Integrating Trauma-Informed Care into Nursing Education: Preparing Future Nurses

The healthcare system can be re-traumatizing for patients with trauma history. Trauma-informed care (TIC) is a patient-centered approach to healthcare that calls on health professionals to provide care in a way that prevents re-traumatization of patients and staff. Grounded in an understanding of the impact of trauma on patients and the workforce, TIC is conceptualized as a lens through which policy and practice are reviewed and revised to ensure settings and services are safe and welcoming for both patients and staff. As integral members of the health care team, nurses have the opportunity to establish a healthy therapeutic relationship with the patients and families that they care for. TIC is applied universally regardless of trauma disclosure and should be incorporated in daily practice, especially in nursing. Nurses have ample opportunities to influence the experience of patients and colleagues, and nursing is a critical field in which to introduce a trauma-informed approach. This article explores the importance of integrating TIC into nursing education to equip future nurses with the knowledge, skills, and awareness necessary to provide compassionate and effective care to all patients.

Understanding Trauma-Informed Care

Trauma-informed care (TIC) is a patient-centered approach to healthcare that not only attends to these elements of quality, but also requires healthcare professionals to attune to the distinct experience of trauma survivors. Trauma-informed care (TIC) is a patient-centered approach to healthcare that calls on health professionals to provide care in a way that prevents re-traumatization of patients and staff. TIC is applied universally regardless of trauma disclosure. Trauma-informed care (TIC) frameworks emphasize the detrimental physical, emotional, and mental health effects on those with a history of traumatic experiences. The widespread effects of trauma are beginning to be recognized as a social determinant of health and are fueling a movement to include trauma-informed care (TIC) approaches universally.

The Substance Abuse and Mental Health Administration (SAMHSA, 2014) offered the following principles for a trauma-informed approach:

Safety (physical and emotional)
Trustworthiness and transparency
Empowerment, voice, choice
Use of peer support
Cultural, historical, and gender responsiveness

Supporters of a trauma-informed approach recognize the prevalence of trauma survivors within healthcare settings, and are aware that the service setting can also be a source of trauma. Whether a patient interaction with providers in a healthcare setting is directly or indirectly related to trauma they have experienced, the potential to be re-traumatized is high. “Understanding how trauma has affected patients’ lives and their interactions with and perceptions of the health care system is fundamental to structuring a healthcare system that responds to these patients’ needs and promotes better physical and mental health outcomes” (Dubay et al., 2018, p. 2).

The Prevalence and Impact of Trauma

Traumatic experiences shape our lives and can significantly impact physical, mental, social, and spiritual health and well-being. Findings of the Adverse Childhood Experience (ACE) Study indicated that exposure to trauma increases the likelihood of health-risk behaviors as well as a person’s lifetime risk for chronic health conditions such as autoimmune disorders, depression, heart disease, liver disease, lung disease, obesity, sexually transmitted diseases, and substance use disorders. (Felitti et al., 1998). As the number of traumatic exposures increases, so does an individual’s overall risk (Center for Health Care Strategies, 2017).

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The healthcare system is populated by trauma survivors, both those providing and receiving care. Among 1,784 patients participating in a Philadelphia health survey, 73% indicated they had experienced at least one adverse childhood experience (ACE) as described by Felitti et al. (1998), while an additional 14% reported trauma related to community violence, including racism (Cronholm et al., 2015).

Stress occurs when individuals are uncertain about how to ensure their own social, physical, or mental wellbeing (Peters, McEwen, & Friston, 2017). In fact, uncertainty is associated with both subjective and physiological measures of stress (De Berker et al., 2016). When a stressor is temporary or manageable, the stress response system is efficient and effective (McEwen, 2007). However, when stressors persist and uncertainty continues, the stress response can become maladaptive and lead to illness and disease (Hackney, 2006; Peters et al., 2017). More than two decades of research have contributed to the knowledge that stress and adversity is associated with poor social, emotional, and physical outcomes later in life (see the seminal manuscript by Felitti et al., 1998). Specifically, childhood adversity or trauma is associated with increased risk of heart disease, diabetes, autoimmune disorders, and even premature mortality (Brown et al., 2009).

The Need for Trauma-Informed Nursing Practice

For TIC to be thoroughly implemented and embodied by a healthcare system, policies, procedures, and culture need to be trauma-informed. This work requires multi-level commitment and can take substantial time and effort. There is value and utility in individual understanding of the principles of TIC and learning to apply them in all levels of nursing practice. Nurses who utilize a trauma-informed lens in practice can enhance job satisfaction, reduce risk for burnout, and improve patient experiences and outcomes (Schulman & Menschner, 2018).

