Continuing Education Certificate in Trauma Skills Among Emergency Nurses: A National Sample Survey Analysis

Abstract

Background:

Trauma population health indicators are worsening in the U.S. Nurses working in trauma care settings require specialized training for patient care. Little is known about national enumeration of nurses who hold skill-based trauma certificates.

Objective:

The purpose was to estimate national 1) skill-based certificate status among nurses who primarily work with emergency or trauma patients, 2) demographic and work characteristic differences between those who report skill-based trauma certificates and those who do not, and 3) continuing education learning needs among nurses who hold skill-based trauma certificates.

Methods:

This was an applied epidemiologic analysis of the 2022 National Sample Survey of Registered Nurses.

Results:

The weighted analysis of 239,893 emergency nurses indicated 57% held skill-based trauma certificates with disparities by rural practice, racial identity, age, and marital status. Among those who held skill-based trauma certificates, the greatest need for continuing education was on topics of mental health, quality improvement, and substance use disorders. Approximately 87% of emergency nurses with trauma skill-based certificates only spoke English fluently.

Conclusions:

Population health management interventions are needed to enhance workforce equity and continuing education opportunities for trauma nurses. Professional nursing organizations, emergency nursing employers, and academic settings should offer continuing education in mental health and quality improvement. These findings also support the need for ongoing activities to enhance language accessibility for non-English speaking patients in the trauma care system.

BACKGROUND

Despite a sophisticated integrated trauma system, several leading population health indicators in the United States are worsening (U.S. Department of Health and Human Services [HHS], 2020). Fatal injuries, unintentional injury deaths, fatal traumatic brain injuries, rates of death in children and adolescents, firearm related deaths, and work-related injuries are worsening in the U.S. (HHS, 2020). Mortality rates from traumatic brain injury increased from 17.0 to 19.2 deaths per 100,000 from 2018 to 2022. Deaths from motor vehicle crashes also increased from 11.1 to 12.9 deaths per 100,000 during the past four years (HHS, 2022). Optimizing public health requires geographically accessible and well-distributed trauma system coverage (Dooley et al., 2020). Providing nursing care for patients of injury and violence requires specialized skills and competencies, regardless of hospital trauma level designation (American College of Surgeons [ACS], 2022; Xie et al., 2023). There are increasing international movements to develop specialized nurse competency in trauma care (Xie et al., 2023). The 2022 ACS Standards require all trauma centers to provide orientation to new nursing staff that will care for trauma patients and require trauma-specific continuing education. Specific examples include organization-developed orientation or skill-based certificate education Advanced Trauma Care for Nurses (ATCN), Trauma Nursing Core Course (TNCC), Pediatric Care After Resuscitation (PCAR), Trauma Care after Resuscitation (TCAR), and Transport Nurse Advanced Trauma Course (TNATC) (ACS, 2022; Jeffries et al., 2023). It is important to note that skill-based certificates are acceptable for trauma orientation according to these standards but are not required if the organization provides their own in-house orientation course. Thus, even among nurses employed in specialized trauma centers, little is known about the national enumeration of nurses who hold skill-based trauma certificates.

Specialized trauma skill-based certificates for nurses are applicable beyond the adult trauma system. Continuing education and specialized training for at-risk populations, such as pediatric trauma nursing care, is also emphasized in designated trauma systems (Roney & Acri, 2019). Although nurses in designated trauma centers must complete standardized education programs to demonstrate and maintain competency, this requirement does not extend to non-trauma centers (Roney & Acri, 2019; Violano et al., 2016). Novel emerging examples of specialized continuing education trauma nursing courses include Trauma Tactics simulation course and Pediatric Trauma Across the Care Continuum (PTACC) (Garvey et al., 2016; Society of Trauma Nurses, n.d.). When considering all nurses who work in emergency and trauma care, and not just in designated trauma centers, little is known about the characteristics of those who hold skill-based trauma certificates or the differences between those who have these certificates and those who do not.

Previously, research team members have generated national estimates of emergency nursing burnout and turnover, continuing education needs of public health nurses, and hospital-based nursing telehealth use (Castner et al., 2022; Castner et al., 2023; Norful et al., 2023). There is a gap in the existing literature on national estimates of trauma skill-based certificates among those who primarily work with emergency or trauma patients, workforce diversity analyses by skill-based certificate status, and continuing education needs among nurses who hold trauma skilled-based certificates.

