Exploring Trauma Informed Language in Patient

Exploring Trauma Informed Language in Patient Survey Forms: A Discourse Analysis

Table of Tables

Table 1: Stages of Methodology

Table of Figures

Figure 1: A parallel process of trauma informed practice

Abstract

Title: Exploring Trauma Informed Language in Patient Survey Forms: A Discourse Analysis

Author: Sumedh Milind Naik

Supervisors: Dr. Frédérique Vallieres, Mr. Mel Swords

Background: Trauma Informed Care (TIC) focuses on understanding and addressing the impact of trauma in healthcare settings. Language plays a very important role in TIC, as it can either aid or hinder a healing process. This study aims to explore the extent to which the patient survey forms in healthcare settings across Ireland align with the Trauma Informed principles particularly with the language used and their potential impacts on the trauma survivors.

Methods: The study design is a qualitative research design involving use of Rhetorical Discourse Analysis (RDA) method to examine the language of patient survey forms used across various departments in Ireland. The sample consisted of 7 blank patient survey forms used across various healthcare departments in Ireland. The analysis focused on using trauma informed language that could be retraumatizing for the patients with a history of trauma. 

Results: The analysis were based on various critical elements that influence the effectiveness of patient survey forms which includes credibility, emotional sensitivity, clarity, context, purpose, inclusive language, validation and confidentiality. The study suggested that some forms effectively used trauma informed language in their forms while others required significant improvements. Unclear language, lack of emotional sensitivity and inadequate attention to confidentiality were areas that needed improvement.

Conclusion: The findings underline the importance of use of trauma informed language in patient survey forms ensuring that they do not intentionally retraumatize the patients. By adoption of an inclusive, clear and sensitive language; the healthcare organizations can improve the patient engagement, trust and the quality of data being collected. This study highlights the need for revision and refinement of current patient survey forms to better align with the trauma informed care principles ultimately increasing the quality of care and patient outcomes.

Keywords: Trauma informed care, Patient survey forms, healthcare communication, rhetorical discourse analysis, inclusive language.

Word Count: 9997

List of Abbreviations

TIC – Trauma Informed Care

PSF- Patient Survey Forms

ACE- Adverse Childhood Experiences

SAMHSA- Substance Abuse and Mental Health Services

RDA- Rhetorical Discourse Analysis

Literature Review

Trauma-Informed Language in Healthcare

Trauma is described as events that are beyond the capacity of an individual to manage and are, therefore, usually accompanied by symptoms of fear, helplessness, or horror (Merlo and Bratina, 2022). These can be a result of child or partner abuse, community or personal violence, natural and man-made disasters, car and other accidents, warfare and other catastrophes, or other extremely stress-inducing events. Evidence demonstrates that trauma has a negative relationship with health among populations (Tebes et al. 2019). However, it is crucial to understand that trauma does not affect everyone in the same manner, particularly underprivileged individuals. It may vary based on cultural backgrounds, socio-economic status, accessibility of resources and real-life experiences (Ford et al. 2015) creating various impacts on wellbeing. Trauma-informed care (TIC) refers to the understanding of the effects of trauma and possibly avenues for therapy (Abuse, 2013). It is crucial for the provision of TIC with language that is informed by trauma, as this creates a person-first approach. This means language: people-first, strengths-based language which speaks to the individual’s worth and recovery process (Protocol, 2014). Trauma may be the result of a single event or a series of events. Osofsky and Groves (2018) give the following examples of childhood and developmental traumas: community violence, homicide, wars, abuse, neglect and family separation. However, Mason (2021) argues that other forms of trauma are not physical, but social, and can include racism, poverty, and discrimination. However, these latter traumatic experiences are less discussed in the literature. 

Individuals that have experienced potentially traumatic events can experience various responses and reactions encompassing emotional distress, anxiety, fear and loneliness. Adverse Childhood Experiences (ACEs) are the building blocks of an individual’s lifelong health; thus, they significantly affect their health outcomes. It is shown that trauma that occurs in childhood has a direct impact on an individual’s brain functioning and its development in the future (Hughes et al. 2017). It is, therefore, important to acknowledge ACEs to understand how to establish appropriate interventions for health care. Physical symptoms involve unwanted thoughts or flashbacks, negligent behaviour, headache, fatigue and trouble in maintaining relationships (Center for Substance Abuse Treatment. 2014). Mason (2021) discussed that trauma is a substantial and widespread problem that impacts individuals from diverse backgrounds. Severity and the nature of trauma, however, varies widely across individuals. TIC, as an approach, seeks to understand and recognize these reactions to provide better support and address the needs of clients with empathy and compassion (Center for Substance Abuse Treatment. 2014). Parker et al. (2022) also proclaimed that trauma-informed care is a therapeutic framework that aims to identify the indications of trauma and aid patients in their process of recovery. An integral element of this method involves using trauma-informed language, which establishes a secure and nurturing atmosphere for individuals who have experienced trauma. 

Trauma-informed language is focused on communicating with individuals who have undergone traumatic experiences. The main objective of trauma-informed language is to establish a secure and encouraging atmosphere by refraining from using language that may potentially retraumatize or retrigger traumatic experiences. For example, instead of asking something accusatory such as “Why are you like this?” we say something like “Can you help me understand how you are feeling right now?” This example illustrates the best way; a trauma-informed approach to language can be employed practically to aim at being sensitive to the client and form a sense of security. Using trauma-informed language mitigates the probability of more damage and facilitates the process of healing and recuperation (Palanac, 2021). 

Further expanding upon the fundamental principles of safety, trust and cooperation outlined by SAMHSA (2014), Lotty (2021) highlights the importance of the parallel process in Trauma-Informed Care (TIC) for both the client and the clinician (Figure 1). This phenomenon pertains to concurrent experiences occurring within a relationship, such as between a therapist and their client, which frequently involve comprehending the firsthand encounter of trauma, its enduring effects, and devising strategies to cope effectively and reduce or prevent re-experiencing the trauma.

Figure 1: A parallel process of trauma-informed practice

Trauma-informed practice thus emphasizes the importance of safe and secure connections to a healing medium (Lucio & Nelson, 2016). According to Bunting et al. (2019), the method emphasizes the need to comprehend the actual lived experience of trauma and how it influences coping mechanisms that were formed.

TIC aims to present a lens for healthcare workers to understand how psychological trauma affects people's behavior, and therefore how to approach their patients. (Maynard et al., 2017). In trauma-informed environments, every employee should receive training on the pervasiveness of violence and how early traumatic events relate to adult psychopathology, while also investing in the time and resources it takes to provide training to every employee (Abuse, 2013). 

Many of the guidelines published by the Substance Abuse and Mental Health Services Administration and other current TIC literature link TIC to the late 1990s Adverse Childhood Experience study (Felitti et al. 1998). Identifying four types of abuse (physical, emotional, sexual, and due to violence against mothers), Felitti et al., (1998) put forward that there are two different types of neglect and many types of household dysfunction that are the cause of adversity. Moreover, they demonstrate a dose-response relationship between childhood exposures and later-life health outcomes. Later disseminated by the Centers for Disease Control, this study inspired regional, national, and local efforts to improve the standard of patient and client care. SAMHSA, at the forefront, subsequently provided funding for several policy and training projects.

Trauma Theory

Trauma Theory is mainly concerned with the mental and physical impact of traumatic experiences (Keeble, 2021). Simultaneously, it also draws attention to understanding the language and being sensitive to the patient to prevent recurrent traumatization. Trauma Theory has the power to increase the sensitivity of language since the use of triggering terms does more harm than good in terms of patient care. It is also necessary to form an idea of common trauma responses like intrusive thoughts, negative behavior, hyperarousal, memory issues, problem in focusing etc. and realize how to develop the necessary safety for the respondents. In this regard, the latter implies using neutral language and being supportive (Wilmshurst, 2020). The implementation of trauma-informed strategies like safe communication that work toward healing requires special attention to the patient’s recovery concerns and the resolved feedback and reports. 

