Student Mental Health Nurses’ Perceptions of Psychological Trauma Education and Its Impact on Their Practice, a Qualitative Study

1. Introduction

Psychological trauma refers to experiences where an individual is overwhelmed by harmful events and/or perceived threat [1]. Individual responses to traumatic experiences are impacted by the type of traumatic event, whether acute or chronic, individual factors such as age and stage of development, and supports available to the person afterwards [2,3]. The impact of psychological trauma has gained significant attention, with growing evidence that psychological trauma can have long-lasting effects on people’s emotional, physical and social health [4].

There is a high correlation between a history of trauma and development of Complex PTSD (Cusack, Frueh & Brady, 2004). The World Health Organisation International Classification of Diseases (ICD-11) identifies Post Traumatic Stress Disorder (PTSD) and Complex Post Traumatic Stress Disorder (CPTSD) separately and does not confine PTSD to a single event. Instead, the two are distinct but related trauma conditions [6].

These developments in diagnosis have led to an increased need for trauma-informed approaches and interventions that acknowledge the impact of trauma on a person’s life and relationships, including recognition that feelings of shame, confusion and disconnection with past experiences prevent individuals from sharing, processing and recovering [7].

Mental health nurses are more likely to provide care to those who have experienced psychological trauma [8] and, therefore, are in an ideal position to adopt a trauma-informed approach. By providing safe and containing (trauma-informed) working relationships, mental health nurses can validate mental distress, reduce the risk of re-traumatisation and potentially support recovery [9].

Those drawn to mental health practice often have their own personal trauma histories. Indeed, Henderson et al. [10], in their literature review concluded that mental health professionals were significantly more likely to have had personal experience of trauma which, in turn, increases their risk of secondary trauma.

Nurse education programmes provide an opportunity to embed foundational knowledge and skills to support the development of trauma-informed approaches. This study explored mental health student nurse’s perspectives on TIE and offers insights into its impact on students’ practice.

2. Background

Since 2015, Scotland has taken a proactive approach to the development of a national trauma training strategy which set out to integrate the knowledge and skills healthcare staff require to effectively support people who have experience of psychological trauma when using health services. This culminated in the launch of the National Health Service (NHS) Education for Scotland (NES) Knowledge and Skills Framework “Transforming Psychological Trauma” in 2017, and associated resources [11], now part of a suite of resources entitled the National Trauma Transformation Programme (NTTP).

Trauma-informed care (TIC) recognises the effects of trauma—the resilience of people in ‘surviving the surviving’ and the systemic factors [12] that can have a knock-on effect on life chances. The approach acknowledges the responsibility of healthcare services to provide an environment that creates physical and emotional safety, and which seeks to reduce re-traumatisation. TIC links to individual, operational and strategic aspects of the care environment, processes, communication, therapeutic relationships, leadership and staff wellbeing [9].

Mental health nurse education in Scotland set out to embed the knowledge and skills outlined in the NTTP framework [11] to ensure students meet “skilled” level practice by the end of their undergraduate programme. Prior to the framework, the mental health education team here at the [author’s university] had begun to develop its trauma informed curriculum. The foundation was set around the six principles of TIC [3] held within the collaboratively developed 2016 nursing curriculum [14]. This started a paradigm shift that aimed to create a workforce who would “promote radical change in culture and practice”. Despite TIE being introduced into nurse education, little is known about its impact and value.

Since Young et al., [14] in 2019, the nurse education programme at the authors university has TIE woven throughout each year, with a significant emphasis in year two, offering a unique opportunity to explore how this focussed education impacts clinical practice. For student mental health nurses, there is an increased focus within three field specific modules in the programme, mapped to “skilled” level by the end of the third year. The main aim of this curriculum thread, in line with the previous vision, was to promote change and improve the experiences of people who use mental health services.

Study Aim:

To evaluate the impact of TIE in an undergraduate mental health nursing programme and explore how student nurses integrate the knowledge and skills related to psychological trauma into their practice.

Research Questions:

What are student mental health nurses’ perceptions of their knowledge and skills related to psychological trauma?

