Organizational Trauma-Informed Readiness, Burnout and Secondary Traumatic Stress among Head Start Staff and Educators during COVID-19

The stressors experienced by Head Start staff and educators during the COVID-19 pandemic may increase their risk for burnout and secondary trauma. During the transition from in-person to online work, research has shown this population experienced increased stressors, accompanied by a decrease in wellbeing promoting activities


Introduction
Head Start early childhood education programs provide lowincome children with a variety of educational and social services to support healthy growth and promote school readiness. Early childhood educators guide children's early educational experiences through their interactions with children and partnership with their parents. While baseline workplace stress is high among early childhood educators, the COVID-19 pandemic has further exacerbated levels of workplace and personal stress for Head Start educators and staff, putting them at risk for developing adverse health outcomes [1]. During the pandemic, low-income families experienced more food and housing insecurity due to job instability [2][3][4], and higher rates of COVID-19 infection and mortality [5]. These stressors and experiences within Head Start families may influence relationships with early childhood educators and their wellbeing. Recent research indicates early childhood educators experience high levels of workplace stress, burnout, and Secondary Traumatic Stress (STS) [6][7][8]. High workplace stress has been associated with adverse mental health outcomes, such as depression, in early childhood educators [9,10].
Head Start educators and staff may be at particular risk for adverse mental health outcomes, given higher rates of risk factors, such as exposure to Adverse Childhood Experiences (ACEs), experienced among Head Start staff [9]. ACEs refer to exposure to potentially traumatic events, such as household dysfunction, abuse (physical, sexual, emotional), and neglect (physical, emotional) that occurs before age 18 [11]. Trauma occurs when experiences exceed a person's ability to cope. ACEs have lasting effects on health and wellbeing throughout the life span; this is important to note given that more than half (61%) of United States adults have reported at least one ACE, and one in six adults reported four or more ACEs [12]. Adults who experience ACEs may experience alterations in neural stress-regulatory circuits that increase stress sensitivity, placing them at increased risk for negative mental and physical health outcomes as adults, such as depression and obesity [13]. These symptoms, rooted in exposure to ACEs, may adversely affect the wellbeing of early childhood educators and staff. This may influence interactions with the children and families they serve [14], as may the social and emotional competence of these educators and their working environment [15]. In addition to experiencing ACEs themselves, Head Start educators and staff may be exposed to potentially traumatic events and situations as part of their work with Head Start children and families.
Compassion fatigue, thought to be an inevitable cost of caregiving [16], refers to the cumulative toll that results from working with traumatized individuals as part of everyday work [17,18]. Compassion fatigue is a state of exhaustion and dysfunction that occurs as a result of deep caregiver empathy resulting in manifesting trauma symptomatology, similar to that of the populations one serves [16]. The symptoms of compassion fatigue include an extreme state of tension, spanning psychological and physiological domains. For instance, symptoms of compassion fatigue may include anger and irritability, reduced empathy, headache, fatigue, and disrupted sleep. Symptoms of compassion fatigue may also include impairment in decision-making and reduced ability to care for those being served [18]. Ultimately, compassion fatigue may lead to increased work absenteeism, psychological injury claims, reduced work productivity, and turnover [18]. Compassion fatigue also influences job satisfaction and performance; importantly, this can impact one's relationship with the population served. However, research among human service professionals found that relationships within the workplace [19] and higher levels of compassion satisfaction [20] may reduce levels of compassion fatigue.
Compassion fatigue is conceptualized as consisting of a convergence of burnout and secondary traumatic stress [18]. Burnout is a phenomenon resulting from chronic stress due to work-related factors, and consists of three dimensions: emotional exhaustion, depersonalization, and lack of personal accomplishment [21]. Burnout increases when, being unable to reach a goal, an individual experiences feelings of frustration, lower morale, a loss of control, and inputting more effort into this goal [22]. Specific symptoms of burnout may include negative workrelated attitudes, cynicism, and apathy [23]. Those experiencing burnout may feel overwhelmed and unsatisfied at work. Research in early childhood teachers has shown burnout contributes to lower rates of productivity, as well as higher work absenteeism and job turnover [24].
Secondary traumatic stress, the second component of compassion fatigue, may develop in individuals who work with clients who have been exposed to trauma. Symptoms of STS are similar to post-traumatic stress disorder [16] and may include intrusive thoughts, avoidance thinking or talking about a trauma, negative cognitions and mood, and changes in arousal and reactivity. According to Stamm, individuals who experience symptoms of STS are overwhelmed by the trauma incurred by those they serve, and unable to stop thinking about those they serve. Burnout and STS are related but distinct concepts. STS encompasses fear, which is not addressed by burnout [25]. Also, burnout focuses on factors related to how work is organized or delivered, rather than the emotional impact of serving others. STS is often discussed in conjunction with vicarious trauma, which is an altering in one's perception of the world as a result of engaging with individuals who have experienced trauma on a regular basis [26]. STS and vicarious traumatization have been associated with adverse physical health symptoms (e.g., high blood pressure, obesity, diabetes) [27] and mental health outcomes, such as anxiety and depression [28].
Compassion satisfaction, which refers to the positive aspects associated with one's role as a caregiver, may protect against the effects of workplace stress [25]. According to Stamm, compassion satisfaction may be thought of as the pleasure one derives from being a caregiver [25]. This construct describes the sense of meaning and purpose in the role. Compassion satisfaction is negatively correlated with burnout and secondary traumatic stress, and clinicians with higher levels of compassion satisfaction are more resilient [29]. Research conducted on early childhood home visitors found these educators experienced high levels of compassion satisfaction compared to the general population [28]. It was hypothesized that higher levels of compassion satisfaction may have buffered the effects of stressful events for these educators. There is also limited data on how these factors have impacted this population during the COVID-19 pandemic. Due to the increased stress that early childhood education teachers and staff are under during the COVID-19 pandemic [1], an understanding of the prevalence of such as compassion fatigue, burnout, and secondary traumatic stress, and potential protective factors such as compassion satisfaction, is important for supporting this population and ultimately, the children and families they serve.
In order to better support the communities they serve, Bartlett and Smith recommend early childhood educators and support staff complete trauma and resilience-informed care (TRIC) training [14]. Trauma and resilience-informed systems within organizations help promote employee wellbeing [30], and Menschner et al. have created trauma-informed principles to help organization readiness [31]. The readiness of an organization to create awareness, address, and support staff with trauma is critical for preventing the negative outcomes associated with these phenomena [27], however, this is understudied in the Head Start context. Given that better wellbeing among early childhood educators has shown to increase positivity in the classroom, enhancing both children and educator experiences [32], this research aims to address this gap in the literature. The aim of this study is to 1) explore adverse childhood experiences in Head Start educators and staff, 2) ascertain the levels of compassion satisfaction, burnout, and STS in Head Start educators and staff during the pandemic, and 3) explore the levels of readiness within organizations to address burnout and trauma, in a nationwide sample of Head Start educators and staff.

