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...
What this article is about
Quick Answer
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 interdisciplinary collaboration, and formalizing institutional TIC policy.
Student takeaways
Key Takeaways
- 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.
Student summary
Why This Research Matters
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.
Source abstract
Study Overview
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.
Evidence appraisal
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.
Practice transfer
Clinical Relevance
- 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.
Faculty notes
Educational Relevance
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.
- What role should interdisciplinary collaboration (e.g., with social workers or psychiatrists) play in supporting nurses who do not feel equipped to independently manage trauma-exposed patients in a busy ED?
- Given that this study used narrative inquiry and reflexive thematic analysis with only eight participants, what kinds of research designs would be needed to test whether TIC training actually changes clinical practice or patient outcomes?
- How might the recommendations in this study (curriculum integration, collaboration, institutional policy) need to be adapted for a Canadian hospital or nursing program rather than the U.S. site described here?
- The authors suggest studying TIC's potential role in addressing health disparities in domestic and international emergency settings. What populations in your own practice context might benefit most from a formal TIC training requirement?
Knowledge check
Quiz
1. What qualitative research design did this study use to explore RNs' perceptions of trauma-informed care education?
- Grounded theory
- Narrative inquiry
- Ethnography
- Case-control study
Rationale: The abstract and methods state the study used 'qualitative narrative inquiry research design to explore RNs' perceptions of TIC continuing education initiatives.'
2. How many registered nurses participated in this study?
- Five
- Eight
- Twelve
- Sixteen
Rationale: The full text states: 'Eight Registered Nurses from the Southern California Medical Center's Emergency Department, employed since May 2020, were selected.'
3. Which analytic framework did the researchers use to analyze interview data?
- Colaizzi's phenomenological method
- Braun and Clarke's reflexive thematic analysis
- Grounded theory constant comparison
- Content analysis using Krippendorff's method
Rationale: The paper states the data 'was analyzed using Braun and Clarke's (2021) reflexive thematic analysis framework.'
4. How many themes ultimately emerged from the data analysis across the three research questions?
- Three
- Five
- Seven
- Ten
Rationale: The full text reports that after refining the coding schema, 'seven themes were used instead of 10,' and Table 1 lists seven emergent themes across the three research questions.
5. According to the study, what was one major finding regarding nurses' understanding of trauma-informed care?
- All nurses reported extensive, consistent understanding of TIC
- Understanding ranged from clear grasp to near-total unfamiliarity with the term
- None of the nurses had ever heard the term before the study
- Understanding was uniformly tied to years of nursing experience
Rationale: Theme 1 (Lack of Understanding) notes some participants 'clearly understood TIC, others lacked awareness or had minimal knowledge,' with one participant stating she had 'not really heard much about it.'
6. What did participants say about the format of TIC training available to them?
- It was exclusively delivered through mandatory in-person workshops
- Online modules existed but were not mandatory, and participants wanted more in-person training
- No training of any kind was ever offered
- Training was only available to nursing management, not frontline RNs
Rationale: The paper states 'online educational modules are available to registered nurses, but they are not mandatory' and that participants 'emphasized the necessity for comprehensive, in-person training rather than relying solely on online graduate modules.'
7. Which conceptual framework did the authors use to interpret their findings on trauma-informed care?
- Maslow's hierarchy of needs
- SAMHSA's trauma-informed care framework and five core principles
- Roy's Adaptation Model
- Benner's novice-to-expert model
Rationale: The conclusion states the findings 'support the conceptual framework of TIC using the Substance Abuse and Mental Health Services Administration's (SAMHSA) framework and five core principles: safety, trust and transparency, choice, collaboration, and empowerment.'
8. What is one of the three recommendations for future practice given by the authors?
- Eliminate all online continuing education for nurses
- Incorporate TIC education into nursing curriculums
- Restrict TIC training to psychiatric nurses only
- Replace narrative inquiry with randomized controlled trials in all future studies
Rationale: The authors list three recommendations for organizational leadership: '(a) incorporate TIC education into nursing curriculums, (b) increase collaboration between healthcare professionals, and (c) develop institutional policies and procedures.'
9. Where was this study's research site located?
- A rural hospital in the Midwest United States
- An acute care hospital in a suburban Southern California community
- A teaching hospital in Toronto, Canada
- Multiple hospitals across several U.S. states
Rationale: The full text states: 'The research was conducted in an acute care hospital in a diverse suburban community in Southern California.'
