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. 2023 Apr 26;18(3):e89–e93. doi: 10.1016/j.teln.2023.04.013

Triple-jeopardy! COVID-19, high ACE scores, and the US–Mexico border: Mitigating risks with trauma-informed pedagogy

Melissa Wholeben 1,⁎, Karen Fowler 1, Jacob Martinez 1
PMCID: PMC10130321  PMID: 37360267

Abstract

With the urgent need to increase the number of diverse nurses in the healthcare system, it is more necessary than ever to explore and discuss solutions that help students succeed in the extremely stressful nursing school environment. COVID-19 has exacerbated stress for nursing students nationwide. Additionally, high ACE scores and living on the US-Mexico border put certain students in “triple-jeopardy” for failing. Trauma-informed pedagogy mitigates this danger by creating a secure and productive learning environment.

Keywords: Adverse childhood events, Nursing Education, Trauma-informed care, Trauma-informed pedagogy

Introduction

With the urgent need to increase the number of nurses in the healthcare system, sharing strategies that facilitate student success in the highly stressful nursing school environment is vitally important. Although the demands of undergraduate programs in nursing have always been considered stressful, Coronavirus disease 2019 (COVID-19) has exacerbated the stress for nursing students worldwide (Goodard et al., 2021). Additionally, some student populations may face additional challenges due to their high adverse childhood experiences (ACEs) scores and living on the United States–Mexico border (Aguilar, 2018; Eno Louden, 2022; Fowler & Wholeben, 2023; McKee-Lopez et al., 2019). According to the Center for Disease Control (2023), there is a correlation between having ACEs and having chronic health conditions, mental illnesses, and substance abuse issues as an adult. ACEs are classified into various categories such as family dysfunction; physical, sexual, and emotional abuse and neglect by parents or caregivers; peer violence; witnessing community violence, and exposure to collective violence (World Health Organization [WHO], 2020). COVID-19, ACE scores, and residence create “triple-jeopardy” for risk of failure. One important strategy to mitigate this risk is trauma-informed pedagogy. This manuscript will share examples that are being used in an undergraduate nursing program with our high-risk student population (Goodard et al, 2021; Harper & Neubauer, 2021).

Stressors created by COVID-19 such as ongoing fear, anxiety, and worry about endangering their own and their family's health, along with the sudden shift to online learning intensified the stress of being a nursing student (Kuru & Ozturk, 2022). Goddard et al. (2021) emphasized the need for nursing education to move away from traditional teaching paradigms and toward a collaborative, relational model with students, that is trauma informed.

In addition to the intensified stressors created by COVID-19 affecting nursing students globally, the additional challenges faced by certain student populations who demonstrate high ACE scores deserve consideration. These higher ACE scores have been tied to increased anxiety, burnout, depression, depression severity, stress, and decreased resilience in nursing students (Hedrick et al., 2021; Fowler & Wholeben, 2023; McKee-Lopez et al., 2019).

Living on the US–Mexico border brings yet another set of challenges. The Paso del Norte region is the largest binational border in the world and is composed of El Paso, Texas, and Ciudad Juarez, Chihuahua (U.S.-Mexico Border Health Commission, 2010). The Paso del Norte Region is divided by the Rio Grande River and is home to a combined population of ∼2.5 million people, of which hundreds of thousands cross this border daily. Although there are permanent residents on both sides of the border, it is not uncommon to find “borderlanders” or natives of the region that commute to live and work in both countries (Moya et al., 2016; Payan & Cruz, 2020).

It is critical to consider the compounding effects of past-personal trauma exposure and traumas experienced while in clinical, or potential future trauma exposures experienced by nursing students, as it can have lasting implications on burnout, attrition, and patient safety (Cieslak et al., 2014; Foli & Thompson, 2019; Walker, 2021). Trauma-informed pedagogy allows for the mitigation of traumas through the provision of anticipatory guidance and practical applications for nursing students at all risk levels (Anderson et al., 2022; Gutierrez & Gutierrez, 2019).