Settings
This study focused on data collected in spring 2021 from a nationwide sample of agencies with Early Head Start and/or Head Start programs. Institutional review board approval was obtained prior to the study's start. The sample consists of 3,313 staff from 40 agencies selected to participate in the inaugural UCLA Trauma Informed Care Institute, selected based on letters of intent and efforts to ensure all 12 Head Start regions (spanning the United States) were represented. An anonymous online SurveyMonkey survey was circulated via email to participating agencies, who then forwarded it to their staff.

Adverse Childhood Experiences Scale (ACEs)
The Adverse Childhood Experiences Scale (ACEs) measures experiences of abuse (physical, emotional, sexual), neglect (physical, emotional), and household dysfunction (mental illness, incarcerated relative, mother treated violently, substance abuse, divorce) before the age of 18 [9]. The respondents indicate either yes or no, and the total score is used in the analysis. ACEs has been used in the adult population [9,11].

Professional Quality of Life (Pro-QOL)
The Professional Quality of Life Scale (ProQOL-5) was used to assess compassion satisfaction and compassion fatigue (burnout and STS) in relation to an individual's occupation [25]. This scale measures these factors on a Likert scale from 1 (Never) to 5 (Very Often). Extensive previous research has been done using the ProQOL-5 to establish validity, although there are some concerns that the reliability and validity for measures of STS and burnout can be improved [33,34].

Vicarious Trauma Informed Organizational Assessment (VT-ORG)
The Vicarious Trauma Informed Organization Assessment (VT-ORG) was used to assess organizational preparedness to address the effects of being exposed to the trauma of clients [35]. Vicarious trauma and STS are both associated with the trauma from exposure to trauma of others that these individuals experience. Previous studies have indicated strong reliability (Cronbach's alpha of .98) with the following results for subscales: leadership and mission (α=0.93), management and supervision (α=0.96), employee empowerment and teamwork (α=0.95), training and professional development (α=0.88), and staff health and wellness (α=0.93).

