What this article is about
In brief
In interviews with eight emergency department RNs, understanding of trauma-informed care ranged from strong to nearly nonexistent, and while TIC modules were available, they were not mandatory or consistently integrated into practice. The authors recommend embedding TIC into nursing curricula, boosting...
For nursing students
Study summary
Trauma-informed care (TIC) is an approach to healthcare that recognizes how trauma shapes a patient's behaviour, trust, and response to treatment, and it asks providers to avoid retraumatizing people who come through the door. This 2024 qualitative study, published in the Journal of Online Graduate Education, looked at how registered nurses (RNs) working in a hospital emergency department (ED) in a suburban Southern California community perceived the TIC continuing education their organization offered them, especially during the stress of the COVID-19 pandemic.
The researchers used narrative inquiry, a qualitative design built around collecting and analyzing people's stories about their own experiences. Eight RNs from the same ED, all employed since May 2020, took part in two 60-minute semi-structured interviews each, conducted over Microsoft Teams. Interviews were transcribed verbatim, and participants reviewed their own transcripts (member checking) to make sure their words were captured accurately. The research team then used Braun and Clarke's reflexive thematic analysis, supported by NVivo Pro software, to code the interviews and group the codes into themes tied to three research questions about (1) how nurses saw leadership's role in providing TIC education during COVID-19, (2) how they perceived the training itself, and (3) what steps they thought were needed to build better ongoing education.
Seven themes emerged. Nurses described a real gap in understanding of TIC: some had a fairly clear grasp of the concept, centered on creating safety and considering a patient's life history, while others, in their own words, had barely heard the term before being invited into the study. Related to that gap, nurses said there was no specific requirement to complete TIC training, and several wanted more comprehensive, in-person sessions rather than only optional online modules, alongside naming scheduling and logistics as real obstacles to getting that training. At the same time, nurses recognized that TIC mattered most for certain vulnerable patients and situations, they valued their organization's willingness to support continuing education (including tuition support for advanced degrees), and they saw leadership playing a role through shift huddles that announced training opportunities. A near-unanimous theme was the importance of building trust with patients through empathy, reading the room, and individualized communication, even when nurses disagreed about whether that approach should apply to everyone or only to patients with identifiable trauma histories. Finally, most nurses (seven of eight) discussed accessing continuing education, with several seeking it out independently through professional associations like the Emergency Nurses Association, online health-stream modules, and conferences, while others relied mainly on what their employer provided.
The authors connect these findings to SAMHSA's trauma-informed care framework and its five core principles: safety, trust and transparency, choice, collaboration, and empowerment. Based on the themes, they recommend three things for healthcare organizations: build TIC content into nursing curricula (including online continuing education units already recognized by the California State Board of Nursing), increase collaboration between nurses and other disciplines such as social workers and psychiatrists, and develop clear institutional policies that make TIC training and practice consistent rather than optional.
For nursing students, this study is a useful example of how narrative inquiry captures the texture of frontline experience that a survey alone might miss, and it is a reminder that having TIC education available is not the same as it being understood, required, or consistently applied. It also illustrates a common gap between an organization's stated commitment to a practice model and what frontline staff actually experience day to day. As you read the study, notice how the same organizational support (continuing education access) could be described positively by one nurse and inadequately by another, and think about what that variation tells you about how training programs are designed, publicized, and reinforced.
Original publication
Source abstract and study details
Read the source abstract
Trauma-informed care (TIC) stands as a beacon of transformative change within healthcare organizations, advocating for consistent practice models and bolstering mental health education across diverse settings (Bunting et al., 2019). For registered nurses (RNs) operating in the high-pressure environment of emergency departments (EDs), TIC emerges as a guiding principle, aiming to cultivate care practices that alleviate patient trauma and safeguard against retraumatization of patients and staff (Fleishman et al., 2019). This research investigated the importance of providing trauma-informed education to RNs in EDs, focusing on RNs' perspectives. The study used qualitative narrative inquiry research design to explore RNs' perceptions of TIC continuing education initiatives led by organizational leadership, particularly in enhancing organizational outcomes. The study highlights the critical need for ongoing education, especially given the challenges posed by the COVID-19 pandemic and the experiences of RNs in the field. This study emphasizes its significance in improving organizational outcomes and patient care quality by contributing to the existing body of research on TIC education. Recommendations stemming from this research include integrating TIC education into nursing curricula, offering online training, promoting collaboration across healthcare disciplines, and establishing institutional policies supportive of TIC principles. Drawing from the TIC conceptual framework and the implications of this study, future research directions are proposed, including investigating the impact of TIC training on nursing practice in person and online, identifying obstacles to TIC implementation, and exploring TIC's potential in addressing healthcare disparities.
