Implementation of Trauma-informed Principles in Nursing Education: An Appeal for Action

Implementation of Trauma-informed Principles in Nursing Education: An Appeal for Action

Exposure to traumatic stress can have a life-altering negative impact on student nurses. Traumatic stress can challenge effective coping, emotional regulation, and the ability to focus, retain, and recall nursing concepts. According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2014), the “3 E” conceptualization of trauma are Event (single or cumulative), Experience (neglect, abuse, betrayal), and Effects (anxiety, loneliness, depression, feeling unsafe ) are manifested in various ways in people with exposure to trauma.

An individualized student-centered approach is crucial in understanding and adapting teaching pedagogy in nursing education to realize, recognize, respond, and resist re-traumatization (SAMHSA, 2014)in student nurses with a history of traumatic stress.

This article discusses the concept of trauma-informed pedagogy in nursing education and its significance in promoting equity and inclusion. Trauma-informed pedagogy suggests that past experiences can negatively impact health outcomes and learning (Garfin D. R. et al., 2018). As a result, educators must be able to identify signs of trauma and adapt their teaching methods to meet their students’ unique needs. It discusses the impact of trauma on nursing students’ physical and mental health functioning, and it then delves into implementing principles of trauma-informed pedagogy in the classroom.


Trauma is defined as an event or set of circumstances that an individual experiences as physically or emotionally harmful or threatening, resulting in lasting adverse effects on their functioning and well-being (Bremner, J. D. 2006). College students, despite their excitement to succeed, often experience severe psychological distress, with 70% reporting such distress. Additionally, 35% of students were diagnosed with anxiety, and 29% had depression (American College Health Association, 2022).

Transgender and LGBTQIA students report higher levels of mental health issues than their straight counterparts. Microaggressions are also experienced by underrepresented students, creating a sense of unsafety on campus. Evidence suggests that Colleges should pivot to a learning space that promotes inclusion and equity. Only 40% of college students think colleges are doing enough to support mental health (Veneable, M.A., & Pietrucha, M. E., 2022).

The Universal Design for Learning ( UDL) recognizes that every student has different learning needs, and a one-size-fits-all approach is an ineffective instructional strategy. Similarly, implementing trauma-informed pedagogy principles within the nursing curriculum is a significant step toward meeting every student’s learning needs and experiences, promoting accessibility, equity, and inclusion in nursing education.

How Traumatic Stress Affects the Brain

Traumatic experiences can affect the brain’s development, structure, and function. It is critical to understand normal brain development to distinguish brain abnormalities. The areas of the brain responsible for stress responses are the amygdala, hippocampus, and pre-frontal cortex (Bremner, J. D., 2006). When an individual is exposed to traumatic stress, there is an increase in the level of cortisol and norepinephrine. Repeated exposure to stress increases the level of cortisol and norepinephrine and affects normal brain functioning and stress regulation, resulting in pathophysiological change(Bremner, J. D. 2006).

Students who are affected by traumatic stress may have difficulty learning concepts, focusing, and retaining information, resulting in course failures and higher attrition rates compared to their peers who have not experienced trauma. Traumatic experiences can cause anxiety and depression in some students. Past and current data suggest that trauma-informed care is critical for the promotion of equity in people with a history of trauma (Han et al., 2021).

Students’ sense of safety is disrupted, and the cumulative effects are difficulty adjusting to college experience, low grades, and high attrition rates. According to (Corello J., 2018), educators should adopt trauma-informed teaching and be compassionate and consistent in the learning environment. Despite the impact traumatic experience has on the brain, there is hope and possibility for students to be successful.

Implications for Nurse Educators

In the Four “Rs in the Trauma-informed approach to teaching student nurses(SMASHA, 2014), the nurse educator must convey empathy, possibilities, and hope to student nurses and focus on “what happened to you, instead of what is wrong with you’. Implementing trauma-informed principles is an issue of equity and inclusion and must be viewed through the lens of disability.