10. What is a key limitation of this study's design that affects how broadly its findings can be applied?
- It used a nationally representative random sample of thousands of nurses
- It was based on eight RNs at a single ED, limiting generalizability
- It only surveyed nursing students, not licensed RNs
- It was conducted before trauma-informed care was defined as a concept
Rationale: The study drew its qualitative data from eight RNs at one Southern California Medical Center emergency department, a small single-site sample typical of narrative inquiry but limiting generalizability beyond that setting.
Study cards
Flashcards
What is trauma-informed care (TIC)?
An approach to healthcare, described in the study as a service system grounded in understanding how trauma affects survivors' neurological, biological, physiological, and social development, aiming to avoid retraumatizing patients and staff.
What research design did Damos and Crowe (2024) use?
Qualitative narrative inquiry, exploring RNs' stories and experiences of TIC continuing education.
How many RNs participated in the study?
Eight registered nurses from one emergency department, all employed since May 2020.
Where was the study conducted?
An acute care hospital in a diverse suburban community in Southern California.
How were interviews conducted and how long did they last?
Two semi-structured audiovisual interviews per participant, conducted via Microsoft Teams, each approximately 60 minutes.
What software was used to organize and analyze the qualitative data?
NVivo Pro, a computer-assisted qualitative data analysis software (CAQDAS).
Which analytic framework guided the thematic analysis?
Braun and Clarke's (2021) reflexive thematic analysis framework.
What technique did researchers use to check the accuracy of interview transcripts?
Member checking — participants reviewed their own transcripts and could amend responses before the second interview.
How many final themes emerged from the data analysis?
Seven themes, mapped across the study's three research questions.
What was Theme 1 of the study?
Lack of understanding — many participants had limited knowledge or misconceptions about trauma-informed care.
What was Theme 2 of the study?
Integration of trauma-informed care into clinical practice, including deficiencies in education and training opportunities.
What did Participant 6 say about their understanding of TIC?
Participant 6 said their understanding was 'extremely limited' and that they had not heard of TIC until being invited into the study.
What theme addressed nurses building rapport with patients?
Theme 6: Building Trust with Patients, which nearly all eight participants discussed.
What theme captured nurses seeking education beyond their employer?
Theme 7: Benefits of Seeking Out Continuing Education, referenced by seven of eight participants (e.g., through the Emergency Nurses Association).
What conceptual framework did the authors use to frame TIC principles?
SAMHSA's trauma-informed care framework, with five core principles: safety, trust and transparency, choice, collaboration, and empowerment.
What are the study's three recommendations for future practice?
(1) Incorporate TIC education into nursing curriculums, (2) increase collaboration between healthcare professionals, and (3) develop institutional policies and procedures.
What are the study's three recommendations for future research?
(1) Investigate the impact of online TIC training on nursing practice, (2) explore barriers to implementing TIC into nursing practice, and (3) investigate TIC's role in addressing health disparities.
What contextual crisis shaped the timing and relevance of this study?
The COVID-19 pandemic, during which participants had been employed at the study site since at least May 2020.
What organization did one participant mention as a source of continuing education outside her employer?
The Emergency Nurses Association, along with online health-stream modules, conferences, and virtual platforms.
What is a key limitation of applying this study's findings broadly?
It is based on eight RNs from a single U.S. emergency department, so findings may not generalize to other settings, hospital types, or countries.
Search-ready answers
Frequently asked questions
What did this study find about nurses' understanding of trauma-informed care?
The study found wide variation: some of the eight participating RNs had a clear understanding of TIC centered on patient safety and life-history awareness, while others reported minimal or no familiarity with the concept before the study.
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 research method was used to analyze the interview data?
Braun and Clarke's (2021) reflexive thematic analysis, supported by NVivo Pro software, was used to code interview transcripts and generate themes.
What themes emerged from the study?
Seven themes emerged: lack of understanding of TIC, integration of TIC into clinical practice, recognizing the need for TIC education, the role of leadership in promoting training, the importance of TIC for specific populations, building trust with patients, and the benefits of seeking continuing education.
What framework did the authors use to interpret trauma-informed care principles?
They used SAMHSA's trauma-informed care conceptual framework, built around five core principles: safety, trust and transparency, choice, collaboration, and empowerment.
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.
What are the main limitations of this study?
Key limitations include a small sample of eight RNs from a single hospital ED, a qualitative design that captures perceptions rather than measurable outcomes, a pandemic-specific context, and reliance on a single researcher's coding without described independent inter-rater checks.