Nurses' Competencies, Barriers, and Experience in Trauma-Informed Care: A Cross-Sectional Study

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Kappi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8882700/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version 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 re-traumatization and to encourage individuals to better engage with therapy. Currently, there is a lack of empirical data regarding the TIC competencies of nurses in the management of chronic pain in Saudi Arabia. Objectives Therefore, this study aimed to: ( 1 ) assess nurses’ knowledge, opinions, competencies, barriers, and practices related to TIC in chronic pain management across work settings, and ( 2 ) examine how these factors influence overall TIC competence in chronic pain management. Methods We conducted a cross-sectional study using an online survey distributed to 272 nurses working in hospitals in the (xxx). We collected data using the TIC Provider Survey to evaluate nurses’ competencies, barriers, and experiences in TIC over three months. Multiple regression analysis was used to evaluate whether years of nursing practice experience influence nurses’ knowledge, attitudes, competencies, and practices related to TIC in chronic pain management. Results Overall knowledge levels varied significantly across work settings, with nurses in operating rooms and mental health units scoring the highest, and those in pediatric units the lowest. Pediatric nurses had the lowest opinion scores for TIC, and OR nurses had the highest. Mental health nurses were the most competent, followed by OR nurses, medical-surgical unit nurses, and pediatric nurses. No major differences were found in TIC implementation barriers across work settings. Greater knowledge of TIC, more positive opinions of TIC, and fewer barriers to TIC were predictive of TIC competence. However, prior training was not a significant predictor. Conclusions Our findings highlight the variability in nurses’ knowledge, opinions, and practices regarding TIC across different work settings. Specifically, mental health and OR nurses demonstrated higher competence than pediatric nurses. To improve competence in TIC and ensure its consistent implementation in nursing practice, addressing barriers, fostering positive attitudes, and enhancing education are crucial. Trauma-informed care Competency Barriers Experiences Chronic pain Nurses 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, of which back pain is the most frequently reported (Almalki et al., 2019). Chronic pain is a disabling and complicated health issue 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,” which emphasizes the multidimensional nature of pain and the need for more person-centered techniques in therapeutic practice (Raja et al., 2020). Various studies have demonstrated an association between trauma exposure and chronic pain (Bussières et al., 2023). For instance, chronic pain and pain-related disability in adulthood are linked to lifetime trauma, such as adverse childhood experiences (ACEs) (Bussières et al., 2023). Furthermore, individuals with a history of psychological or physical trauma are more likely to develop persistent pain and exhibit impaired coping abilities (Bussières et al., 2023). In Saudi Arabia, trauma is common; moreover, it impacts pain trajectories (Alhalal & Alhalal, 2025; Al-Sayaghi et al., 2022). In the Eastern province, it was shown that lifetime exposure to ACEs increases the likelihood of developing mental and physical health disorders (AlHemyari et al., 2022). In Saudi Arabia, chronic pain management is focused on pharmacotherapy and referral to rehabilitation centers (Almalki et al., 2019), and other approaches supporting trauma-informed pain management are seldom integrated into patient care. Trauma-informed care (TIC) is an approach used to reduce the risk of re-traumatization and promote therapy (Goldstein et al., 2024). 