Reviewed findings
Main findings
- Across eight RN participants, understanding of trauma-informed care varied widely: some nurses articulated a clear grasp centered on patient safety and life-history awareness, while others reported having little or no familiarity with the concept before the study.
- Participants identified a lack of specific institutional requirements for TIC training and expressed a preference for comprehensive in-person sessions over reliance on optional online graduate modules alone, citing scheduling and logistical barriers to accessing training.
- Nurses viewed hospital leadership as supportive of continuing education broadly (e.g., daily huddle announcements, tuition assistance for advanced degrees) but noted that TIC-specific education was not consistently prioritized or promoted, especially during the COVID-19 pandemic.
- Building trust with patients through empathy, individualized communication, and 'reading the room' emerged as a near-universal theme, though participants differed on whether trauma-informed approaches should be applied universally or only to patients meeting specific trauma-risk criteria.
- Seven of eight participants discussed accessing continuing education, with several seeking it out independently through sources such as the Emergency Nurses Association, online modules, and professional conferences, while others relied mainly on employer-provided training, reflecting variable reliance on self-directed versus organizational pathways.
For teaching and learning
Education implications
- Because RN understanding of TIC ranged from comprehensive to nonexistent within the same unit, organizations should not assume that offering TIC modules translates into consistent staff knowledge or practice.
- Making TIC continuing education mandatory, rather than optional, may be necessary to close the gap between nurses who value TIC principles and those unfamiliar with the term, particularly during high-stress periods such as a pandemic.
- Combining brief online modules with periodic in-person or case-based sessions may better address the comprehensiveness that participants said online-only training lacked, especially for complex interpersonal skills like trauma-sensitive communication.
- Interdisciplinary collaboration (nursing with social work and psychiatry) may better support RNs who reported not feeling fully equipped to manage trauma-exposed patients using nursing skills and resources alone.
- Institutional policy that formally embeds TIC principles (safety, trust and transparency, choice, collaboration, empowerment) into onboarding and continuing education may create more consistent practice than relying on individual nurses' initiative to seek outside training.
For educators
Teaching and appraisal notes
This qualitative narrative inquiry study, published in the Journal of Online Graduate Education (Vol. 7, Iss. 3, 2024), examined registered nurses' (RNs) perceptions of trauma-informed care (TIC) continuing education in an emergency department (ED) at an acute care hospital in a suburban Southern California community. The authors, Patricia Damos and Dale Crowe of National University, framed the study around three research questions addressing RNs' perceptions of organizational leadership's role in providing TIC education during the COVID-19 pandemic, perceptions of the training's adequacy for working with trauma-exposed patients, and RNs' views on necessary next steps for continuing education.
Methodologically, the study is a strong exemplar of applied narrative inquiry for a graduate teaching case. Following IRB approval and flyer-based recruitment, eight RNs employed since May 2020 completed two 60-minute semi-structured, audiovisual interviews each via Microsoft Teams (16 interviews total), with verbatim transcription and member checking between interviews to strengthen credibility. Data were organized in NVivo Pro and analyzed using Braun and Clarke's (2021) reflexive thematic analysis, with the researcher explicitly documenting reflexivity practices to manage positionality bias. The coding process moved from an initial 25-35 codes down to a refined 26 codes with four subcodes, and from an initial 10 candidate themes to seven final themes, each supported by a reference-count and participant-frequency table (Table 1) — a transparent audit trail worth pointing out to students learning to evaluate qualitative rigor.
