Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2025 Nov 1.
Published in final edited form as: Psychol Serv. 2023 Nov 13;21(4):792–796. doi: 10.1037/ser0000823

Brief Trauma-Informed Care Training to Enhance Health Care Providers’ Knowledge, Comfort, and Implementation of Trauma-Informed Care in Primary Care Clinics: A Pilot Effectiveness Study

Abigail Powers 1, Ryan A Langhinrichsen-Rohling 1, Stan C Sonu 2,3, Tamara Haynes 1,2, Emma C Lathan 1
PMCID: PMC11089069  NIHMSID: NIHMS1948789  PMID: 37956055

Abstract

Trauma informed care (TIC) training may be valuable for patient-facing health care providers within primary care in urban healthcare settings serving patients with high levels of trauma exposure. This study tested the pilot effectiveness of a clinic-wide TIC initiative to enhance providers’ knowledge, comfort in caring for trauma-exposed patients, and implementation of TIC within a primary care clinic of an urban safety net hospital using a single-arm longitudinal within-subjects design. Measures were obtained at baseline (T1), post-training (T2), 1-month (T3), and 6-months (T4). Twenty-nine providers who completed TIC training were included in study analyses. Twenty-one completed T2 and 14 completed T3 and T4. Knowledge was measured with the Providers’ Knowledge Regarding Injury-Related Posttraumatic Stress, comfort with a researcher-generated 2-item measure, and TIC implementation with an eight-item binary scale from the Trauma Provider Survey. Repeated-measures general linear model examining within subjects change over time in knowledge was significant (n=8; F3 = 4.74, p = .01, ŋ2p = .40); the model measuring change in comfort was not significant but trending (n=9; F3 = 4.56, p = .06). The model examining change in TIC implementation from T1 to T4 was not significant (n=14; F3 = 4.32, p = .21). This pilot study demonstrated the preliminary effectiveness of a brief TIC training on improving health care provider knowledge and comfort working with trauma exposed patients that sustained through 6-months post-training. The findings indicate that additional support is needed to change behaviors in provider implementation of TIC in primary care clinic settings.

Keywords: trauma, posttraumatic stress disorder (PTSD), trauma informed care, training

Low-income, ethnoracial minoritized populations are disproportionately affected by trauma exposure and its adverse health effects (Asnaani & Hall-Clark, 2017; Margevich, 2016; Merrick et al., 2018), with more than 90% endorsing trauma exposure and up to 50% experiencing posttraumatic stress disorder (PTSD) in their lifetime (Gillespie et al., 2009; Gluck et al., 2021). Importantly, systemic racism is a major driver of these health inequities (Harnett & Ressler, 2021) and experiences of race-related stress interact with trauma to heighten risk for the development of PTSD (Mekawi et al., 2021). Yet trauma and PTSD often go unrecognized and untreated in medical settings where minoritized individuals present with co-occurring medical problems, such as primary care (Magruder & Yeager, 2008). There is a strong need for trauma-informed care to both understand and address the unique needs of patients in urban publicly funded “safety net” healthcare settings.

Trauma-informed care (TIC) is an organizational framework that includes four key competencies: Realize the widespread impact of trauma; Recognize its signs and symptoms; Respond by integrating trauma-related knowledge into policies, procedures, and implementation of practices to Resist Retraumatization (SAMHSA, 2014). Despite broad enthusiasm for TIC, many health care providers do not receive specialized training in the provision of TIC as part of their medical training or onboarding (Piper et al., 2021; Roberts, Chandler, & Kalmakis, 2019). Health care providers’ exposure to brief TIC training programs can effectively enhance comfort in caring for trauma-exposed patients, knowledge about trauma and its effects on health, use of TIC, and overall quality of care (e.g., Cannon et al., 2020; Goldstein et al., 2018)). Yet short follow-up periods constitute a major limitation of the extant literature on TIC trainings for health care providers and it remains unclear what longer-term benefits exist from TIC training on knowledge, comfort, and TIC implementation (Purtle, 2018).

