Trauma-Informed Educational Practices within the Undergraduate Nursing Classroom: A Pilot Study

Abstract

Background: Ongoing evidence of trauma in nurses, beginning in nursing school, requires educators to take a trauma-informed approach to teaching and learning to minimize re-traumatization and to ultimately achieve socially-just student outcomes. Methods: The purpose of this study was to evaluate the outcomes of trauma-informed educational practices (TIEP) on nursing students and the trauma-informed climate in the classroom using an intervention comparison group pre-posttest design. Results: Secondary traumatic stress (STS) scores declined for both groups pre- to post-test. There was a statistically significant difference in STS change scores between intervention and comparison groups (p < 0.05), but not in the direction hypothesized. Conclusion: Findings from this study indicate that other factors in the nursing classroom might have contributed significantly to a reduction in STS. In addition to outcomes, future TIEP evaluations should explore student awareness and experiences of trauma, resilience, professional preparation, and learning outcomes in the classroom setting.

1. Introduction

Given high rates of nurse turnover, poor student retention, issues of diversity, and equity and inclusion in higher education, nurse educators are becoming increasingly attuned to the importance of resilient and trauma-informed educational practices (TIEP). Higher rates of personal traumas such as adverse childhood experiences (ACEs) in nursing students coupled with exposure to nurse profession-based potentially traumatic events [1] can increase the risk for traumatic stress and burnout in students compared to the general population. These outcomes play a role in student and nurse retention, and satisfaction with their work as a helper [2,3]. A proactive, trauma-informed approach to sources of student and nurse turnover can have wide ranging implications for students, nurses, healthcare and educational organizations, and patients. Despite increasing calls to incorporate resilient and trauma-informed practices in nursing education, there is limited evidence on how best to achieve this aim [3,4]. The purpose of the evaluation was to determine the outcomes of a pilot TIEP classroom-based intervention on nursing student resilience, perceptions of a trauma-informed classroom climate, and secondary traumatic stress (STS) scores compared to teaching as usual.

Higher rates of adverse childhood experiences (ACEs), traumatic stress, compassion fatigue, and burnout scores in nurses and nursing students when compared to the general population are known, and have impacts on nursing and nursing student retention and well-being [2,3]. The COVID-19 pandemic has increased rates of traumatic stress, compassion fatigue, and burnout, and has advanced inequities in these outcomes based on race, gender, and age [5,6]. The relationship between these concepts is found in Stamm’s (2010) Diagram of Professional Quality of Life where they define professional quality of life (ProQOL) as “the quality one feels in relation to their work as a helper” [7] (p. 8). Compassion Satisfaction (CS) (positive), Compassion Fatigue, Secondary Traumatic Stress, and Burnout (negative) are aspects of ProQOL.

1.1. STS and Sources of STS

Secondary traumatic stress (STS) is a negative feeling driven by fear and work-related trauma. Some traumas at work can be direct (primary) trauma. In other cases, work-related trauma can be a combination of both primary and secondary trauma. Bride et al. [8] went further to describe STS as symptoms professionals experience that arise from the indirect exposure to traumatic events that result from the care provided to traumatized clients. The concept includes three symptom dimensions which activate a fear response within the individual, and increase the risk for developing negative symptoms associated with burnout, depression, and the development of posttraumatic stress disorder [9]. It is known that STS in nurses was high pre-pandemic and continues to be elevated compared to the general population; however, less is known about the STS that nursing students have in nursing school [10,11]. Chachula and Ahmed [12] found that nursing students experienced more traumatic events during the pandemic than before. The negative effects of STS may include fear, sleep difficulties, intrusive images, or nightmares, or avoiding reminders of the person’s traumatic experiences.

