Nurses’ competencies, barriers, and experience in trauma-informed care: a cross-sectional study

Abstract

Background

Chronic pain is a significant public health issue in Saudi Arabia, and its prevalence is consistent with global trends. Trauma-informed care (TIC) is an approach that is used to reduce the likelihood of traumatization and to encourage individuals to better engage with therapy. Currently, empirical data concerning the TIC competencies of nurses in the management of chronic pain in Saudi Arabia are lacking.

Objectives

This study aimed to: (1) assess nurses’ knowledge, opinions, competencies, barriers, and practices related to TIC across work settings, and (2) examine how these factors are associated with overall TIC competence in chronic pain management.

Methods

We conducted a cross-sectional study using an online survey distributed to nurses working in hospitals in the Jazan region. A total of 272 nurses were recruited using convenience sampling. We collected data using the TIC Provider Survey to evaluate nurses’ competencies, barriers, and experiences in TIC over five months. Multiple regression analysis was used to evaluate whether years of nursing practice experience were associated with nurses’ knowledge, attitudes, competencies, and practices related to TIC in chronic pain management.

Results

Significant differences were observed across work settings in knowledge, opinions, and competencies (all p < 0.001), but not in perceived barriers (p = 0.61). Nurses in mental health and operating room settings demonstrated higher competence than those in other units, whereas pediatric nurses reported the lowest scores. Regression analysis indicated that greater knowledge (β = 0.32, p < 0.001), more positive opinions (β = 0.28, p < 0.001), and fewer perceived barriers (β = 0.19, p < 0.001) were significant predictors of TIC competence, explaining 52% of the variance.

Conclusions

This study presents new evidence regarding the variability of TIC competencies among nurses in different work settings. The results highlight the significance of knowledge, opinions, and practices in determining TIC competence. Targeted training, incorporation of TIC into nursing curricula, and institutional support are crucial for advancing trauma-informed practices in chronic pain management and for improving patient-centered care outcomes.

Background

Chronic pain is a significant and highly prevalent public health issue in Saudi Arabia, with a prevalence consistent with global trends. A national survey conducted across five regions in Saudi Arabia revealed that 46.4% of Saudi adults experience chronic pain, with back pain being the most frequently reported condition [2]. Chronic pain is also a disabling and complex condition that requires treatment approaches that address biological, psychological, and social causes. In 2020, the International Association for the Study of Pain revised its definition of pain to emphasize it as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” thereby emphasizing the multidimensional nature of pain and the need for more person-centered techniques in therapeutic practice [23].

Various studies have demonstrated an association between trauma exposure and chronic pain [11]. For example, lifetime trauma, including adverse childhood experiences (ACEs), has been linked to increased pain-related disability in adulthood [11]. Furthermore, individuals with a history of psychological or physical trauma are more likely to develop persistent pain and demonstrate impaired coping abilities [11]. In Saudi Arabia, trauma is common, and it has been shown to influence pain trajectories [5, 6]. In the Eastern province, lifetime exposure to ACEs increases the likelihood of developing mental and physical health disorders [4]. In Saudi Arabia, chronic pain management is focused on pharmacotherapy and referral to rehabilitation centers [2], and approaches that address trauma-related factors are seldom integrated into patient care.

Trauma-informed care (TIC) has emerged as an approach that aims to reduce the risk of re-traumatization and promote recovery [14]. TIC is particularly relevant to chronic pain management, as trauma can alter pain perception, increase sensitivity to stress, and negatively affect coping and treatment engagement [19, 29, 30]. The Substance Abuse and Mental Health Services Administration (SAMHSA) outlines six fundamental TIC principles: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and cultural, historical, and gender considerations [25]. TIC has been widely applied across different healthcare settings [14]. For instance, the use of TIC supports recovery from severe illnesses by improving communication and patient satisfaction in emergency rooms and intensive care units (ICUs) [26]. It has also been used in obstetric (OB) [27] and pediatric care settings to alleviate distress and improve the quality of relationships [28]. Thus, TIC should be applied uniformly across the health care system, not only to trauma-specific services [17].