Trauma-informed nursing practice requires cultivating nurses who are aware, sensitive, and responsive. Principles of TIC can be applied on a macro-level to systems of care and on a micro-level to nurses’ daily interactions with all patients. Trauma-informed nursing practice requires cultivating nurses who are aware, sensitive, and responsive. In alignment with the principles of safety, respect and trust, we suggest that nurses can begin to ask themselves, and their colleagues, three simple questions as a first step to applying a trauma-informed lens to their practice, as follows:

Safety: Does this cultivate a sense of safety?
Respect: Am I, and others, showing respect?
Trust: Does this build trust?

Based on many years of nursing experience and several years of implementing TIC in medical settings, we have come to understand how nuanced and impactful TIC is on patient and staff experience. The persistence of the COVID‐19 pandemic has led to a multitude of changes in the ways nursing education, research, and practice are carried out.

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In addition to the demands of shifting to remote education as well as finding alternatives to direct patient care learning, nursing faculty and students are directly confronting morbidity and mortality among classmates, colleagues, friends, and family members. These experiences unquestionably meet criteria for traumatic experience, and this must be accounted for in nursing education as they can have detrimental effects on learning, teaching, and well‐being. The current generation of nursing students and faculty will necessarily carry the traumatic experiences of this chaotic time into workplace, classroom, and community settings. Understanding how to manage this trauma appropriately not only supports individuals through this experience but provides increased opportunity and capacity for the provision of trauma‐informed care (TIC) to patients and colleagues going forward.

Integrating TIC into Nursing Curriculum

Graduate nursing programs must create a curriculum centered in TIC to help nurses understand their own trauma and to have tools to cope. Lack of support, knowledge, and resources available to students in graduate nursing programs can cause emotional exhaustion and hinder a student’s overall ability to perform. The growing development of trauma curricula in other health science disciplines provides guidance for integrating trauma content into nursing education (Li et al., 2019). As trauma can evolve from a vast array of life events, training would include tools that enable nurses to adapt to diverse patient populations and communities. To better prepare nurses to provide TIC, nurses must first understand the key elements of TIC in graduate nursing education. Another component of training would consist of strategies that help nurses to develop skills to deal with personal and professional stressors. This process can begin by first developing trauma content to address barriers to educational innovations for trauma-informed care in graduate nursing programs and identifying facilitators to promote innovative strategies for trauma-informed care in this population.

Our team developed course materials to help nursing faculty incorporate trauma-informed healthcare practice concepts into all aspects of the undergraduate and graduate nursing curriculum. As integral members of the health care team, nurses have the opportunity to establish a healthy therapeutic relationship with the patients and families that they care for. WHY - A strong foundation in understanding the prevalence and impact of trauma on our patient populations is important in the development of nursing students. This resource will provide nurse educators with a trauma-informed care educational slide set to provide nursing students with an understanding of trauma and trauma-informed care, with the goal of developing a shared language as nurse educators infuse additional trauma-informed nursing resources into courses. WHAT - Access to a PDF version of a Trauma-Informed 101 slide deck with instructor notes. HOW - This slide deck, with accompanying instructor notes, can serve as a guide for nurse educators to provide foundational trauma-informed education to their students. We recommend that this education occurs prior to engaging in trauma-informed physical health assessment. WHY - Nurse Educators have to meet many demands, including preparing students for their licensing exam and preparing nursing students to be prepared for the clinical environment. In the midst of these demands, it is critical that nurse educators have the knowledge and skills to develop learning environments where students have a sense of felt safety and can optimal have mastery over the content. HOW - This is a self-paced module for nurse faculty use prior to engaging with nursing students on concepts related to trauma-informed healthcare practice. WHY - Integrating individual modules on trauma-informed healthcare practices or developing entire courses on trauma-informed nursing is becoming a more common practice. WHAT - Our team developed a Trauma-Informed Nursing Course Syllabus Template that provides a full course syllabus and individual modules. WHAT - Access to slide sets with accompanying instructor notes for both the Adult and Pediatric Health History versions. HOW - Decide whether you will focus on an Adult or Pediatric Health History (for some courses it may be both). We suggest that you have your students complete the Trauma-Informed Care 101. You have access to the Trauma-Informed Health History Adult version or Trauma-Informed Health History Pediatric version, along with accompanying slide sets to guide your teaching. HOW - Select which courses might be most relevant to your teaching. These course materials are being developed by a group of interdisciplinary health care professionals at leading health systems and universities in the Philadelphia area.

Strategies for Academic Institutions

Limited data exist on the best ways to apply a trauma-informed approach to advanced practice nursing education. Recommendations provided here synthesize approaches suggested for various health professional training programs as well as for general educational systems (Bosse et al., 2021; Carello & Butler, 2015). One way to categorize these principles within the context of graduate nursing education is to consider three primary domains: (a) organizational practices; (b) classroom practices; and (c) faculty preparation.