The top reasons new nurses leave a job include dissatisfaction and stress. New nursing professionals are especially vulnerable to burnout and vicarious trauma [13,14]. Antecedents, attributes, and consequences of compassion fatigue in undergraduate students include factors such as coping ability, psychological stress, witnessing negative experiences, and intention-to-leave [12]. Reported sources of STS for nurses during the COVID-19 pandemic included an individual’s personal characteristics and exposures to traumatic stressors, such as the rise in violence in healthcare settings, repeated exposure to the Coronavirus, fear of infecting family members, lack of personal protective equipment and medications, and prolonged heavy workloads [9,15]. STS is related to Vicarious Trauma (VT) as it shares many similar characteristics. Two concepts that can mitigate traumatic experiences and have been widely discussed in the literature include the individual-level concept of ‘Resilience’ and ‘Trauma-Informed Care’ [16].

1.2. Resilience and Trauma-Informed Practices

Campbell-Sills and Stein [17] define resilience as a person’s ability to thrive despite adversity or the ability to adapt to challenges in one’s life. Resiliency in nurses was high pre-pandemic. In the United States, nurse resilience decreased; while in China, it increased during the pandemic [18]. Nursing student resilience scores were measured during the pandemic by Keener et al. [19], and 38% of the students had scores below 27 on the CD-RISC 10 resilience scale, representing poor resilience. Pre-pandemic, Mathad et al. [20] found that nursing students were moderately resilient (26.31 ± 6.28). Sources of resilience for nurses and nursing students include creating a personal and professional support network, individual self-management strategies, and work-life balance factors [20,21].

Trauma-informed care (TIC) is defined as an approach to care that fosters an understanding that individuals have experienced trauma in their lives and is guided by the principles or core values of: safety, collaboration and mutuality, choice, voice, and empowerment, peer support, trustworthiness and transparency, and cultural, historical, and gender issues [22,23]. These principles help counter the impact of trauma on an individual’s life and minimize re-traumatization in social interactions [23]. The trauma-informed approach is guided by four assumptions, known as the “Four R’s”: Realization about trauma and how it can affect people and groups; Recognizing the signs of trauma; having a system which can Respond to trauma; and Resisting re-traumatization [23]. Community programs implementing TIC in schools, primary care, and with families estimate that for every $1 spent on TIC, $5 is saved in lifetime costs [23]. Recently, trauma-informed approaches have been supported to address systemic trauma such as racism in educational settings. Ramasubramanian [24] advocated for educators to use a TEAM (Trauma-informed Equity-minded Asset-based Model) approach, following “Six R’s” as strategies. These strategies were reflective of the “Four R’s” plus “Replacing egalitarianism with equity-mindedness and Reframing deficit ideology with an asset-based lens to learners” [24] (p. 2).

Organizational prevention programs are believed to help maximize helpers’ well-being and reduce the risk of developing secondary trauma partly by addressing the organizational climate. Hales et al. [21] defined Trauma-Informed Climate (TICS) as an environment that prioritizes staff and client experiences. The TICS in healthcare organizations has been measured infrequently [21]. A call for trauma-informed organizations has increased in the context of the COVID-19 pandemic. Trauma-Informed Climate (TICS) is negatively associated with burnout and positively associated with commitment to the organization.

1.3. Trauma-Informed Educational Practices

The term trauma-informed educational practice (TIEP) was coined by Carello and Butler in 2015 [25] and describes educational practices that followed TIC principles in higher education. The purported impacts of TIEP on students and nurses are multi-faceted and have included: reduction in stress, traumatic stress, and improvements in resilience and trauma-informed climate [26,27,28]. While there have been many recommendations made pre-pandemic and during the pandemic for trauma-informed practices, few intervention studies have been conducted in the higher education classroom setting. Most trauma-informed educational interventions found in the literature discuss primary and secondary school, and organizational level interventions [25]. Tested intervention recommendations in both clinical and didactic educational settings have focused on resilience, and have included strategies such as mindfulness, meditation, Cognitive Behavioral Training (CBT), and self-care education with mixed results [29,30]. At the time of this study, only two primary research articles were found that specifically discussed higher education classroom interventions to minimize or prevent re-traumatization by piloting practices of reciprocal inhibition and titration of exposure in the classroom including content warnings [31,32]. One framework article by Carello and Butler [25] and one review article by Li et al. [4] also informed the development of a TIEP manual for pilot use within the nursing classroom in this study [33]. Measurement of outcomes in the primary research studies included student attitudes toward the general use of trigger warnings in the classroom [32], and a post-course exit questionnaire on student experiences during the course including measurement of intrusive thoughts [31]. Neither study used validated survey measurement tools to measure student outcomes of trauma reduction interventions on secondary traumatic stress (STS) and symptom dimensions of intrusion, avoidance, and arousal nor symptoms associated with burnout, depression, and posttraumatic stress disorder.