Trauma-Informed Organizational Assessment
The trauma-informed organizational assessment was used to assess the organization's readiness to address trauma. This assessment is separated into three parts: 1) Training & Education, 2) Adapting Policies, and 3) The Secondary Traumatic Stress-Informed Organization Assessment (STSIOA), with response options of Not at all, Rarely/Somewhat, and Mostly/Completely. This instrument is useful for understanding practices within an agency but is not used for comparison across agencies. This assessment was completed by one staff member at each agency. Having learned from our prior experiences with Head Start agencies that staff response rates were maximized when surveys are written at an appropriate literacy level, we chose to adapt questions from several surveys, with the goal of assessing their agency's level of preparation to engage in trauma-informed practices. Parts one (Training & Education) and two (Adapting Policies) included questions from the staff development and adapting policies sections of the Agency Self-Assessment for Trauma-Informed Care, created from the National Center on Family Homelessness Trauma-Informed Organizational Self-Assessment [36,37]. One question was added: "the agency has a system in place to develop/ sustain common trauma-informed objectives and SMART goals,"

Demographics
Respondents were asked to report demographic information consisting of individual and organizational characteristics. Individual characteristics included role/position, age, and the number of years they have been working for Head Start. In order to decrease the likelihood that smaller agencies could disaggregate data about staff, information on gender, race, and ethnicity were not collected. Organizational characteristics were submitted by one representative from each agency, and included services provided (Early Head Start, Head Start, or both), organization type, setting (urban, rural, or mixed), agency region, number of children served, and number of staff employed.

Data Analysis
Frequencies were reported for each measure, representing a baseline data collection for this population. One-way ANOVA tests were performed for compassion satisfaction, burnout, and STS scores across 14 different roles in direct and indirect categories.

Demographics
The majority of participants were age 30 or older (57.4%) Nearly one half of the sample were teachers (46.5%) and have been with Head Start for 5 years or less (49.6%). Full demographics are provided in Table 1.

Adverse Childhood Experiences (ACEs)
The results from the ACEs scale (n=453) show that the three in four Head Start Staff (77%) have experienced at least one adverse childhood experience (ACE), and one in three Head Start staff (35%) have experienced four or more ACEs (Figure 1).  Note: The referent population is the sample mean. ProQOL scores range from 10 to 44, with the following cutpoints: Low (10-22), Moderate (23-41), High (42-44). Other1: One more or more of the following were true: participants had a combination of listed direct and indirect roles, a role not listed here, or did not disclose their role, potentially due to a fear of being identified based on small agency size. *Significant at the p<0.05 level; **Significant at the p<0.01 level; ***Significant at the p<0.001 level.

Compassion satisfaction
The comparison of direct and indirect roles showed there is no significant difference in compassion satisfaction levels. Participants in nutrition, food services, content management and coordinators had significantly lower compassion satisfaction scores (39.25 (SD=5.05), p=0.004) compared to the sample mean.

Burnout
Higher mean levels of burnout were reported among

Vicarious Trauma Informed Organization Assessment (VT-IOA)
Participants reported the frequency that their agency focuses on the different areas of organizational readiness to address vicarious trauma: leadership and mission; management and supervision; employee empowerment and work environment; training and professional development; and staff health and wellness. The average scores for staff health and wellness were lower than all other areas. The individual statements for this area are depicted in Table 3

Trauma-Informed Organization Assessment (T-IOA)
The trauma-informed organization assessment was completed by one person at each agency. The majority of respondents disagree or responded rarely/somewhat to several critical items in this assessment, as shown below in Table 4 The agency has a written statement that includes a commitment to understanding trauma and engaging in trauma-sensitive practices. 69% Written policies are established based on an understanding of the impact of trauma on staff. 65% The agency has a system in place to develop/sustain common trauma informed objectives and SMART goals. 61%

PART III: The Secondary Traumatic Stress-Informed Organization Assessment (STS-IOA)
The organization promotes resilience-building activities that enhance the following: Rarely/Somewhat

Discussion
There is a dearth of scholarship about early childhood educators' professional quality of life during the COVID-19 pandemic, although it is known that stress levels of early childhood educators increased drastically during the COVID-19 pandemic [1]. This paper expands upon previous research by further exploring employee professional quality of life and Head Start Centers' organizational readiness to respond to stress and trauma in a national sample of Head Start educators and staff. The results of this study show the need for Head Start agencies to implement trauma and resilience-informed care practices within their agencies.