Research suggests that 66%-85% of youth report exposure to traumatic events by the time they enter college (Read et al., 2011). Additionally, approximately three-quarters of college students, 77 %, experienced moderate to severe psychological distress (ACHA, 2022). Understanding that traumatic experiences can affect the development, structure, and function of the brain, the nurse educator must acknowledge that trauma happened and provide a trusting teaching environment that emphasizes hope and transformation.

Realizing that trauma affects the student’s ability to function optimally, the nurse educator must stay involved in world events that may be traumatic to students: for instance, racism, disability, COVID-19, sexism, sexual harassment, and sexual orientation. Modeling emotional intelligence skills, self-reflection, and situational awareness, the nurse educator can convey trust and transparency when discussing and understanding sensitive topics in the classroom.


The nursing process is a framework taught in nursing education to provide care for diverse populations. It begins with an assessment. Likewise, the nurse educator must be able to recognize signs of traumatic stress and respond with empathy, kindness, and understanding. Some signs and symptoms are difficulty focusing on a topic, lack of engagement, absenteeism, anxiety, low grades, and difficulty adjusting to the college environment.

It is essential to acknowledge that the traumatic event happened, and an evidence-based action plan is activated to promote healing and agency to enhance academic success. The nurse educator must be knowledgeable about topics or events that may trigger traumatic stress and develop a lesson plan or teaching strategies to avoid triggers—for instance, disparities in healthcare outcomes for minorities. Nurse educators must adopt several strategies to effectively support students’ learning experiences in teaching sensitive topics. To this end, the nurse educator should consider the value of establishing eye contact with students and facilitating opportunities for them to share their lived experiences. The nurse educator must also demonstrate a genuine interest in the student experience. By applying these strategies, nurse educators can foster an environment that supports students’ learning journey and promotes their well-being.


When a student goes through a traumatic experience, their sense of safety can be severely affected. As a nurse educator, it is essential to demonstrate emotional intelligence while conversing with such students regarding traumatic stress. Using the student’s name and giving them enough time to contemplate and respond is crucial. In addition, the nurse educator should offer their presence to show kindness and compassion, which can provide comfort and support for the student.

As a nurse faculty member, you can support your student’s academic journey by referring them to the Office of Accessibility and Disability. The office provides essential services to students with disabilities, ensuring they have the resources to succeed in their studies. Letting your students know you are available for office hours and phone calls is essential, as this can help them feel more comfortable and supported.

Creating a respectful and inclusive learning environment is crucial to the success of all students. You can do this by promoting a culture of civility and respect in your classroom and being mindful of your students’ diverse needs. If a student is experiencing anxiety or stress, consider extending assignment due dates to help alleviate their concerns.

Finally, it is essential to recognize that some students may have a history of trauma that could impact their ability to learn. To increase the accessibility and inclusion of these students, incorporate multiple teaching modalities that address the cognitive, psychomotor, and affective domains of learning. Doing so can help ensure that all your students can succeed.

Resist re-traumatization 

In a nursing education culture that prioritizes diversity, equity, and inclusion, it is essential to recognize that some college students may have experienced trauma. By intentionally incorporating transformative, trauma-informed practices into nursing education, we can foster a sense of human dignity, promote academic growth, and help students thrive. To prevent re-traumatization, faculty and peers must have zero tolerance for discrimination against students. The learning environment must prioritize civility, human caring, compassion, and consistency (Corello, 2018) while avoiding punitive measures and implementing clear policies and procedures. Sensitive topics should be approached with empathy and understanding, and training modules focused on trauma and its effects can help create awareness and build a strong sense of community.  


Integrating trauma-informed practices into nursing education requires comprehensive changes across multiple levels, from micro to macro systems. At the micro level, nurse faculty must demonstrate empathy, benevolence, courtesy, and honor towards individuals who have survived trauma. They must also remain watchful in recognizing, validating, and averting re-traumatization for student nurses who have experienced trauma. By nurturing a learning environment that fosters personal development and transformation, faculty and students can collaborate to establish a warm and accommodating community open to everyone.


1. American College Health Association -National College Health. (2022). Assessment III: Undergraduate Student Reference Group Executive Summary Spring 2022. Silver Spring, MD: American College Health Association.