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 (SAMHSA et al., 2014). In addition, TIC has been developed and applied across different settings (Goldstein et al., 2024). For instance, the application of TIC helps support recovery from severe illnesses by improving communication and patient satisfaction in emergency rooms and intensive care units (ICUs) (Schroeder et al., 2021). It has also been used in obstetric (OB) (Sachdeva et al., 2022) and pediatric care settings to alleviate distress and improve the quality of relationships (Shoptaugh et al., 2025). Thus, TIC should be applied uniformly across the health care system, not only to trauma-specific services (Huo et al., 2023). Nurses play a crucial role in implementing TIC across different work settings by overseeing patient education, triage, care coordination, and continuous therapeutic communication (Fleishman et al., 2019). However, there are organizational and workforce challenges to implementing TIC in healthcare settings. Systematic reviews have highlighted constraints such as limited training and protected time, inadequate leadership support, resource shortages, and misalignment with current policies (Goldstein et al., 2024; Huo et al., 2023). However, they have also identified facilitators, such as interagency collaboration, co-design with staff and service users, and continuous tailored education (Goldstein et al., 2024; Huo et al., 2023). Nursing competencies encompass knowledge, clinical skills, attitudes, and critical thinking that are essential to delivering effective, person-centered care [14]. TIC competencies include understanding trauma and its consequences, ensuring physical and psychological safety, and delivering culturally informed care (Almarwani et al., 2023). Developing competencies in TIC requires a systematic educational framework, reflective practice, and a supportive organizational culture to effectively incorporate knowledge into patient outcomes (Almarwani et al., 2023). Therefore, examining the factors that influence the competence of TIC nurses is essential for providing guidance for professional development and improving the delivery of TIC. The TIC Provider Survey is an instrument used to evaluate healthcare providers' knowledge and practices. However, its application across various pain management contexts and nursing roles has been inconsistent. Moreover, there is a lack of empirical data on nurses’ knowledge, opinions, competencies, and practices regarding the implementation of TIC, as well as the influence of work settings, particularly in Saudi Arabia (Al-Sayaghi et al., 2022). The 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 influence their overall competence in TIC in chronic pain management. Methods Study Design This study was a multicenter, cross-sectional study. Participants were nurses working at three different hospitals in the (xxx). Inclusion criteria were those aged 18–65 years with a minimum of one year of clinical nursing experience. Study Sample We obtained ethical approval from the Institutional Review Board of (xxx). Initially, all of the hospitals in the region were selected. Then, three hospitals were selected at random from a random number generator. An email was sent to the Head Nurse, and a WhatsApp message included a link to an online survey and a request to participate in the study. The nurses who agreed to participate in this study were selected through convenience sampling. Data were collected over five months using online surveys. The formula (n =Z 2 × σ 2 / E 2 ) was used to calculate the sample size (Ahmed, 2024). Assuming a 95% confidence level (Z = 1.96), an estimated population standard deviation (σ) of 0.9 based on previous studies, and a margin of error (E) of 0.1, the computed sample size was approximately 277. A total of 272 nurses were recruited through convenience sampling from participating hospitals that met the inclusion criteria. This sample size was considered adequate to ensure representation and statistical accuracy. 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) comprises five domains (Bruce et al., 2018): 11 items evaluating providers’ knowledge regarding TIC; 9 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. All items were measured using a five-point Likert scale ranging from “strongly disagree” to “strongly agree” (Additional file 1). Cronbach’s alpha coefficients for the TIC Provider Survey range from 0.78–0.92 across the five domains (Ghosh et al., 2023; King et al., 2021). The survey has also been validated for use by different healthcare providers, such as nurses, physicians, and social workers (Ghosh et al., 2023; King et al., 2021). Data Analysis Data were analyzed using SPSS software version 31 for Windows. Descriptive statistics (i.e., means, standard deviations, and frequencies) were calculated for demographic information and the main outcomes. Variables of interest (i.e., TIC knowledge, opinions, competencies, barriers, and recent practices) were compared among work settings using a one-way analysis of variance, and post-hoc analyses were conducted using the Games-Howell test because Levene’s test identified unequal variances among groups. Multiple regression analysis was also performed to evaluate whether nurses’ knowledge, opinions, barriers, and practices regarding TIC in chronic pain management affect TIC competencies. A p < 0.05 was considered significant for all analyses. 