Improving Teamwork in Rural Child Advocacy Centers: A Hybrid-Effectiveness Implementation Trial of TeamTRACS
Phase: NA
Conditions: Teamwork, Implementation
Sponsor: University of Pittsburgh

 
 
 
 
 
Study Protocol and Statistical Analysis Plan 
 
Study Title:  
TeamTRACS Pilot (CTSI) 
 
ClinicalTrials.gov ID (NCT number):  
NCT05370157 
 
Document Date:  
March 14, 2024 
 
 
 

Study Overview 
This research study is a cluster-randomized controlled effectiveness-implementation hybrid trial 
of TeamTRACS. The trial will take place in 6 rural Child Advocacy Centers (CACs) in the 
southern United States. It will use mixed methods (quantitative and qualitative) to evaluate the 
effects of TeamTRACS and assess the acceptability, appropriateness, and feasibility of self-
guided implementation via pre/post surveys and qualitative interviews. 
 
The primary aims of this pilot trial are to test the effects of TeamTRACS on knowledge, skill 
use, and team functioning in addition to evaluating the acceptability, appropriateness, and 
feasibility of self-guided implementation. Six rural CACs will be randomized to TeamTRACS (n 
= 4 CACs) or a waitlist comparison (n = 2 CACs). Participants will be team members at 
participating CACs (estimated N = 25 per CAC; total N = 150). We expect team members to 
change during the study period and will include only current team members at each timepoint.  
We will evaluate the effects of TeamTRACS on learning (i.e., knowledge), transfer (i.e., skill 
use), and results (i.e., team functioning). Knowledge, skill use, and team functioning will be 
assessed at baseline and 3 months with online surveys and qualitative interviews of team 
members. We will also assess hypothesized long-term outcomes (i.e., team performance, 
workforce outcomes). Individuals involved in implementation in the 4 CACs randomized to 
TeamTRACS will participate in semi-structured key informant interviews during the 
implementation process. They will rate the acceptability, appropriateness, and feasibility of self-
guided implementation at the beginning, middle, and end of the study, and we will track 
completion of implementation activities in each CAC. 
 
Background 
Children in rural areas are nearly twice as likely as their urban peers to experience maltreatment, 
increasing risk for physical/mental health, academic/vocational, and interpersonal problems. 
They have high rates of unmet mental health needs and experience greater impairment than those 
in urban areas. CACs are uniquely suited to serve at-risk rural children through effective, 
efficient, and trauma-informed investigations and services. Rural Child Advocacy Centers 
(CACs) rely on multidisciplinary team members employed by independent organizations.  
 
Interventions that improve team functioning can improve teams’ performance, strengthen the 
workforce, and ultimately improve service quality and outcomes for children and families. Team 
training is a specific type of team intervention that targets affective, behavioral, and cognitive 
team functioning by teaching teamwork knowledge, skills, and abilities. We recently adapted 
TeamSTEPPS to fit CAC multidisciplinary teams. TeamSTEPPS, developed by the Agency for 
Healthcare Research and Quality, is the most widely used model of team training in healthcare 
and a promising model for improving team functioning in other service settings. We worked 
collaboratively with CAC team members and leadership to adapt the format (in-person to 
virtual), setting/population (healthcare to CACs), personnel (internal trainer to external trainer), 
and content (e.g., tailoring language, reordering). Our adapted training, TeamTRACS (Team 
Training in Roles, Awareness, Communication, and Support), is designed to fit the specific 
needs and context of CAC multidisciplinary teams. It targets knowledge, skills, and attitudes 
related to team member roles, shared awareness, communication, mutual support, and goal-
setting. TeamTRACS is structured, easy to use, flexible in length and intensity, and requires few 

resources. We piloted TeamTRACS with one rural CAC and found high acceptability, 
appropriateness, and feasibility (ratings >4 on 1-5 scale). 
 
This research study will test the effectiveness of TeamTRACS in a cluster-randomized trial in 6 
rural Child Advocacy Centers. We will also partner with the National Child Advocacy Center 
(NCAC) to refine our implementation strategies. Rural teams serving high-need/low-resource 
areas may find it challenging to implement new practices. This study will use a self-guided 
implementation approach that requires few resources and builds local capacity for change. We 
will assess the acceptability, appropriateness, and feasibility of self-guided implementation in 
participating CACs. Self-guided implementation will allow the training to be rapidly scaled up 
and disseminated to CACs nationwide. Improving teamwork in CACs has the potential to 
positively impact service quality and outcomes for hundreds of thousands of children served by 
CACs. 
 