1.4. The TIEP Pilot Intervention

In the fall of 2019, a team of nursing faculty and students came together to pilot trauma-informed educational practices within the undergraduate nursing classroom based on recommendations from the literature. The overall aim was to enhance teaching and learning (T&L) and student academic success by countering the impact of trauma on an individual’s learning and minimizing re-traumatization in the nursing classroom. A TIEP Manual [33] was organized by practice principles outlined by Li et al.’s [4] review of the current state of trauma-informed education, with accompanying teaching and learning (T&L) strategies for implementation in the classroom. For example, T&L strategies for Principle 1: Preparation [4] in the intervention classroom included a syllabus and online learning platform statement informing students about trauma and material covered in the classroom (see

Table 1. Trauma-Informed Educational Practice Intervention Overview.

Main Principles following Li et al. [4] Strategies	T&L Sample Strategies	Implementation Sample Overview
Preparation	Syllabus and Online Learning Platform statement	Copy and paste statement into page 1 of syllabus after course description. Read/Review statement in first class of the semester. Revisit statements periodically throughout the semester.
Ongoing Assessment	Evaluation Methods for Ongoing Assessment	Post-course faculty interviews: How implemented? Process Perspectives, what worked well/did not work well/how can it be improved?
Respond to students’ trauma disclosures	Resourcing: Resource Slide	End every class with this resource slide. Verbally review resources at the end of every class.
Titrate students’ exposure to the traumatic material	In-class resourcing/self-care PowerPoint slide deck Titration of Exposure Protocols	Before potentially traumatic material (self-identified by faculty member) is shown/discussed in class, begin with an in-class resourcing/self-care slide (from slide deck created). Before potentially traumatic material (self-identified by faculty member) is shown or discussed in class, inform students of class material to be shown or discussed. Include the following information when informing students: What will be discussed or seen Read healthy engagement statement Include length of activity (e.g., 10 min) Inform students of end-of-activity debrief protocol prior to exposure using a debriefing & critical conversation tool.
Give students control over the class material	Syllabus and Online Learning Platform statement Slides 1, 2, 3: Healthy Engagement Safe Space Ground Rules Content Notifications	Insert slides at the beginning of every class slide deck in the following order: 1–3. Verbally review slides every class.
Build Safety	Syllabus and Online Learning Platform statement Slides 1, 2, 3 Titration of Exposure Protocols ‘Thank you for participating’ slide	Co-Creating Class Ground Rules: With a partner or in small groups, develop guidelines for making the classroom a safe place to learn and to take risks. Take 10 min to discuss.
Self-Care	Syllabus and Online Learning Platform statement Resourcing: Resource Slide In-class resourcing/self-care PowerPoint slide deck	Begin and end every class with an in-class resourcing/self-care PowerPoint slide from the slide deck created. Choose from: positive affirmations, calming pictures, mindfulness/mediation, grounding, OR deep breathing exercises. Rotate as desired.

for additional strategies and implementation procedures by principle). Students were informed about their rights to remove themselves from the classroom if distressed or activated by course content. Students were reminded that they would be responsible for understanding all course material and completing all assignments on time. Campus resources and self-care practices were also provided in the statements. A detailed classroom-based implementation procedure was provided for each T&L strategy in the intervention manual, along with a faculty orientation to TIEP with preparation materials provided prior to the start of the semester.

The TIEP intervention was piloted in two nursing courses in the spring semester of 2020 with multiple sections in each course to serve as intervention or comparison groups:

Course A: Population health/conventional junior cohort/concept-based curriculum model (2 sections)

Course B: Family nursing/transfer senior cohort/subject-based curriculum model (4 sections)

The School of Nursing (SON) was undergoing a curriculum transition from subject-based to concept-based curriculum during the time of this study, and the intervention was piloted in both types of curricula. Half of the sections in each course served as a comparison group, while the other half served as the intervention group. Educators in the intervention classrooms implemented practices according to the TIEP Manual in addition to their usual practices, while the comparison groups continued teaching as usual-only. Students enrolled in both courses attended weekly class sessions over a course of 15 weeks.