Nurses play a crucial role in implementing TIC across different work settings by overseeing patient education, triage, care coordination, and continuous therapeutic communication [12]. However, there are organizational and workforce challenges associated with implementing TIC in health care settings. Systematic reviews have highlighted constraints such as limited training and protected time, inadequate leadership support, resource shortages, and misalignment with current policies [14, 17]. However, they have also identified facilitators, such as interagency collaboration, co-design with staff and service users, and continuously tailored education [14, 17].

Nursing competencies encompass knowledge, clinical skills, attitudes, and critical thinking that are essential to delivering effective, person-centered care [17]. TIC competencies include understanding trauma and its consequences, ensuring physical and psychological safety, and delivering culturally informed care [3]. The development of competencies in TIC requires a systematic educational framework, reflective practices, and a supportive organizational culture to effectively incorporate knowledge into patient outcomes [3]. Therefore, examining the factors that are associated with the competence of TIC nurses is essential for providing guidance for professional development and improving the delivery of TIC.

This study was guided by the Knowledge–Attitude–Practice (KAP) model [20] with competency-based theory [21, 9]. The KAP model suggests that knowledge shapes attitudes, which then influence clinical practices, creating a sequential pathway for behavior change in healthcare [34]. In TIC, nurses’ understanding of trauma and its effects is expected to foster positive attitudes toward TIC and support consistent implementation of trauma-informed practices [10, 22]. Competency-based theory views clinical competence as a multidimensional construct comprising knowledge, skills, attitudes, and contextual factors that together determine professional performance [3]. In this study, TIC competence is defined as an outcome shaped by nurses’ knowledge, opinions (attitudes), and practices. Perceived barriers are considered organizational and system-level constraints that may impede the effective translation of knowledge into practice [14, 17]. This integrated framework provides a comprehensive theoretical basis for examining relationships among study variables and identifying key predictors of TIC competence.

The association between trauma exposure and chronic pain is increasingly recognized. However, TIC is rarely integrated into chronic pain management. In Saudi Arabia, a biomedical model dominates pain management. Trauma-related factors that impact patient experiences and outcomes are often overlooked. Empirical research on nurses’ knowledge, attitudes, competencies, barriers, and practices related to TIC in chronic pain management is also lacking [6]. It is vital to examine these themes because nurses are central to patient-centered care. This study aims to fill this gap by providing evidence on TIC-related competencies among nurses managing chronic pain. It also seeks to identify key determinants of these competencies across different healthcare settings in Saudi Arabia. The results are expected to guide targeted educational interventions to improve clinical practice and support the integration of trauma-informed approaches into pain management.

Aim of this study

• To assess nurses’ knowledge, opinions, competencies, barriers, and practices of TIC in chronic pain management across different work settings.

• To evaluate whether nurses’ knowledge, opinions, and practices are associated with their overall competence in TIC for chronic pain management.

Methods

Study design

This multicenter, cross-sectional study was conducted and reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies [32]. The participants were nurses working at three different hospitals in the Jazan region. The inclusion criteria were as follows: individuals aged 18–65 years with at least one year of clinical nursing experience who were currently employed in a full-time clinical role (e.g., staff nurse or charge nurse) and provided direct patient care in departments relevant to chronic pain management, including medical–surgical units, intensive care units (ICU), operating rooms (OR), emergency departments (ED), mental health, obstetrics (OB), and pediatric units. Nurses working exclusively in administrative roles or without direct patient care responsibilities were excluded.

Study sample

We obtained ethical approval from the Institutional Review Board of Jazan Cluster Health. Initially, all of the hospitals in the region were selected. Three hospitals were then randomly selected using a random number generator to ensure institutional-level representativeness. An email was sent to the head nurse, and a WhatsApp message included a link to an online survey, and an invitation to participate was distributed to eligible nurses. Within the selected hospitals, participants were recruited using a convenience sampling approach based on voluntary response to the survey link. Data were collected over five months using online surveys.