Purpose

The purpose of this educational innovation is to discuss the implications of a trauma-informed pedagogy with examples drawn from an undergraduate pre-licensure nursing program.

Preliminary Research and Implications

Preliminary research was conducted by Fowler and Wholeben (2023) to investigate the relationships between resilience, ACE scores, and learning outcomes in Hispanic Nursing students. Undergraduate nursing students completed the Adverse Childhood Experiences International Questionnaire (ACE-IQ) instrument. The ACE-IQ measures childhood adverse events as well as witnessed community violence. Across all ACE categories, there are a total of 13 subdomains. The subdomains cover the following components: family dysfunction; physical, sexual, and emotional abuse and neglect by parents or caregivers; peer violence; witnessing community violence, and exposure to collective violence (World Health Organization [WHO], 2020). Individuals reported experiencing 1–3 subdomains (21.74%) and 4–5 subdomains (21.74%). The majority of participants (56.52%) reported that they have experienced six or more of the subdomains before their 18th birthday.

The results of this preliminary study demonstrated that nursing students in the border community witnessed or experienced higher levels of ACEs when compared to nonborder communities. In a national survey by Clark et al. (2021), 40.68% of nursing students experienced four or more ACE events, in contrast to Giano et al. (2020), who found that 13.3% of the general population experienced four or more ACE events. Events in the recent past, such as border violence and the COVID-19 pandemic, may have strained coping abilities (Aguilar, 2018; Fowler & Wholeben, 2023; McKee-Lopez et al., 2019). A higher need for coping coupled with lowered abilities (related to high ACEs) is a detrimental combination for nursing students. These results demonstrated the urgency of implementing the trauma-informed care pedagogy for our student population (Fowler & Wholeben, 2023; George et al., 2022; McKee-Lopez et al., 2019).

Trauma-Informed Pedagogy

Trauma-informed pedagogy (and inclusive practices) are associated with positive outcomes. Trauma-informed care includes six core values: (1) Safety, (2) Trustworthiness and Transparency, (3) Peer Support, (4) Collaboration and Mutuality, (5) Empowerment, Voice & Choice, and (6) Gender, Cultural, and Historical Issues. Utilizing the trauma-informed care framework core values allows faculty to understand a student's life experiences and improve their engagement in the academic environment (Goodard et al., 2021; Harper & Neubauer, 2021). When classrooms/clinical practices incorporated inclusive, safe, and transparent teaching strategies, nursing students' self-confidence and learning outcomes improved (Metzger & Taggart, 2020). A trauma-sensitive classroom setting includes supporting staff development, fostering a safe and supportive workplace, identifying student needs, developing skills/collaboration approaches, and modifying policies/procedures (Goodard et al., 2021; Harper & Neubauer, 2021; Harris, et al, 2001; Substance Abuse and Mental Health Services Administration [SAMSHA], 2014). The sections that follow will discuss academic integration examples of the six core values of trauma-informed care to include faculty governance, and how the College of Nursing at the University of Texas at El Paso (UTEP CON) incorporated trauma-sensitive strategies into their didactic, clinical, and online courses.

Safe Environment

The building of a safe and supportive workplace includes both physical and emotional safety (Goodard et al., 2021; SAMSHA, 2014). Trauma-related triggers might be from previous experiences or from novel and unpredictable conditions. Nurse educators must provide a safe and supportive atmosphere by knowing the triggers that may develop in various scenarios and using verbal and nonverbal tactics to de-escalate crises or reduce traumatic experiences. Allowing students to practice skills in a simulated environment prior to entering a clinical setting is one example. This secure environment allows students to accomplish assignments in a nonthreatening atmosphere where they can learn from mistakes without endangering patients. Examples in the classroom could include open communication between instructors and students, as well as opportunities for discussion to assist students to understand subjects taught in class.