OBJECTIVE

The purpose of this project was to estimate the United States national 1) skill-based certificate status among nurses who primarily work with emergency or trauma patients, 2) demographic and work characteristic differences between those who report skill-based trauma certificates and those who do not, and 3) continuing education learning needs among nurses who hold skill-based trauma certificates.

METHODS

This study was an applied epidemiology analysis of the 2022 National Sample Survey of Registered Nurses (NSSRN) (Health Services and Resource Administration, 2022). The NSSRN survey is administered periodically to assess characteristics of the nursing workforce in the U.S. The federally administered survey study details are available elsewhere with the United States Census Bureau (Health Services and Resource Administration, 2022). The dataset analyzed for this study was downloaded on March 25, 2024. As a publicly available dataset, this analysis was not considered human subject research. Thus, no institutional review board review was required.

Selection Variables and Measures

The analytic sample was selected in three filtering steps (Figure 1). First, RNs (not APRNs) currently employed in nursing were selected by filtering the dataset to participants who answered “Yes, I am licensed as an RN, but not an APRN.” Second, the dataset was narrowed to RNs (not APRNs) who were employed in nursing either “Nursing Full-Time” OR “Nursing Part-Time.” Third, nurses who primarily worked with emergency or trauma patients were selected by including participants who endorsed any one of three employment settings: working in either “Emergency”, “Hospital emergency or transport” or “Urgent, emergency care, or transport”.

Figure 1.

National Sample Survey of Registered Nurses (NSSRN) survey questions and responses used as inclusion criteria for participants in this study

The main grouping variable of interest was skill-based trauma certificates. This variable was measured as whether the participant endorsed the answer “Trauma Nursing (TNCC, ATCN, ATN, etc.)” to the survey question labelled A12 as “On December 31, 2021, which of the following skill-based certifications did you have?” Variables were analyzed for participant sex, age group, racial and ethnic identity group, marital status, veteran status, household income, highest educational attainment, and rurality of work setting.

Continuing education learning needs were identified in three main areas: 1) according to training topics where the participant reported they had not received sufficient training, 2) in disaster preparedness, and 3) in languages fluently spoken other than English. For continuing education learning needs, 12 “No” response item options were analyzed to the question labelled C32 of “Do you feel that you have received sufficient training in this area? Mark (X) Yes, No, or N/A for EACH row.” These 12 response items were grouped under the themes of care delivery, population focused care, and healthcare leadership. The four specific topics under care delivery were evidence-based, patient-centered, team-based, and value-based care. The six specific topics under the population focused care theme were population-based health care, working in an underserved community, caring for medically complex/special needs patients, social determinants of health, caring for patients with mental health conditions, and caring for patients with substance use disorders. The two specific topics grouped under the theme of healthcare leadership were quality improvement and practice management/administration.

Disaster preparedness was analyzed using participant “No” responses to the survey question labelled as B14 of “Within the past year, have you received or provided emergency preparedness training in any of the following areas specifically related to patient care or medical response to these emergencies? Mark (X) Yes or No for EACH item.” The six specific topics for this time included chemical, nuclear or radiological, infectious disease epidemic, biological, natural disaster, or other public health emergency.

Languages other than English were analyzed by participant endorsement of no additional languages, Spanish, Filipino, Chinese, Russian, Korean, Vietnamese, American Sign Language, or Other to the survey question L7 of “What languages do you speak fluently, other than English? Mark (X) ALL that apply.”

Data Analysis

Data were analyzed using Statistical Analysis System, or SAS, version 9.4. Population estimates were generated using the federal survey developed complex survey weighting that was aligned with the population representative survey sample design. Details on the sampling weights and recommended analytic design are available elsewhere, which were applied here. The weighted population estimates are reported, and group differences using the Rao-Scott Chi-Square test as appropriate for group testing with complex survey sample design.