We conducted a pilot effectiveness study of a clinic-wide TIC initiative to enhance health care providers’ knowledge of TIC, comfort in caring for trauma-exposed patients, and implementation of TIC within a primary care clinic of an urban safety net hospital using a single-arm longitudinal within-subjects design. We predicted that providers would report greater knowledge of trauma and PTSD, greater self-reported comfort working with trauma-exposed patients, and increased TIC implementation within a 6-month period following TIC training.

Method

The study sample consisted of patient-facing health care providers (medical residents, physicians, nurses, and certified medical assistants) within a primary care clinic at a large, urban public hospital. The primary care clinic in the hospital includes 4 pods serving approximately 45,000 patients per year with 28 regular patient-facing nursing staff and 19 certified medical assistants. The healthcare system at which the study was conducted is a teaching hospital affiliated with several universities in Atlanta, GA; many providers are rotating students or professionals affiliated with more than one university with appointments across departments. For this study, we used a broad definition of health care provider to include members of the health care team beyond doctors; nurses and medical assistants engage with patients and give mental health screening measures (e.g., depression) and thus training in TIC is highly relevant.

Participants were recruited for the study via advertisements posted in the primary care provider newsletter and other sources of provider communication. Upon clicking the survey link in the recruitment advertisement email, health care providers were brought to a REDCap page explaining the study purpose. Inclusion criteria included ability to read, speak, and understand English, and willingness to participate in a research study and provide informed consent. Enrolled participants provided electronic informed consent prior to completing the baseline assessment. Between May and August 2022, sixty-seven health care providers completed the baseline survey (T1); of these, 29 health care providers completed the TIC training and were included in study analyses; 21 completed the post-assessment (T2) and 14 completed the one-month (T3) and six-month (T4) follow-up surveys; see Table 1 for demographic details of participants.

Table 1.

Sample Characteristics

Variable % (n) or M(SD )
Age M = 34.5 years (SD = 8.51 years)
 Missing 17.2% (n = 5)
Race
 White/Caucasian 48.3% (n = 14)
 Black/African American 17.2% (n = 5)
 Asian/Asian American 34.5% (n = 10)
Ethnicity
 Not Hispanic or Latinx 89.7% (n = 26)
 Hispanic or Latinx 6.9% (n = 2)
 Missing 3.4% (n = 1)
Gender
 Woman 62.1% (n = 18)
 Man 34.5% (n = 10)
 Non-binary 3.4% (n = 1)
Occupation
 Physician 58.6% (n = 17)
 Resident/Intern 27.6% (n = 8)
 Medical Assistant 10.3% (n = 3)
 Nurse 3.4% (n = 1)
Years in Current Position M = 4.39 years (SD = 4.39 years)
 Missing 3.4% (n = 1)
Years in Healthcare M = 6.59 years (SD = 5.91 years)
 Missing 6.9% (n = 2)
Education
 Doctorate 86.2% (n = 25)
 Masters 3.4% (n = 1)
 Associates 6.9% (n = 2)
 High School Diploma/GED 1.4% (n = 1)
Have you ever received training on providing TIC? Number of hours
 No 51.7% (n = 15)
 Yes 48.3% (n = 14) M = 6.23 (SD = 6.29)
N=29
Open in a new tab

All assessments were conducted using RedCap. Each survey was estimated to take 15 to 20 minutes. Participants were also sent a REDCap link via email for follow-up data collection purposes. Survey completion windows were closed fourteen days after post-training survey links were sent via email. At the end of surveys, participants were debriefed, thanked for their participation, and offered a list of community mental health resources. Participants could choose not to initiative the survey in its entirety or could opt out of answering any particular question. Participants were compensated $25 for T1 survey completion, $30 for T2 survey completion, $30 for T3 survey completion, and $30 for T4 survey completion, with a potential total of $115 compensation throughout the course of the study. Payment occurred immediately after survey completion. Data collection and study procedures were approved by the Emory Institutional Review Board and the Grady Research Oversight Committee in accordance with the latest version of the Declaration of Helsinki.