How do student mental health nurses use their psychological trauma informed knowledge and skills in their clinical practice?

How do student mental health nurses use their trauma informed knowledge and skills to support their own wellbeing?

What do mental health student nurses perceive are the barriers and facilitators to adopting a trauma informed approach in mental health care environments?

3. Methods

The study adopted a qualitative phenomenological methodology to explore student nurses experience and perceptions of TIE within their undergraduate programme. Phenomenology focusses on meaning from the individual perspective, illuminating the essence of the experience from their view [15,16], and the meaning they construct [17]. Hermeneutic phenomenology has become established in health-related research, potentially due to its focus on the lived experience that is consciously interpreted leading to unique understanding of the world [18] which is closely aligned to person-centred approaches to healthcare practice today [19,20].

This study used 3 online focus groups, using MS Teams, with a total of 11 participants, adopting the Recovery Conversational Café approach [21] to gather data. This recovery-informed approach aims to encapsulate principles of equal participation, potentially an issue with focus groups [22], while promoting curiosity and dialogue, ensuring that everyone’s contributions are welcomed. A semi-structured focus group guide was developed to create a strengths-based and empowering environment. The methods adopted aligned with phenomenology and provided participants the opportunity to share and explore the experiences related to TIE as peers leading to richness and depth to the discussion [23].

Research Team Characteristics

The authors were the research team and experienced qualitative researchers. Authors 1 and 2 were lecturers in the university and known to the participants, therefore were not involved in the focus group facilitation to avoid bias or coercion. Authors 3 and 4 were focus group facilitators and not employed by the university. Primary analysis was conducted by Author 1, experienced in thematic analysis. In line with [24] guidance, the analysis was reflexive, with initial coding and themes shared and discussed in depth with the research team.

Context and Sample

The study was carried out in a higher education institution in the United Kingdom that delivered a three-year undergraduate mental health nursing pre-registration programme. A purposeful sampling approach was adopted. Invitations to participate were sent to all final year students on the BSc Mental Health Nursing programme. The inclusion and exclusion criteria are detailed in Table 1. All participants had completed the psychological trauma focussed education within the programme and undertaken at least one clinical placement following the education.

3.1. Recruitment

A total of 125 students, across both the 2020 and 2021 cohorts BSc Nursing (Mental Health), were eligible to participate when in the final year of their programme. Following institutional ethical approval (Project ID 10629), study information was disseminated via announcements in their virtual learning environment and in class following module presentations and lectures.

Contact information and links to study information and the consent form were provided to those interested. Once consent was confirmed, participants were asked to join an online Recovery Conversation café.

3.2. Participants

The Cafés held between May 2023 and May 2024. Eleven students participated and one peer participant joined group one and two (see Table 2). There were two males and nine female participants, broadly in line with the wider cohort.

3.3. Ethical Considerations

Ethical considerations were based on the Declaration of Helsinki [25]. Consent was obtained from all participants prior to the conversation café via an online form and verbally confirmed at the start of each conversation café. Participant confidentiality was maintained by ensuring participants details were stored electronically within the lead researcher’s password protected laptop. Transcripts were anonymised and pseudonyms allocated.

The risk of personal disclosure—hearing about psychological trauma while in practice—was present. Facilitators received training on ‘hearing a disclosure’ from a member of the research team who is an expert in trauma-informed practice. Details of resources and support networks were shared with all participants post interview, and the facilitator and peer participant engaged in reflexive discussions the research team post interview.

3.4. Data Analysis

Data from the audio recordings from the three focus groups were transcribed verbatim and analysed using Braun & Clarke's [24] reflective thematic analysis. One researcher, experienced in thematic analysis, identified the initial themes and sub themes through close analysis of the transcriptions, attending to the individual perspectives and meaning-making. Reflexive discussions with the wider research team, using the transcripts and coding, consolidated and agreed the final themes titles and sub themes..

4. Findings

Three themes were identified: 1. A compass for practice; 2. Mental health nursing: Between Paradigms; 3. Supporting personal development and wellbeing (see Table 3).