RESULTS

Sample Selection and National Skill-based Trauma Certification Estimates

The survey sample represented 4,349,377 estimated RNs total, with 3,065,868 RNs and not APRNs employed in nursing between December 31, 2020 and December 31, 2021. From these RNs employed in nursing, 239,893 emergency nurses who worked in emergency department settings or reported primarily working with emergency or trauma patients were selected. Of these emergency nurses, an estimated 137,146 (57.17%) reported holding skill-based trauma certificates.

Demographic and Work Characteristic Differences by Skill-based Trauma Certificate Estimates

Table 1 depicts demographic and work characteristic differences between those who report skill-based trauma certificates and those who do not. There were no differences by sex, veteran status, household income, or highest educational attainment. There were demographic differences by age, reported racial identity, and marital status. A greater proportion of emergency nurses held skill-based trauma certificates who reported White racial identity or were younger in age. A lower proportion of emergency nurses who were widowed, divorced, or separated held trauma-based certificates compared to never married and married counterparts. There was also a work characteristic difference between those who hold skill-based certificates and those who do not in rural work settings, with a lower proportion of those practicing in rural settings reporting obtaining skill-based trauma certificates.

Table 1.

Demographic and Work Characteristic Differences by Skill-based Trauma Certificate

Characteristic	Total Respondents		Nurses with Trauma Certificate		Nurses without Trauma Certificate		Group Difference by Trauma Certificate Status
	N	%	N	%	N	%
Sex							NS
Male	60633.00	25.27	35680.00	14.87	24952.00	10.40
Female	179260.00	74.73	101465.00	42.30	77795.00	32.43
Age Group							10.35**†
<29	29941.00	12.48	16934.00	7.06	13007.00	5.42
30 to 34	44212.00	18.43	30043.00	12.52	14169.00	5.91
35 to 39	44730.00	18.65	26651.00	11.11	18080.00	7.54
40 to 44	35017.00	14.60	22145.00	9.23	12872.00	5.37
45 to 49	22434.00	9.35	9470.00	3.95	12963.00	5.40
50 to 54	23575.00	9.83	13490.00	5.62	10084.00	4.20
55 to 59	18417.00	7.68	10492.00	4.37	7925.00	3.30
60 to 64	12232.00	5.10	4454.00	1.86	7778.00	3.24
65 to 69	6933.00	2.89	2286.00	0.95	4647.00	1.94
70 to 74	2045.00	0.85	1180.00	0.49	864.11	0.36
>75	358.00	0.15	--	.	357.82	0.15
Racial/Ethnic Identity							6.61*‡
Hispanic	29524.00	12.31	13371.00	5.57	16153.00	6.73
White only, non-Hispanic	166551.00	69.43	103680.00	43.22	62871.00	26.21
Black only, non-Hispanic	19562.00	8.15	9715.00	4.05	9847.00	4.10
Asian only, non-Hispanic	17255.00	7.19	3842.00	1.60	13413.00	5.59
American Indian only, non-Hispanic	1147.00	0.48	1019.00	0.42	127.97	0.05
Pacific Islander or Multiple races, non-Hispanic	5854.00	2.44	5520.00	2.30	334.61	0.14
Marital Status							6.58*
Married Or in Domestic Partnership	163223.00	68.04	89696.00	37.39	73527.00	30.65
Widowed, Divorced, Separated	30355.00	12.65	15784.00	6.58	14572.00	6.07
Never Married	46314.00	19.31	31666.00	13.20	14648.00	6.11
Veteran Status							NS
Never Served in The Military	223483.00	93.16	127700.00	53.23	95784.00	39.93
Only On Active Duty for Training in The Reserves or National Guard	3959.00	1.65	1895.00	0.79	2064.00	0.86
Now On Active Duty or On Active Duty in The Past	12450.00	5.19	7551.00	3.15	4899.00	2.04
Household Income							NS
$25,000 Or less	2325.00	0.97	11.77	0.00	2313.00	0.96
$25,001 To $35,000	1698.00	0.71	307.70	0.13	1390.00	0.58
$35,001 To $50,000	1853.00	0.77	884.86	0.37	967.95	0.40
$50,001 To $75,000	27369.00	11.41	13588.00	5.66	13781.00	5.74
$75,001 To $100,000	55033.00	22.94	38415.00	16.01	16618.00	6.93
$100,001 To $150,000	84811.00	35.35	49860.00	20.78	34952.00	14.57
$150,001 To $200,000	42044.00	17.53	23644.00	9.86	18400.00	7.67
More Than $200,000	24760.00	10.32	10434.00	4.35	14325.00	5.97
Highest Educational Attainment							NS
Diploma	2356.00	0.98	1356.00	0.57	999.42	0.42
Associates, LVN-To-RN Program	56672.00	23.62	30307.00	12.63	26365.00	10.99
Bachelors	153586.00	64.02	90036.00	37.53	63550.00	26.49
Masters/Post Masters Certificate	25578.00	10.66	14890.00	6.21	10688.00	4.46
Doctorate	1701.00	0.71	556.41	0.23	1145.00	0.48
Rural Work Setting							6.72**
Yes	34289.00	15.49	24213.00	10.94	10076.00	4.55
No	187070.00	84.51	101752.00	45.97	85318.00	38.54