The formula (n =Z² × σ² / E²) was used to calculate the sample size [1]. Assuming a 95% confidence level (Z = 1.96), an estimated population standard deviation (σ) of 0.9 on the basis of previous studies, and a margin of error (E) of 0.1, the computed sample size was approximately 277. A total of 272 nurses who met the inclusion criteria were recruited through convenience sampling from participating hospitals. This sample size was considered adequate to ensure representation and statistical accuracy. This sample was also considered sufficient for representation, statistical accuracy, and regression analysis, as a minimum of 10–15 participants was recommended for each of the predictors, ensuring adequate statistical power.

Measures

Sociodemographic questionnaire: Participants completed a structured self-administered questionnaire to capture the following demographic information: age, sex, level of education, years of experience, and department/health care facility.

TIC Provider Survey: The TIC Provider Survey (version 2.0) included five domains [10]: 13 items evaluating providers’ knowledge regarding TIC; 7 items assessing opinions related to TIC; 12 items measuring competence; 7 items evaluating barriers to the implementation of TIC; 9 items assessing providers’ experiences of performing TIC in the past 6 months. Knowledge and opinion items were rated on a four-point scale ranging from 1 “strongly disagree” to 4 “strongly agree”, whereas competence and barrier items were rated on three-point scales, and practice items were scored dichotomously (0 = no, 1 = yes). The score ranges were as follows: knowledge (13–52), opinions (7–28), competencies (0–24), barriers (0–14), and practices (0–9). Reverse scoring was applied to negatively worded items (items 2, 3, 7, and 14) prior to computing total scores.

The Cronbach’s alpha coefficients for the TIC Provider Survey range from 0.78 to 0.92 across the five domains [13, 18]. The survey has also been validated for use by different health care providers, such as nurses, physicians, and social workers [13, 18]. In this study, the internal consistency of the Trauma-Informed Care (TIC) Provider Survey was assessed using Cronbach’s alpha for each domain. The results demonstrated reliability ranging from acceptable to excellent across all domains. Specifically, the competencies domain showed the highest internal consistency (α = 0.96), followed by barriers (α = 0.92) and practices (α = 0.91), all of which demonstrated excellent reliability. The opinions domain (α = 0.87) and knowledge domain (α = 0.73) both showed good internal consistency.

Data analysis

The data were analyzed using SPSS software version 31 for Windows. Descriptive statistics, including means, standard deviations, frequencies, and percentages, were calculated for demographic characteristics and study variables. Differences in TIC knowledge, opinions, competencies, barriers, and recent practices across work settings were examined using one-way analysis of variance (ANOVA). Because Levene’s test indicated unequal variances across groups, post hoc comparisons were conducted using the Games-Howell test. Multiple linear regression analysis was performed to examine whether TIC knowledge, opinions, barriers, and recent practices significantly predicted TIC competencies among nurses in chronic pain management. TIC competencies were entered as the dependent variable, while TIC knowledge, opinions, barriers, and practices were entered as independent variables. A p-value of less than 0.05 was considered to indicate statistical significance for all analyses.

We defined “TIC training” as participation in structured educational activities such as workshops, seminars, in-service training programs, or continuing professional development courses focused on trauma-informed care. Before the regression analysis was conducted, the assumptions were assessed. The normality of the residuals was confirmed through visual inspection of histograms and normal probability (Q-Q) plots, with no evidence of heteroscedasticity or significant multicollinearity. There were no missing data points in the final dataset because the online survey required responses to all the items before submission.

Results

A total of 272 nurses participated in the study. Most participants were aged 25–30 years (58.1%), Saudi (91.2%), and female (81.6%). With respect to educational level, 75.7% had a bachelor’s degree, and 32.4% had two to five years of experience. The participants were primarily employed in medical-surgical units (27.2%) or emergency departments (27.2%), and 36.8% of the nurses reported having undergone TIC training (Table 1).

Table 1.

