Trauma Informed Educational Practices: An Educational Innovation for Graduate Nursing Students

Traumatic experiences shape our lives and can significantly impact physical, mental, social, and spiritual health and well-being.Traumatic experiences shape our lives and can significantly impact physical, mental, social, and spiritual health and well-being (Substance Abuse and Mental Health Service Administration [SAMHSA], 2014). 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). Major organizations, including the Institute for Healthcare Improvement (IHI) and the National Academy of Sciences, Engineering and Medicine (NASEM), have identified reduction of clinician burnout and promotion of clinician well-being as top priorities to ensure a functioning healthcare system in the United States and internationally (National Academy of Medicine, 2019).

Nurses who are graduate students must often balance concurrent stressors...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. This article will review what is known about trauma informed care (TIC) to specifically apply a trauma-informed framework to graduate nursing education to promote effective student learning and enhance student well-being.

Defining Trauma and Trauma Informed Care

These experiences could have occurred either recently or in the remote past.Trauma-informed practices have been well-described in the healthcare literature as interventions to address social and healthcare needs and work to reduce healthcare disparities that stem from structural inequities (SAMHSA, 2014). Trauma-informed care (TIC) frameworks emphasize the detrimental physical, emotional, and mental health effects on those with a history of traumatic experiences (Cannon et al., 2019). Within the trauma-informed approach community, trauma has been defined in diverse ways. However, the most recognized definition, as espoused by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2014), is the response of an individual to an event, series of events, or set of circumstances that is perceived as physically or emotionally harmful or threatening. These experiences could have occurred either recently or in the remote past. They are shaped by an individual’s developmental stage at the time of the traumatic event and by the social support and resources available to an individual at the time of the event and afterwards.

The effects of trauma may be long-lasting and have an adverse effect on individual well-being, functioning, and response to other harmful or threatening events. Examples of circumstances that are potentially traumatic include emotional, physical, or sexual abuse; sudden separation from a loved one; childhood neglect; family members with a mental health condition; poverty; and discrimination (Center for Health Care Strategies, 2017). The National Child Traumatic Stress Network (2018) has identified an additional set of circumstances as potentially traumatic. These include community violence; natural disasters; intimate partner violence; medical procedures and care; refugee and war zone experiences; school violence; and terrorism.

As the number of traumatic exposures increases, so does an individual’s overall risk.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). TIC was developed to address these elevated health risks by creating respectful healing environments of care that support patient engagement through recognition of past traumas.

Elements of Trauma-Informed Care
...the paradigm should be incorporated at the patient/family, organizational, community, and policy levels.To successfully employ a trauma-informed approach in clinical care, the paradigm should be incorporated at the patient/family, organizational, community, and policy levels (Center for Health Care Strategies, 2017). To this end, SAMHSA describes the 4 “R”s of trauma-informed care: 1) realization of the impact of trauma, 2) recognition of the signs and symptoms of trauma, 3) responding to trauma by integrating policies, principles, and practices, and 4) resisting re-traumatization (SAMHSA, 2014).

Realize. Learning about the prevalence and incidence of trauma is the first step in this process. It is also important to embrace the idea that recovery from trauma is possible. All parties need to recognize that affected individuals and communities are not “broken” from trauma. Rather, trauma injures individuals and communities.

Recognize. To provide trauma-informed care it is important to understand that life experiences may affect engagement and quality outcomes. Nursing professionals should seek resources which foster their ability to recognize the signs and symptoms of trauma (Center for Health Care Strategies, 2017). Table 1 summarizes some signs and symptoms of trauma exposure and basic principles for a trauma-informed approach.

Table 1. Signs and Symptoms of Trauma Exposures and Principles for a Trauma-Informed Approach

(Fleishman et al., 2020)

Respond. There are six key principles that guide a successful trauma-informed approach. These can be incorporated both in day-to-day practices and in formal government and organizational policies. SAMHSA (2014) lists these six key principles as 1) safety; 2) trustworthiness and transparency; 3) peer support; 4) collaboration and mutuality; 5) empowerment, voice, and choice, and 6) cultural, historical, and gender considerations. A trauma-informed system acknowledges that these principles apply to patients and families as well as staff, students, faculty, and leadership. It is important to provide affected individuals and families with opportunities to access supportive interventions that bolster recovery and resilience (SAMHSA, 2015).

Re-Traumatization. A trauma-informed approach is characterized by leadership and staff members who think about and respond to those who have experienced harmful or threatening events, past and present. The approach includes acknowledgment of widespread trauma; supportive, trauma informed care for staff, faculty, and leadership; and an environment of safe and restorative spaces, both built and emotional.

Trauma and Graduate Nursing Students

With the global COVID-19 pandemic, the effects of work-related trauma were amplified.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. Choi et al. (2020) added that the trauma experienced from COVID-19 has resulted in a second pandemic resulting in symptoms of complicated grief.