2. Materials and Methods

The purpose of the evaluation was to determine the outcomes of a pilot TIEP classroom-based intervention on nursing student resilience, perceptions of a trauma-informed classroom climate, and secondary traumatic stress (STS) scores compared to teaching as usual. We hypothesized that the intervention group would have a statistically significant (p < 0.05): (1) decline in STS change scores, (2) increase in resilience change scores, and (3) increase in trauma-informed climate change scores—compared to comparison groups over 15 weeks related to the TIEP classroom-based intervention. The study occurred in a small, private School of Nursing in the U.S. in the Spring of 2020, and involved undergraduate, baccalaureate junior, and senior nursing students in two nursing courses.

2.1. Evaluation Design

A pretest-mid-posttest nonequivalent comparison group design was used to evaluate outcomes. Measures occurred over a period of two weeks at (1) the start of spring semester, (2) at mid-semester, and (3) at the end of spring semester 2020.

2.2. Recruitment

After receiving approval from the University Institutional Review Board (#2020005), all students enrolled in both courses were invited to participate in the study. Recruitment occurred through email and an investigator class presentation where the purpose of the study was described including risks and benefits of participation. The primary investigator recruited participants, and was not affiliated with the courses in which recruitment occurred nor with the students recruited.

2.3. Survey Tools

Data were collected through questionnaires pre-, mid-, and post-intervention. Questionnaires included three validated tools: (1) Bride et al. [8] Secondary Traumatic Stress Scale (STSS), (2) Campbell-Sills and Stein’s [17] CD-RISC 10 Resilience scale, and (3) Hales et al.’s [21] Trauma-Informed Climate Scale-10 (TICS-10) scale. Permissions to modify and/or use tools as-is were received from tool authors. In addition to the tools, participants were asked about demographic questions and adverse childhood experiences (ACEs) as ACEs can increase the risk for traumatic stress [34].

2.3.1. STSS

The 17-item STSS [8] is a self-report instrument that assesses the frequency of intrusion, avoidance, and arousal symptoms from working with traumatized persons. Symptoms are associated with STS, and the STSS demonstrated strong reliability during scale development (α = 0.93) [8]. Scores range from 17 (no symptoms) to 85 (highest score). Scores less than 28 indicate little or no secondary traumatic stress. Scores 28 to 37 indicate mild secondary traumatic stress. Scores 38 to 43 indicate moderate secondary traumatic stress. Scores 44 to 48 indicate high secondary traumatic stress. Scores at 49 or above indicate severe secondary traumatic stress [8]. In this study, Cronbach’s alpha for the STSS pre and post were 0.91 and 0.93, respectively. To obtain a baseline measure of classroom STS, participants were asked how frequently statements were true for them as applied to the classroom/classwork from the previous semester (a modification). At mid-test (mid-course) and post-test (end-of-course), participants were asked how frequently statements were true for them in the previous seven weeks (a modification).

2.3.2. CD-RISC-10

The CD-RISC-10 Resilience scale [17] has 10 self-reported items measuring perceived resilience. Responses range from 0 (not true at all) to 4 (true nearly all the time). A higher score indicates greater resilience [17]. CD-RISC-10 scores lower than 27 indicate poor resilience among college students in the United States [35]. The Cronbach’s α reliability score in this study pre and post were 0.83 and 0.85, respectively. The 10-item CD-RISC displays excellent psychometric properties with Cronbach’s alpha of 0.85 on previous testing [17]. The resilience questions and instructions did not change from pre, mid, to post and followed Campbell-Sills and Stein’s [17] CD-RISC 10 Resilience scale questioning.

