to do so. | “I think it made me reflect on some of the patients that I had, and I think it's about being a bit more mindful of the behaviours that those patients show, and perhaps a bit more of the patience that you need to demonstrate with those patients, and understanding about where they might be coming from.” (P16) “I'd not thought about it in that context. So it was quite nice to have some of those examples to go, oh, I hadn't considered that before.” (P17) “It is something I haven't really thought about before despite working exclusively with cancer patients.” (P3) “I thought that, yeah, what you had about you know that [pause]. Yeah, that kind of trauma was really important. And I think that it kind of goes to all of the other things that you're presenting as well that you know not everyone is going to have trauma, but the people who do it's a huge part of their experience, and it's really good that we can listen to that, and that you're highlighting that as an issue.” (P14). | |
Generates implementation ideas | The module provided participants with the opportunity to reflect on ways to implement TIC personally in the scope of their own practice | “I have a patient that speaks Russian and speaks no English, so I was even like, oh, how can I make it so that it's more client-centred in in that regard.” (P15) “I had to change [my lanyard] to one of those hip-mounter little retractable thingies which kind of hides you know that opportunity for me to put I guess a Pride flag or something like that as a pin there. I don’t have that [at the moment] and that really made me remember, you know, that’s - I need to find another solution for that.” (P8) “That was something for me is just maybe like, just slow down a little bit sometimes, and just take stock. And perhaps have this - just this sort of general, you know, discussion or these general questions that you ask just to, I think, maybe like, cultivate a little bit more of a safe space.” (P29) | |
Scaffolding implementation | Benefits of seeing things in practice | Participants emphasised the benefits of seeing skills demonstrated to facilitate practical application of TIC. | “Seeing how the clinician used different strategies to manage that situation was helpful, because it really kind of helped me understand how I could apply in my daily work.” (P31) “I think they just the explicit examples from the case study that was in there was pretty valuable, I think it's rather than kind of saying it could be this, or it could be that...these are the things that are on the table and the things that we don't see that we do need to be aware of.” (P6) “[I] found it quite practical in terms of some of the sort of skills and tools that are suggested. To be able to see some sort of clinical examples, and sort of observe some conversation around, and navigating it as well, was great.” [P26) |
Support to bridge theory and practice | Participants identified the need for further supports to help transfer knowledge to practice e.g. printable PDF of summary points, typing next steps. | “At that time I did think of one way to implement it. However, I have to admit that I have forgotten what that one way was. Because yeah, fast forward, you know, one or two weeks and I think what might have helped me remember it was if let's say that one call to action could maybe include, like a little text box.” (P31) “I rated 'I feel confident that I can provide trauma-informed exercise support due to completing the module' a 6/10. This was my lowest score because despite the training being very informative, I fear I may forget what was learnt once it comes to providing such care.” (P9) “The skills are well presented and the post-video questions helped to highlight them, but a PDF of dot points would help as a take-away for practicing (possibly true for other take-aways from the course too), but from experience I feel that people particularly need written scripts or notes to help them cover important content in tricky conversations.” (P41) | |
Desire for extended learning | Participants reported a desire for more in-depth content such as specific case studies and communication strategies to cement knowledge and build confidence implementing TIC in practice. | “I had a patient to me sort of bring up her history of sexual abuse as a child, and that was in the middle of a gym which didn't have many people in it. But I guess you know, that's just an example. So something just thinking along the trauma related care, you know something like, okay, how do you deal with that? (P6) “It was a great overview and good beginning point for learning about trauma informed care. I think more practical applications, real life case studies would be helpful too.” (P34) “Cancer patients have a whole bunch of stuff going on…So what I would want to see I think a little bit more of is again, like, how do you deal with quite difficult situations or in terms of like emotion, but also the importance of looking after yourself and your own health.” (P7) “We're seeing a lot more referrals come through, for patients that have you know, like oncology patients that do have a bit of a history of mental health things going on either during treatment or post treatment. So maybe something around yeah, that side potentially as well, like how to maybe address some of those conversations where people might not be in the best mental place.” (P48) | |
Limits of online format | While participants identified increased awareness of TIC due to the module, they highlighted the limitations of the online format to provide practical reinforcement. | “I feel like I've learned enough to be aware of trauma informed care but perhaps more practical modules could be useful to build confidence in providing care.” (P 42) “I think it's very hard to just build skills from a module, though as well. I think you can have that outline a few tools or basic strategies. But you're still not going to give all the skills that's going to build confidence to manage people with a lot of trauma. It's still going to be a lot more complex than that.” (P16) “I think providing practical ways to test our own skill in providing trauma informed care [is needed]. I am unsure how you would achieve this on a LMS platform.” (P45) |
Acceptability themes
Engaging design
Participants broadly reported they found the module engaging and often attributed this to its overall structure, style and delivery. When asked about their general impressions, participants reflected positively on the concise presentation of content and the absence of heavy text. They also noted that the module’s use of mixed media helped to sustain attention and reduce the temptation to skim content. Participants generally felt that the module was easy to use, however a subset noted experiencing some confusion with the alternate use of text and audio components. A few participants reported that the module interface did not support completion while traveling due to the need for audio and reduced responsiveness on mobile devices.