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%). Regarding educational level, 75.7% had a bachelor’s degree, and 32.4% had two to five years of experience. Participants were primarily employed in medical-surgical units (27.2%) or emergency departments (27.2%), and 36.8% of nurses reported having undergone TIC training (Table 1 ). Table 1 Participant characteristics (N = 272) Variables Mean (SD) n (%) Age 25–30 years 150 (58.1) 31–35 years 58 (21.3) 36–40 years 48 (17.6) ≥ 41 years 8 (2.9) Sex Female 222 (81.6) Male 50 (18.4) Nationality Saudi 24 (8.8) Non-Saudi 248 (91.2) Level of education Associate 46 (16.9) Bachelor 206 (75.7) PhD/MSN 20 (7.3) Years of experience 10 years 80 (29.4) Work setting Medical-surgical unit 74 (27.2) ICU 40 (14.7) OR 6 (2.2) ED 74 (27.2) Mental health unit 6 (2.2) OB unit 26 (9.5) Pediatric unit 46 (16.9) Received formal training for TIC Yes 100 (36.8) No 172 (63.2) SD, standard deviation; PhD, Doctor of Philosophy; MSN, Masters in Nursing Science; ICU, intensive care unit; OR, operating room; ED, emergency department; OB, obstetric; TIC, trauma-informed care Nurses’ knowledge As shown in Table 2 , nurses who worked in ORs and mental health units reported the highest knowledge levels, whereas those who worked in pediatric units had the lowest knowledge of TIC. Knowledge scores differed significantly among work settings (F(6,265) = 4.01, p < 0.001, η² = 0.08, moderate effect size). However, there were no significant pairwise differences. Table 2 Mean scores of nurses’ knowledge, opinions, competencies, barriers, and recent practices of trauma-informed care by work setting (N = 272) Work setting/ units Knowledge Opinions Competencies Barriers Recent practices in the past 6 months Medical-surgical 18.6 ± 2.8 16.3 ± 3.9 15.7 ± 4.7 8.1 ± 4.1 7.2 ± 2.8 ICU 18.9 ± 4.2 16.3 ± 5.8 13.1 ± 5.9 8.4 ± 3.7 8.4 ± 1.6 OR 21.0 ± 2.5 23.0 ± 1.0 17.5 ± 7.1 9.2 ± 3.0 4.5 ± 3.4 ED 18.6 ± 3.7 17.1 ± 4.8 14.3 ± 6.7 8.8 ± 3.9 7.7 ± 1.9 Mental health 20.6 ± 2.5 20.0 ± 3.2 21.0 ± 3.2 9.6 ± 3.3 8.3 ± 1.0 OB 16.9 ± 3.6 15.4 ± 4.7 17.5 ± 7.1 8.0 ± 3.7 4.5 ± 3.4 Pediatric 16.0 ± 5.1 11.9 ± 6.9 10.1 ± 8.2 7.3 ± 4.9 5.3 ± 3.6 ICU, intensive care unit; OR, operating room; ED, emergency department; OB, obstetric Nurses’ opinions Nurses who worked in ORs had the most favorable opinion of TIC, followed by those who worked in mental health units and EDs. In contrast, nurses who worked in pediatric units 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 ORs 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 highest competence in TIC, followed by nurses who worked in ORs and medical-surgical units. Pediatric nurses had the lowest competency scores. There was a significant difference in competency scores among work settings (F(6,265) = 4.95, p < 0.001, η² = 0.10). Post hoc comparisons showed that nurses who worked in mental health settings had significantly higher competence than those who worked in pediatric units, OB units, EDs, and ICUs. Barriers to TIC Mean scores for barriers to TIC were similar across work settings, which indicated that challenges to TIC implementation were consistent across the various work settings. There were no significant differences in the perceived barriers to implementing TIC by work setting (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, mental health units, and Eds, whereas the lowest levels were observed in those who worked in ORs and pediatric units. Significant differences were found in recent TIC practices among work settings (F(6, 265) = 7.78, p < 0.001, η² = 0.15). Post hoc tests revealed that nurses who worked in pediatric units reported a significantly lower level of recent TIC practices than those who worked in OB units, EDs, ICUs, and mental health units ( p < 0.05). The multiple regression analysis showed that the overall model was significant (F = 48.03, p < 0.001, R = 0.52) and indicated that 52% of the variance explained 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 have a significant effect on TIC competence (β = 0.06, t = 1.43, p = 0.15). Table 3 The impact of nurses’ knowledge, opinions, and recent practices of TIC on their competencies in TIC Variables B SD β P Knowledge 0.52 0.11 0.32 < 0.001 Opinions 0.33 0.08 0.28 < 0.001 Barriers 0.31 0.08 0.19 < 0.001 Recent practices 0.15 0.11 0.06 0.15 SD, standard deviation 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 on 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 (Ayhan et al., 2024; Bruce et al., 2018). 