Adverse Childhood Experiences
This scale was originally sent to organizations as part of the survey to be administered to their staff. However, it was removed after two days because organizations became concerned that staff who previously experienced trauma may be triggered by the questions posed in the survey. For those who completed the ACEs scale, results revealed respondents were more likely to have one ACE (77% versus 61% in a national sample) and three times more likely to report they had experienced four or more ACEs [12]. Specifically, participants experienced higher rates of physical, emotional, and sexual abuse, and physical and emotional neglect compared to the national sample. Rates of household dysfunction (e.g. mental illness, incarcerated relative, mother treated violently, substance abuse, divorce) were also higher than the general population sample. These results are similar to previous reports of increased ACEs in Head Start staff. Whitaker, Dearth-Wesley, and Gooze found that among Head Start staff who had experienced 3 or more ACEs, 23% reported poor wellbeing [9]. This may lead to increased risk of negative health outcomes [13].

Professional Quality of Life
Head Start educators reported higher levels of compassion satisfaction (M=42) as compared to the average of a sample of healthcare employees also surveyed during the early months of the pandemic (M=40.85) [23]. This finding is consistent with previous research, which demonstrated that early childhood home visitors experienced high levels of compassion satisfaction compared to the general population [28]. The high levels of compassion satisfaction expressed by Head Start educators and staff in both direct and indirect roles may be due to the meaning staff derive from serving the Head Start community. Research has shown that human service professionals often find multiple personal rewards related to their work, such as the opportunity to build relationships, alleviate suffering, and develop resilience [19]. Notably, some Head Start employees may have a personal mission to devote themselves to the community, as they may be previous Head Start graduates or parents themselves [40].
Compassion satisfaction serves to buffer against the challenges of professional caregiving. It may be a major contributor to being able to handle daily job-related stressors, burnout, and secondary traumatic stress [20,29]. High levels of compassion satisfaction are likely a strong motivator for continued commitment to the Head Start community [41]. High rates of compassion satisfaction among staff may permeate through the organization to benefit colleagues and the families served, but cannot be expected to fully mitigate the stressors faced by these populations.
Although the average burnout score for this population fell in the moderate range, it was a much higher score (M=38) compared to the average burnout score for a sample of healthcare employees (M=22.27) [23]. This finding is eye opening considering the stressors placed upon healthcare employees during this time. Of note, Head Start executive directors and directors, education content managers and coordinators, and center directors and assistant directors reported higher rates of burnout as compared to the sample mean.
Increased rates of burnout among staff with indirect roles are likely multifactorial in nature. Head Start staff in leadership positions generally bore the responsibility for enacting and enforcing new organizational guidelines and policies related to COVID-19 (mask and vaccine mandates). They also had to quickly adapt curriculum and family services in response to these new policies. These adaptations occurred in an environment in which new information about the pandemic, and subsequent Head Start policies were constantly changing. Additionally, families with lower incomes have less access to technology, which may impact ability to access online educational opportunities and resources [42], thus leading to increased stress for Head Start educators and staff working to provide remote learning and services. In addition to possibly experiencing personal stress and challenges within their own families related to the pandemic, Head Start executive directors and directors, and center directors and assistant directors may have also been concerned for, and working to manage, their staffs' stress and burnout. This may have in turn impacted their own levels of burnout [1]. Levels of burnout should be of concern given its associations with negative attitudes towards one's role [23], and higher rates of absenteeism and turnover, as well as lower rates of productivity [24]. in essential worker occupations to work from home during the pandemic. Families with lower socioeconomic status also faced disproportionately greater instability in work conditions and income, impacting food and housing security during the pandemic [2][3][4]. Furthermore, these families often have less access to health services to screen for the virus and manage infection [2]. Overall, economically vulnerable families experienced a higher incidence of infection and mortality from the virus, as compared with more economically advantaged families [5]. These factors increase the risk for stress and trauma in families, which in turn may increase the risk for stress and adverse mental health outcomes in Head Start educators and employees who are directly exposed to the struggles faced by the children and families they serve [10].