2. Bremer, J. D. (2006). Traumatic stress: effects on the brain. Dialogues in Clinical Neuroscience, 8(4), 445-61.

3. Carello, J. & Thompson, P. (Eds). (2021). Lessons from the pandemic: Trauma-informed approaches to college, crisis, change. Palgrave Macmillan.

4. Garfin, D. R., Thompson, R. R., & Holman, E. A. (2018). Acute stress and subsequent health outcomes: A systematic review. Journal of Psychosomatic Research, 112, 107-113. doi: 10.1016/j.jpsychores.2018.05.017

5. Goddard, A., Jones, R. W., Esposito, D., & Janicek, E. (2021). Trauma-informed education in nursing: A call for action. Nurse Education Today, 101. doi: 10.1016/j.nedt.2021.105064

6. Han, H. R., Miller, H. N., Nkimbeng, M., Budhathoki, C., Mikhael, T., Rivers, E., Gray, J., Trimble, K., Chow, S., Wilson, P. (2021). Trauma-informed interventions: A systematic review. PLoS One, 16(6), e0253209. Doi: 10.1371/journal.pone.0253209

7. Kubala, J. (2020). Of Trauma and Triggers: Pedagogy and Affective Circulations in Feminist Formations, 32(2), 183-206.

8. Read, J. P., Wardell, J. D., Vermont, L. N., Colder, Ouimette, P., & White, J. (2012). Transition and change: Prospective effects of posttraumatic stress on smoking trajectories in the first year of college. Health Psychology, 32(7), 757-767.

9. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. (2014). HHS Publication No. (SMA) 14-4884. Substance Abuse and Mental Health Services Administration, Rockville, MD.

10. Veneable , M. A., & Pietrucha, M,E. (2022). 2022 College Mental Health Report, Best Colleges.

New ENA Foundation Program Promotes Diversity in Nursing Research

New ENA Foundation Program Promotes Diversity in Nursing Research

The ENA Foundation’s new Emergency Nursing Diverse Voices Research Fellowship aims to increase diversity in nursing research.

In partnership with the Emergency Nursing Research Advisory Council and the Emergency Nurses Association Diversity, Equality and Inclusivity Committee, the ENA Foundation is accepting applications for the ENDVR Fellowship through March 3. The fellowship will better support and mentor emerging researchers who are members of underrepresented groups.

“The ENDVR Fellowship embodies two important foci for ENA including the important work of the DEI committee that began in 2019 and is in line with the Foundation’s efforts to increase the visibility of research grants,” said ENA Foundation Chairperson Jeff Solheim, MSN, RN, CEN, TCRN, CFRN, FAEN, FAAN. “It’s hoped that the ENDVR Fellowship will encourage nurses from underrepresented communities to undertake research projects that will reflect and address important issues in their communities.”

Selected applicants will attend and participate in research activities at Emergency Nursing 2022 in Denver; partner with a member of the Emergency Nursing Research Advisory Council who will serve as a mentor; develop a research project to be conducted locally; attend advisory council meetings; and present their results and findings at either Emergency Nursing 2023 or 2024. The fellowship may extend to two years as required.

“The Emergency Nursing Diverse Voices Research Fellowship is important because underrepresented nurses have been systematically excluded from research opportunities in nursing. This exclusion often means that critical perspectives are missing from the research that guides our practice,” said ENA DEI Committee Chairperson Anna Valdez, Ph.D., RN, FAEN, FAADN. “We are excited about this opportunity to work with and support diverse nurses who have an interest in emergency nursing research. I am looking forward to meeting and working with new fellows.

“I encourage diverse nurses to apply for the fellowship and want them to know that their voices and contributions to the profession are welcomes and valued at ENA,” Valdez added.

Click here to learn more about or apply for the Emergency Nursing Diverse Voices Research Fellowship.

About the ENA Foundation

The ENA Foundation, a 501(c)(3) tax-exempt organization, is the philanthropic arm of the Emergency Nurses Association. The Foundation fuels the future of emergency nursing with a mission focused on providing academic scholarships and research grants to emergency nurses. Since 1991, the ENA Foundation has awarded approximately $5.3 million to more than 2,300 emergency nurses to help them earn degrees, expand their skills through continuing education and conduct research projects directly related to emergency nursing and led by nurse researchers.