2.3.3. TICS-10

The TICS-10 [21] has 10 self-reported items measuring one’s perception of trauma-informed climate in the areas of safety, trust, choice, collaboration, and empowerment. The response options ranged from 1 (strongly disagree) to 5 (strongly agree), with a higher score indicating better climate [21]. The 10-item TICS had excellent reliability in scale development (Cronbach’s α 0.91) [21]. Interpreting the means, scores in the 4 to 5 range are good/great, 3.75 to 4 moderate, and scores less than 3.75 in need of development (T. Hales, PhD, e-mail communication, May 2020). Each of the items’ correlations with the external factors of burnout and commitment were high [21]. In this study, Cronbach’s alpha for pre and post TICS-10 were 0.49 and 0.73, respectively (higher values denoting increased reliability on post-test). To obtain a baseline measure of classroom climate, participants were asked how frequently statements were true for them as applied to the classroom in the previous semester (a modification). At mid-test (mid-course) and post-test (end-of-course), participants were asked how frequently statements were true for them in the previous seven weeks (a modification).

2.4. Analysis

Mean scores and standard deviation (SD) at pre-, mid-, and post-measure were described for intervention and comparison groups. Pre- and post-matched surveys were analyzed for change in mean pre-post test scores. Statistical analysis was performed by a statistician using R Statistical Software (R Foundation for Statistical Computing, Vienna, Austria). Paired t-tests were used for comparison of pre- and post-test mean scores.

3. Results

3.1. Context

The School of Nursing involved in this study operates on a semester system. Spring courses began in mid-January 2020 and went on through early May 2020. In addition to the courses that were part of this pilot study, spring courses for juniors included: a pathophysiology and pharmacology course, a population health clinical practicum, and a weekly clinical reasoning seminar; and for seniors included: a didactic and clinical practice course in pediatrics and obstetrics, and a didactic and clinical course in applied population health. Unprecedently, during the implementation of the intervention, the COVID-19 pandemic occurred. This resulted in a transition of courses from in-person to an online format in March of 2020 during the implementation of the TIEP intervention. The intervention continued in an online format as the intervention strategies could be applied as intended, online (see Table 1). However, findings should be interpreted and understood within the context of the COVID-19 pandemic, the disruption in courses, and the transition of courses online for the remainder of the semester.

3.2. Participant Demographics

Completed matched pre- and post-intervention questionnaires were returned by 17% (20/116) of intervention eligible participants and 18% (19/105) of comparison group eligible participants. Most participants were 18–22 years old. Demographics were similar between intervention and comparison groups (

Table 2. Demographics.

Characteristics	Total (N = 39)	Intervention (N = 20)	Comparison (N = 19)	I-C Group Differences
Course A (Junior-level)	19	12	7	p = 0.205, two-tailed Fisher’s exact test
Course B (Senior-level)	20	8	12
Junior in college	17	10	7	p = 0.523, two-tailed Fisher’s exact test
Senior in college	22	10	12
Female	35	17	18	p = 0.231, two-tailed Fisher’s exact test
Male	4	3	1
18–22 years old	34	18	16	p = 0.865, two-tailed Fisher’s exact test
not 18–22 years old	5	2	3
White/Caucasian	22	11	11	p = 0.103, two-tailed Fisher’s exact test
Asian	6	2	4
Latino or Hispanic	5	5	0
Two or more	6	2	4
Employed Part-time	23	15	8	p = 0.13, two-tailed Fisher’s exact test
Seeking opportunities	12	4	8
Adverse Childhood Experiences (ACE-Q), mean (SD)	1.28 (1.7), N = 39	0.95 (1.23), N = 20	1.63 (2.06), N = 19	t = −1.245 (p = 0.223)

). Of the 39 respondents, 35 were female. Total mean ACEs scores using the Adverse Childhood Experiences Questionnaire (ACE-Q) [36] were 1.7 across nursing students and did not vary significantly between intervention and comparison groups at baseline. No significant demographic differences were found between intervention and comparison groups at Measure 1 (baseline).

3.3. Resilience, STS, and Climate Scores

Pre-, mid- and post-test unadjusted means on the CD-RISC 10, STSS, and TICS-10 for matched data are displayed in

Table 3. Results. Unadjusted means of outcome measures pre- and post-intervention for matched data.