The impact of trauma on professional nurses can be significant.Individuals are subject to emergence of trauma symptoms when they experience a trigger that may cause re-traumatization (Gesi et al, 2020; Kassam-Adams et al., 2015). 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. These data have led to an urgent call for interventions to address nurses’ mental health, including that of undergraduate and graduate-level nursing students.

Applying Trauma-Informed Approaches in Graduate Nursing Education

...there is a significant need to incorporate trauma-informed practices within graduate nursing curriculum to address mental health concerns...Trauma can have an adverse effect on a student’s ability to perform effectively in and out of the classroom. Goddard et al. (2022) assert that there is a significant need to incorporate trauma-informed practices within graduate nursing curriculum to address mental health concerns that graduate nursing students struggle with during their programs of study. This approach aims to provide a safe and supportive environment for students who have been affected by trauma and would benefit from tools to eliminate barriers to success. While measures may have been suggested in the past to address students’ unmet needs, it is not clear if specific innovations geared towards a trauma-informed educational milieu for nursing students have been incorporated. Perhaps such initiatives would serve as a foundation for graduate level nurse educators to incorporate trauma-informed principles throughout the curriculum (Goddard et al., 2022).

Integration of trauma informed education throughout graduate nursing programs would address several measures that have been lacking in the profession. In healthcare settings, nurses often are the first point of contact and are likely to work with patients who are survivors of trauma. However, nursing programs that do not equip students with trauma-based training fail to recognize the long-term effects it may have on a nurse’s ability to offer optimal professional patient care.

Graduate nursing programs must create a curriculum centered in TIC to help nurses understand their own trauma and to have tools to cope.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. Students require support from educators in their graduate programs so that they are not left to determine next steps independently (Goddard et al., 2022). Table 1 lists resources for educators to consider for a TIC approach to curriculum.

Table 2. Resources for Educators

The growing development of trauma curricula in other health science disciplines provides guidance for integrating trauma content into nursing education.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. The growing development of trauma curricula in other health science disciplines provides guidance for integrating trauma content into nursing education (Li et al., 2019). The literature indicates that integrating TIC into a graduate nursing curriculum is feasible, beneficial, and allows educators to role model trauma coping skills and values central to nursing practice.

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. Successful integration and creation of a trauma-informed learning environment requires collaboration across multiple segments of the academic environment.

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.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. Academic policies pertaining to attendance, grade grievances, leave of absences, academic progression, and student accommodations may need to be reviewed to ensure that they reflect a trauma-informed philosophy.

Messaging from administrative leaders should include rationales and allow for feedback.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. Additionally, ensuring that staff and faculty are trained in trauma-informed practices will facilitate development of a trauma-informed organization.

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. Employing these and other similar strategies can build an organizational culture that supports a trauma-informed approach.

...offering opportunities for self-reflection and self-care are important.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). Providing time at the beginning or conclusion of class or clinical is an important ritual which can support these competencies of self-reflection and self-care to come to fruition.

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 is different. The majority of advanced practice nurses work one-on-one with a preceptor and may not have the opportunity to have an end-of-day debrief with their peers. Creating an opportunity for peer feedback at the end of a clinical practicum day (or perhaps week, if clinical experiences of all students are not synchronized) is one way to provide peer support, collaboration, and safety.

Other recommended practices include providing a warning or advisory prior to assignments or tasks that may be triggers for some students and allowing students the opportunity to not participate or to choose a different method of evaluation (Beverly et al., 2018; Stout & Martin, 2022). To address issues of transparency and trustworthiness, it is important that faculty clearly articulate policies and expectations of the class at the beginning of the semester (Center for Teaching and Learning, n.d.). Other strategies that may be used in the classroom or clinical setting include reflective journaling and reaching out to students who may be struggling. If conflict arises within the classroom, the use of restorative techniques has been recommended as an effective way to address this issue (Gonzalez et al., 2019).

Faculty Training. It is important to educate all faculty and clinical preceptors about trauma-informed approaches to teaching. Training should encompass not only the significance and need for a trauma-informed pedagogy, but strategies to identify trauma-impacted students, and awareness about appropriate resources within the university and the community (Center for Teaching and Learning, n.d.). Faculty may need to re-examine course syllabi, assignments, evaluation metrics, clinical placement experiences, simulation exercises, and classroom discussion topics to determine whether these activities and/or requirements align with a trauma-informed approach. Additional considerations for faculty include incorporating feedback throughout the semester, versus only at the conclusion of courses; allowing opportunities for peer interaction and engagement in class (either in-person or through class discussion posts); and acknowledging difficulties that students may experience within their personal and professional lives.

It is important to educate all faculty and clinical preceptors about trauma-informed approaches to teaching.By incorporating these strategies, graduate nursing programs can foster and develop a trauma-informed approach. These strategies should occur in tandem and may not all be accomplished within the same academic year. We recognize that other institutional processes or constraints may limit the ability of graduate nursing programs to fully adopt these recommendations. Transformation is a process and should be continually appraised to ensure that actions taken to create a trauma-informed program remain relevant to students who are being served.