The Nursing Program Admissions Gauntlet

The Nursing Program Admissions Gauntlet

To address health inequities in the United States, the American Association of Colleges of Nursing, Robert Wood Johnson Foundation, and the Institute of Medicine recommend increased representation of Black and other underserved populations in the health professions. Black nurses are more likely to work in underserved communities, but due to multiple barriers in our current admissions processes, Black students’ have limited access to RN education.

The majority of U.S. Registered Nurse (RN) graduates train in associate and bachelor’s degree programs. They apply first to the academic institution, complete prerequisite courses, and apply to the nursing program one or more years later. However, in a study of almost 2,500 pre-nursing students, only 44 of 252 Black students submitted a nursing application, with the majority withdrawing after freshman-level anatomy and physiology.

I have 28 years of experience as a professional nurse and 17 years in academia, yet my 3.3 high school grade point average (GPA) and 1,100 SAT score would have precluded my admission to most nursing programs. I was able to enter the field through an alternate pathway, the accelerated Master’s entry program in nursing at UC San Francisco, a program for students with bachelor’s degrees in other fields. Without this pathway and the use of holistic admissions review (HAR), I would not be a RN today.

HAR is one strategy to increase admission of Black students because it features the balanced use of academic metrics (e.g, GPA and standardized test scores), personal characteristics, and experiences in admissions selection. This is critical because academic metrics are significantly influenced by racial bias and economic privilege. According to a 2014 survey, a majority of dental (93%), medical (91%), and pharmacy (78%) programs embraced HAR in their admissions policies. However, only 47% of nursing programs used HAR. In 2021, 50% of nursing programs still relied exclusively on academic criteria for admissions. Several misconceptions sustain the admissions status quo in nursing education.

Misconception 1: “Black students are not interested in nursing.”

Reality: Thirty-two percent of nursing assistants and 23% of licensed vocational nurses are Black, far exceeding the representation in the general population (13%). Highly selective admissions criteria in colleges and universities could disqualify interested applicants before or during the admissions process. Black students, who are more likely to be educated in segregated and underfunded schools, might be overlooked in admissions screening due to lower test scores and grades. Additionally, health and liability insurance requirements can deter students who lack financial resources.

Misconception 2: “GPA and test score ranking is the most fair and efficient way to make admissions decisions.”

Reality: Academic metric-driven admissions are the fastest method, but not the most equitable. Compared to White and higher-income applicants, Black students’ perceived and actual performance is negatively affected by grading bias (elementary and higher education), disproportionate school suspension rates, arrests, and limited tutoring and test preparation access. In addition, they typically work more than their counterparts leaving less time for studying and test preparation.

Misconception 3: “Academic support services must be established before admitting Black students.”

Reality: The admission of Black students is not equivalent to admitting unqualified students. Programs that implemented HAR reported unchanged or increased GPAs, graduation, and licensure pass rates. However, Black students could benefit from university services such as summer bridge, academic advising, counseling, and financial aid programs to address non-academic stressors (because income is a predictor of nursing program success). Nursing programs can also work to promote a sense of belonging and engagement to boost performance without increasing resource demands.

Misconception 4: “Students admitted using lowered admission standards will fail licensure exams.”

Reality: The admission of qualified Black students is not equivalent to lowered admission standards. More Black students might qualify for admission if programs used HAR for the selection process. Graduation and licensure pass rates are associated with science GPA and standardized nursing tests (TEAS), but not overall GPA (most common). Additionally, there is no evidence to suggest that a student with a 3.5 GPA and a 58 test score is less likely to succeed than one with a 4.0 and 85.

Misconception 5: It is illegal to consider race in admissions.

Reality: Since the 1996 ban on Affirmative Action, academic institutions successfully defended their use of race as a mission-aligned component of admissions policies in 3 Supreme Court cases. HAR is one of few evidence-based approaches to increase student diversity in health professional education programs.

