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.

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.

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.

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).

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).

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.

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.