Perceived value
A
Participants frequently expressed that they found completing the module to be a valuable experience, relevant to their day-to-day professional practice, with many indicating a willingness to share it with colleagues. Also mentioned was the low burden of the task, and the idea that the module was worth the short time taken to complete it (i.e. cost-effective). While most participants agreed with the importance of trauma-informed and patient-centred principles, one participant felt TIC inflated the definition of trauma, while another expressed concern that the module’s focus on LGBTQI + experience could hinder engagement among health professionals with differing cultural or personal beliefs.Figure 5. Conceptual framework of acceptability and efficacy themes.
Fig. 5
Conceptual framework of acceptability and efficacy themes.
Note. Conceptual framework outlines the dynamic relationships between Acceptability and Efficacy themes, including the differing influences of Brevity and Broad Applicability on each construct. While not included here to maximise clarity, relationships are hypothesised between all themes and sub-themes. Solid lines indicate relationships shown by the data while dotted lines indicate a hypothesised relationship.
Note
Conceptual framework outlines the dynamic relationships between Acceptability and Efficacy themes, including the differing influences of Brevity and Broad Applicability on each construct. While not included here to maximise clarity, relationships are hypothesised between all themes and sub-themes. Solid lines indicate relationships shown by the data while dotted lines indicate a hypothesised relationship.
Table 3. Acceptability themes, sub-themes and illustrative quotes
Efficacy themes
Formalising TIC
A
Participants indicated that the module’s formal conceptualisation of trauma-informed care (TIC) validated their existing practices, offering affirmation and reinforcing confidence in their current approach to service delivery. For professionals with prior knowledge, the module also clarified and expanded participants’ understandings of TIC, particularly around the scope of traumatic experiences and the breadth of relevant practices available to support patients. A
Some participants expressed confusion about how TIC could be differentiated from other practices such as patient-centred care and cultural sensitivity, and expressed a desire for further clarification. Some professionals also reported assuming the term ‘trauma-informed’ implied the experience of physical or surgical trauma.Shaping intention
Participants expressed varying levels of intention to be more trauma-informed after the module. They often described completing the module as a thought-provoking experience that elicited personal reflections on the importance of TIC, while others expressed intention to incorporate TIC more proactively into their practice, and to seek further education in this area. A number of participants showed increased awareness of opportunities to implement trauma-informed principles in these contexts (e.g. taking time to explain procedures, checking in more frequently with patients). Others relayed specific implementation ideas such as creating flashcards to facilitate better communication with non-English speaking clients and ways to improve the visibility of LGBTQ+-supportive signs in clinic.
Scaffolding implementation
A
Beyond intention, participants described ways in which the module either facilitated or inhibited effective implementation of TIC. The benefits of seeing skills demonstrated in practice were consistently emphasised and it was widely reported that the video demonstrations offered a clear and practical insight into providing TIC. However, participants also described needing further support to bridge the gap between online learning and practical implementation. Reflecting on the call-to-action at the end of the module, participants often expressed liking the ‘idea’, yet reported not engaging with the activity or could not recall reflections made at the time. They emphasised the importance of documentation, additional follow-up (e.g. email reminders) and tangible resources such as printable PDF summaries to support implementation beyond the module.Participants also expressed a desire for extended learning opportunities within and outside the scope of the module. More specific and challenging case studies were identified as a means to facilitate more advanced and in-depth application of concepts presented.