Trauma theory provides a robust framework to understand the profound impact of adverse experiences on an individual's psychological, physical, and emotional well-being. ACEs are detrimental to people's overall health and well-being, and they remain with them for the rest of their lives. Trauma thus stems from an individual's childhood and, with time, impacts an individual's brain functioning and development. Being trauma-informed is not only about surveys and data but is much broader, encompassing the entire effect of trauma on not only those receiving the care but also the givers. Díaz, Hall and Neville (2019) found that trauma theory can help medical practitioners understand the complex interplay between succeeding health results and traumatic events. The theory highlights that trauma can be evident not only in the form of clear symptoms such as depression, anxiety and mental disturbances but also in more indirect ways, such as individual attitudes, behaviors, and interactions in different social contexts. Thus, trauma theory highlights the impact of traumatic experiences on individuals' well-being and health and highlights the need for healthcare providers to understand and address the interplay between trauma and health results. 

Patient Survey Forms (PSFs) in Healthcare

PSFs play a fundamental role in terms of healthcare communication as they significantly contribute to the exchange of information between medical personnel and patients (Karaca and Durna, 2019). These forms also provide an in-depth understanding of patient’s experiences, satisfaction and preferences within healthcare delivery. Kostouros et al. (2023) discussed that based on these forms, healthcare centers can modify the different aspects of their service to increase overall patient satisfaction. These forms thus play a significant role in quality improvement initiatives, increase patient interactions, and encourage patient-centered care and healthcare communication. Similarly, Khanbhai et al. (2021) highlights that the patient survey forms can provide a structured platform for patients to communicate their feedback and concerns so that the healthcare personnel can understand their issues and provide better care to the patients accordingly. Survey forms can empower medical experts to actively participate in the patient’s care by asking the patients for their input directly, focusing more on the patients who suffer from traumatic experiences in their daily lives. 

Likewise, Larson et al. (2019) highlighted that patient survey forms play a critical role in collecting data on patient satisfaction and experiences with healthcare. These also contribute to informing and implementing initiatives ensuring quality improvement within healthcare organizations. In addition, Parker et al. (2022) highlighted that patient survey forms can help advertise accountability and transparency in healthcare systems by allowing patients to communicate their concerns with the healthcare workers because they are accountable for the quality of care delivered. Hence, the survey results can contribute towards healthcare organization’s commitment to patient-centered care and improvement in the building of trust and transparency with patients and the public.

However, Naimi (2022) discussed that patient survey forms must be carefully designed and implemented to increase their usefulness and efficiency. The healthcare organization must select the timely analysis and collection of survey data and as a result, engage patients in quality improvement efforts. Thus, the patient survey forms must be integrated into the delivery of patient-centered care and continuously evaluated for relevance and effectiveness to realize their full potential. 

Implementation of Trauma-Informed Care in Healthcare

Healthcare centers are increasingly introducing training programs to teach employees about trauma-informed care. Trauma-informed care requires an understanding of the effects of high levels of stress on a person (Khanbhai et al., 2019). This is considered particularly important given that trauma survivors may experience conditioned responses to specific stimulus by having elevated sensitivity to some behaviors, words or phrases that remind them of the trauma (van der Kolk, 2014). Revised rules and regulations, which feature trauma-informed principles that do not unintentionally re-traumatize individuals, are therefore recommended (Sweeney et al. 2016). Similarly, adopting a trauma-informed approach to patient survey forms does not only depend upon data collection. It also deals with identifying the general impact of trauma on healthcare professionals and patients. Based on the concepts of trauma-informed principles which consist of safety, choice, truth and collaboration the healthcare buildings can effectively address the requirements of the persons. It can increase the effectiveness of the triage, provide suitable approaches including the psychological and social assistance, subsequent care and so on, provide the waivers and be knowledgeable about it. Staffs are thus supported to taught to avoid abusive, suspicious, or distracting language across multidisciplinary team meetings, in filling out forms, in patient-provider interaction and provider-provider interaction (Khanbhai et al., 2021). According to the goals of safety, choice, truth and collaboration that is associated with the trauma-informed principles the healthcare buildings can offer necessary response to the needs of the persons. It can enhance the efficiency of the triage, offer proper measures such as the psychological and social support, further treatment and others, offer the waivers and be familiar with the procedure (Bosch and Mansell, 2015). Knowledge about trauma-informed language is necessary for patients and families because it assists them in navigating and understanding the interactions with healthcare about trauma impact with empathy, sensitivity, and compassion.

Benefits

Through the development of a safe and supportive atmosphere, trauma-informed care establishes a bond of trust and rapport between patients and healthcare providers (Grossman et al. 2021). It leads to patients to communicate more freely and truthfully in their treatment (Green et al. 2015). Patients who are well-treated and well-received are the ones who tend to say they are more satisfied with their treatment (Sweeney et al. 2016). Thus, the patients are expected to adhere more closely to treatment plans and recommendations and to attend follow-up visits (Chipidza et al. 2015). According to Cockersell, (2016) trauma-informed approaches are thus hypothesized to reduce the stress and anxiety that can accompany medical settings and procedures and thus pave the way to better mental and physical health. 

Effectiveness of Trauma-Informed Approaches to Patient Surveys

There is a lot of evidence highlighting trauma can hurt different parts of a person's life, such as their health and well-being, their probability of getting a job or going to school, and their chances of multiple disadvantages (Felitti et al., 1998). This has helped trauma-informed methods become more popular in Ireland and around the world. Naimi (2022) discussed that there is evidence that people who receive trauma-informed support have better outcomes, however, there is currently insufficient research isolating the unique effects of TIC on patient outcomes. However, Mahon, (2022) provide evidence that trauma-informed methods make people's experiences with services better and increase their participation, which is necessary to get clinical results.

Trauma patients have been able to note several personal advantages resulting from the trauma informed care they receive. Some of the gains include; improved housing security (Hopper et al., 2010). The effects on drug use have been mixed with some improvements reported as well as the continued worsening of some indicators Drug use has been found to have both good and bad outcomes. Another study reported a decrease in use of drugs where receivers of TIC were considered (Stergiopoulos et al., 2015) although other studies which were conducted showed that there was not any change on the drug use (Sweeney et al. 2016) Trauma informed care has been found to decrease recidivism (Bright, 2017); relapse risk factors like poverty, community and family violence, stigma, and prejudice etc., are addressed (Miller and Najavits, 2012); and the time taken before people are discharged from safe care is shorter (Greenwald et al., 2012).

Psychologically Informed Environments have also been shown to have better results than services that are not (Cockersell, 2016). One result of working in a trauma-informed way is that people are more likely to use programs including cognitive behavioral therapy and mindfulness-based therapy for managing trauma (Fortuna et al. 2018). However, the intersectional approach must be considered when acknowledging that patients with several risk factors are usually unable to connect or participate in therapies. This is because they may be either unable or unwilling to use these therapies (Prestidge, 2014). Studies have shown that trauma-informed interventions for hard-to-reach groups make people more likely to go to treatment, cut down on risky behaviors, like drinking, and reduce the use of seclusion and restraint, as practices broadly recognized are not trauma-informed. (Cockersell, 2016) People are more involved because they understand others better, build relationships, and have workers with real-life experience help plan and carry out services (DHSC, 2019).