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 practice, which may reflect limited training and education regarding TIC (Goddard et al., 2022; Özbay et al., 2023). 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. Research has shown that when staff members witness the positive effects of TIC on patients' well-being and on collaboration during operations, they frequently express appreciation for TIC (Goldstein et al., 2024; Ross et al., 2025). 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 (Anderson et al., 2023). Variations in nurses’ opinions about TIC across different work settings (Qin et al., 2025) 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. This finding is consistent with previous research reporting a link between TIC proficiency, experience-based learning, supervision, and continued reflective practice (Qin et al., 2025). 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 (Williams et al., 2025). 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 (Alhalal & Alhalal, 2025). 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 (Goldstein et al., 2024). Nurses working in ICUs, EDs, and mental health settings had the highest level of recent TIC practices, which is likely attributed to the frequent exposure to patients presenting with acute distress or complex trauma histories. Nurses in these settings will often apply TIC principles, such as safety, trust, and empowerment, during crisis care (Anderson et al., 2023). 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 (Qin et al., 2025). Finally, we evaluated whether nurses’ knowledge, opinions, and practices of TIC in chronic pain management influence their competencies. We found that lower perceived barriers were all significant predictors of competence in TIC. This supports the idea that cognitive understanding, attitudinal readiness, and organizational support all contribute to improving TIC skills (Zhang et al., 2025). 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 (Holod et al., 2025). Limitations This study has limitations that should be acknowledged. First, the data were collected using self-reported surveys, which may have introduced bias and overestimated competencies. The sample sizes for some subgroups (i.e., the OR and mental health unit nurse groups) were relatively small compared with others, which may have limited the statistical power for the pairwise group comparisons. However, we addressed this issue by using the Games-Howell post hoc test, which is robust against differences in variance and group sizes. Additionally, the study was conducted within a specific geographic region, which limits the generalizability of our findings to other cultural contexts. To gain a clearer understanding of how nurses’ TIC skills develop over time, future studies should use longitudinal or mixed methods designs, recruit from more diverse populations, and incorporate objective measures or performance assessments. Conclusions This study identified significant disparities in nurses’ knowledge, opinions, competencies, and practices regarding TIC across various clinical contexts. Nurses working in mental health units and ORs had superior knowledge and competence of 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. 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 the management of 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 healthcare environments. 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. Availability of data and materials The dataset used and analyzed during the current study is available from the corresponding author on reasonable request. Competing interests The author declares that they have no competing interests. Funding The author received no financial support for the research, authorship, and/or publication of this article. Author’s Contribution 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. Acknowledgments The author would like to thank the nursing managers and staff nurses from the participating hospitals for their participation in this study. References Almalki MT, BinBaz SS, Alamri SS, Alghamdi HH, El-Kabbani AO, Mulhem A, Alzubaidi AA, Altowairqi SA, Alrbeeai AT, Alharthi HA, W. M., Alswat KA. Prevalence of chronic pain and high-impact chronic pain in Saudi Arabia. Saudi Med J. 2019;40(12):1256–66. https://doi.org/10.15537/smj.2019.12.24690 . Almarwani AM, Alzahrani NS. Factors affecting the development of clinical nurses' competency: A systematic review. 