Organizational Practices: As with any successful organization or culture change, having full commitment (i.e., buy-in) from leadership is critical (By, 2021). Within the academic environment, organizational leadership is usually headed by the dean. The dean may be supported by other administrators, such as associate deans, department chairs, and/or program directors. Leadership buy-in from all administrators sets the stage for the creation and development of policies and practices that foster and embrace a trauma-informed approach. By promoting and sharing a unified vision of a trauma-informed organization, academic administrators are positioned to influence the overall culture of the organization. For example, administrators may wish to incorporate a trauma-informed approach into the school mission statement or program outcomes. To address the trauma-informed concepts of safety, trustworthiness, transparency, collaboration, and empowerment, administrators should ensure that communication between all parties (e.g., administrators, faculty, and students) is clear and open. Messaging from administrative leaders should include rationales and allow for feedback. Committees that may create or influence policies for students should have representation from graduate students in order to provide students a voice in decision making. Paramount to the sustainability of a trauma-informed organization is ensuring sufficient resources. Examples of these resources might include providing time for faculty and staff to connect with one another; facilitating connection to community resources; and allowing opportunities for students, staff, and faculty to engage in self-care.

Classroom Practices: Classrooms, clinical practicum sites, and simulation labs are also areas in which a trauma-informed approach should be considered. Providing students with a safe space to verbalize or express concerns and offering opportunities for self-reflection and self-care are important. These concepts are not only part of a trauma-informed approach but align with the American Association of College of Nursing ([AACN], 2021) revised core competencies for nursing education. Specifically, domains 9 (professionalism) and 10 (personal, professional, and leadership development) of the AACN Essentials emphasize accountability, collaboration, self-reflection, as well as diversity and inclusion (AACN, 2021). Creating an opportunity for peer feedback at the end of a clinical practicum day…is one way to provide peer support, collaboration, and safety. In undergraduate nursing clinical education, it is common for students to have pre-and/or post-clinical practicum debriefings. These sessions allow students to reflect on the day’s experiences. With graduate nursing students, the clinical practicum experience…

Trauma-Informed Principles in Academic Settings during COVID-19

The COVID‐19 pandemic has led to myriad changes in the way health care is accessed, provided, and even conceptualized. In addition to the demands of shifting practices, providers are faced with patient morbidity and mortality-and with their own risk for contracting the disease. The key assumptions are that a TIC approach (1) realizes the prevalence and impact of trauma as well as potential paths to recovery; (2) recognizes signs and symptoms of trauma; (3) responds by ensuring trauma awareness is integrated into the environment; and (4) actively resists retraumatization. The six guiding principles then identify the elements necessary to put such an approach into practice: (1) Safety; (2) Trustworthiness and transparency; (3) Peer support; (4); Collaboration and mutuality; (5) Empowerment, voice and choice; and (6) Cultural, historical, and gender issues.

Cultural, Historical, and Gender Issues

Trauma thus clearly intersects in numerous ways with culture, history, and gender. A trauma‐informed approach acknowledges the contributions of cultural, historical, and gender issues to trauma and seeks to move past stereotypes and biases to provide policies, protocols, and processes responsive to the cultural needs of individuals. To effectively apply trauma‐informed principles in responding to the COVID‐19 pandemic, it is critical that the nursing profession recognize whose voices are least often heard and thus less likely to be incorporated into response strategies. Dominant voices in academia can easily marginalize underrepresented groups, particularly when there are large differences in circumstances and perspectives between groups. Rather than setting goals unattainable for some faculty, nursing academia should provide the flexibility and options to match differing circumstances of all faculty. Doing so requires the input of a diverse range of faculty in terms of demographics as well as rank, experience, and scholarly focus.

Safety

In nursing, this often means having confidence in routines, protocols, and procedures. This is nigh impossible under the current circumstances as information about SARS‐CoV‐2, the healthcare response to the pandemic, and even procedures and precautions are in constant flux. For nursing students, constantly shifting plans for clinical instruction have created uncertainty, and promulgated fears of contagion and about being unable to complete courses. Recognizing and accounting for these variables, and providing clear information about institutional strategies to protect these individuals can aid in fostering an environment where individuals feel safe. At the same time, these strategies must avoid singling out those affected, such as by requiring formal exemption procedures or other “proof” of need. At an institutional level, variables such as access to PPE, availability of no‐cost testing, and local and state policies also factor into what activities may be deemed safe at any particular time. Promoting a trauma‐informed response to these situations also requires clear communication regarding policies, budgets, and institutional responses to those who may be in these situations. Promoting Safety thus involves supporting all members of the academic nursing community through sharing of information and encouraging individual choices about what is in fact “safe.”