The TIC trainings occurred after baseline data collection and were open to any provider (regardless of participation in the study) and led by a doctoral-level psychologist during the medical faculty division meeting, scheduled resident didactics, and medical staff lunch and learn events and lasted approximately one hour. Trainings were conducted as part of a clinic-wide initiative and were approved by departmental and clinic leadership. Training material was based on SAMHSA’s (2014) 4R conceptualization of TIC and modeled research-driven TIC initiatives’ content (e.g., Center for Health Care Strategies’ Advancing Trauma-Informed Care initiative) (Center for Health Care Strategies, 2023). This included content on the importance of trauma-informed healthcare, how to screen patients for trauma symptoms in a trauma-informed manner from initial patient contact to potential trauma-specific referral, and other ways to implement trauma-informed principles into routine medical practice. A live demonstration of how to administer the Primary Care PTSD Screen for DSM-5 was conducted. The leader facilitated an interactive discussion on practical ways to ensure the screen is conducted sensitively. TIC trainings also outlined ways in which providers can respond to positive screens to intentionally resist re-traumatization. The TIC training was tailored to the needs of each training group, as determined by focus group discussions with a subset of primary care providers (n=12), average training level, and discipline (Li et al., 2019). Broadly, in the focus groups, certified medical assistants requested a greater focus on administering the screener in a trauma-informed way, while physicians desired to learn trauma-sensitive strategies to address trauma symptoms while minimizing emotional distress and increase awareness of community referral options.

Measures

Provider knowledge was measured using an 11-item modified version of the Providers’ Knowledge Regarding Injury-Related Posttraumatic Stress (Li et al., 2019). Example items include “Some early traumatic stress reactions in patients can be part of a healthy emotional recovery process” and “Almost everyone who experiences a traumatic event has at least one traumatic stress reaction in the immediate aftermath of the event”. Items span 3 subcategories: prevalence, risk factors, and course (5 items), signs and symptoms (4 items), and effectiveness of screening and intervention (2 items). Each item was answered on a 1 (Strongly Disagree) to 4 (Strongly Agree) Likert scale, and items were summed to generate total scale scores (possible range 11–44).

Provider comfort was measured using a researcher-generated 2-item measure of comfort providing care to trauma-exposed individuals including the items: “How comfortable are you providing care to a patient with a known trauma history” and “How competent do you feel in providing care to a patient with a known trauma history”. Responses were measured using a Likert scale from 0 (Not at all) to 5 (Extremely). Items were summed to create a total score (possible range 0–10).

TIC implementation was measured with an eight-item binary scale of Kassam-Adams et al.’s 38-item Trauma Provider Survey originally developed for pediatric trauma nurses (Bruce et al., 2018) that includes if they ask a patient or family members questions to assess their symptoms of distress, teach a patient or family members ways to manage pain or anxiety during a procedure or cope with upsetting experiences, or provide information to family about emotional/behavioral reactions that may indicate the need for assistance, and if they screen for trauma in their practice. These items were summed to create a total score (possible range 0–8).

Data Analysis

Descriptive information on the study sample was obtained. Then, repeated measures generalized linear models (GLM) were used to examine changes in knowledge and comfort from T1 to T4. Finally, repeated measures GLM was used to examine change in TIC implementation from T1 to T4. Listwise deletion was used to handle missing data.