Trauma-Informed Organization Readiness
Trauma and resilience informed systems place an emphasis on the health and wellbeing of individuals who make up the system, and not incurring further harm to that population [30]. Fundamental to trauma and resilience-informed organizations are a shared mission and foundational principles. Both the vicarious trauma-informed organizational assessment and trauma-informed organizational assessment revealed that the majority of respondents felt they did not receive appropriate training for navigating stress and engaging with traumatized individuals. Additionally, participants indicated there is a lack of current organization policies focusing on the effects of trauma on staff and wellness among staff, in addition to the lack of organization participation in developing and implementing trauma-informed objectives and SMART goals for the organization. They also reported a lack of implementation of activities focused on building resilience and addressing STS in Head Start educators and staff. These results, and the high prevalence of ACEs in early childhood educators suggest a logical next step that would be to implement a trauma and resilience-informed framework within Head Start agencies. Bartlett and Smith recommend that organizations implement this type of training in order to prevent the negative health outcomes from trauma exposure [14,27]. Additionally, SAMHSA has developed and disseminated five core trauma-informed principles to guide system transformation and approach to providing services: family/child empowerment; choice; collaboration in treatment and services planning; safety; and trustworthiness [31]. Head Start agencies may consider adopting this framework.

Limitations
Research on professional quality of life, wellbeing, and organization readiness in Head Start staff is limited. A strength of this study is that it sheds light on professional quality of life among a national sample of Head Start staff (n=3313) and organizations' preparedness to address secondary and vicarious trauma in the early months of the pandemic. One limitation of this study is the short duration of the ACEs survey, as collection was paused in response to agency requests to avoid potential triggers for respondents in the early days of the pandemic. In this case, being responsive to the needs of our study population was paramount. A second limitation is the potential for bias due to self-report. Those who chose to participate in the survey may also have been more motivated to discuss these topics than the general population, and their views may not accurately reflect those of staff who did not participate due to disinterest, discomfort, fear of disclosure, lack of time, or other barriers. An additional limitation is that participants were recruited from agencies who have previously participated in Health Care Institute programming and submitted a letter of interest, which means that experiences of agencies that have not participated in the institute are not accurately reflected. In attempts to protect their identity, some individuals did not disclose their agency role. In consideration of the small size of some reporting agencies, race and other demographic factors were not collected (in efforts to protect participants from potential disaggregation). Further research should explore how experiences vary among this population by race, ethnicity, gender, and other factors.

Implications
The results of this study have implications for policy and practice in early childhood education programs. Burnout and STS have been previously positively associated with adverse health outcomes [27,28], while compassion satisfaction has shown to possibly serve as a buffer against stressful situations [28]. The wellbeing of early childhood educators and the working environment affect the stability of child and teacher/ adult relationships [8,14,15]. For example, early childhood educators who are mentally and physically healthier are better able to effectively perform job tasks and provide quality care and education to children, as well as effectively deal with the stress of the job [9]. Employees who consider themselves healthy have less absenteeism, are more present in their interactions with children, and model positive behavior in the classroom [32]. A focus on Head Start employee wellbeing, with goals to bolster compassion satisfaction and prevent burnout and STS, will positively impact not only staff, but children and families. Trauma-informed care training is critical for raising awareness within individuals and organizations to create and maintain a healthy workforce in order to best serve Head Start communities.

Conclusion
The UCLA Health Care Institute conducted this large study of professional quality of life and organizational readiness among Head Start staff throughout the United States in the early months of the pandemic to better understand the extent to which individuals were experiencing compassion satisfaction, burnout, and secondary traumatic stress. Agencies were also surveyed to Volume 6; Issue 03 J Community Med Public Health, an open access journal ISSN: 2577-2228 assess organizational readiness to effectively respond to these factors. The findings of this study indicate that overall, both direct and indirect roles are experiencing significantly high levels of burnout and STS. However, compassion satisfaction may serve as a protective factor against burnout and STS [43].
Future research will continue to explore professional quality of life and evaluate organizational readiness in Head Start programs in order to achieve a better understanding of the steps that have been taken and their impact. In the year since this data was collected, a trauma-informed care institute was developed to respond to the needs of this population as identified by this study. Two cohorts of Head Start agencies have completed workshops three weeks in duration to educate them on stress management and trauma-informed approaches at the individual and organizational level. Our future research will publish one-year follow-up data to determine the institute's impact, acknowledging that the pandemic may be affecting the population differently during this time.