Sociodemographic characteristics of study participants (N = 272)

Variables	n (%)
Age
25–30 years	158 (58.10)
31–35 years	58 (21.30)
36–40 years	48 (17.60)
≥ 41 years	8 (2.90)
Sex
Female	222 (81.60)
Male	50 (18.40)
Nationality
Saudi	24 (8.80)
Non-Saudi	248 (91.20)
Level of education
Associate	46 (16.90)
Bachelor	206 (75.70)
PhD/MSN	20 (7.30)
Years of experience
< 2 years	68 (25)
2–5 years	88 (32.40)
6–10 years	36 (13.20)
> 10 years	80 (29.40)
Work setting
Medical-surgical unit	74 (27.20)
Intensive Care Unit	40 (14.70)
Operating Room	6 (2.20)
Emergency Department	74 (27.20)
Mental health unit	6 (2.20)
Obstetric Unit	26 (9.50)
Pediatric unit	46 (16.90)
Received formal training for TIC
Yes	100 (36.80)
No	172 (63.20)

Note. PhD, Doctor of Philosophy; MSN, Masters in Nursing Science; TIC, trauma-informed care

Nurses’ knowledge

As shown in Table 2, nurses who worked in ORs (21.00 ± 3.77) and mental health units (20.66 ± 2.58) reported the highest levels of knowledge, whereas those who worked in pediatric units (16.00 ± 5.18) reported the lowest knowledge of TIC. Knowledge scores differed significantly across work settings (F(6,265) = 4.01, p < 0.001, η² = 0.08, moderate effect size). However, there were no significant pairwise differences. However, Games–Howell post hoc comparisons did not reveal statistically significant pairwise differences, likely because of unequal subgroup sizes and reduced statistical power in smaller groups, particularly the operating room and mental health units.

Table 2.

Mean scores of trauma-informed care knowledge, opinions, competencies, barriers, and recent practices by work setting (N = 272)

Work setting/ units	Knowledge (Mean ± SD)	Opinions (Mean ± SD)	Competency (Mean ± SD)	Barriers (Mean ± SD)	Recent practices (Mean ± SD)
Medical-surgical	18.62 ± 2.81	16.31 ± 3.99	15.77 ± 4.71	8.14 ± 4.05	7.22 ± 2.88
Intensive care	18.95 ± 4.22	16.39 ± 5.83	13.08 ± 5.91	8.43 ± 3.79	8.43 ± 1.62
Operating room	21.00 ± 3.77	23.00 ± 1.06	17.50 ± 7.11	9.25 ± 3.05	4.50 ± 3.42
Emergency	18.64 ± 3.77	17.11 ± 4.82	14.35 ± 6.72	8.83 ± 3.90	7.71 ± 1.96
Mental health	20.66 ± 2.58	20.00 ± 3.22	21.00 ± 3.22	9.66 ± 3.38	8.33 ± 1.03
Obstetric	16.92 ± 3.61	15.46 ± 4.70	17.50 ± 7.11	8.07 ± 3.74	8.15 ± 1.48
Pediatric unit	16.00 ± 5.18	11.93 ± 6.94	10.18 ± 8.21	7.37 ± 4.97	5.37 ± 3.69

Note. SD = Standard deviation; Score ranges: knowledge (13–52), opinions (7–28), competencies (0–24), barriers (0–14), and practices (0–9)

Nurses’ opinions

Nurses who worked in ORs had the most favorable opinion of TIC (23.00 ± 1.06), followed by those who worked in mental health units (20.00 ± 3.22) and EDs (17.11 ± 4.82). In contrast, nurses who worked in pediatric units (11.93 ± 6.94) had the lowest opinion scores. Opinions toward TIC varied significantly according to work setting (F (6,265) = 7.45, p < 0.001, η² = 0.14). Post hoc analysis indicated that nurses in pediatric units had significantly lower opinion scores than those in medical-surgical, ED, OR, and mental health settings (p < 0.05). Nurses who worked in the OR scored significantly higher than those who worked in all other units except mental health units.

Nurses’ competencies

Nurses who worked in mental health units demonstrated the greatest competence in TIC (21.00 ± 3.22), followed by nurses who worked in ORs (17.50 ± 7.11) and medical-surgical units (15.77 ± 4.71). Pediatric nurses had the lowest competency scores (10.18 ± 8.21). There was a significant difference in competency scores across work settings (F (6,265) = 4.95, p < 0.001, η² = 0.10). Post hoc comparisons revealed that nurses working in mental health settings had significantly greater competence than those working in pediatric units, OB units, EDs, and ICUs.