Results

Repeated measures GLM examining within subjects change over time in PTSD knowledge was significant (n=8; F3 = 4.74, p = .01, ŋ2p = .40; see Figure 1); there was an increase in knowledge from T1 (mean = 21.38, SD = 2.92) to T2 (mean = 24.63, SD = 3.89) that was sustained in T3 (mean = 24.00, SD = 3.12) and T4 (mean = 23.00, SD = 3.85). The repeated measures GLM with comfort was not significant but trending (n=9; F3 = 4.56, p = .06); mean levels showed an increase from T1 (mean = 3.89 SD = 0.78) to T2 (mean = 4.78, SD = 1.09) that was sustained in T3 (mean = 4.22, SD = 0.83) and T4 (mean = 4.67, SD = 0.71). Finally, a repeated measures GLM examining change in TIC implementation from T1 to T4 was not significant (n=14; F3 = 4.32, p = .21), although mean levels did increase from T1 (mean = 4.07, SD = 2.53) to T4 (mean = 4.86, SD = 1.51).

Figure 1.

Figure 1.

Open in a new tab

Significant increase in PTSD knowledge following TIC training across post-assessment, one-month follow-up, and six-month follow-up periods.

Discussion

This pilot study was conducted to evaluate the effects of a brief TIC training on health care provider PTSD knowledge, comfort working with trauma exposed patients, and TIC implementation in a sample of patient-facing providers in an urban safety net primary care clinic serving predominantly low socioeconomic status and minoritized individuals (Kassam-Adams et al., 2015). In support of our hypothesis, we found that a brief TIC training for providers offered as part of regular didactic scheduling was effective at increasing knowledge of PTSD and its effects, a necessary and important step toward behavioral change in engaging with trauma-exposed patients in medical settings (addressing the first two Rs of TIC: Realize and Recognize). Additionally, although change in comfort working with trauma-exposed patients did not reach statistical significance, we observed a trend toward increased comfort following TIC training as hypothesized. Both increases in knowledge and comfort are essential among providers to increase the likelihood of effective and trauma-informed implementation of universal PTSD screening, a critical secondary intervention strategy that can be included in standard primary care medical visits along with other screenings (e.g., depression, intimate partner violence social determinants of health).

Within this small sample, we did not see significant change in TIC implementation, although mean levels trended up from pre-training to 6-month follow-up. It is likely that interconnected layers of support are needed for TIC implementation to be effective. At the individual patient level, motivation and buy in by the provider are needed and this requires provider knowledge and comfort (Huo et al., 2023; Reuter et al., 2022). While a brief training like the one administered in this pilot study was particularly useful at increasing knowledge, offering hands-on trainings such as simulated patient encounters and/or longitudinal coaching to increase providers’ comfort with use of TIC may help in supporting consistent implementation of TIC. At the system level, this requires administration buy-in and willingness to allocate resources to ensure provider wellbeing (e.g., addressing burnout or compassion fatigue), offer ongoing TIC training and consultation, and monitor routine screening procedures to address issues (Huo et al., 2023). One example of how clinic-level consultation was formed within this study’s clinic was the formation of an interdisciplinary workgroup, “Addressing Challenging Patient Behaviors in the PCC”; through this quarterly group, providers bring difficult situations to the group and ask for guidance from the team of faculty experts in the areas of trauma, psychology, psychiatry, and ethics on how best to serve the patient and the provider involved. Clinic leadership help lead and support these workgroup sessions and it often leads to actionable change in clinic-wide systems and procedures. Future implementation research should test training elements and number of training sessions to better understand key factors to include in clinic-wide TIC training.

Limitations and Future Directions

Our study was limited by sample size and attrition; follow-up studies are necessary with larger cohorts and with no-training comparison groups to fully understand the benefits of brief TIC training in university settings serving multiply marginalized individuals with high levels of trauma exposure and resulting adverse health consequences. Although inclusion of health care providers with varied levels of training was a strength of this study, further understanding the unique training needs of each provider type would be valuable in future, larger studies. Potential sampling bias represents another limitation. Given the nature of the safety net hospital at which this study was conducted, we were unable to determine how representative this sample is of the population of health care providers. Additionally, the training tested was brief (1-hour) and not all providers could attend the in-person or virtual sessions on the given week provided; incorporating training in medical student and resident didactic schedules and through online modules for providers would likely promote sustainability of training initiatives and the ability to expand beyond a single training and reach more providers. Finally, use of PTSD screening measure was not examined as an outcome; there is an initiative to implement universal PTSD screening in the clinic at present and that has not yet been implemented.