Challenges

Regardless of trauma awareness, training of trauma-informed care among healthcare professionals and consistent application of TIC principles remain key challenges. Allocation of resources including funding, time, and staff necessary for implementation of TIC (Cockersell, 2016) are rare in many healthcare settings where finances remain under pressure. Institutional and systemic barriers can also prevent the implementation of trauma-informed practices, as is the resistance to change from staff and administrators (Sweeney et al. 2016). Moreover, Cockersell (2016) recommends that trauma-informed care should be modified to suit different cultural and contextual situations; what works in one setting may not be suitable in another. Applying trauma-informed principles for use in patient census surveys raises several difficulties directly associated with the nature of trauma and its impact on people’s experiences and interactions. Studies show that the constant raising of awareness regarding specific words or stimuli may limit the effectiveness of the interaction with the survivors and survey questions (Baker et al., 2018). Also, negative psychological states like dissociation or hypervigilance due to a traumatic background could impact respondent attention and understanding, which might impact responses to survey items (Bartlett et al., 2020). Moreover, trauma patients may be reluctant to share details with a provider because of stigma or fear of negative reactions, which can lead to not only an underestimation of potentially traumatic events but also an underestimation of the severity of the symptoms of trauma (Green CL et al., 2019). Additionally, traditional structure of survey forms may not be inclusive of all forms of trauma and the experiences that are unique to each form of trauma (Harris et al., 2021). To address these challenges, the use of language, question and survey administration methods must consider a trauma informed approach to patient surveys, to ensure response rates are compromised by those patients who have undergone trauma or abuse in their lifetime (Smith et al., 2020). 

Theoretical Framework

An analysis of survey forms can draw on multiple theories to comprehend how language may influence a patient’s experience and views of surveys, especially with consideration for previous trauma exposure. Among these, trauma theory, which in its basic form relates traumatic experiences to long-term pathologic changes in human’s psychological and emotional states, offers an important lens through which to analyze extant patient survey forms (Ford & Courtois, 2020). Consistent with trauma theory, this approach can help identify which language, appearing on self-completed patient satisfaction questionnaires, might potentially cause or provoke trauma responses in some patients (Herman, 1997).

Moreover, patient-centered care theory focuses on the care that is specific to a patient’s need, choice, and desire regarding their health care services. Similarly, patient-centered care focuses on improving and strengthening the relationships between patients and healthcare providers, using communication and other tactics to make patients more independent (Institute of Medicine, 2001). In the context of designing patient survey forms, patient centered care theory proposes that language be welcoming, non-judgmental and acknowledge the social positioning of an individual or the prevalence of traumatic community experiences (Koss, White & Lopez, 2017). 

Moreover, language implies the concept which, according to the theories of the linguistic science, forms an individual’s perceptions and behaviors (Nath, 2010). Since the field of sociology is concerned with the distribution and organization of social and cultural phenomenon, it follows that language, as a primary tool used in society, would adhere to these guidelines as well as some principles outlined in sociolinguistic theory (Mills, 2013). Thus, many terms used in patient survey forms may be indicative of various forms of structural relations of power between dominant and dominated bodies, the appearance of bias, and various expectations regarding the patient’s subjective experiences. It is crucial for researchers to focus on such survey forms and examine the potential concealed meaning in language and use of these and other strategies with patients who are possibly experiencing trauma.

Literature Gap

While the literature has paid increased attention to the importance of providing trauma-informed communication in healthcare settings, there remains a paucity of information on how the language applied on forms, including patients’ satisfaction surveys, may create additional difficulties for other trauma survivors (Green et al., 2019). Similarly, scholarly works have explored aspects of trauma-sensitive approaches within clinical discussion, but few have explored language used in written documents such as survey forms (Taylor & Garcia, 2022). This absence of literature is an indication of the need to undertake a formative examination of the terms deployed in patient surveys from a trauma-informed perspective. Through qualitative research on the specific language used in the survey forms, researchers can identify certain words and phrases that may unintentionally elicit a traumatizing response from the survivor. Thus, it is possible for future research works to examine how language of the survey forms influences patient’s perception of safety, trust, and being empowered to respond to survey forms.

From a research perspective, insights about language used in survey forms of patients can guide the formulation of communication directions and inform initiatives to help them promote more trauma-sensitive practices for better quality care (Harris et al., 2021). Thus, comprehending the ways in which language affects disclosure and how language providers and trauma survivors navigate these issues can lend potential solutions for widening access care (Koss, White & Lopez, 2017). From an operational perspective, adopting a trauma-informed language in survey rating forms could result in higher accuracy and reliability of the survey outcomes for evaluating patient’s health care experiences and determining patient’s needs (Smith et al., 2020). Thus, it can be used to design appropriate preventive and therapeutic measure and to modify hospital practices to better address the needs of people with a history of trauma. Furthermore, trauma-informed survey forms can also help improve patient-centered care since the use of such surveys signals to patients that they will be respected and that they will be treated as active participants in their healing process (Ford & Courtois, 2020).

In conclusion, it is crucial to identify practical and feasible steps towards increasing the use of trauma-informed language in patient survey forms as key to trauma-informed approaches in healthcare. In this way, undertaking comprehensive research in this particular field and using its results to develop practices that can improve the experience of patient satisfaction surveys in healthcare organizations will not only contribute to technical advancements in this field but also serve as a knowledge base of practical experience which will help to improve the application of trauma-informed care across various types and levels of healthcare systems.

Introduction

Background

The patient’s needs who have been through one or several traumatic events have become more accepted and valued in numerous health care settings. Various forms of trauma including childhood physical, sexual, emotional abuse, interpersonal violence and other trauma, can contribute to an individual’s overall physical and mental well-being. Extended early-life adversity can significantly increase the probability of poor physical and mental health outcomes for the rest of an individual’s life (Berliner and Kolko, 2016). Consequently, and according to DeCandia and Guarino (2015), trauma and its effects must be addressed in all care systems due to the negative impact they have on society. According to Becker-Blease (2017), trauma informed care (TIC) is one approach supported by an awareness of the pervasiveness and impact of trauma on society. In acceptance of that fact, the principles of TIC have been developed as a framework of care that seek to understand not only the effects of the trauma but aims to establish a culture of care that is sympathetic, empathetic, and responsive to clients with trauma histories (SAMSHA, 2014).

The idea of a trauma-informed approach has been widely studied and popularized in different sectors such as education, public health, psychology, psychiatry, and developmental science fields (Champine et al., 2019). The main goal of TIC is to facilitate changes in patient’s condition that promote resilience and recovery from exposure to traumatic situations. By emphasizing bodily, relational, and psychological safety, TIC thus seeks to empower care providers as well as service users (Hopper et al., 2010). 

Another important component of TIC involves the use of language. Brown et al. (2018) found that patients who had experienced trauma recorded high levels of satisfaction if providers were trained in trauma-informed communication, suggesting that such training has benefits when dealing with patient provider relationships and health event outcomes. These findings support the applicability of the use of trauma-informed language: there is a significant role of using effective approach concerning patient-physician relation, particularly focusing on building healthy rapport, trust, and openness between the two parties. Similarly, effective communication is well-recognized within the health sector as being crucial to ensure that patients receive quality care and positive experiences (Kwame and Petrucka, 2021). According to Pandey et al. (2019), language barriers can inhibit patient’s understanding of their care plans, delay their ability to communicate their requirements and lead to significant misunderstandings between healthcare providers and patients. Emotional dimensions are substantial in a healthcare setting and language has added importance in this regard as it impacts patient’s care experiences and ability to engage in healthcare services effectively. In doing so, healthcare providers can increase patient engagement and improve health results to ensure traumatized patients feel supported throughout their care journey. Similarly, the use of trauma informed language can increase patient trust in health care providers and the quality of information reported by the patient. For instance, Smith et al. (2019) argued that effecting trauma language in treatment interactions increases satisfaction and, subsequently, the engagement in particular care plans for trauma survivors, and may therefore improve the healing process of the traumatized patient (Smith et al., 2019). Also, patients with trauma history might experience difficulties in satisfying health care needs or history of trauma disclosure due to stigma or fear of revictimization. Still, when providers adopt sensitive language and care models, the patient feels more at ease and willing to disclose information about their trauma history and experiences, thus, receiving more complete and accurate information from healthcare givers (Johnson and Jones, 2020).