NS=Not significant;

^*p<.05;

^**p<.01;

^†Group difference tested among combined age groups of up to 34, 35–49, and 50+;

^‡Group difference tested between White only, non-Hispanic and all other groups combined.

Continuing Education Learning Needs

Table 2 depicts the weighted national estimates of general continuing education learning needs among emergency nurses with skill-based trauma certificates. The three most frequently endorsed training area topics were mental health (22%), quality improvement (18%), and substance use disorders (16%). Nationally, this represents the learning needs of an estimated 29,598, 24,019, and 22,348 emergency nurses.

Table 2.

Weighted National Estimates of General Continuing Education Learning Needs among Emergency Nurses with Skill-based Trauma Certificates

Training Area Topic	Theme	%	Frequency	SE
Mental Health	Population-Focused Care	21.58	29,598	3432
Quality Improvement	Healthcare Leadership	17.51	24,019	3081
Substance Use Disorders	Population-Focused Care	16.29	22,348	2554
Value-based Care	Care Delivery	14.30	19,613	2980
Medically Complex/Special Needs Patients	Population-Focused Care	13.39	18,363	2387
Social Determinants of Health	Population-Focused Care	13.37	18,343	2377
Population-based Health Care	Population-Focused Care	12.24	16,791	2790
Team-based Care	Care Delivery	11.71	16,058	2546
Practice Management and Administration	Healthcare Leadership	10.89	14,939	2082
Underserved Community	Population-Focused Care	10.60	14,543	2141
Evidence-based Practice	Care Delivery	9.45	12,957	1578
Patient-centered Care	Care Delivery	8.69	11,920	2218

Table 3 relays the learning needs specific to disaster topics, with most respondents indicating they had not received sufficient training in nuclear or radiological (63%) and biological (50%) disasters. Given that the survey was administered during the COVID-19 pandemic, the disaster training topic with the fewest participants who endorsed they had not received sufficient training was infectious disease epidemic (21%).

Table 3.

Weighted National Estimates of Disaster Preparedness Continuing Education Learning Needs among Emergency Nurses with Skill-based Trauma Certificates

Disaster Topic	%	Frequency	SE
Nuclear or Radiological	63.04	151,230	7708
Biological	50.07	120,104	7181
Other	44.87	107,644	6829
Chemical	44.80	107,468	7232
Natural	42.55	102,085	7802
Infectious Disease Epidemic	20.78	49,847	5529

Table 4 includes the weighted national estimates of languages fluently spoken besides English among emergency nurse participants who held skill-based trauma certificates. Most emergency nurses holding skill-based trauma certificates spoke no other language fluently besides English (N=119,045, 86.81%). A national estimate of 8,999 emergency nurses holding skill-based trauma certificates endorsed they were fluent in Spanish (6.56%). Due to the small estimated number of emergency nurses who hold skill-based trauma certificates and are fluent in American Sign Language and Korean, these results should be interpreted cautiously. The weighted standard errors are very close to the weighted population frequency (609 to 695 and 510 to 514), meaning these estimates reveal great uncertainty and may be near zero. Likewise, Chinese and Vietnamese could not be estimated as no emergency nurse survey participants with skill-based trauma certifications endorsed language fluency in these languages.

Table 4.