Conclusion

Incorporating a trauma-informed approach into graduate-level nursing education is a critical component of supporting the educational needs of these students. As previously stated, a distinguishing feature of advanced practice nursing students is that many concurrently practice as registered nurses while returning to school to earn an advanced degree. Their lived experiences may result in disproportionate trauma exposure due to their roles as professional caregivers (Chen et al., 2021). In turn, this may impact their academic needs and learning styles.

Although there have been recommendations on ways to apply trauma-informed approaches to teaching, most of the recommendations focus on educating non-healthcare providers, or those who have not yet entered professional practice (Marquart & Baez, 2021; Sanders, 2021). Implementing the six SAMHSA (2014) tenets of a trauma-informed approach to reform policies, procedures, and practices in nursing education may minimize stressors and decrease the risk of re-traumatization, as well as support overall health and healing. Nurse faculty play a pivotal role in the restructuring of curriculum design to include these principles of a trauma-informed approach to promote inclusivity, safe learning spaces, and collaborative opportunities that foster mutual respect and dignity for all students.

Adopting a “universal precautions” approach is necessary to identify trauma and support graduate students.Creating and sustaining a trauma-informed academic setting requires awareness, open-mindedness, empathy, and incorporating educational practices that promote healing and mitigate harm. Academic organizational culture change is vital and requires administrative leadership support. Adopting a “universal precautions” approach is necessary to identify trauma and support graduate students. Changing the cultural mindset from “What’s wrong with you?” to “How can we support you” will create a paradigm shift that enhances awareness and compassion for the effects of trauma on students (SAMHSA, 2014). Early recognition of signs of trauma and its influence on how students perceive themselves, others, and the academic environment is fundamental to address the issue.

Knowing that the academic environment affects the health and well-being of students creates an urgency to create a safe, trauma-informed learning atmosphere. Safeguarding the well-being of graduate students is critical to retain the growth and sustainability of the nursing workforce and ensure the health and safety of all patients. Although the impact of trauma informed educational practices for pre-licensure nursing students is beyond the scope and breadth of this article, the authors believe the basic principles described here may demonstrate applicability across levels and programs in nursing education.

Authors

Nadine M. Aktan, PhD, APN-BC
Email: nmaktan@sn.rutgers.edu
ORCID ID: 0000-0001-9824-5118

Nadine M. Aktan (she/her/hers) is a Clinical Professor and Assistant Dean at Rutgers School of Nursing Advanced Practice Division. She has developed a national presence in the area of improved health outcomes for at-risk populations. Dr. Aktan is an advocate for health equity and improved social mobility of nursing students.

Jeffrey Kwong, DNP, MPH, AGPCNP-BC, FAANP, FAAN
Email: jeffrey.kwong@rutgers.edu
ORCID ID: 0000-0001-9748-2234

Jeffrey Kwong (he/him) is a Professor in the Division of Advanced Nursing Practice at Rutgers School of Nursing. He is a practicing clinician at Gotham Medical Group in New York. Dr. Kwong is a widely respected authority in the field of HIV treatment and prevention.

Mamilda Robinson, DNP, APN, PMHNP-BC
Email: poema@sn.rutgers.edu
ORCID ID: 0000-0003-2731-6753

Mamilda Robinson is a Family Psychiatric and Mental Health Nurse Practitioner and faculty at Rutgers School of Nursing Advanced Practice Division. She is actively involved in clinical scholarship and provides patient-centered, population specific, and trauma informed care. She is passionate about her work in mental health and brings much expertise and value to the Psych-Mental Health specialty and the profession of nursing at large.

Sallie Porter, DNP, PhD, APN, PED-BC, CPNP, FNAP
Email: portersa@sn.rutgers.edu]
ORCID ID: 0000-0002-2077-649X

Sallie Porter is an Associate Professor, Division of Advanced Nursing Practice, at Rutgers School of Nursing. Dr. Porter's research focuses on infants with developmental, health, and social challenges and their families and communities. She also serves as Nursing Discipline Coordinator for the New Jersey Leadership Education in Neurodevelopmental and Related Disabilities (NJLEND) which is part of the Robert Wood Johnson Medical School.

Latoya Rawlins, DNP, RN-BC, CNE
Email: rawlinln@sn.rutgers.edu

Latoya Rawlins is a Clinical Assistant Professor in the entry to the Baccalaureate Division at the Rutgers University School of Nursing. She has over twenty-three years of clinical nursing experience. Dr. Rawlins brings over a decade of experience as a nurse faculty with a specialty in pediatric nursing to her work in nursing academia.

Caroline Dorsen, PhD, FNP-BC, FAAN
Email: caroline.dorsen@rutgers.edu
ORCID ID: 0000-0001-8972-9954

Caroline Dorsen (she/her/hers) is an Associate Professor and Associate Dean at Rutgers School of Nursing. For over 15 years, her teaching, research and advocacy has focused on the intersection between health and social justice. Among her many honors and awards, she was inducted as a Fellow in the American Academy of Nursing in 2021.