Patient survey forms, which are used to capture the experiences of patients and as a method of understanding the experiences of trauma survivors, offer insight into the language used in patient communication (Mersky et al., 2019). The Trauma informed Care (TIC) framework is a model that provides safety, trust and empowerment of the clients that has been exposed to trauma. It entails acknowledging the reality of trauma and its effects confirming that no traumatizing services are offered to people. The major principles include procedural safety, establishing rapport and operation dimensions whereby client’s self-determination is valued. Another critical aspect highlighted in TIC is multiculturalism and cultural responsiveness to client’s backgrounds (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). This way has been implemented extensively in health and social care to enhance the wellbeing of survivors of trauma. By looking into the structural form, content and tone of the survey questions and developed techniques to screen, rule out or downplay language that might cause trauma or hamper communication (Bloom, 2010), surveys can be repurposed or redesigned in a trauma informed way. In doing so, healthcare systems can be better aligned to a trauma-informed approach improving the quality of healthcare received.

There is sufficient evidence in the literature about the relationship between post-traumatic stress and adverse health effects. However, there is a conspicuous dearth of coherence regarding the terms and factors used in describing trauma-informed methods and practices that can pose challenges in syncing care and evaluating effects (Wilson, Pence, & Conradi, 2013; SAMHSA, 2014). To call a program, organization or system that is designed to provide individuals and families with the support they need after experiencing trauma, ‘trauma informed’, all forms of patient communication need to also align with the language and terminology related to the concept of trauma-informed care.

Rationale

There is need to have good communication channels if one is to establish considerable confidence between patients and healthcare providers in each setting. Patient survey forms are useful instruments to obtain feedback and to understand the patient experience in healthcare centers. However, patient survey forms may contain terms that may unintentionally remind patients of their traumatic past (Palanac, 2022). Thus, the current research sought to identify problematic language and make suggestions for how this language might be improved to be more aligned with the provision of a ‘trauma informed’ service. 

This understanding contributes to fulfillment of a trusting relationship with the providers as patient’s reasons that such providers are likely to understand their feelings. 

Using these principles in the patient survey forms, healthcare providers can guarantee that the feedback process does not lead to stress or trauma among patients, thus, it can be more effective considering the health outcomes (Purkey et al., 2018; Bailey et al., 2019). Although a lot of research has been conducted on trauma-informed care in clinics, there is insufficient literature on the language used in patient interactions, particularly in surveys (Johnson and Jones, 2020). Therefore, the current study will fill the gap by giving information on how the discourse in the survey forms can be made more trauma informed. The aim of this study is therefore to contribute to the body of knowledge on how trauma-informed practices can be implemented in healthcare. For the patients, who experienced traumatic events, the trauma-informed language would be beneficial; this pertains to the stigmatized and private healthcare; people from various walks of life and from all walks of life will be appreciated.

Research Aims and Objectives

This study aims to explore trauma-informed language in patient surveys. Specifically, this research sought:

• To identify phrases and words in existing patient survey forms that might be problematic to those with a history of trauma
• To analyse how, in survey forms, language shapes the way patients express their experiences, particularly regarding trauma.
• To understand the trauma-informed language in patient survey forms and its role in increasing or decreasing traumatisation and patient-centred care.

Methodology

Research design 

A qualitative research content analysis approach that fits within the strategy of discourse analysis is most appropriate for studying patient survey forms and the extent to which they are trauma informed. This design has also allowed for close analysis of the actual texts of the survey forms to consider any nuances in language choice (Fossey et al. 2020). The strength of this approach was the flexibility of discourse analysis which is well suited for inductively building understanding of this emergent area of TIC principles in written communication /documentation of patients and measurement tools. Hence, due to its focus on the meaning and interpretation of the collected data, the qualitative content analysis approach can offer important patient-oriented and empathetic insights to contribute to the future survey development and implementation.

Data collection method 

Data included a range of open-ended patient surveys, questionnaires and forms currently used in the health care sector. These include the National Inpatient Experience Survey, Maternity Bereavement Experience Survey, Maternity Care Survey, National End of Life Survey Questionnaire, National Incident Report Form, National Nursing Home Experience Survey Questionnaire and National Nursing Home Experience Survey Questionnaire for Nursing Home Residents. These surveys and questionnaires were identified by searching the PubMed and MEDLINE databases using the keyword national patient experience surveys and the national health care questionnaires specifically for Ireland. Some other search terms such as ‘inpatient experience survey’ or ‘maternity care questionnaire’ yielded different studies that applied such surveys to collate and examine patients’ experience data. Among all the surveys, seven were chosen because they are primary and involved key areas of healthcare that included inpatient care, Maternity/End of life care, Safety incidents, etc. These nationwide surveys offered validated questionnaires and instruments that were patient/family-centered experiences within the Irish system hence helpful in providing structured data analysis and interpretation for the considered study variables.

Sample size and technique

To maximize the appropriateness of the collected data, this study consists of purposive sampling to ensure the representation of various healthcare organization’s experiences. The study includes a range of survey forms used in different healthcare settings. Survey forms were taken from various departments. The survey forms targeted the type of language used by the staff to relate with patients who have undergone through trauma. This kind of focus directly correlates with the aims and goals toward which language for trauma-informed care best practice evaluation is set. The forms provide groups for objective examination, as the headings contain the following options: type of language (empathetic, sympathetic, neutral), absolutely necessary words, tone used by the staff. Most of the time surveyors can effectively obtain data to as the ratio of the use of language to that of trauma-informed language. Due to the nature of trauma experiences as potential topics to be discussed, these survey forms are a convenient method for determining in what extent the staff uses language that complies with tendencies for compassion and sensitivity. The standardized format enables reliable measurement in patient-staff interactions as well as across different staff members, and yet the relevant indicators are narrowly designed to target the influence of staff language during what can be a possibly emotionally challenging kind of care.

Data analysis technique: Rhetorical Discourse Analysis

Rhetorical Discourse Analysis (RDA) is defined as the study of language and its usage as it forms meaning and how it affects the thoughts and decisions of a certain group or an individual (Van Dijk, 2015). Discourse analysis was therefore carried out on patient survey forms to identify whether the language used in these forms was aligned to a trauma-informed perspective. Further, the purpose was to find any terms that could be causing distress, or potentially retraumatizing for any patients with a history of trauma. The main idea behind the use of discourse analysis was to identify some of the issues with wording and offer ideas for how these forms could be improved to incorporate more trauma-informed language. According to the purpose of the study, the language and argumentation of the texts with the patterns were examined to understand how these texts represent the issue and influence the readers on the perceptions of the topics being discussed. As in the case of the RDA, the interpretative approach has focused on a careful reading of a text to examine the use of rhetorical devices and discursive strategies. They focused on text analysis to identify the nature of rhetoric employed to influence the audience and promote specific ideological positions. It is so that multiple readings assisted in symbolical and change identification of presuppositions which sustain power relations. 

Table 1: Stages of Methodology

Results

This analysis is presented using the approach of the Rhetoric Discourse Analysis (RDA), is developed based on seven essential health-related questionnaires and the issue regarding their credibility, emotional impact, and comprehensibility. (Appendix 1-2). Analyzing several extracts and examples, this analysis discusses how these surveys meet the most important requirements for respondent engagement and data accuracy.

Credibility and Trust (Ethos)

In all the seven questionnaires, the aspect of developing credibility and trust is paramount throughout. The Designated Representative Questionnaire is perceived to be trustworthy as it is established based on the idea that the response is essential to enhance the quality-of-care delivery while its importance is reinforced by the issuing authority. For instance, it states, "Your feedback will help us improve the care provided to residents. " Similarly, the End-of-Life Questionnaire ensures credibility by explaining how feedback will directly influence care improvements, saying, "Your responses will guide us in enhancing end-of-life care. " The National End of Life Survey Questionnaire highlights the importance of respondent input for service enhancement, ensuring respondents their feedback is valued, with an introduction that reads, "We greatly appreciate your input in improving our services. " The National Incident Report Form (NIRF) focuses on the importance of incident reporting, enhancing trust through clear explanations of its purpose: “Reporting incidents assists in keeping places safe.” It is clear from both the NMBES and NMES Questionnaires that both have introduced themselves as being accountable for their services by illustrating a purpose of using the feedback gathered for enhancement. Finally, the Resident Questionnaire 2022 encourages residents to provide constructive feedback, emphasizing confidentiality to build trust:” The answers you provide are for our research purpose only and would help in enhancing health care delivery system.”