4.1. Theme 1: A Compass for Practice

Analysis of the data identified that TIE provided both a sense of direction—a compass—as well as an anchor in the form of a set of principles through which to understand, define and practice relationship-based, individualised care. Participants placed importance on developing skills to navigate clinical practice and viewed TIE principles, interpersonal skills and relationship-based approaches as the essential tools. A compass for practice engenders a sense of direction, an approach that helps students move forward and identify aspects of mental health practice that require some navigation.

“it's harder for students when you go on a placement at your first day and you were like, ohh yeah, go do a one to one with this person, when actually you don't know anything about them.” RC2 Nicole

However, tensions are evident in the comments from Emily, indicating that people may be disingenuous and they may be viewed as being “taken advantage” of by others. Potentially showing some underlying stereotypical views of mental health service users:

“…but it can be quite difficult sort of navigating sometimes.. is this person being genuine right now, or are they sort of taken an advantage [of me] to degree, because of the type of person you are, does that makes sense?” RC1 Emily

There are also some risks in taking over simplified and generalised aspects of TIE, leading to students seeing everything through a ‘trauma lens’ at the exclusion of other perspectives:

“…it really opened my eyes to the extent of the consequences of, you know, ACEs adverse childhood experiences and the impact on mental health but also physical health. Emm, And the the actual changes in the brain and emm hormones and things like that. Actually people's brains act differently when they've been traumatised” RC3 Grant

Sub-themes included participants drive to find strategies to develop their trauma-informed skills and knowledge and to promote a relationship-based way of working with others. Lucy described a holistic approach to trauma-informed skills to avoid harm:

“I basically started asking people like, what happened to them like instead of asking what's wrong or, you know, like, just to look at the person as a whole, not just as a as a diagnosis.” RC3 Lucy

Knowledge gained through TIE supported students in finding approaches that promote positive relationships and that help avoid “causing harm”. Focus group conversations highlighted that trauma-informed principles were being embedded in practice whether a trauma history was known to be present or not. For example, the skills were being used to reduce the risk of re-traumatisation, to increase the importance of validation and create a sense of safety:

“So it [TIE] gives us something to fall back on and say I know these principles work for everybody, no matter whether they've disclosed or not. So if I stick to these, there's less chance of me causing this person harm.” RC2 Nicole

“I think I was it in [placement] when we were on the trauma-informed module, and that definitely helped me go into the placement and use that trauma like.. lens as they say. So you're ‘okay what's happened to you that’s lead you down that path’ as opposed to going “why are you using [substances]” RC2 Sophia

“… because you don't want to retraumatise people or just, you know, trying to be respectful and just, like, keep them safe” RC3 Lucy

“Do you know that people just even just asking you, you know, is this OK if I do this? Does this upset you or am I OK to come into your room?” RC3 Kim

This offered re-assurance for participants when connecting with people receiving mental health care and establishing relationships with members of the healthcare team.

“I think it is also about the staff, some of the staff have their own experience as well so its recognising when you might have to step in or check in with” RC2 Sophia

Importance was placed on the use of language, avoiding pre-judgement and recognising when others hold different views. Participants describe tensions between adopting a trauma-informed approach in practice:

“It definitely did influence me because when you go out in practise, you hear people talking about trauma and how like some patients will have significant trauma in their background. But you it's there's, it's never a weight on these words. So it's just being mentioned. But like people just like, oh, she's difficult. Yeah, yeah. She had loads of trauma in her life.” RC3 Lucy

Adopting a trauma-informed approach helped participants to identify barriers in practice and find ways to challenge these and promote positive change.

4.2. Theme 2: Mental Health Nursing: Between Paradigms

Healthcare systems, leadership, policies and procedures, and staff culture influenced whether a workplace is trauma-informed. Participants described tension between their education experience and the ‘real world’ (clinical practice). For some, this was explicit, with staff describing students as naïve by people who are considered as being “at it”:

“I do feel sometimes a bit disheartened when I I tried to implement that [TIE] into practise. It's almost met with a bit of scepticism and, you're a bit naive, you know. “They're just at it”. That’s a common one. And or “it's just behavioural.” RC3 Lucy