To promote a culture of safety, UTEP CON faculty implement color-coded “response cards” for didactic lectures. This allows students to answer questions and demonstrate their knowledge without fear of appearing unprepared or becoming worried about how their answers may affect their grades. In a clinical setting, faculty members discuss patient assignments with students throughout the day and after each patient encounter. Students also engage in simulated hospital days and skill-teaching sessions that permit instructors to evaluate each student individually. Zoom meetings are used when necessary to enable faculty and students in online courses to discuss projects, assignments, and concerns.

Trustworthiness and Transparency

Each term, nurse educators should make a contract with their students and work to create an atmosphere that promotes student success (Goddard et al., 2021). Assessing student needs, whether related to test-taking, communication with patients, skill competency, or other course objectives, is an integral part of this environment. Educators actively reevaluate student needs by frequently speaking with them directly to pinpoint specific challenges and advise them on strategies that promote their success throughout a semester, such as recommending specific support services. Support services may include quiet testing venues, additional time practicing skills, peer support and encouragement, and outside services such as counseling and tutoring when trauma-informed practices are used. As educators, it is important to keep track of students’ progress, identify any trauma-related needs, and ensure that they have access to trauma specific services.

For Trustworthiness and Transparency, the UTEP CON faculty provides students with realistic and transparent course schedules and expectations. For clinical, each student receives specific assignment instructions on how to complete care plans, skill check-off lists, skills testing processes, and strategies for successfully carrying out group projects. Expectations are made clear, and the consequences for failing to meet expectations are plainly explained. For online courses, faculty have an open-door policy for email and text messages, subject to certain time constraints, for example explicitly stating hours in which the instructor will read messages and respond. Course evaluations reflect that students appreciate the clear guidelines and expectations given during class. They also stated that they feel they are able to contact the faculty with any questions or concerns.

Peer Support

Nurse educators often grapple with challenging clinical environments in which students are exposed to emotionally heavy situations. Peer support offers nursing students the opportunity to exchange firsthand experiences related to patient care and nursing interventions (Goodard et al, 2021; SAMSHA, 2014). These shared experiences can build a greater feeling of understanding and empathy among nursing students and facilitate the formation of meaningful bonds. Nurse educators can provide opportunities, especially during postconference, for student-led debriefing that allows them to discuss with each other outcomes and feelings of that clinical shift. Not only does this debriefing time allow for students to cope with and process their emotions, but it allows time for other students (including the educator) to practice active listening and provide reflective responses and increase social awareness. Additionally, this customary practice in postconference allows an opportunity for students to develop their relationship skills by providing thoughtful opportunities to practice their communication skills, reflect on both positive and negative choices made throughout the clinical day, and foster a positive and respectful environment that supports collegiality and relationship building among student peers. Lastly, responsible decision-making skills can also be enhanced, when nurse educators develop healthy environments in which students feel open to sharing their thoughts and opinions on any clinical situation encountered, while also providing thoughtful feedback to help students understand cause and effect.

Peer support is an essential skill that facilitates the sharing of experiences. The faculty at UTEP CON encourage small study groups (groups of three or four) during lectures so that students can not only study, but also get to know one another, support one another, and develop healthy relationships. During clinical, instructors place students in groups on various units to facilitate teamwork. In addition, the students will take turns discussing their patient care in postconference debriefings. In online courses, students work in groups on projects to foster collaboration and peer support. Students’ evaluation of group work indicated that they improved their communication skills and ability to support each other in their studies.

Collaboration and Mutuality

Fostering collaboration allows for trauma-sensitive classrooms to place a greater emphasis on choice, a sense of agency, and control to empower survivors (Goodard et al., 2021). Interpersonal communication throughout the collaborative process values involvement, active listening skills, and respectful environments. Nurse educators should provide environments in which healthy interactions occur and respect toward students is demonstrated. Nursing educators must be aware of potential triggers and work to mitigate these at all costs. Nursing students struggle when they are overwhelmed, confused, and feel disrespected. Flexibility with scheduling meetings and engaging in student interactions that are respectful and empathetic, while also understanding and respectful of potential cultural differences that may influence this relationship are also important educator competencies. For example, in Hispanic cultures (norms, spiritual norms, values, etc.), there may be a greater emphasis and value on family, and how decisions can be made with families in mind (Sabogal et al, 1987). Nurse educators should identify ways in which to include a student's support system (including family) in their conversations to provide education on the impact of trauma and promote resilience.