Weighted National Estimates of Languages Spoken other than English among Emergency Nurses with Skill-based Trauma Certificates

Language	%	Frequency	SE
None	86.81	119,045	6208
Spanish	6.56	8999	2648
Other	3.70	5081	1300
Russian	0.90	1235	780.84
Filipino	0.71	2191	985.48
American Sign	0.51	695	609.32
Korean	0.37	514	510.14
Chinese	-	--	--
Vietnamese	-	--	--

DISCUSSION

This analysis quantified national estimates of nurses who primarily work with emergency or trauma patients and hold a skill-based trauma certificate, tested demographic differences between those who reported holding skill-based trauma certificates and those who do not, and continuing education learning needs among nurses who hold skill-based trauma certificates. More than 5 out of every 10 RNs who work with emergency and trauma patients hold skill-based trauma-specific certificates with disparities by rural practice, age, racial identity, and marital status. Among those who held skilled-based trauma certificates, the greatest need for continuing education was on topics of mental health and quality improvement. Lastly, 87% (119,045) of emergency nurses with trauma skill-based certificates spoke no other language fluently besides English. This highlights the ongoing need for language accessibility support for non-English speaking patients in the emergency and trauma care system.

Skill Based Certificates and Certification

Our findings indicate that 57% of emergency nurses hold trauma skill-based certificates. The NSSRN data set is a nationally weighted sample representing the U.S. nursing workforce. Therefore, responses are not exclusive to nurses working only in designated trauma centers. All participants responded that they worked primarily with emergency patients. Since injury-related emergency department (ED) visits in the U.S. account for approximately 30% of all ED patient volume, trauma skills-based education is important for all emergency nurses (Centers for Disease Control and Prevention, 2021). Those working in non-trauma centers often see injured patients if the EMS system is bypassed or if injuries are severe enough to cause airway obstruction or cardiac arrest, requiring stabilization at the closest hospital before transfer.

Additionally, injuries in the elderly and pediatric populations are most often under-triaged in the pre-hospital setting and may arrive at a non-trauma center (Lupton et al., 2022; Uribe-Leitz et al., 2020). Nationally, less than 5% of all pediatric patients arrive at the hospital by EMS (Ramgopal et al., 2022), and the public may be unfamiliar with designated trauma centers in their area. Nurses who work outside of designated trauma centers likely have limited access to continuing education for trauma, reimbursement opportunities, or mentors who encourage trauma education. Smaller bedside teams and fewer resources lead us to believe that continuing education for trauma patients’ nursing care would be valuable for all nurses in non-trauma centers.

The ACS requires participating trauma centers to provide trauma nursing orientation and continuing education, including performance improvement and patient safety issues specific to the population served (ACS Committee on Trauma, 2022). However, lack of published research or expert guidance led to numerous methods to meet the standard but without a standard process by which nurses are deemed competent and qualified to care for trauma patients (Haley et al., 2017). Trauma nursing orientation and continuing education standards may vary based on regional trauma coordinating centers and governmental regulations. Holding a national skill-based certification or certificate enables one potential vehicle to establish and test national standardization of nurse trauma competencies. Additional research is warranted to evaluate the effect of trauma orientation and continuing education programs on nurse or patient outcomes.

Existing research studies evaluating trauma orientation courses demonstrated a high risk for bias in research designs focused on nurse outcomes. Awwad et al. (2021) conducted a systematic review of studies that evaluated nurses’ knowledge or skills after completing the Advanced Trauma Care for Nurses (ATCN) program. They found four single group pre/post-intervention studies that assessed knowledge or skills once after program completion, all demonstrating a positive effect on nurses’ knowledge. They recommended more rigorous research designs for future research. Ding et al. (2016) reached similar conclusions in their integrative review of trauma nursing education evaluation literature. Although findings from other research found improvements in nurses’ knowledge post-education, using single group designs or lack of equivalent comparison groups calls into question the validity of results (Canzian et al., 2016; Chowdhury et al., 2022). Considering the resources devoted to developing and implementing trauma nursing orientation programs, additional research is indicated to ascertain the impact of these programs on improving nurse and patient outcomes beyond knowledge improvement following course attendance.