Without targeted efforts to increase Black student enrollment, highly selective admissions policies will continue to present access barriers for qualified students in nursing. The American Association of Colleges of Nursing and the Association of American Medical Colleges published guides for HAR implementation, yet, the majority of nursing programs rely solely on academic metric criteria for admissions even though qualified Black students are disadvantaged by them. The original purpose of GPA and standardized test use in U.S. higher education was to segregate White American students from immigrants and Black students. Their use in 2022 as a standard of admissions policy continues to restrict Black student access to nursing education, as evidenced by the fact that 74% of the RN workforce, health care’s largest sector, identify as White. In order to facilitate diverse workforce development that enhances health and education equity, exclusionary college admissions policies must be replaced with HAR.

To Disclose or Not to Disclose?

To Disclose or Not to Disclose?

What are some reasons you do not disclose your race or ethnicity? Have you ever felt better not responding to this information? Why or why not?  I know I have never felt like I should go back in an application and check the box as being Black or African American. There has been a certain level of gratification of going into an interview without this information being disclosed. I remember getting rejection letters and wait list letters from universities and often thought why when explanation was not given except for the high number of applicants. As a registered nurse with experience and higher than a B average in all undergraduate studies these questions often surfaced. Was I not selected due to information disclosed about my background? One starts to wonder when meeting exceeding the minimum qualifications.

There is a great feeling of being considered for employment or chosen for a nursing program by review of my accolades from my curriculum vitae without my race and ethnicity being accounted for. The question of demographic reporting was brought up in a meeting last week. The question was asked about why some students do not check this box when applying to nursing programs. Is this information necessary to disclose? Why should they disclose?

Should students have to be asked this information or encouraged to do so? My first thought was this demographic data is great reporting to nursing program accreditation. However, currently diversity in students and faculty is reviewed but, not a criteria that will impact a nursing programs ability to obtain accreditation. What made me feel uncomfortable in this conversation was that only one other faculty could answer the question for the most likely cause along with myself as to why these questions are often left unanswered. It is hard to fathom that itself racism and structural racism barriers continue to exist in higher education.

Students of color may fear a difference in treatment or not getting acceptance into the program if they chose to disclose. We have to continue working toward breaking barriers in the area of structural racism. This is an example of a potential bias that may be occurring to students from diverse backgrounds. We must continue to have faculty from diverse backgrounds available to mentor these students and who look like them in university settings.

Another question would be do we eliminate this information from the applications. Is this discriminatory in any way? Should the results be seen only from an administrative view? There are so many questions about why this information is used. We could potentially limit who see’s this data. Admissions committees should be limited on this information so that implicit bias are not occurring.

Diversity in Nursing Faculty

Diversity in Nursing Faculty

Diversity in the nursing faculty has been an ongoing topic of discussion. Over the last year, there has been a degree of discourse in the United States. Many universities created or are in the process of creating position statements for diversity, equity, and inclusion. The question is, why did we have to wait? Why not be proactive instead of being reactive?

At my alma mater, Norfolk State University, a historically Black university, I was welcomed with open arms, not just from the nursing faculty but all faculty. It resonates with the student and self-efficacy when they can see people who look like them, who have reached the goals they are attempting to achieve.

As an African-American nursing faculty member for RN, MSN, Nurse Practitioner, and DNP students, my goal is to help my students reach their goals. It is a bonus to help inspire a person of color that may not have felt the encouragement of their counterparts.

While I am here to make a difference, there still are challenges that I face as a doctorate-prepared professor, where I am not treated equitably. Researchers Christine Salvucci and Carolyn A. Lawless reported in the  2016 that minority faculty of color have unique experiences, which has an impact on interpersonal relationships and the professional components of their career compared with White colleagues. In some of the articles that were reviewed, there was a review of topics that included “Insincerity and Putting You in Your Place,” “Invalidation of Sense of Self,” and “Unequal Standards.” As some of my colleagues of color and I have discussed and experienced these topics, the aforementioned topics resonate with me. There is increasing diversity in the students that are presenting to advance their education. How can we begin to retrospectively attempt to address diversity, equity, and inclusion for the students, and we have not properly addressed for the faculty? We have to do better. More research is required, and change is necessary.