Trustworthiness and Transparency

Both play an important role in developing functional and flourishing educational systems, which can only occur when institutions are nimble and able to adapt to the changing needs of their communities. These requirements create both a ranked system of privilege and a significantly isolating situation for students. A second clear example of lack of trust and transparency within nursing education during the pandemic is the use of surveillance technologies. Students and faculty are increasingly being asked to be on camera and to download software programs that track their computer histories and record their personal environments in the interest of limiting academic misconduct. This diversified syllabus allowed students to demonstrate their mastery of content in multiple formats rather than relying primarily on one method. The “Plan B” policy was written into the syllabus and designed for students to have a clearly identifiable way to contact the instructor when the original assignment was not feasible-and to propose a workable and appropriate “Plan B.” No further explanation was required. As an example of transparent communication, one school of nursing instituted multiple changes to ensure students, faculty and staff had up‐to‐date information regarding the evolving pandemic. These included: (1) weekly safety briefs, (2) just‐in-time information communicated directly to affected students, (3) all COVID related resources posted publicly on an intranet site for ease of access by students and clinical faculty and updated or replaced when needed.

Peer Support

Under remote learning protocols, students and faculty may only interact with each other and their peers via technology, and only in structured settings such as class or organizational meetings. In‐person education, by contrast, offers less formalized opportunities for interaction and connection within the educational milieu. It may thus be especially helpful to promote and foster access to resources not affiliated with the academic institution (e.g., community resources providing aid for internet access, local mental health resources, programs to promote technology literacy) such that privacy and confidentiality can be better assured. Along the same lines, maintaining open channels of communication among faculty, students, and administration with regard to needs and supports is critical to peer support. Ensuring that the diverse needs of faculty and students are taken into account, and that there is flexibility as well as equity across environments, further promotes engagement with the academic environment, and reduces both isolation and potential for overextension of individual coping.

Collaboration and Mutuality

The circumstances of the pandemic require both collaborative interaction and acknowledgment of collective and individual needs among students and faculty. One example of a novel, successful collaboration is that of a university where PhD students were offered summer stipend funding to help faculty transition courses to online learning. While some faculty may be unaccustomed to allowing greater leeway in coursework and participation, absolutist approaches are not only unfeasible but potentially detrimental in the current circumstances.

Empowerment, Voice, and Choice

Educators, particularly in the demanding discipline of nursing, have tremendous power over the students in our programs and may be feared as much as respected. Faculty must therefore be mindful of how interactions are perceived. For example, there has been much faculty discussion about the difficulty of teaching online when students do not have their cameras on. Some faculty even expressed desire to tie attendance or participation points to whether or not a student enabled video during class times, but this approach exacerbates an extant power imbalance. While teaching online presents different challenges than teaching in person, a student may have their video off for a multitude of reasons. There is also the issue of being “camera ready.” For some students this may require a significant outlay of time or energy, due to mental health concerns, stress, or simple lack of confidence in their appearance.

The Significance of Trauma on the Nursing Workforce

The significance of trauma on the nursing workforce is of utmost importance in graduate nursing education. Competing roles of graduate nursing students, such as the demands of nursing practice and advanced education, can increase vulnerability to trauma and chronic stress. Stressors associated with graduate nursing education can significantly impact student and program outcomes. Incorporating a trauma-informed approach to graduate-level education can be an essential component to support the needs of this student population. Creating and sustaining a trauma-informed academic setting requires awareness, open-mindedness, empathy, and incorporating educational practices that promote healing and mitigate harm. Nurse faculty can play a pivotal role in restructuring curriculum design to include principles of a trauma-informed approach.

Healthcare professions, including nursing, have been identified as intensely demanding and stressful careers due to long hours, shift work, lack of needed resources, and the physical and emotional burden of caring for others in crisis. The COVID-19 pandemic has amplified these stressors leading to an unprecedented exodus of healthcare providers from the workforce (Chen et al., 2021). Nurses who are graduate students must often balance concurrent stressors of nursing work on the front lines and the demands of rigorous graduate nursing education. Nurse faculty have an investment in ensuring best practices to support these students, who may bring not only the current collective trauma of caring for patients during the global public health crisis, but their individual life experiences, such as adverse childhood experiences (ACEs), racism, sexism, homophobia, ableism, and other forms of stigma. These experiences could have occurred either recently or in the remote past.

Individuals who pursue the profession of nursing are subject to a variety of job-related stressors that can result in psychological trauma. A large body of literature has documented the professional trauma of being a nurse experienced by nurses worldwide (Foli et al., 2021). One of the main consequences of these experiences is job burnout and an exodus from the profession. Spurlock (2020) described the importance of retaining nurses at all levels and backgrounds to address the ongoing nursing shortage. With the global COVID-19 pandemic, the effects of work-related trauma were amplified. The impact of trauma on professional nurses can be significant. A recent study (Guille, 2021) found that female nurses had double the risk of suicide than the general population of women.

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