Procedures 
Randomization 
CACs will be randomized to TeamTRACS (n = 4) or a waitlist comparison (n = 2) using an 
online randomization tool. We may stratify CACs based on team size if there is significant 
variability across the 6 CACs. CACs randomized to TeamTRACS will receive the intervention 
described below after completing the baseline survey. CACs randomized to the waitlist will 
receive the intervention after completing the follow-up survey. 
 
Team Training Intervention 
TeamTRACS (Team Training in Roles, Awareness, Communication, and Support), is a team 
training intervention that is adapted from TeamSTEPPS (Team Strategies and Tools to Enhance 
Performance and Patient Safety), which is a widely used evidence-based team training approach 
developed by the Agency for Healthcare Research and Quality. TeamTRACS was developed via 
a systematic and participatory adaptation process (see McGuier et al., 2023). 
 
TeamTRACS targets knowledge, skills, and attitudes related to team member roles, shared 
awareness, communication, mutual support, and goal-setting. TeamTRACS is structured, easy to 
use, flexible in length and intensity, and requires few resources. It incorporates didactic 
instruction, discussion, and interactive activities and can be delivered virtually or in-person. 
Presentation slides, detailed instructor guides, and worksheets were created for each module (see 
“TeamTRACS Instructor Guide”). Team members are encouraged to identify specific goals for 
their team and make plans to use specific strategies from the training. The training will delivered 
in a single session and be at least 4 hours. Teams will determine the length and delivery method 
(e.g., in-person vs. virtual) as part of the implementation process. The training workshop will be 
facilitated by an experienced team trainer from NCAC; this approach is responsive to pilot data 
favoring use of an external facilitator and is sustainable given available resources. 
 
All team members at each CAC will be invited to participate in the training. Prior to the start of 
the training, the PI will review a brief consent script and provide an opportunity for questions. A 
copy of the consent script will be provided to all team members. We will record team members’ 
attendance at the training. 
 

Baseline and Follow-up Surveys 
Team members will complete online surveys (<30 minutes) before training and 3 months after 
training via REDCap, a secure online database. The surveys will assess knowledge and use of 
teamwork skills, team functioning, team performance, and team member work outcomes (see 
“Team Member Survey”). Team members will be sent an email with information about the study 
and a link to review the online consent form.  
 
Key Informant Interviews 
In the 4 CACs randomized to TeamTRACS, key informants (leadership and team members 
involved in the implementation process) will be invited to participate in qualitative interviews. 
Semi-structured interviews will be conducted approximately once a month during the 
implementation process to assess change over time. Questions will assess perceptions of and 
experiences with self-guided implementation, as well as progress through implementation phases 
and steps (see “Implementation Interview Guide”). Interviews will take 30-60 minutes. Key 
informants will also rate the acceptability, appropriateness, and feasibility of self-guided 
implementation at the beginning, middle, and end of the study. 
 
Document Collection 
CAC staff at the 4 CACs randomized to TeamTRACS will be asked to share documents created 
during the implementation process, including completed worksheets, action plans for training, 
team goals, and revised policies or protocols. The research team will review documents to assess 
fidelity to the implementation guide and completion of implementation activities. At all 6 CACs, 
staff will be asked to report team members’ attendance at case review meetings and any changes 
in team members (e.g., turnover, addition of new members). 
 
Statistical Analysis Plan 
Preparatory Analyses 
We will calculate survey response rates, look for patterns of missing data, and examine 
descriptive statistics for all measures. 
 
Analyses of Effectiveness Outcomes 
We will test changes in knowledge, skill use, and team functioning from baseline to 3-month 
follow-up using linear mixed models to account for repeated measures and clustering within 
CACs. We will also explore changes in team performance and team member outcomes. Our 
primary analyses are intent-to-treat analyses including all participants in each condition. We will 
also conduct ‘per protocol’ analyses testing for changes in knowledge and skill use by training 
attendance. This pilot study is adequately powered to detect changes in individual outcomes 
(e.g., knowledge of teamwork skills), but underpowered for team-level outcomes. Accordingly, 
after aggregating measures of team functioning and performance to the team level (assuming 
sufficient within-team agreement), we will plot data to visually examine team-level results. 
 
Analyses of Implementation Outcomes 
We will use rapid analysis to code qualitative key informant interviews using an a priori coding 
scheme focused on barriers, facilitators, and suggestions for change. We will assess the 
proportion of implementation activities completed in each CAC and examine descriptive 

statistics for acceptability, appropriateness, and feasibility ratings. Mean ratings >4 on the 1-5 
scale will indicate that TeamTRACS is acceptable, appropriate, and feasible.