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Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Mar, 2026 Reviews received at journal 23 Mar, 2026 Reviewers agreed at journal 16 Mar, 2026 Reviews received at journal 14 Mar, 2026 Reviewers agreed at journal 08 Mar, 2026 Reviewers invited by journal 06 Mar, 2026 Editor invited by journal 26 Feb, 2026 Editor assigned by journal 19 Feb, 2026 Submission checks completed at journal 19 Feb, 2026 First submitted to journal 14 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Kappi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYDACHgYGZgYDG2YYn7GBSC1pJGthOAznE9bC33P44eeCgvPs/P2Hnz3mYbCR3XCA/eEHfFokzrYZS88wuM0sceCYuTEPQ5rxhgM8xhJ4rTnPYCDNA9TCcLDBTJqH4XAiUAsDXi3y59k//+YxOMcsf5j9G1DLf6AW9sc/8GkxONsDNNzgALPBMR6QLQeAWhjM8NpieOZMmfUMg2RmwzM8ZZJzDJKNZx7mMbPAp0XuTPrm2wV/7JLlzh/fJvGmwk6273j74xv4tMBAMtSdDOBoIgrYEaluFIyCUTAKRiIAAOr1RWf5a9g+AAAAAElFTkSuQmCC","orcid":"","institution":"Jazan University","correspondingAuthor":true,"prefix":"","firstName":"Amani","middleName":"A.","lastName":"Kappi","suffix":""}],"badges":[],"createdAt":"2026-02-14 22:08:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8882700/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8882700/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104780520,"identity":"b85435f9-cbc5-45e0-8989-257a7f35aaec","added_by":"auto","created_at":"2026-03-17 07:53:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":612073,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8882700/v1/7005be0a-130f-4325-b0f7-77b278b5e7e0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Nurses' Competencies, Barriers, and Experience in Trauma-Informed Care: A Cross-Sectional Study","fulltext":[{"header":"Background","content":"\u003cp\u003eChronic 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, of which back pain is the most frequently reported (Almalki et al., 2019). Chronic pain is a disabling and complicated health issue 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,” which emphasizes the multidimensional nature of pain and the need for more person-centered techniques in therapeutic practice (Raja et al., 2020).\u003c/p\u003e \u003cp\u003eVarious studies have demonstrated an association between trauma exposure and chronic pain (Bussières et al., 2023). For instance, chronic pain and pain-related disability in adulthood are linked to lifetime trauma, such as adverse childhood experiences (ACEs) (Bussières et al., 2023). Furthermore, individuals with a history of psychological or physical trauma are more likely to develop persistent pain and exhibit impaired coping abilities (Bussières et al., 2023). In Saudi Arabia, trauma is common; moreover, it impacts pain trajectories (Alhalal \u0026amp; Alhalal, 2025; Al-Sayaghi et al., 2022). In the Eastern province, it was shown that lifetime exposure to ACEs increases the likelihood of developing mental and physical health disorders (AlHemyari et al., 2022). In Saudi Arabia, chronic pain management is focused on pharmacotherapy and referral to rehabilitation centers (Almalki et al., 2019), and other approaches supporting trauma-informed pain management are seldom integrated into patient care.\u003c/p\u003e \u003cp\u003eTrauma-informed care (TIC) is an approach used to reduce the risk of re-traumatization and promote therapy (Goldstein et al., 2024). 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 (SAMHSA et al., 2014). In addition, TIC has been developed and applied across different settings (Goldstein et al., 2024). For instance, the application of TIC helps support recovery from severe illnesses by improving communication and patient satisfaction in emergency rooms and intensive care units (ICUs) (Schroeder et al., 2021). It has also been used in obstetric (OB) (Sachdeva et al., 2022) and pediatric care settings to alleviate distress and improve the quality of relationships (Shoptaugh et al., 2025). Thus, TIC should be applied uniformly across the health care system, not only to trauma-specific services (Huo et al., 2023).