A
There was also interest in more concrete communication strategies to guide implementation of TIC, support patients’ mental health and respond to difficult disclosures. Overall, while participants reported a greater cognisance of trauma-informed principles and strategies following the module, they often noted the limitations of the online format to provide practical reinforcement around the delivery of TIC.Table 4. Efficacy themes, sub-themes and illustrative quotes
Acceptability-Efficacy themes
Two themes, ‘Broad Applicability’ and ‘Brevity’, were identified as being facilitators of acceptability, while posing a barrier to potential efficacy (outlined conceptually in Fig. 5).
Broad applicability
A
Participants frequently perceived the module as applicable for practitioners at different stages in their career, acting both as a ‘reminder’ of TIC for more experienced practitioners and a ‘good introduction’ for emerging practitioners. This broad applicability appeared to extend to different workplace settings, as participants working across private practice, exercise research, hospital and palliative care expressed that the content was applicable to their day-to-day work. Some participants also perceived this broad applicability to be a limitation of the module, and that they would have liked more examples of scenarios specific to cancer care (e.g. addressing the bodily impacts of treatment). Some participants also felt that due to its general nature, the module did not offer new knowledge, and that the principles presented were already an implicit part of care.Brevity
The brief duration of the module appeared to have something of a competing influence on the constructs under investigation. Participants reported appreciating how the module’s short length made completion feasible in the context of a busy workday, while also supporting attention. Conversely, some participants also felt the brevity of the module limited their confidence in implementing TIC by its conclusion. Many expressed that a longer module could provide more in-depth information and the opportunity to explore a greater variety of treatment scenarios that would consolidate knowledge of TIC.
Table 5. Acceptability-Efficacy themes, sub-themes and illustrative quotes
Theme | Sub-theme | Description | Illustrative quotes |
|---|---|---|---|
Broad applicability | Not oncology-specific | Participants reported finding that the module content was not specific to oncology patients. | “I think the sort of the trauma informed care aspects came in really clearly. I didn't see that much individualization, I guess, towards the cancer diagnosis and the cancer experience… like I said, it had plenty of great information. It just that was one thing that struck me by the end of it is that kind of felt that it was not as specific for cancer care as I guess what I expected.” (P8) “I think the purposes of the unit was a really good introductory type level. But maybe if you were wanting to target specifically to cancer care, maybe, you know, delving in a little bit deeper about some of those cancer specific complexities of encouraging and supporting someone during active treatment.” (P39) “For me, the patients didn't necessarily seem like oncology people, if that makes sense. They could have - they could have been videos about anyone.” (P7) |
All-level applicability | Participants perceived that the module would be relevant for a range of clinical settings and levels of expertise. | “I know that the examples in the videos that were used were patients that were, you know, in more like an outpatient gym setting. But I think, yeah, those principles probably still could be applied to even like an inpatient setting, or patients with more advanced cancer as well.” (P13) “Some of those scenarios were really great for me to be like oh, it's a good way to sort of help bridge that gap between, you know, students who may - may not have experience in that space and those who - and the patients, you know, who have been through something that's pretty harrowing and traumatic.” “Being reminded that that's not always the experience of our patients, whether you're a new graduate or a senior clinician, I think it doesn't hurt to have that little reminder.” | |
Not new knowledge | Some participants felt the generality of the module content meant it did not add meaningfully to existing knowledge | “I don’t feel I learnt a great deal given I'm already implementing the displayed skills regularly.” (P30) “I don't think it taught me anything that I hadn't already learnt from working with oncology patient[s].” (P15) | |
Brevity | Supports feasibility | Participants reported that the brevity of the module helped to alleviate logistical barriers to completion | “Usually, the issue for most people when it comes to managing training is not being able to fit it in with their day. But I just think the length of it, and the fact that it, you know, there's not a lot of unnecessary content in there. It's all you know, very useful and not time intensive.” (P19) “I got it done, you know, in 15 to 20 min, which is really valuable, especially within the context of a workday that might be busy.” (P31) |