Barriers to TIC

The mean scores for barriers to TIC were similar across work settings, ranging from 7.37 ± 4.97 among pediatric nurses to 9.66 ± 3.38 among mental health nurses, indicating that challenges to TIC implementation were consistent across settings. There were no significant differences in perceived barriers to implementing TIC across work settings (F (6, 265) = 0.74, p = 0.61, η² = 0.02).

Recent TIC practices

The highest levels of recent TIC practices were reported by nurses who worked in ICUs (8.43 ± 1.62), mental health units (8.33 ± 1.03), and obstetric units (8.15 ± 1.48), whereas the lowest levels were observed among those who worked in ORs (4.50 ± 3.42) and pediatric units (5.37 ± 3.69). Significant differences were found in recent TIC practices across work settings (F(6, 265) = 7.78, p < 0.001, η² = 0.15). Post hoc tests revealed that nurses working in pediatric units reported significantly lower levels of recent TIC practices than those working in OB units, EDs, ICUs, and mental health units (p < 0.05).

The multiple regression analysis showed that the overall model was significant (F(4, 267) = 65.55, p < 0.001, R2 = 0.52, Adjusted R2 = 0.51), explaining 52% of the variance in TIC competence. As shown in Table 3, greater knowledge (β = 0.32, t = 4.43, p < 0.001), positive opinions (β = 0.28, t = 3.80, p < 0.001), and fewer barriers (β = 0.19, t = 3.91, p < 0.001) were significant positive predictors of TIC competence. However, past TIC training did not significantly affect TIC competence (β = 0.06, t = 1.43, p = 0.15).

Table 3.

Multiple linear regression analysis predicting trauma informed care competence (N = 272)

Variables	B	SD	β	95% CI	P-value
Knowledge	0.52	0.11	0.32	0.29, 0.75	< 0.001
Opinions	0.33	0.08	0.28	0.16, 0.50	< 0.001
Barriers	0.31	0.08	0.19	0.15, 0.47	< 0.001
Recent practices	0.15	0.11	0.06	-0.06, 0.37	0.15

Note. Model Summary: R² = 0.52; Adjusted R² = 0.51; F(4,267) = 65.55, p < 0.001; B = Unstandardized coefficient; SD = Standard deviation; β = Standardized coefficient; CI = Confidence interval

Discussion

This study aimed to assess nurses’ knowledge, opinions, competence, barriers, and practices regarding TIC in chronic pain management within different clinical work settings. The results showed that nurses working in ORs and mental health units had the greatest knowledge of TIC, whereas those working in pediatric units had the lowest level of knowledge. These differences may impact nurses’ opportunities for specialized training. TIC principles are increasingly being recognized owing to the frequent management of patients with significant psychological needs by nurses working in mental health units and ORs [8, 10]. In contrast, pediatric nurses often place greater focus on the development of child- and family-centered care, and studies have reported low competence in TIC practices, which may reflect limited training and education regarding TIC [15, 31].

We also found that nurses working in ORs and mental health units held more favorable opinions of TIC than those in pediatric and OB units did. Research has shown that when staff members experience positive effects of TIC on patients’ well-being and on collaboration during operations, they frequently express appreciation for TIC [14, 24]. The lower opinion scores in pediatric contexts may be a consequence of the burdens of TIC and the misconceptions that trauma-informed approaches are either time-intensive or secondary to medical care [7]. Variations in nurses’ opinions about TIC across different work settings [22] highlight the importance of fostering positive attitudes through reflective practice, modeling, and leadership engagement.

Nurses who work in mental health units demonstrated the highest level of competence, followed by those working in ORs and medical-surgical units. These findings are consistent with previous research that has reported a link between TIC proficiency, experience-based learning, supervision, and continued reflective practice [22]. Nurses in mental health units are trained to practice empathy, emotional control, and patient-centered communication, all of which are important skills for effective TIC [33].

We found no significant differences in barriers across work contexts, indicating that systemic issues are prevalent across all hospital settings. Furthermore, a previous study identified several similar barriers, such as inadequate policies, time constraints, insufficient training, and a lack of institutional support [5]. Therefore, future interventions should emphasize leadership involvement and organizational culture over unit-specific approaches. Specifically, hospitals should incorporate TIC into their policies, foster teamwork among clinical staff, and provide ongoing training [14].