“you can sometimes be told “don't engage with that person, don't encourage you know they want your you want, they want you to, they want to suck you in and tell you everything and that's not helpful for them.”” RC3 Rachel

However, TIE supported students’ confidence to do things differently, even when negative views of adopting trauma-informed principles were held by senior staff:

And just things being softer and I think a lot of it would have to to be kind of maybe from the the top down as well. Do you know it's just the culture of how you're treated?” RC3 Kim

Some environments were felt to be more challenging than others when adopting trauma-informed principles, such as inpatient acute care:

“…a trauma informed environment would be anything that was a flip side of a [an acute] ward because it's like, so [], just do the opposite, you know?” RC3 Jade

“mean I think there are good intension, but I think it rarely happens on the acute ward that you get that quality time to actually ask the patient what is happening for you today.” RC3 Anna

Supervision, and a team culture of wellbeing were recognised as protective factors, however, these were more likely to be visible and present in community settings:

“I'm going on about the community so much, but it's just because this is what I saw this [trauma informed practice] being done” RC3 Jade

Participants recognised that where they encountered staff who were dismissive or unsupportive regarding adopting a trauma-informed approach, it impacted their motivation:

“you can tell.. I don't know how to explain it but, there's some people that you can have those conversations with like staff wise and others that you think there's no point” RC3 Rachel

These negative attitudes presented barriers to being trauma-informed. These experiences resulted in feeling disheartened, unsure and created self-doubt:

“I think I've given up and avoid challenging the the culture that can be present in a lot of the wards which is sad in a way” RC3 Grant

“[some staff say] “You're just feeding into their sort of attention seeking and manipulation” and I think that makes me feel quite unsure as to the best way to to approach like the way that we were advised at uni emm, is not really what happens in in practise, [[ ] it does leave me feeling a bit unsure, sometimes just. What are the staff going to say if I engage too much with this person?” RC3 Rachel

Supervision, both formal and informal, was indicated as maintaining a positive environment. Being able to talk and reflect on practice experiences supported learning and self-awareness, creating a culture that is inclusive:

“Supervision was something that can can be used to try and kind of help people, kind of like deal with that and still be able to kind of like just just so that they're not getting burned out” [ ] “Or if something difficult had happened during like one of the groups or something like that, the team were all they were all amazing at it basically. So somebody would come in and say, listen, this happened and then everybody stop and…. like a reflective group almost” RC3 Jade

Participants recognised that environments where there were higher staff ratios supported trauma-informed approaches, however, there was acknowledgement that decisions about this were out with the control of nurses:

“I think some of the things that are done in there [community] would be great if they could be done in an acute ward, but I appreciate there's probably reasons why they aren't happening. [ ] So there's a maximum of 12 patients, but there's a still the same number of staffing [[ ] I'm not sure why, you know who decides that that ratio? I'm guessing that someone high up.” RC3 Rachel

4.3. Theme 3: Supporting Personal Development and Wellbeing

TIE, with its focus on mental wellbeing and self-awareness, encouraged participants to reflect on and value their own mental health. Participants described engaging in coping strategies—self-care activities to support their wellbeing, grow their self-awareness, personal and professional development and confidence levels:

“I think that having this framework has probably saved a lot of people's.. a lot of students mental health as well. Because actually it has prompted us to think about ourselves” RC2 Nicole

“It's crucial for any sort of trauma approach like it’s crucial for any sort of self-development or sort of self-understanding. So because sometimes like due to the trauma you can be really really toxic toward yourselves. And I think like the the very big step first step like is to learn what self compassion is. So definitely the the teachings from the the modules in that has has you know, I have been learning from that.” RC3 Grant

Personal wellbeing and resilience were viewed as important with participants describing strategies that supported the emotional demands experienced. There was a combination of active processes where participants described purposefully reflecting on thoughts, emotions and reactions to experiences, while running or walking:

“…it has been quite good [walking] and not taking my phone with me or not listening to audio books, which is usually my kind of go-to, but just having the silence. So it's been quite nice. And all your kind of thoughts come in then.” RC3 Kim

While some used physical activity, others used activities to distract and focus attention on other things to stop thinking about their experiences. Although this could be considered as a form of avoiding processing difficult experiences, participants described these activities as helpful:

“So that's something [physical activity] that I do regularly. It's quite intense, but I think it stops me thinking about things because you need to think about what you're doing and it gets to the point where you're just so tired that you can't think about anything anyway, so that's quite good. I quite like that.” RC3 Jade

Focussing on achievement and what has gone well encouraged positive thinking and recognition of personal strengths, creating an emotional ballast to draw on when times get difficult, ‘giving yourself that reassurance’, being able to buoy yourself up and keep afloat:

“…taking that time to reflect and being like, right, OK, was there anything I done really, really well today, I know for a fact that that person probably felt a lot calmer after speaking to me” RC1 Emily

There was recognition that working in the field of mental health is challenging, and acute mental health in-patient care specifically was described as frightening and chaotic:

“But, it [acute care] was like hellfire in the ward and you were just consistently firefighting” RC 1 Anna

“You know, it's frightening [acute wards]. It's really frightening. I would be terrified.” RC3 Kim

Participants account of protecting their own wellbeing were set within the context of being able to engage with others in a trauma-informed way:

“Emm, And..but you can't pour from an empty cup, and it's something that's been kind-off drilled into us and I'm really glad it has because, as much as, the profession is challenging, [[ ] it's very much about taking care of yourself first.” RC2 Sophia

Adopting trauma-informed principles to both their practice and their own life, encouraged participants to engage in reflection, increasing self-awareness and helping to recognise and connect with feeling overwhelmed and taking action to address this:

“it’s actually one of the questions you ask yourself before you go to try and administer mental health first aid, is actually, ‘am I the best person that we doing this? Am I in the right space?’” RC2 Nicole

“…it [TIE] definitely makes you reflect on your own experiences and you know the trauma that you maybe have experienced, things that you might not even.. things could be particularly triggering for you” [[ ] I definitely have more self-awareness and I'm much more aware of, you know what things I I find difficult and the you know for me […]that definitely is contributed to me feeling a lot more resilient.” RC3 Rachel

The BSc Nursing programme was seen as challenging. Participants reported feeling overwhelmed by the many demands, limiting the time to look after their own wellbeing.

“Like, I feel a bit overwhelmed lately with like, either having to work all the time and then when I'm not working, I'm basically studying so it is getting a bit too much.” RC3 Lucy

TIE supported confidence by providing a set of skills that can be used in different situations with different people:

“like I say, when you've got these tools, your confidence builds. [[ ] I think you're confidence in what you're doing” RC2 Daniel

“…[TIE] helps to inspire trust and hope between you and whoever you're interacting with” RC2 Nicole

5. Discussion

The findings indicate that participants not only have good knowledge of the principles of trauma-informed practice, but they also apply the skills in practice and in looking after their own wellbeing. However, applying trauma-informed principles depends on the environment, leadership, culture and attitudes held by staff.

TIE was indicated as providing a compass for navigating mental health practice. Participants connected TIE to supporting their confidence and skills to maintain a values-based and relationship-centred approach to their practice, in line with findings from Robinson et al. [8]. TIE is embedded throughout the nursing programme, in line with recommendations by Bosse et al., (2021), however, how this is sustained and maintained beyond pre-registration education is worth considering.

Participants in this study indicated that community settings demonstrated more engagement with TIC principles and reflection. This was in stark contrast to acute inpatient settings, which were described as chaotic and not conducive to being trauma-informed. Wilson et al. [27] acknowledged that there was a lack of implementation of TIC in acute settings, citing the lack of adequate TIE and preparation of staff and the environment as key barriers. Heffernan et al., [28] report that TIE needs to be delivered in a cyclical and sustainable way and be open to all. This approach may bring opportunities to challenge stigmatising views and negative attitudes experienced.

Heffernan et al. (2024) propose that staff need to identify and make use of support networks. However, in this study, there is a sense that staff in acute care settings were “fire-fighting”, therefore, finding the time and space to engage in education and support may be challenging. Commitment from senior leadership is needed for TIP to be integrated into the current biomedical focused MH care system [28,29] if change is to be implemented and sustained.