Outcome Measure	Pre-TIEP	Mid-TIEP	Post-TIEP	Difference	t-Ratio	DF	p Value
	Mean	Mean	Mean
STS score
Intervention group	38.5 (19)	29.0 (5)	29.9 (19)	−8.5	−2.90	18	0.01
Comparison group	42.8 (19)	28.5 (6)	26.3 (19)	−16.5	−6.58	18	<0.0001
STS score Intervention-Control Difference:				7.9	2.06	35.1	0.047
Resilience score
Intervention group	28.9 (20)	27.2 (5)	28.1 (20)	−0.8	−0.83	19	0.42
Comparison group	30.4 (19)	28.3 (6)	28.6 (19)	−1.7	−1.60	18	0.13
Resilience score Intervention-Control Difference:				0.9	0.64	36.2	0.68
TICS score
Intervention group	3.28 (20)	3.1 (5)	3.4 (20)	0.16	1.07	19	0.30
Comparison group	3.42 (19)	3.8 (6)	3.7 (19)	0.26	2.37	18	0.03
TIC score Intervention-Control Difference:				−0.10	−0.53	34.3	0.60

Paired t-tests were used for comparison of pre- and post-test mean scores (p < 0.05).

. There was not a statistically significant difference in CD-RISC 10 resilience change scores for intervention or comparison groups from pre- to post-test. STSS scores declined for both groups pre- to post-test, and there was a statistically significant difference in STS change scores between the intervention and comparison groups (p < 0.05), but not in the direction hypothesized. Comparison group STSS change scores declined significantly more than intervention STS change scores over the 15-week period coinciding with the course. TICS-10 scores increased significantly for the comparison group pre- to post-test (p < 0.05), but there was not a statistically significant difference in TICS-10 change scores between the intervention and comparison groups over the 15-week period.

4. Discussion

In this study we sought to determine the outcomes of a pilot TIEP classroom-based intervention on nursing student resilience, perceptions of a trauma-informed classroom climate, and secondary traumatic stress (STS) scores compared to teaching as usual. Based on findings from this study, the TIEP intervention implemented did not have a significant effect on student STS, resilience, or perceptions of trauma-informed classroom climate scores over a 15-week period pre- to post-intervention compared to teaching as usual. The range of STSS scores reported at baseline and follow-up (26.3 to 42.8) indicated little or no secondary traumatic stress (<28) to moderate secondary traumatic stress (38–43) for nursing students. Kinker et al. [37] found medical students’ individual range of total STS scores varied between 17 (no symptoms) and 55 (severe symptoms). STSS scores were higher at baseline and could have been impacted by prior course or clinical work. For juniors, this included fall courses in health and wellness across the lifespan, anatomy and physiology, pathophysiology and pharmacology, and a health assessment class. Seniors took a medical-surgical course, didactic and clinical practice course, and separate pathophysiology and pharmacology courses in the fall semester.

The statistically significant increase in TICS-10 scores for the comparison group pre- to post-test (p < 0.05) should be further explored considering the finding that comparison group STS change scores declined significantly more than intervention STS change scores over the 15-week period coinciding with the course. Antidotally, the impacts of TIEP on students have been described as positive: working towards goals of safety, collaboration, empowerment, trauma awareness, and minimizing re-traumatization, and this finding supports this assertion [26,27,28]. Overall, TICS-10 scores ranged from 3.3 to 3.7 at baseline and follow-up; mean scores of less than 3.75 indicate an organizational climate in need of development (T. Hales, PhD, e-mail communication, May 2020). Further development of the trauma-informed climate in the school of nursing in which this study took place is recommended with potential impacts on the reduction in student STS scores in the classroom that should be further examined.

The pilot TIEP classroom-based intervention did not have a significant effect on student-reported resilience scores, and post-intervention across both intervention and comparison groups. Contextually, the range of CD-RISC-10 scores reported (28.1–30.4) indicated moderate resilience and are comparable to nursing student resilience scores reported elsewhere [19,38]. In an integrative review on healthcare worker resilience during the COVID-19 pandemic, data from the United States showed a decrease in nurse resilience compared with pre-pandemic levels [18]. These findings could partially explain why, despite our planned intervention, no change was observed in resilience scores pre- and post-intervention. Other characteristics or actions in the nursing classroom, such as aspects of the climate scale, might have contributed more significantly to a reduction in STS and should be further explored.