Nurses working in ICUs, EDs, and mental health settings had the highest level of recent TIC practices, which is likely due to frequent exposure to patients who are experiencing acute distress or complex trauma histories. Nurses in these settings often apply TIC principles, such as safety, trust, and empowerment, during crisis care [7]. Lower scores among pediatric nurses and/or nurses may indicate procedural environments that prioritize efficiency over psychosocial engagement. Such discrepancies highlight the impact of clinical context on TIC implementation. Promoting interdisciplinary sessions and cross-unit learning may help improve the consistency of TIC implementation across departments [22].

Finally, we evaluated whether nurses’ knowledge, opinions, and practices of TIC in chronic pain management were associated with their competencies. We found that lower perceived barriers were all significant predictors of competence in TIC. This finding supports the idea that cognitive understanding, attitudinal readiness, and organizational support contribute to the improvement of TIC skills [34]. However, practicing TIC did not significantly improve nurses’ competencies, suggesting that current routine approaches alone, without structured guidance or reinforcement through formal competency-based assessments, are inadequate for improving TIC competencies [16].

Limitations

This study has several limitations that should be acknowledged. First, the use of self-report surveys may have introduced response bias, particularly social desirability bias, which could lead to overestimation of competencies. Incorporating objective or observational measures, such as direct clinical observations or performance-based assessments, would provide a more comprehensive assessment of competency. Furthermore, the sample sizes for some subgroups, particularly in the OR and mental health unit nurse groups, were relatively small, which may have reduced the statistical power of the pairwise comparisons. However, we addressed this issue by using the Games-Howell post hoc test, which is robust to unequal variances and group sizes. Also, specific information regarding the duration and type of TIC training was not captured in the dataset. Additionally, the study was conducted within a specific geographic region using a convenience sample, which limits the generalizability of our findings to other cultural contexts. Longitudinal, multicenter studies involving nurses from more diverse populations and using random sampling methods would provide a clearer understanding of how TIC competencies develop over time and across diverse healthcare settings.

Implications

This study has important implications for nursing practice, education, and policy. Differences in trauma-informed care knowledge, attitudes, and skills across work settings highlight the need for targeted, practical training, especially for pediatric and obstetric nurses. Integrating TIC in undergraduate and professional curricula will prepare nurses for patient-centered care. Also, health care institutions should prioritize TIC across clinical guidelines, policies, and training. Overcoming barriers such as a lack of training and poor organizational support is essential for effective implementation. In addition, intervention-based, longitudinal designs using mixed-methods and objective performance measures may provide strong evidence of TIC’s effectiveness in clinical practice.

Conclusions

This study revealed significant disparities in nurses’ knowledge, opinions, competencies, and practices regarding TIC across various clinical contexts. In this sample, nurses working in mental health units and ORs had better knowledge and competence in TIC than those working in other settings. In contrast, those working in pediatric and OB units scored most poorly, which indicated the impact of clinical context and exposure to trauma-related interventions on TIC implementation. We also found that greater knowledge, more positive attitudes, and fewer perceived barriers were key factors for TIC competence among nurses in the participating hospitals. This highlights the importance of knowledge, attitudinal preparation, and organizational support, and suggests that structured, competency-based training is essential for translating TIC concepts into effective clinical performance. Our findings underscore the need for the systematic integration of TIC frameworks into nursing education, professional development, and institutional policies. Enhancing TIC competencies among nurses, particularly in managing chronic pain, will improve patient-centered care, foster emotional safety, and promote holistic recovery. Future interventions should include longitudinal programs, interdisciplinary collaboration, and ongoing TIC evaluation to facilitate ongoing practice reforms within health care environments.

Author contributions

AK contributed to the study’s conception and design, data acquisition, and data analysis, wrote the first draft of the manuscript, revised the final draft, and gave final approval of the version to be published.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Data availability

The dataset used and analyzed during the current study is available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Institutional Review Board of Jazan Cluster Health. The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki. Informed consent was obtained from all participants before they responded to the online surveys.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.