Given the enormous toll of trauma-related sequelae in urban minoritized communities (Gillespie et al., 2009; Gluck et al., 2021) and the high percentage of trauma-related symptoms left unrecognized and untreated in medical settings (Magruder et al., 2008), the need for culturally responsive and trauma informed hospital-based approaches to address the unique needs of trauma exposed patients in urban safety net healthcare settings is clear. This pilot study showed that brief TIC training of health care providers increases knowledge of trauma and PTSD and that knowledge is sustained through 6-months post-training. Yet, more work needs to be done. TIC initiatives in safety net hospital or clinic settings must be culturally responsive and directly address the needs of multiply marginalized groups, and this should be studied explicitly. Support for TIC is growing nationally and continued efforts to engage in system-wide TIC training and understand their reach is necessary as we work toward improving patient health outcomes for trauma exposed patients and reducing system-wide burdens.

Impact Statement.

Brief trauma informed care training was helpful in increasing health care provider knowledge of trauma and posttraumatic stress disorder and effects were sustained through 6-months post-training, highlighting the value of incorporating universal trauma informed care training in medical settings serving patients with high rates of trauma exposure.

Funding:

This work was supported by the Emory Medical Care Foundation and the National Center for Complementary and Integrative Health (K23AT009713).

Footnotes

Disclosures: The authors have no conflicts of interest to disclose.