The faculty at UTEP CON implement various strategies for the core value of Collaboration and Mutuality. For didactic courses, instructors craft realistic classroom scenarios for students to solve collaboratively. Students also practice dosage calculations in groups so they can quickly identify errors and assist one another in resolving them. For many clinical rotations, a group concept paper is completed that permits collaboration from the entire group. At the end of the group collaboration, students complete both self- and peer evaluations. For online courses, projects include outside interviews with healthcare professionals and course-specific discussion boards. As an additional measure, nursing students collaborate in various health-related interdisciplinary professional education (IPE) activities alongside students of other healthcare professions, such as medicine, pharmacy, social work, public health, physical therapy, and occupational therapy. IPE activities are set as evolving cases with a patient from a vulnerable population (e.g., immigrant, refugee, transgender patient). Students are provided the opportunity to discuss relevant border health-related issues, while also providing top-quality care at all stages of care (from admission to postdischarge from hospital and outpatient settings). The interdisciplinary setting for many nursing students allows for an expanded view of healthcare professional roles. Students receive real-time feedback on patient care strategies and interactive collaborative learning opportunities related to the social determinants of health, trauma-informed care, and a variety of cultural and patient-sensitive learning experiences to improve the care of vulnerable populations. Participants indicated during debriefings that the IPE events have been beneficial for learning the roles of other healthcare providers and how to work together for optimal patient care.

Empowerment, Voice, and Choice

Social and Emotional skills are integral components of trauma-sensitive strategies that serve as buffers of trauma while simultaneously increasing resilience (Goodard et al., 2021). Nurse educators can implement trauma-sensitive skills and strategies that will help student learners mitigate the potential effects of trauma by addressing self-awareness, self-regulation, social awareness, relationship skills, and responsible decision-making in the clinical environment. More specifically, to increase self-awareness, nurse educators can provide students with opportunities to increase self-confidence by acknowledging students’ strengths in the clinical setting in areas such as assessment, therapeutic communication, or other clinical skills that are vital to nursing functions (Clark et al., 2021). Nurse educators should also encourage students to identify different types of emotions and levels of intensity associated with the identified emotions throughout the day. This activity should be performed in clinical situations where students may feel overwhelmed or struggle to manage emotions. In such instances, nurse educators can help increase self-management, by incorporating breathing exercises and/or offering positive support to students who may be experiencing difficulties in self-regulating emotions.

Students must have the opportunity to be autonomous and make decisions throughout their educational journey. The didactic faculty of UTEP CON maintain open office hours. They discuss incidents involving errors and the potential repercussions for patients. In addition, instructors provide justifications for specific expectations. This allows students to take responsibility for their own education. During clinical, students are permitted to evaluate their simulation and group project performance, while also allowing for a period of reflection for their clinical week. Students are made aware of improvement needs. IPE-related activities also allow for interdisciplinary team-based learning on emotional self-regulation and care of vulnerable populations. For online courses, instructors empower students to succeed by providing assignment-specific feedback that builds toward subsequent assignments. Student evaluations indicate that these types of activities provide ample and rich opportunities to discuss and share beneficial and effective coping strategies that may not be taught in traditional healthcare professional curriculums but are vital to carry out quality care provision.

Cultural, Historical, and Gender Issues

Faculty can foster culturally responsive strategies by focusing on diversity, equity, and inclusion (DEI) within the academic environment. By incorporating cultural, historical, and gender issues into curriculum and practice, faculty will demonstrate their genuine concern for their students’ needs and move DEI from an idea to action (Bersted et al., 2022). One strategy involves highlighting students’ cultural backgrounds and heritage and using it as a strength in learning nursing practice concepts. In addition, the development of policies and procedures within the academic setting that are sensitive to the racial, ethnic, and cultural needs of their nursing students is a crucial component of this trauma-sensitive strategy (Bersted et al., 2022). The success of nursing students and the quality of care they provide to patients will improve if nurse educators recognize gender and cultural historical concerns in the student population and provide support for moving beyond them toward healing.