Participants employ trauma-informed principles to reflect on, make sense of, and manage their responses to the mental health care settings they are working within. Interestingly, participants did not talk about needing to use trauma-informed skills to respond to the ‘felt trauma’ of the people using services, but that they do employ it to make sense of what is happening in terms of the practice environment and approaches they see nurses adopt. This contrasts with the literature demonstrating the impact of vicarious trauma on staff [9,30,31,32]. The focus on self and navigating practice for this group of participants, may be linked to their student status, being assessed and time limited exposure to the healthcare environment.

For those working therapeutically with people who have experienced complex trauma, there is increased risk of vicarious traumatisation when compared to other care contexts [32]. Coleman et al. [32] and Bulford et al [30] share the view that, given the increased prevalence of psychological trauma, clinical staff are required to be appropriately prepared and supported if they are to manage the emotional load of these interactions. Staff training is valuable [8], however it needs to be ongoing to maintain benefits. Our study offers some insights into mental health student nurses’ strategies for self-care and how TIE may encourage more focus on self-care therefore building resilience within the future mental health workforce.

TIE appears to have encouraged participants to reflect on the healthcare system and their role within it. The analysis highlighted subtle tensions, for example, the moves participants must frequently make back and forth between diagnostic categories and biomedical understanding of mental health and the psychological trauma-informed approach. This tension, highlighted also by Heffernan et al. [28], may speak to a tension within the healthcare system more generally. Working side by side with those who hold different perspectives can sometimes be complimentary, and sometimes not, rubbing against each other, creating friction. This shift in paradigm is discussed by Bulford et al. [30] in their literature review of primary care practitioners experience of TIC. They note that many primary care practitioners were experiencing a changing paradigm, where there is a move away from biomedical explanations of health to a more holistic one.

More broadly, there is a balance to be found so that TIE does not result in the next generation of mental health nurses proposing that people should make sense of their experience through this lens. The implications (and unintended consequences) could be that we replace one way of understanding ‘problems’ or ‘medical diagnosis’ with another, potentially imposing meaning onto others experiences in unhelpful ways [33], and limiting what is available to people in terms of how we imagine and make sense of our experiences.

Strategies supporting resilience included actively processing thoughts, emotions and ideas: walking, running, being outside and reflecting. Others adopted distraction: stopping thoughts, shifting focus, attention on something else, “switching off” and disconnecting with the emotional impact of mental health practice. The latter potentially has risk, for example, limiting the processing of emotions, however, were valuable for participants finding ways to create distance or separation between practice, study and life. Xiao et al, [34] discusses positive coping for student nurses, confronting and resolving negative emotions is more likely to bring about increased resilience than avoidance, which may lead to being more susceptible to its influence on wellbeing.

6. Conclusions

Overall, this study found that student mental health nurses feel appropriately confident in their knowledge and skills related to psychological trauma and reported applying the principles widely following comprehensive and embedded TIE. Participants also indicate that they use trauma-informed knowledge and skills to support their own wellbeing, recognising that working in mental health settings and with distress, can have an impact on their wellbeing and that their wellbeing can impact their clinical practice. There was recognition that different environments and team cultures in clinical practice affected their wellbeing. TIE was cited as positive in relation to enhancing self-awareness, improving resilience and navigating challenging clinical practice.

7. Recommendations

As TIE enabled students to identify and apply principles of trauma-informed care both personally and in their practice, it is recommended that TIE is embedded in health-care education programme more generally.

Further research is needed to establish the potential benefit of TIE in other healthcare programmes. Equally, there would be value in a longer-term study to provide evidence on the impact of TIE as students’ progress into their professional career.

8. Limitations

Of 125 student mental health nurses, 11 took part in recovery café sessions, and selection bias is important to consider. The high levels of agreement across participants there may be a chance that social desirability may have influenced some participants.

Arranging the Recovery Cafés for students when on placement proved challenging (RC 1 & 2), resulting in poor recruitment. The final café was arranged when students were in university resulting in improved recruitment.

The research team was not able to seek feedback on the thematic analysis as once available; the students has completed their programme.