References

  1. Asnaani A, & Hall-Clark B (2017). Recent developments in understanding ethnocultural and race differences in trauma exposure and PTSD. Current Opinion in Psychology, 14, 96–101. 10.1016/j.copsyc.2016.12.005 [DOI] [PubMed] [Google Scholar]
  2. Bruce MM, Kassam-Adams N, Rogers M, Anderson KM, Sluys KP, & Richmond TS (2018). Trauma providers’ knowledge, views and practice of trauma-informed care. Journal of Trauma Nursing: the Official Journal of the Society of Trauma Nurses, 25(2), 131. 10.1097/JTN.0000000000000356 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Cannon LM, Coolidge EM, LeGierse J, Moskowitz Y, Buckley C, Chapin E, … & Kuzma, E. K. (2020). Trauma-informed education: creating and pilot testing a nursing curriculum on trauma-informed care. Nurse Education Today, 85, 104256. 10.1016/j.nedt.2019.104256. [DOI] [PubMed] [Google Scholar]
  4. Center for Health Care Strategies [Internet]. Advancing Trauma-Informed Care; [about 4 screens]. c2015–2019 [cited 2023 Mar 5]. Available from: https://www.chcs.org/project/advancing-trauma-informed-care/
  5. Gillespie CF, Bradley B, Mercer K, Smith AK, Conneely K, Gapen M, … & Ressler KJ. (2009). Trauma exposure and stress-related disorders in inner city primary care patients. General Hospital Psychiatry, 31(6), 505–514. 10.1016/j.genhosppsych.2009.05.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Goldstein E, Murray-García J, Sciolla AF, & Topitzes J (2018). Medical students’ perspectives on trauma-informed care training. The Permanente Journal, 22. 10.7812/TPP/17-126 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Gluck RL, Hartzell GE, Dixon HD, Michopoulos V, Powers A, Stevens JS, … & Gillespie CF. (2021). Trauma exposure and stress-related disorders in a large, urban, predominantly African-American, female sample. Archives of Women’s Mental Health, 24, 893–901.2021;24:893–901 10.1007/s00737-021-01141-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Harnett NG, & Ressler KJ (2021). Structural racism as a proximal cause for race-related differences in psychiatric disorders. American Journal of Psychiatry, 178(7), 579–581. 10.1176/appi.ajp.2021.21050486 [DOI] [PubMed] [Google Scholar]
  9. Huo Y, Couzner L, Windsor T, Laver K, Dissanayaka NN, & Cations M (2023). Barriers and enablers for the implementation of trauma-informed care in healthcare settings: a systematic review. Implementation Science Communications, 4(1), 1–20. 10.1186/s43058-023-00428-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Kassam-Adams N, Rzucidlo S, Campbell M, Good G, Bonifacio E, Slouf K, … & Grather D. (2015). Nurses’ views and current practice of trauma-informed pediatric nursing care. Journal of Pediatric Nursing, 30(3), 478–484. 10.1016/j.pedn.2014.11.008 [DOI] [PubMed] [Google Scholar]
  11. Li Y, Cannon LM, Coolidge EM, et al. (2019). Current state of trauma-informed education in the health sciences: Lessons for Nursing. Journal of Nursing Education, 58(2), 93–101. 10.3928/01484834-20190122-06 [DOI] [PubMed] [Google Scholar]
  12. Magruder KM, & Yeager DE (2008). Patient factors relating to detection of posttraumatic stress disorder in Department of Veterans Affairs primary care settings. Journal of Rehabilitation Research & Development, 45(3). 10.1682/jrrd.2007.06.0091 [DOI] [PubMed] [Google Scholar]
  13. Margevich AK (2o16). A critical review of the psychological literature. Trauma, Schools, and Poverty Project, Rutgers Center for Law, Inequality, and Metropolitan Equity (CLiME) [Internet]. cited 2023 Mar 5. Available from: https://www.clime.rutgers.edu/blog/tsp-report-release-a-critical-review-of-the-psychological-literature [Google Scholar]
  14. Mekawi Y, Carter S, Brown B, Martinez de Andino A, Fani N, Michopoulos V, & Powers A (2021). Interpersonal trauma and posttraumatic stress disorder among black women: does racial discrimination matter?. Journal of Trauma & Dissociation, 22(2), 154–169. 10.1080/15299732.2020.1869098 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Merrick MT, Ford DC, Ports KA, & Guinn AS (2018). Prevalence of adverse childhood experiences from the 2011–2014 behavioral risk factor surveillance system in 23 states. JAMA Pediatrics, 172(11), 1038–1044. 10.1001/jamapediatrics.2018.2537 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Piper KN, Schiff J, Riddick C, Getachew B, Farber EW, Kalokhe A, & Sales JM (2021). Barriers and facilitators to implementation of trauma support services at a large HIV treatment center in the Southern United States. AIDS care, 33(3), 316–325. 10.1080/09540121.2020.1764473 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Purtle J (2020). Systematic review of evaluations of trauma-informed organizational interventions that include staff trainings. Trauma, Violence, & Abuse, 21(4), 725–740. 10.1177/1524838018791304 [DOI] [PubMed] [Google Scholar]
  18. Reuter K, Genao K, Callanan EM, Cannone DE, Giardina EG, Rollman BL, … & Moise N. (2022). Increasing Uptake of Depression Screening and Treatment Guidelines in Cardiac Patients: A Behavioral and Implementation Science Approach to Developing a Theory-Informed, Multilevel Implementation Strategy. Circulation: Cardiovascular Quality and Outcomes, 15(11), e009338. 10.1161/CIRCOUTCOMES.122.009338 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Roberts SJ, Chandler GE, & Kalmakis K (2019). A model for trauma-informed primary care. Journal of the American Association of Nurse Practitioners, 31(2), 139–144. 10.1097/JXX.0000000000000116 [DOI] [PubMed] [Google Scholar]
  20. Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). Trauma-Informed Care in Behavioral Health Services: Treatment Improvement Protocol (TIP) Series 57. Rockville (MD): HHS Publication No. (SMA) 13–4801; pp 343. [PubMed] [Google Scholar]

RESOURCES