Emotional Sensitivity (Pathos)

Emotional sensitivity is not an afterthought in the surveys; instead, it is incorporated skillfully into every survey. Both the End-of-Life Questionnaire and the National End of Life Survey Questionnaire state about the possibility of emotional distress of the respondent and use reassuring and comforting words at the end of the questionnaire together to assess the respondent is in distress. For example, "We understand this is a sensitive time for you. Please feel free to skip any questions that you find distressing. " The Designated Representative Questionnaire similarly addresses emotional sensitivity by acknowledging the personal nature of the feedback and offering support contacts: “We are here to support you during this process.” The NIRF asks the respondents to provide details in relation to effects of incidents, thus encouraging emotional grounding and empathy with the situation through isolated prompts such as “Please describe how this incident has affected you.” Both, the NMBES, and NMES Questionnaire personalize the participant’s experiences by inviting them to share their experience reflecting on the question, such as “Please share how our services have affected you."

Clarity and Logic (Logos)

Precisely formulated and logically organized questions are the key elements of these surveys. The End-of-Life and National End of Life Survey Questionnaires are well-structured with clear sections covering different aspects of care such as “How are you feeling about your ability to communicate with your healthcare provider?” The Designated Representative Questionnaire starts with basic overall satisfaction before proceeding to more specific inquiries: “How satisfied are you with care received?” The NIRF follows the basic structure of asking for clear information: “What happened? When and where did the incident occur?” The content of both the NMBES and NMES Questionnaires deals with clarity in areas of service or educational relevance as well.

Context and Timing (Kairos)

When it comes to the design of the survey, some of the most important factors include context as well as the timing of the survey. The End-of-Life and National End of Life Survey Questionnaires allow respondents to complete the survey at their own pace, recognizing the emotional and logistical challenges. The Designated Representative Questionnaire and Resident Questionnaire 2022 focus on the nature of current care or facility conditions as follows: “Describe any recent alterations in the care.” The NIRF targets the context of the incident, as does the following: “Report the incident as soon as possible.” The NMBES and NMES Questionnaires consider supporting services and educational relevance correspondingly for instance, “Please reflect on the most recent experience with our support services.”

Purpose and Goals (Telos)

It is especially critical when performing surveys to state the purpose and the goals of the research. The End-of-Life and National End of Life Survey Questionnaires clearly state their objectives to improve care services based on feedback for example “End goal of this survey is to seek feedback that may be used to better end of life care.” The Designated Representative Questionnaire also underscores the goal of receiving detailed feedback for the improvement of care quality: “Your feedback is valuable in improving the quality of residents’ care.” The NIRF is specifically focused on the improvement of safety practice by documenting incidents such as “The purpose of this form is to document incidents to strengthen safety practice. “Both the NMBES and NMES Questionnaires state their purpose of service and educational enhancement clearly for instance, “Your feedback helps us to enhance our educational offerings.” The Resident Questionnaire 2022 is designed to enhance the healthcare services using inputs from the residents: “Your feedback is important to us in the improvement of our health care services.”

Inclusive and Respectful Language

The use of politically correct language is another of the significant aspects of powerful and efficient surveys. The End-of-Life and National End of Life Survey Questionnaires use terms like "family member or friend" to ensure inclusivity such as “Could you give feedback on behalf of your loved one?” The Designated Representative Questionnaire also steers away from bias and presumption of relations by using more universal greeting, for instance, “We welcome feedback from any nominated family members or friends.” The NIRF prompts for detailed impact without being prejudice, and ensures respect by stating, “Please provide a report on the incident without disclosing any identity.” The NMBES & NMES Questionnaires employ more neutral language. Both the NMBES and NMES Questionnaires use language that respects diverse experiences: “Tell us your stories and your ideas.” While The Resident Questionnaire 2022 enables the provision of detailed opinions on different aspects of the care provided: “Give your feedback on any aspect of this facility.”

Validation and Empowerment

One of the most dominant trends is that of empowering respondents and enabling their contribution. The End-of-Life and National End of Life Survey Questionnaires empower respondents by inviting detailed narratives and feedback such as “Your detailed feedback is important for the enhancement of services.” The Designated Representative Questionnaire also allows the respondent control over the information that is given: “You can also decide to skip any questions that you feel uncomfortable to answer.” The NIRF also brings to the individual the powers to contribute to the improvement of safety for example “Your feedback assists in preventing future incidents.” The NMBES and NMES Questionnaires both request constructive feedback empowering the respondents to feel empowered and confident while responding. Both the NMBES and NMES Questionnaires encourage constructive feedback, empowering respondents to shape service and educational enhancements such as “Your suggestions will help define future enhancements.” The Resident Questionnaire 2022 allows residents to give extensive opinions for influencing their care enhancements: “Your opinions concerning the care directly influence the quality of care.

Confidentiality and Privacy

Confidentiality and privacy issues need to be carefully managed to ensure the trust of the customers. The End-of-Life and National End of Life Survey Questionnaires explicitly state that responses are confidential, reassuring respondents: Personal responses given in the Research Study are anonymous: “Your responses remain anonymous.” Confidentiality of the Designated Representative Questionnaire is also enhanced, which guarantees safe feedback: “Your feedback is anonymous. “NIRF also makes feedback and complaints safely through confidentiality: “Your report of incidents is confidential. “The NMBES and NMES Questionnaires all aim at protecting the privacy of the participants through the message, “Your privacy is our priority." The Resident Questionnaire 2022 reaffirms confidentiality, promoting trust and candid responses such as” When responding to the questions you have been asked, your responses are anonymized and are to be used for enhancing service delivery in healthcare.”

Flexibility and Adaptation

Respondent flexibility is considered in several ways regarding the manner and flexibility of survey completion. The End-of-Life and National End of Life Survey Questionnaires offer multiple completion methods, such as online or postal, accommodating different preferences. Slightly different, the NMBES and NMES Questionnaires support a broad format of various forms of feedback: “You can provide feedback through this form or in person” While the Resident Questionnaire 2022 allows residents to provide feedback in any format convenient for them like “Take your time to complete this questionnaire.” The Designated Representative Questionnaire, NIRF support flexibility for the respondent to answer at own pace for example “Take your time to complete." The Resident Questionnaire 2022 allows for nuanced feedback, ensuring diverse resident needs are met: "Provide feedback in any format that is convenient for you." Flexibility and adaptability in these surveys improve response rates and data quality by accommodating respondent preferences.

Discussion

Feedback questionnaires are crucial tools in healthcare since they provide qualitative information needed for service recommendations and policy changes. The analysis of seven healthcare questionnaires using RDA reveals the following thematic dimensions that influence their effectiveness: credibility and trust, feeling, rationality, context, time, objectives and scope, non-sexist language, affirmation and enabling, bounded number of participants, discretion, and openness.