Nursing Workforce Disparities in Skill Based Trauma Certificates

Our study corroborates research demonstrating nursing workforce education and training disparities among rural nurses (Jones et al., 2019). Nurses practicing in rural settings often must travel longer distances for education and training opportunities. Remoteness from care is an emerging social determinant of care concept and metric (Eckersley, 2024). For rural nurses, the remoteness of Level 1 Trauma care hubs may provide an important metric in the regional availability of education and training opportunities in specialty trauma skills. Access to virtual trauma training, consistent rural setting trauma training outreach, employer incentives, and rural trauma system training reimbursement policies and regulations are interventions that require further development and research to address the rural disparity described in our findings.

Our findings indicate a racial disparity in skill-based trauma certificate attainment. Restorative practices may include partnering with minority serving institutions in train-the-trainer programs to enhance capacity to offer skill-based certificate programs and validations as professional development (Waite et al., 2023). Representative and visible role models, additional coaching and mentoring support, support from minority-serving professional organizations, and employer compensation may also enhance workforce equity. Nursing professional development specialists are in key roles as change agents to enhance emergency nursing workforce equity in certificate attainment. For employees of hospitals engaged in the American Nurses Credentialing Center’s Magnet^® or Pathways to Excellence designation, there are structured and important opportunities to align nursing career pathway structures and employee incentives with skill-based trauma certificate achievement for emergency nurses (American Nurses Credentialing Center, n.d.).

Further research is warranted to examine if our findings in age disparities and marital status are expected findings related to career stage and progression or if these findings present additional opportunities to seek equity in professional development education for emergency nurses.

Continuing Education Learning Needs

For the largest proportion of emergency nurses, mental health, quality improvement, and substance use disorders were the training topics where there was the greatest need for ongoing professional development. Given the crisis nature of care provided by emergency nurses, additional resources, updated clinical practice guidelines, and meaningful and applied training are needed for mental health topics, including crisis response; violent and aggressive patient response; trauma informed care approaches; suboxone administration in the emergency department; and Screening, Brief Intervention, and Referral to Treatment (SBIRT) (Gormican & Hussein, 2017; Herring et al., 2024; Patel et al., 2018). Although quality improvement has long been a standard competency for the nursing discipline, the need for more training may indicate a need for more influential access to professional governance structures to enact practice innovations and improvements, align financial healthcare incentives with nurse-driven quality care and quality improvement, or indicate a need for training in more rigorous and updated methods of scale using implementation science methodologies (Glasgow et al., 2019).

Specific to disaster preparedness, nuclear, radiological, and biological emergencies were the professional development topics that emergency nurses reported needing additional training. This result is an expected finding since the subpopulation analyzed in the current research is a national sample, and the hazard vulnerability and risk for nuclear and radiologic disasters tend to cluster geographically around sites with nuclear reactors or high population density. Our findings corroborate the results of Veenema et al. (2019) on a deficit in national nurse readiness for large scale nuclear or radiologic disaster response outside of specialty designated institutions in the Radiation Injury Treatment Network (RITN) (2024). Nuclear and radiation emergency response and readiness resources can be accessed at the RITN site for organizational or individual clinical training. Similarly, the Centers for Disease Control and Prevention offers specialized resources for clinician training in all hazards, including nuclear and radiation emergencies, biological, and chemical. The third most frequently endorsed disaster-related training need for nurses focused on “other” response options. The NSSRN survey may be improved by generating response items that align with more expanded standard disaster taxonomies (Amberson et al., 2024; Dickason et al., 2023). Overall, the findings here corroborate previous research that nurses report the need for additional disaster preparedness education, training, and practice relevant to the duties and competencies they will be expected to perform in disaster contexts (McNeill et al., 2020). Given that the survey was administered during the COVID-19 pandemic, it is unsurprising that this research found that the lowest proportion of emergency nurses endorsed the need for additional infectious epidemic training.