Changes in teaching as usual in the context of the pandemic likely influenced study results, such as alterations in policies on exams to accommodate online learning during the pandemic semester, a cancellation in face-to-face clinical experiences, lenient attendance policies, and flexible classroom expectations. Nursing education studies suggest that some of the major stressors for nursing students are clinical encounters and exams [39,40]. Sherwood et al. [27] reported adjustments to teaching and learning that were made in the context of going online during a pandemic that mirror Carello and Butler’s [28] recommendations to minimize activating traumatic responses (flexibility, using neutral language, a strength-based approach, consistency, provision of feedback on assignments, and the academic rigor of a course). Other factors could also explain a reduction in the frequency of symptoms associated with STS, including working from home vs. working at school [41] and differences in course content between the fall and spring semesters, as well as the increased level of support provided to students, such as health and counseling resources and flexibility with assignment due dates [42].

Despite a major disruption in educational format and teaching as usual mid-semester, student’s STS scores continued to trend downwards during this transition in both intervention and comparison groups, and this was an unexpected finding given the literature to date on the impact of the pandemic and pandemic trauma on nursing students [27]. This finding might be explained by the initial ‘heroic’ or ‘honeymoon’ where people come together during a disaster. This serves as a protective factor against stress and increases student to student and student to faculty connection [27,43,44]. Further, changes made in nursing education during the pandemic should be explored for their potential to reduce student STS and enhance learning. Though not planned, educators were able to implement TIEP strategies (Table 1) in the online environment.

Challenges in recruitment of participants resulted in lower response rates than expected and could be attributed to the COVID-19 pandemic and the transition to online learning that occupied much of faculty and student time. Different instructors for intervention and comparison groups introduce extraneous variables that could impact the outcomes of the intervention. Process evaluation measures would have been useful to characterize similarities and differences between ‘teaching as usual’ and ‘trauma-informed teaching’ in the classrooms and the impact on findings. Future studies should measure student exposure to nurse profession-based potentially traumatic events (PTEs) during the pilot because PTEs can increase the risk for traumatic stress and burnout in students [45,46]. Low reliability on pre-test of the TICS-10 should be further examined in relation to either a low number of questions and poor inter-relatedness between items and/or heterogeneous constructs on the tool. Despite these limitations, this study contributes to the sparse TIEP evaluation literature and raises questions about the impact of resilience vs. trauma-informed climate (environment) on student STS in the classroom.

5. Conclusions

In the context of a major pandemic that caused significant academic upheaval and required a major transition for students and faculty to online learning, student STSS scores declined. Why this occurred should be explored further. In addition, exploration of the climate survey factors is relevant given recent findings that say placing the responsibility for racial gaps in literacy, skills, and competencies on the system and educators rather than only on individual learners, their families, or their culture, can be an effective approach [24]. We recommend testing TIEP interventions with diverse populations, across schools of nursing, and over a longer duration of time. Further, exploring the shorter-term outcomes of a classroom-based TIEP intervention, such as student awareness of trauma and personal resilience, professional-preparation, and learning outcomes (factors that contribute to enhanced resilience and reduced STS), could yield different results. A focus on post-traumatic growth and the benefit of strong emotions to student learning should also be further examined.

There continues to be few TIEP-based intervention studies conducted in the higher education classroom despite calls for trauma-informed approaches in nursing education. Our pilot TIEP findings did not show a significant impact on STS in students pre- to post-intervention, though Black [31] practices of reciprocal inhibition and titration of exposure in the psychology classroom showed promising results for helping to prevent students from experiencing intrusive symptoms related to course material. Returning to nursing education as usual is not recommended. Trauma-informed nursing education offers one path forward in addressing nursing student distress, and should be further tested for its potential to enhance professional resilience, personal learning, and nursing student retention in higher education and practice settings.