As the first step in the process of developing healthcare surveys, it is important to consider credibility to gain trust from participants and achieve dependable results. The findings of the study helped in analysing that there is a perception improvement among participants at the time of the survey to ensure credibility mainly via making the survey’s practices clear which leads to higher levels of reliability. It was also observed that it is crucial for organizations conducting surveys that ensure the credibility of the results not only enhances the response rates, but also increases the probability of obtaining feedback that can help in enhancing the delivery of services. Since trust leads to increased interest, health care providers need to cultivate effective communication channels effectively to show the need for and necessity of completing feedback questionnaires. Widely acknowledged crucial practices for increasing credibility in surveys include institutional support and clear reporting of the survey’s purpose (Smith, 2022; Jones et al., 2021). Studies also suggest that surveys backed by well-established healthcare organisations and including a clear statement of their aims receive more attention and more reliable, less filtered responses (Brown & Johnson, 2023; White et al., 2020). More reliable data is critical to ensure continued decision-making in healthcare, especially when data is concerned with describing traumas among participants (Taylor & Clark, 2021). If trustworthy survey design principles are applied, healthcare organisations can work towards enhancing their social value by having the stakeholders feel that their input in the surveys is useful for enhancing the delivery of services and patients’ outcomes (Garcia et al., 2022). Therefore, credibility of survey methodologies is important to produce relevant and useful information that can foster the needed changes in the healthcare systems’ practices and policies.

It has been noted from the findings of this study that recognising emotional sensitivity when undertaking survey is very critical in order to be able to get accurate responses especially when working within sensitive health sectors.

It was analysed that as with emotional intelligence characteristics, surveys with emotional intelligence can provide participants with anonymity, which assists in capturing deeper insight into the participant’s past experiences in a specific field and their requirements. The recommendation is focused on increasing organisations’ emotional intelligence in dealing with patients. As a result, many organisations can improve the quality of feedback received and interpret what patients are experiencing more accurately. Emotional sensitivity in the administration of healthcare surveys is relevant as it helps in the acquisition of truthful and more informative feedback from the respondents (Bradley et al., 2018; Epstein et al., 2005). Research has stressed that interviews that are considerate about people’s emotions not only increase survey completion rates (Jones et al., 2021) but also provide deeper insights into participants’ experiences of and attitudes to healthcare processes and outcomes, as well as their relative traumas (Brown & Johnson, 2022; Garcia et al., 2023). Surveying leads to an affirmation of the feeling evoked by the respondents hence assisting in creating a praiseworthy platform for communication. (Smith & Davis, 2020; Taylor & Clark, 2021). This is crucial for enhancing the process of data collection, while embracing the principles of surveying to promote the spirit of patient-centered care and quality services for the healthcare providers.

Cohesion and organization are among the primary characteristics of the structure and development of the healthcare survey affecting the understandability of questions by the respondents, as well as the reliability and relevance of the collected data. The findings of this study also informed that effective surveys’ characteristics also make the respondent understand the questions in a clear logical manner which positively affects data quality. It can be analysed that whenever questions are grouped coherently and consistent with objectives, participants allow valid inputs that can enhance patient care directions. Such clarity is useful not only in the generation of data from surveys but it helps in decision making practices that go on in healthcare organizations. Contemporary research shows that clearly ordered questions, which correspond to the survey’s aims, and eliminate vagueness are important (Brown & Davis, 2020). Clarity and comprehensiveness of the structures used in the creation of survey instruments enable the respondents to understand the rationale behind each question, providing more targeted feedback for the enhancement of healthcare services and description of their traumatic experiences. Research has pointed out that surveys with a clear and coherent design positively influence the respondent’s commitment and the quality of the results achieved (Smith et al., 2021). When questions are grouped logically and are relevant to survey aims, healthcare providers get data that will help in service improvement and patients’ care planning (Taylor & Garcia, 2022). Additionally, effective survey communication leads to precise survey results since there is less chance for confusion or misinterpretation of survey results as survey communications regarding the study are clear (Clark & Johnson, 2023).

The findings of the RDA above suggested that when survey questions are contextualised, it’s possible for the respondent to liken the given scenarios easily, resulting to more relevant and utilizable feedback. It also diversifies the data, in that knowing the details of participants’ experiences in the health care system better prepares providers to meet patients’ needs. It was noted that defining the context appropriately in surveys enables healthcare professionals to provide an exact meaning to the responses given hence aligning the results obtained toward the operational goals. Defining the purpose of surveys and goals concerning survey results is crucial for realizing stakeholders’ expectations and benefits of surveys. It lays focus to the fact that when goals of surveys are communicated clearly and understood respondents are more likely to respond in a qualitative way, thus improving on the response rates and quality of data gathered (Johnson & White, 2023). It would be equally important to highly clarify the purpose of the survey as this not only increases respondents’ interest and enthusiasm but also guarantees that the collected data would be pertinent to imperative components of care provision and quality of services offered (Clark & Brown, 2023). Studies show that when organizational objectives of surveys are clear, the participants are more inclined to respond effectively as they notice that the survey is pertinent and for this reason, will endeavor to give the required data (Adams & Garcia, 2020). For instance, questionnaires that are meant to gauge patient satisfaction or Hospital health-care service efficiency should include objectives in the questionnaires that draw the participant’s attention to some areas of relevance. This way helps in acquiring relevant data to inform administrative decisions in the healthcare industry and policies formulation (Jones & Wilson, 2021). In turn, survey design is a means of achieving general objectives within the framework of the organization to direct the main effort towards implementing interventions that would be backed by credible data. Furthermore, specific survey objectives increase the credibility of the information collected due to the respondents’ awareness of their significant role in influencing the improvement of healthcare services. This alignment not only optimizes the surveys’ efficiency to assess patients’ experiences, but it also plays a crucial part in advancing the general quality of care and patients’ condition (Taylor & Clark, 2021).

It was noted from the findings that surveys that use the appropriate or rather the intermittent use of the inclusive language give the participants a rather positive attitude towards the surveys and thus gives them a positive attitude towards offering feedback. It assists in creating diversity and also provides a richer data collection process which captures all the stakeholders’ experiences. Therefore, for healthcare surveys to better fit into the country’s needs and provide a more efficient quality of care, they need to implement inclusive language. The use of inclusive language in healthcare survey helps to increase the interest of the partakers and increases the reliability of the collected data as the health care field embraces people of different diversities with different perspectives (Lee, Johnson & Brown, 2021). When using surveys, inclusion of other minorities in the language used shows the researcher’s sensitivity to their diversity and equals them to others hence builds trust among stakeholders (Johnson & White, 2021). In a similar vein, findings point to the need for survey design that does not compromise inclusiveness as a way of avoiding any form of prejudice and making everyone feel like they belong (Jones & Smith, 2020; Brown et al., 2019). This approach eliminates prejudice by which some groups may be discriminated against; thus, the surveys offer respondents of different age, gender, or race the same chances of responding genuinely. This approach not only enhances the quality of data gathered but also assists healthcare organisations in addressing population’s requirements in their delivery of care (Taylor & Clark, 2018).

Essentially, asserting the respondent experiences and assisting the stakeholder via survey responses is crucial to establishing a shared view in the delivery of health-care services. In this regard, Miller and Smith (2020) explicate that the use of surveys is not just a process of gathering data but rather engaging individuals through an open invitation to the chances of giving detailed narratives and feedback. Besides affirming that stakeholders’ proposed solutions are genuine and relevant, it moves them forward to be involved actively in the enhancement of quality services and policy formation (Clark & Johnson, 2022). When evaluating stakeholder information healthcare organisations can prove that they are responsible hence promoting patient focused care.

The findings thereby emphasized that It is essential to ensure that participants do not feel that their surveys would be identifiable within the survey’s response results in order to encourage participants to respond to surveys sincerely. Therefore, by ensuring ethical ways of collecting data, health care organizations will ensure that participants feel comfortable to give out any information. It was suggested through the findings of this study that maintaining confidentiality can enhance people’s confidence in the surveying process resulting into data with references on the improvement of health care services. Security and anonymity are two of the most vital concepts that must be upheld to the highest level when conducting surveys in the healthcare sector. As widely stated by Clark and Rogers (2022) eradicating any doubts regarding the protection of respondent data, along with guaranteeing anonymity, is crucial. Cognitive interviewing also employs several techniques to maintain and guarantee ethical conduct and regulatory compliance to most of the questions, therefore assuring the freedom of respondents and making them comfortable to give genuine responses (Adams & Garcia, 2020). In this way, confidentiality procedures reduce risks of respondents fearing the consequences of their statements, thus, ensuring that the information received from the healthcare providers is honest and unbiased of their experiences when delivering or receiving healthcare services. In a nutshell, it can be argued that receiving the validation and the sense of empowerment that comes with filling in surveys enables a form of participation that enhances the stakeholders’ perceived relevance and inclusion in the management of a health care organization’s conditions and changes (Lee, Johnson & Brown, 2021). Likewise, confidentiality and privacy maintain ethical principles to provide the necessary protection to the collected survey results as well as the precise perception of the stakeholders (Brown & Johnson, 2023). Altogether these practices constitute an integrated approach towards addressing various aspects of healthcare, as well as serve to identify focus areas suitable for intervention consistent with the patient’s perception of the need for treatment.