The seven themes cluster into three areas mapped to the research questions: (1) lack of understanding of TIC and gaps in its integration into clinical practice; (2) recognition of the need for TIC education and the role of leadership in promoting it (largely through informal channels like daily huddles and tuition support rather than mandatory curricula); and (3) the importance of TIC in specific populations, the centrality of building patient trust, and nurses' own initiative in pursuing continuing education outside their employer (e.g., through the Emergency Nurses Association). Direct participant quotations throughout make the coding decisions traceable, which is useful for a class session on demonstrating an audit trail in qualitative work.
The discussion situates findings within SAMHSA's trauma-informed care framework and its five principles (safety, trust and transparency, choice, collaboration, empowerment), and yields three practice recommendations — embedding TIC into nursing curricula and CEUs, increasing interdisciplinary collaboration, and formalizing institutional policy — plus three future-research directions concerning the impact of online TIC training, implementation barriers, and TIC's potential role in addressing health disparities in domestic and international emergency contexts.
For teaching purposes, this is a good vehicle for discussing single-site sampling limits, the difference between a training program's stated availability and its actual uptake or mandate, and how thematic saturation and member checking are used (or should be probed) in small qualitative samples. Discussion should also address the study's single-organization, U.S. hospital context and the resulting caution needed before generalizing to other EDs, health systems, or the Canadian regulatory and CEU landscape.
Critical appraisal
Limitations
- The sample consisted of eight RNs from a single emergency department at one Southern California hospital, limiting generalizability to other EDs, hospital types, regions, or countries, including the Canadian nursing context.
- As a qualitative narrative inquiry design, the study describes perceptions and experiences rather than measuring TIC training's actual effect on clinical behaviour or patient outcomes.
- All participants had been employed at the site since May 2020, meaning their perceptions are shaped by a specific pandemic-era organizational context that may not reflect current or pre-pandemic conditions.
Classroom use
Discussion Questions
- How did the range of understanding of trauma-informed care among the eight nurses in this study reflect broader gaps you have seen (or expect to see) between policy availability and staff awareness in clinical settings?
- The study found that TIC modules were available but not mandatory. What are the potential benefits and drawbacks of making trauma-informed care training a mandatory requirement rather than an optional resource?
- Participants disagreed about whether trauma-informed approaches should be applied to every patient or reserved for those with identifiable trauma histories. Which position do you find more defensible clinically, and why?
- How might the COVID-19 pandemic context specifically have shaped these nurses' perceptions of leadership's role in promoting (or failing to promote) TIC education?
- Several nurses described pursuing continuing education independently through professional associations rather than through their employer. What does this suggest about the adequacy of employer-provided training pathways?
- The authors link their themes to SAMHSA's five TIC principles (safety, trust and transparency, choice, collaboration, empowerment). Choose one principle and describe how it appeared, or was missing, in the nurses' quoted experiences.
Source-based questions
Frequently asked questions
Was trauma-informed care training mandatory for the nurses in this study?
No. The paper reports that online TIC educational modules were available to registered nurses at the study site, but they were not mandatory requirements.
How many nurses were interviewed and how were they recruited?
Eight registered nurses from a Southern California Medical Center emergency department were recruited via flyers posted in the ED breakroom, after IRB and department manager approval, and were employed at the site since May 2020.
What practical recommendations did the study make for hospitals and nursing programs?
The authors recommend incorporating TIC education into nursing curriculums, increasing collaboration between nurses and other healthcare disciplines like social work and psychiatry, and developing formal institutional policies supporting TIC.
Does this study prove that TIC training improves patient outcomes?
No. This qualitative narrative inquiry describes nurses' perceptions and experiences of TIC education; it does not measure clinical behaviour change or patient outcomes, and the authors explicitly recommend future research to investigate training's actual impact.
What role did the COVID-19 pandemic play in this study?
The pandemic forms the backdrop for participants' experiences, since all eight nurses had been employed at the ED since at least May 2020; the authors note the pandemic period highlighted gaps in ongoing TIC education.