Limits confidence | Participants felt the current brevity of the module inherently limited the depth of the content and left a desire to learn more to build confidence. | “It is probably too short and superficial to really leave clinicians feeling confident that they have the skills and knowledge to provide good quality trauma informed care going forward.” (P17) “It was pretty compact which I think is definitely good on one hand. And then also, I guess, sort of just limits the - the depth I guess, of you know how much you can do in a short timeframe.” (P24) “I think that probably just as a standalone module, I definitely still had lots of questions, so I don't know if it necessarily like, met all my needs. It was definitely a really great like toe in the water.” (P29) |
Discussion
The aims of this study were to evaluate the acceptability and potential efficacy of a TIC training module for exercise oncology professionals. Results indicated the training module demonstrated good acceptability, with positive evaluations across all domains of the Theoretical Framework of Acceptability. High scores for affective attitude were reflected in participants’ positive feedback on the module’s engaging design elements, content relevance and cost-effectiveness in qualitative interviews. Low burden and opportunity cost scores were also consistent with reports of an easy navigational experience and short time taken to complete the module. This affirms existing research on the benefits of interactive, multimodal designs to support learner engagement [33, 34], as well as the importance of good usability as a primary condition of acceptable digital interventions [35, 36]. Interestingly, quantitative results showed a few negative assessments of the module’s ethicality, which may reflect concerns raised qualitatively.
A
In particular, some participants expressed concern that TIC may inflate the concept of trauma or disproportionately foreground LGBTQIA + experiences. This may be due to a lack of intercultural awareness among some health professionals, which has been documented in previous health research [37]. Furthermore, the perception that TIC overemphasises trauma and LGBTQIA + experiences may reflect broader societal discomfort with recognising structural and identity-based forms of trauma.The module also demonstrated good potential for efficacy, as evidenced by positive evaluations across Capability, Opportunity and Motivation domains. Notably, participants reported high self-efficacy to implement TIC after the module despite lower scores on capability. As many participants reported that the training module affirmed current trauma-informed practices and facilitated the opportunity for reflection, it may be that motivation plays a more central role in being able to draw on existing skills. This aligns with adult learning principles, which emphasise how adults incorporate current expertise to inform ongoing learning, allowing skill mastery to become partly self-directed [38]. The expressed value of the training module both as a formalising framework and timely reminder to experienced professionals further suggests that brief, regular training in TIC may be a useful tool for professionals to establish and maintain competency, as indicated by prior interventions [29–31].
A
Wider formalisation could also help distinguish TIC from other adjacent concepts such as patient-centered care, while tapping into existing self-efficacy.While qualitative findings reiterated the benefits of video role-plays to provide explicit modelling of skills in practice, scores across capability were the lowest among the COM domains. This may be linked to the view the brevity and non-specificity of the training content to oncology limited confidence, despite supporting aspects of module acceptability.
A
Specifically, participants’ wish for extended learning around mental health difficulties and sensitive disclosures attest to the complex life experiences patients bring to exercise services and thus the importance of extending TIC training to allied health professionals.Lower capability ratings may also be linked to participants’ reports that the online format of the module did not facilitate practical reinforcement of trauma-informed service delivery. This is a common concern cited in e-learning, yet research has not found robust effect differences in skill acquisition when comparing online and traditional learning modes [39, 40]. Nonetheless, providing opportunities to reproduce taught behaviors forms an integral part of Bandura’s (1977) social learning model [41] and may be especially important for person-centred practices such as TIC that require interpersonal communication [42]. In the interim, findings reiterate existing consensus on the benefits of post-intervention resources to support knowledge retention and translation to practice [34, 43]. Alternatively, providing more in-depth content through a segmented adaptive learning approach may help to accommodate differing learning needs while ensuring training remains acceptably time efficient. [44].
Overall, results affirm the complex and dynamic relationship between acceptability and intervention effectiveness emphasised in implementation research [26, 28]. By measuring acceptability and potential efficacy simultaneously, findings elaborate on the interrelationship between constructs by highlighting how intervention properties contributing to acceptability might necessarily detract from potential efficacy (and vice versa). In this way, early feasibility testing can prompt developers to identify important trade-offs between acceptability and potential efficacy to guide implementation.