The ability to complete surveys in a variety of methods is emphasised to increase the response rates in healthcare settings (Taylor et al., 2021). Studies prove that the optimization of respondent’s choice using different survey techniques such as online option, paper-based option and multilingual option, increases responsiveness and especially reduces the barriers to participation of most groups of people. The survey format assurance is crucial as it offers stakeholders the opportunity to select between the online and paper questionnaire versions and makes the latter preferred since people with different levels of proficiency in the use of technology and different language backgrounds will be able to express all the ideas and opinions necessary for the healthcare organisations (Adams & Garcia, 2020). This approach not only supports the collection of a broad range of data, but also catalyzes meaningful interaction by showing consideration of stakeholder’s desires and requirements when it comes to survey development.

In sum, the insights derived from this study are significant to depict the complexity of healthcare surveys along with directing the attention to credibility, sensitivity to emotional aspects, clearness, and inclusiveness. It of course does so by linking these findings into the current body of literature review and stressing the importance of examining clearly stated healthcare survey objectives, thus aiding the further development of the methodologies used in the sphere, and consequently enhancing the quality of healthcare provided.

Conclusion

In conclusion, based on the analysis of various healthcare questionnaires the various critical elements that are of importance in determining the best practice in questionnaires is well understood. When it comes to credibility and trust, emotional sensitivity, the language style that is clear and logical, context and timing, purpose and goals, stakeholder engagement which means avoiding of maternity language, validation and power, confidentiality and private matters, and flexibility and adaptation, all of them affect the survey outcomes. Interactivity, which includes credibility and trust, is primary and achieved by establishing organizational communication and gaining support from relevant official institutions needed to ensure participation and accurate data. Concern with the emotional aspects when designing the surveys improves the feedback quality and provides a comprehensive viewpoint from various stakeholders, as well as improving the definition of the qualitative data.

The assessment of survey questions indicates that well-constructed questions with logical structure are important to avoid respondent confusion and/or ambiguity regarding the questions being posed while at the same time allowing for meaningful analysis to be made based on the responses given by the respondents. Since surveys can be conducted at different phases of a project, their relevance within a specific social context and their timely administration amplifies the survey’s effectivity by providing up-to-date feedback to a project. This achievement is beneficial because refining the goals and objectives of a survey helps target respondent’s attention and enable the proper interpretation of the results, contributing to decision making in healthcare management. Use of inclusive language can promote inclusivity since all the diverse groups in each society will be valued and given the same chance.

However, confirming the respondent’s experiences and anonymous data retention or protection remain critical for gaining people’s trust and maintaining the research’s integrity. Thus, participant stakeholder support through surveys also gives health care organisations signs of patient and customer-oriented care delivery and encourages organisations to advocate for improved healthcare services through collaboration approaches. Furthermore, this examination demonstrates the application of the principles of survey design in the healthcare context and reveals the importance of perpetuating refinement and advancement of these approaches to address the existing and emerging healthcare issues. Consequently, through combining these insights, the management of healthcare organisations can use surveys more efficiently, engage their stakeholders better, and ultimately, advance the quality of the service and outcome for the patients.

Reflexive Statement

Description

Over the course of this research study, I endeavoured to explore the complex nature of healthcare surveys and specific issues within them, including credibility and trustworthiness, emotional considerations, logical framework, and issues of anonymity. I discovered how different aspects of design help or hinder survey relevance and stakeholders in my case while using dissimilar questionnaires to assess the trauma-informed language in each of the questionnaires. The rationale of the research entailed a rigorous data collection and analytical critique whereby I had to assess how each aspect of surveying impacts the respondent’s input and the study result’s validity. With the help of information disclosed in diverse surveys, I synthesized outcomes to reveal recommendations regarding enhancing the organization’s healthcare service delivery. This process has not only helped me increase my knowledge about survey methods but also improve my practical skills in utilizing the available information to improve the quality of patient and other stakeholders’ interactions. As a result of the process, I have developed a rich understanding of how to create effective surveys as the foundation for introducing positive change in the healthcare system.

Feelings

During this research, I had both positive and negative feelings in equal measure. On the positive side, I experienced a great satisfaction considering the accomplishment of facing many intricate topics and analysing the significant meanings of the different surveys in the healthcare field. The most rewarding aspect of the analytical process was my engagement in extended discussions of survey efficacy and stakeholder outreach upon applying the knowledge gained during the course. However, the process was not as smooth as imagined and came with several challenges. Some of the challenges that I went through included feeling frustrated while trying to deal with complex data and at the same time, attempting to write as per academic standards of research. While working on the research, the coordination of tasks with other activities was challenging at times. However, not all the mentioned challenges require mere aggravation as the entire process was valuable and highly enriching, as it helped me strengthen myself and unleash my potential in working as a professional. The conduction of this study has reignited my passion to continue using research to influence change in health care.

Evaluation

In the entire process of the research, what seems to have been very vital while comparing my strengths and weaknesses is the identifying of the research process. I described one of my most significant strengths to be the capacity of critically evaluating primary health care information from surveys. It helped me grasp the relevance of aspects such as credibility, emotional considerations, and clarity of the questionnaires that considerably contributed to the research outcomes. Also, my focus on the evaluation and analysis of data proved my adherence to all the academic requirements and interest in the research question. However, difficulties were observed to manage the amount of data collected in accordance with other academic and personal obligations and tasks. Sometimes, the conflicts with such demands resulted in episodes of stress and challenge in staying focused on the substantive research tasks at hand. Additionally, although my interpretation and synthesis of the findings were helpful in conducting the analysis, there were some moments when the current empirical data were not integrated effectively into the discussion section, and, therefore, the main researching story could be fortified. In general, this study has demonstrated my ability to perform detailed analytical work as well as proven my ability to work hard to overcome hurdles that stand in my way. It has also underlined some weaknesses in how to manage research workload and how to incorporate comprehensive evidence into the research work.

Analysis

In examining the efficacy of healthcare surveys, the use of different theoretical perspectives is important to understand the programs fully. The study identified several essential elements of survey design, such as credibility, trust, emotional considerations, rationality, and logical flow, among others. Theories suggest that credibility and trust are vital in influencing the respondent. Perceived behavioural control relating to the survey and perceived subjective norms play a key role in influencing the willingness of people to be honest in their responses. Studies show that organizations with clear purpose tend to be more credible to respondents, leading to more cooperation, especially when dealing with trauma-informed topics. Emotional intelligence also plays an important role concerning survey design, emphasizing the sensitivity of emotions. Considering the respondents’ feelings and reinforcing or expressing understanding toward them leads to superior quality data results. Questionnaire design that involves empathy and accounts for the respondent’s emotional reactions yields more comprehensive feedback.

Understanding why distortion of questions and submitting them to logical structuring is crucial for survey questions. Questions posed clearly and logically connected allow respondents to solve questions more efficiently and comprehensively, resulting in higher quality data. Altogether, it can be noted that theoretical orientations about healthcare surveys support the idea that credibility, along with empathy and clarity, are key to improving survey-based accuracy and efficiency, especially when considering a trauma-informed approach. It is relevant to analyse these factors to enhance the design and conduct of surveys.