Developing a DEI environment is crucial. When students ask questions, UTEP CON faculty members listen attentively. They encourage students to employ the same method when educating and caring for patients. Additionally, faculty members encourage self-reflection regarding their own beliefs and biases. Bersted et al. (2022) reported that highly engaged leaders (faculty) are essential for success in any DEI initiative which will ultimately improve the student environment. Students are not permitted to refuse patient care based on race, gender, or medical condition during clinical rotations. During clinical, students are required to obtain patient consent before providing care. In online courses, instructors require students to introduce themselves and identify their names. Consideration is taken for assignments in relation to religious observations.

Faculty Leadership Governance

It is essential that educators are part of leadership governance in relation to forming and adopting policies and procedures. One of the primary purposes of written policies and procedures is to ensure the practice aligns with the organization's mission and vision (Brown, 2017). Support for staff development is core to ensuring a trauma-sensitive learning environment. Faculty are tasked to ensure consistency in educational programs, including trauma-informed education practices (TIEP). In order to implement strategies, faculty must be educated to do so. Didactic training alone may not consistently lead to implementing strategies in the classroom. The application of constructive pedagogy comprises various learning experiences, creating patterns of variation, thus promoting seamless learning (Voon et al., 2020). Active learning techniques such as the use of mentors, case studies, and role-playing can translate didactic material into behavioral changes implemented in a trauma-sensitive classroom.

In the study by Fowler and Wholeben (2023), the results highlight the need for current policy to align with core principles of trauma sensitivity. According to a study by Fellitti (2019), nursing students reported high frequencies of ACEs. Policies related to TIEP are essential to ensuring the sustainability of educational changes to minimize the occurrence of trauma reactivation in students. Faculty may seldom know the extent of trauma experienced by students; therefore, policies consistent with TIEP should be included in each course (Bosse et al., 2021). Outlining the expectations of TIEP in the course syllabus/or instructions will enable students to engage in self-care and will ultimately promote a safe learning environment for diverse student groups. Faculty at the UTEP CON gather evidence from the course and clinical evaluations, student reflections, end-of-program surveys, and National Council Licensure Examination pass rates to document the effectiveness of these trauma-sensitive strategies.

Conclusion

Integrating trauma-informed pedagogy is a strategy to provide a physically and emotionally safe environment conducive to learning and student achievement. Nurse educators must be mindful of the impact of trauma on nursing students and consistently integrate trauma-sensitive practices to create emotionally safe environments conducive to learning. The preliminary research by Fowler and Wholeben (2023) that set the foundation for this manuscript reported higher numbers of ACEs when compared to a national survey of nursing students and the general population. The confluence of COVID-19, high ACE scores, and living on the US–Mexico border placed these students in “triple-jeopardy” that primed them for experiencing the ill effects of trauma on their learning. Using trauma-sensitive strategies in academia enables nursing students to manage trauma-induced stressors and develop the resilience that will allow them to thrive in their future nursing careers.

Data Statement

Due to the sensitive nature of the questions asked in this study, survey respondents were assured raw data would remain confidential and would not be shared.

Funding

This work was supported by the SIGMA Foundation for Nursing & the National Association of Hispanic Nurses [NAHN] [Award Number NAID20200368]

Declaration of Competing Interest

All authors declare no conflict of interests.

Acknowledgments

We would like to thank Dr. D. Monsivais (University of Texas at El Paso College of Nursing) for her assistance regarding mentoring and content editing for the manuscript. We would also like to thank the following faculty members (University of Texas at El Paso College of Nursing) for their input on trauma sensitive strategies within their classroom: Dr. S. Copeland, Dr. S. Y. Jimenez, Mrs. Y. Elias, Dr. R. Johny, Dr. A. Tolouian, and Mrs. D. Rankin.

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