Strengths and limitations
The mixed-method approach was a key strength of this study, allowing for a precise, empirical measurement of constructs together with a contextualised understanding of mechanisms underlying intervention impact. It is possible however that the convenience sampling led to an overrepresentation of experienced practitioners. Including a more diverse range of experience levels via purposive sampling is recommended for future evaluations, particularly as participants expressed this module could be particularly beneficial for emerging practitioners.
Further, while a possible deleterious effect of experience on knowledge acquisition was noted in qualitative data, this was not verified quantitatively due to the low statistical power. Future studies should explore how level of experience and prior knowledge of TIC statistically moderate perceptions of intervention acceptability, as well as impacts on efficacy. This is of relevance given that professionals often reported integrating TIC, despite no formal training.
Finally, participants’ concerns regarding knowledge translation in an online learning environment, together with little evidence for behaviour change measures reported in digital health training, suggest the inclusion of a third-level behaviour change measure should be encouraged in later evaluations [44]. This would help further resolve outstanding questions regarding the long-term efficacy of trauma-informed interventions to reliably influence professional practice in exercise and beyond.
Next steps for implementation
The key findings of this preliminary evaluation suggest that the training module is highly acceptable to exercise professionals and has good potential to be efficacious. Subsequently, and in line with Bowen’s (2009) feasibility framework, it is appropriate to recommend the module for further efficacy testing. This should be carried out with a purposive sample and with a view towards evaluating clinical outcomes. In the spirit of iterative implementation, prior to the secondary evaluation, developers may consider 1) defining trauma-informed in relation to patient-centred care at the outset of the module and 2) adding a typed response function to the reflective task to support practitioners’ intentions towards behaviour change. Future trauma-informed interventions in exercise oncology should also consider co-design opportunities to further explore the specific educational needs outlined in this study.
Conclusion
This preliminary evaluation demonstrates that brief, well-designed trauma-informed care training is both acceptable and potentially efficacious for exercise oncology professionals. The module affirmed existing good practice, enhanced awareness, and supported motivation toward trauma-informed behaviours, particularly through its engaging design and relevance to clinical values. However, limitations in capability scores and expressed desire for deeper, oncology-specific content highlight the need for expanded scaffolding and ongoing support to enable sustained behaviour change. As the first known TIC training tailored to this context, these findings provide a strong rationale for further efficacy testing and co-designed refinements that better bridge the gap between intention and implementation, supporting more inclusive, sensitive, and effective exercise oncology care.
A
Acknowledgement
The training module was developed with funding from the Victorian Cancer Agency and the University of Melbourne. Content was initially developed by University of Melbourne Staff and Students (A/Prof Camille Short, Ms Xingyi Wu, Dr Tamara Jones, Ms Sarah Stratulate, Ms Jessica Lees, A/Prof Selina Parry, Mr Cordell Lofting, Ms Gwyneth Chua) and generously reviewed in kind by: Rebecca Van Lloy (Clinical Psychologist), and Danielle Parent (Registered Nurse), Valion Health; Beth Dogget (Social Worker), Rare Cancers; Daniel Van Roo (Cancer Patient), Viviana Cicconi (Cancer Patient), and Jasmyne Lee (Physiotherapist), Peter MacCallum Cancer Centre.The module was a recommendation from a co-design study, co-led by University of Melbourne researchers (A/Prof Camille Short, Dr Tamara Jones, Dr Lara Edbrooke, Prof Linda Denehy, and Dr Shaza Abo) in collaboration with staff and patients linked to the Peter MacCallum Cancer Centre prehabilitation exercise service. We give thanks to all co-design participants for sharing their experiences and insights. The following people volunteered their time to appear in module videos: Tamara Jones – Exercise Professional, Camille Short – “Patient”, Roman Marcano - “Patient”
A
Data Availability
Participants in this study have consented for their de-identified data to be used for future research, with the understanding that it will be stored at the University of Melbourne and destroyed after the retention period (5 years after publication). Access to the data will be available by contacting the corresponding author upon reasonable request.
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