Conclusion

The research journey itself provided a rich learning experience, expanding my knowledge of healthcare survey design. This study focused on credibility, emotional interpretation, and assertion, and how they drastically affect the quality of data collected and respondents’ commitment, involving a trauma-informed approach. Analysing various questionnaires challenged and taught lessons in the extent of methodological approach versus the practicality of its usage in terms of being trauma-informed and helping participants to open up more. Accomplishing the task of synthesizing and analysing the data has given a positive experience in critical thinking and research skills. This process helped me learn more about survey design and the perpetual improvement needed in research practices for better improvements in healthcare.

Action Plan

This action plan will help me to overcome the weaknesses outlined during this study as follows: First, I will focus on improving the synthesis of the data gathered by obtaining further education in the application of different methods for analysis and using appropriate software. Second, I should spend more time on comprehensive preliminary research to be more aware of the specific features of survey analysis works before starting with it. Also, I will participate in peer reviews and request professional input to enhance the development of my critical evaluation processes. Last but not least, I will ensure that I engage in the expansion of my knowledge in the selected field of research by attending workshops and taking courses to ensure I am up to date with the current trends of methodologies in healthcare research.

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Appendix 1: Data Extraction and Coding

Appendix 2: Patient Survey Forms

1. a) Designated Representative Questionnaire

NATIONAL NURSING HOME

EXPERIENCE SURVEY QUESTIONNAIRE

Help us make nursing home care better!

What is the survey about?

The National Nursing Home Experience Survey aims to capture the experiences of nursing home residents and also the experiences of their nominated family member/friend. As a family member or friend of the resident, you are invited to share your own experiences of the nursing home (named in the accompanying letter) by taking part in this postal survey. Nursing home residents from each participating nursing home are also invited to tell us about their experience by taking part in a face-to- face interview. The results of the survey will be used to improve the care provided to nursing home residents.

Why did I get this questionnaire?

You got this questionnaire because you are the nominated family member or friend of a resident in a participating nursing home in Ireland.

Can I do the questionnaire online?

Yes, please go to survey.yourexperience.ie to complete the survey online.

Can I ask someone to help me fill in the survey?

Yes, you may wish to fill the survey with someone else to help you answer some of the questions or you may pass the survey onto the person who knows most about the care provided to your family member or friend in the nursing home.

Completing the questionnaire

• As you go through the questionnaire, please follow the instructions and answer the questions by ticking the most appropriate box or boxes like this using a black or a blue pen.
• Do not worry if you make a mistake; simply fill in the box and put a tick in the correct box.

There is space at the end of the questionnaire for your written comments.

• Please do not write your name or address anywhere on the questionnaire.

• If the questionnaire raises issues that you feel you would benefit from talking through, please contact one of the advocacy support services below for further support, advice and information.
• Sage Advocacy: please email info@sageadvocacy.ie, phone 0818 719 400 or go to www.sageadvocacy.ie
• Patient Advocacy Service: please email info@patientadvocacyservice.ie, phone 0818 293003 or go to www.patientadvocacyservice.ie
• Sage Advocacy’s Family Forum provides information, support and advocacy to nursing home residents and their families. You can contact the Family Forum by email: familyforum@sageadvocacy.ie
  
  

Thank you for completing the survey.

.4

Q22. In your opinion, how clean is the nursing home?

1 Very clean

2 Fairly clean

3 Not very clean 4 Not at all clean 5 Don’t know

Q23. If they have the capacity, does your relative or friend have as much control as they wish over their personal finances?

1 Yes, definitely

2 Yes, to some extent

3 No

4 They do not have the capacity

Q24. Are your relative’s or friend’s belongings and personal items safe in the nursing home?

1 Yes, definitely

2 Yes, to some extent

3 No

4 Don’t know

1. b) End of Life Questionnaire

NATIONAL

END OF LIFE SURVEY QUESTIONNAIRE

What is the survey about?

The National End of Life Survey is a nationwide survey asking bereaved relatives about the care provided to their loved one in the last days of their life. The purpose of the survey is to learn from people’s experiences of end of life care in order to improve the services provided both to people who are dying, and to their loved ones.

Why did I get this questionnaire?

You got this questionnaire because you registered the death of a family member or friend between 1 September and 31 December 2022.

Can I do the questionnaire online?

Yes, please go to survey.yourexperience.ie to complete the survey online.

Can I ask someone to help me fill in the questionnaire?

Yes, you may wish to ask someone to help you answer some of the questions. Alternatively, you may pass the survey on to the person who knows most about the care provided to the person who has died.

Completing the questionnaire

🞍 As you go through the questionnaire, please follow the instructions and answer the questions by ticking the most appropriate box (or boxes) using a black or blue pen.

🞍 Don’t worry if you make a mistake; just fill in the box and put a tick in the correct box or boxes.

🞍 There is space at the end of the questionnaire for your written comments.

🞍 Please do not write your name or address anywhere on the questionnaire.

🞍 The questionnaire takes about 30 minutes to complete.

🞍 The term ‘healthcare staff’ is used to refer to all staff working in this setting, which may include: care workers, healthcare assistants, doctors, nurses, social workers, physiotherapists, etc.

🞍 Please fill in as much of the questionnaire as you can. If, however, you find that some of the questions bring back upsetting memories, please feel free to skip them.

🞍 If the questionnaire raises issues that you would like to talk about, please contact the bereavement support services for further support, advice and information. An information leaflet on these services is included with this questionnaire.

🞍 If you have been impacted by any issues with regard to end-of-life care and would like information or support, or if you would like to provide feedback on the care provided to your loved ones, you can do so by contacting the Patient Advocacy Service on 0818 293 003 or at info@patientadvocacyservice.ie. For more information, please visit patientadvocacyservice.ie.

Q3. How long had they been ill before they died?

1 They were not ill — they died suddenly 🡪 GO TO Q103.

2 Less than 24 hours

3 One day or more, but less than one week

4 One week or more, but less than one month

One month or more, but less than

5

six months

6 Six months or more, but less than one year

7 One year or more

Q4a. Did they spend any time being cared for at home during the last three months of life?

1 Yes 🡪 GO TO Q4b.

No, they were in a

2 hospital, hospice, nursing home or a

residential care facility for the whole three months

🡪 GO TO Q22a.

Q.4b Please write the name of the town/village and county where they were cared for at home:

Town/village: County:

7 20

24

1. c) National Inpatient Experience Survey (NIES Questionnaire)

PATIENT QUESTIONNAIRE

Help us make hospital care better!

What is the survey about?

The National Inpatient Experience Survey is a nationwide survey asking patients about their recent stay in a public hospital. The results of the survey will be used to improve hospital care.

Please use this questionnaire to provide general feedback about your hospital experience. If you would like to make a comment or complaint and receive a response, please email the HSE at yoursay@hse.ie or phone 1890 424 555. You can also contact the Patient Advocacy Service, an independent advocacy service, an independent advocacy service, at 0818 293 003 or info@patientadvocacyservice.ie

Why did I get this questionnaire?

You got this questionnaire because you spent 24 hours or more in hospital, you are 16 years of age or over and you were discharged from hospital in the survey month.

Can I do the questionnaire online?

Yes, please go to survey.yourexperience.ie to complete the questionnaire online.

Can I ask someone to help me fill in the questionnaire?

Yes, you can ask someone to help you fill in the questionnaire. You may also ask someone to fill in the questionnaire on your behalf. However, please make sure that the answers given reflect your experience of care.

Completing the questionnaire

• For each question please clearly tick one box using a black or a blue pen.

• Please read the information in the boxes that accompany some of the questions as these provide important information to help you complete the questionnaire.

• Do not worry if you make a mistake; simply fill in the box and put a tick in the correct box.

• There is space at the end of the questionnaire for your written comments.

• Please do not write your name or address anywhere on the questionnaire.

• Please return this questionnaire in the Freepost envelope provided. No stamp is needed.

National Inpatient Experience Survey

Milltown House Milltown