Language Accessibility Considerations

One of the priorities of the Centers for Medicare and Medicaid is the need to improve language access, health literacy, and culturally relevant health care services (Centers for Medicare and Medicaid, 2022). Our current findings reveal that 8 to 9 out of 10 RNs with skill-based trauma certificates only speak English fluently. This finding corroborates our previous evidence among the public health nurse specialty, where less than 10% fluently spoke Spanish, Filipino, Russian, Chinese, Korean, American Sign Language, or other languages (Castner et al., 2023). Trauma resuscitation is often fast-paced, and effective communication reduces fear and anxiety among injured patients (Granstrom et al., 2019; Kaufman et al., 2017). Language barriers can lead to reduced patient safety and quality of healthcare delivery (Shamsi et al., 2020). Nursing workload and stress often increase when caring for patients with a language barrier (Gerchow et al., 2021). Non-English-speaking patients report anger, dissatisfaction, and confusion during hospitalization (Villanueva, 2023). Our findings reveal an important ongoing need to ensure language accessibility for emergency and trauma patients to optimize communication in healthcare encounters. While this analysis revealed low rates of second language proficiency among emergency nurses with trauma certificates, additional analysis on the language fluency among nurses who work within specific settings with high proportions of non-English speaking populations would further understanding of the language accessibility needs across the integrated trauma care system.

LIMITATIONS

The analysis for this study was completed using a publicly available data set. Therefore, the wording of questions and responses were developed by the sponsors of the original survey and not our research team. The main grouping variable of interest was skill-based trauma certificates. Participants were asked to answer in the affirmative if they had completed a certificate in “Trauma Nursing (TNCC, ATCN, ATN, etc.)” The wording of this question does not include all the national trauma courses or certificates available, which may have led some nurses to misinterpret the question. Also, the terms “certificates” and “certifications” in trauma nursing may have led some nurses to wonder if the question included board certifications such as Trauma Certified Registered Nurse (TCRN) or Certified Emergency Nurse (CEN). Future data surveys should be more specific about the types of nursing certifications to include in the responses. In addition, since this is a weighted sample, it is possible that study conclusions do not accurately represent the nursing workforce in every area or the language fluency of nurses who work primarily in communities with a high percentage of non-English speaking residents.

Conclusion

U.S. population health trauma and injury indicators demonstrate a need for improvement and timely intervention. Nurses working in every integrated trauma care system setting require specialized training for trauma patient care. The research reported here filled a gap in the published literature to enumerate emergency nurses with skill-based trauma certificates. Among emergency nurses who were not advanced practice nurses, the findings demonstrate 57% held skill-based trauma certificates with disparities by rural practice, racial identity, age, and marital status. Among those who held skilled-based trauma certificates, the greatest need for continuing education was on topics of mental health, quality improvement, and substance use disorders. These findings are relevant to professional nursing organizations, emergency nursing employers, and academic settings offering nursing education and training to further develop mental health and quality improvement competencies and education. Most emergency nurses with trauma skill-based certificates spoke no other language fluently besides English. These findings support the need for ongoing activities to enhance language accessibility for non-English speaking patients in the trauma care system. This analysis focused on RNs who are not APRNs; future research is warranted on advanced practice nurses specializing in trauma care and holding advanced practice trauma certifications. For example, the Society of Trauma Nurses highlights the crucial role of the Clinical Nurse Specialist as an advanced practice nurse leader in trauma care, with specific roles to lead evidence-based, multi-disciplinary systems change in trauma programs. The national enumeration of emergency nurse practitioners specializing in trauma care remains elusive. It indicates another key area of future research, particularly in the face of emergency physician workforce shortages and limited reach in some underserved geographies.

Population health management interventions are needed to enhance workforce equity and continuing education opportunities for nurses across the integrated trauma system setting continuum. Policy development for employers, professional organizations, and higher education is warranted to enhance resources and trauma skill-based certificate access and completion for nurses in rural settings and those with racial minority identities.

KEY POINTS.

1. Trauma nurses require specialized training, yet little is known about national enumeration of nurses who hold skill-based trauma certificates.

2. More than 5 out of every 10 RNs who work with emergency and trauma patients hold skill-based trauma-specific certificates, with disparities noted by rural practice and racial identity.

3. Among emergency nurses who held skill-based trauma certificates, the greatest need for continuing education included topics on mental health, quality improvement, and substance use disorders.

4. Approximately 87% of emergency nurses with trauma skill-based certificates only spoke English fluently, and additional research on language accessibility for patients across the integrated trauma care continuum is warranted.

5. Policy development for employers, professional organizations, and higher education is warranted to enhance resources and trauma skill-based certificate access and completion for nurses in rural settings and those with racial minority identities.