\u003c/p\u003e \u003cp\u003eNurses play a crucial role in implementing TIC across different work settings by overseeing patient education, triage, care coordination, and continuous therapeutic communication (Fleishman et al., 2019). However, there are organizational and workforce challenges to implementing TIC in healthcare settings. Systematic reviews have highlighted constraints such as limited training and protected time, inadequate leadership support, resource shortages, and misalignment with current policies (Goldstein et al., 2024; Huo et al., 2023). However, they have also identified facilitators, such as interagency collaboration, co-design with staff and service users, and continuous tailored education (Goldstein et al., 2024; Huo et al., 2023).\u003c/p\u003e \u003cp\u003eNursing competencies encompass knowledge, clinical skills, attitudes, and critical thinking that are essential to delivering effective, person-centered care [14]. TIC competencies include understanding trauma and its consequences, ensuring physical and psychological safety, and delivering culturally informed care (Almarwani et al., 2023). Developing competencies in TIC requires a systematic educational framework, reflective practice, and a supportive organizational culture to effectively incorporate knowledge into patient outcomes (Almarwani et al., 2023). Therefore, examining the factors that influence the competence of TIC nurses is essential for providing guidance for professional development and improving the delivery of TIC.\u003c/p\u003e \u003cp\u003eThe TIC Provider Survey is an instrument used to evaluate healthcare providers' knowledge and practices. However, its application across various pain management contexts and nursing roles has been inconsistent. Moreover, there is a lack of empirical data on nurses’ knowledge, opinions, competencies, and practices regarding the implementation of TIC, as well as the influence of work settings, particularly in Saudi Arabia (Al-Sayaghi et al., 2022).\u003c/p\u003e\n\u003ch3\u003eThe Aim of This Study\u003c/h3\u003e\n\u003cp\u003e \u003c/p\u003e\u003cul\u003e \u003cli\u003e \u003cp\u003eTo assess nurses’ knowledge, opinions, competencies, barriers, and practices of TIC in chronic pain management across different work settings.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo evaluate whether nurses’ knowledge, opinions, and practices influence their overall competence in TIC in chronic pain management.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003cp\u003e\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e\n\n \n\n "},{"header":"Methods","content":"\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis study was a multicenter, cross-sectional study. Participants were nurses working at three different hospitals in the (xxx). Inclusion criteria were those aged 18–65 years with a minimum of one year of clinical nursing experience.\u003c/p\u003e\u003ch3\u003eStudy Sample\u003c/h3\u003e\u003cp\u003eWe obtained ethical approval from the Institutional Review Board of (xxx). Initially, all of the hospitals in the region were selected. Then, three hospitals were selected at random from a random number generator. An email was sent to the Head Nurse, and a WhatsApp message included a link to an online survey and a request to participate in the study. The nurses who agreed to participate in this study were selected through convenience sampling. Data were collected over five months using online surveys.\u003c/p\u003e\u003cp\u003eThe formula (n =Z\u003csup\u003e2\u003c/sup\u003e × σ\u003csup\u003e2\u003c/sup\u003e / E\u003csup\u003e2\u003c/sup\u003e) was used to calculate the sample size (Ahmed, 2024). Assuming a 95% confidence level (Z = 1.96), an estimated population standard deviation (σ) of 0.9 based on previous studies, and a margin of error (E) of 0.1, the computed sample size was approximately 277. A total of 272 nurses were recruited through convenience sampling from participating hospitals that met the inclusion criteria. This sample size was considered adequate to ensure representation and statistical accuracy.\u003c/p\u003e\u003ch3\u003eMeasures\u003c/h3\u003e\u003cp\u003e \u003cem\u003eSociodemographic questionnaire\u003c/em\u003e: 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.\u003c/p\u003e\u003cp\u003e \u003cem\u003eTIC Provider Survey\u003c/em\u003e: The TIC Provider Survey (version 2.0) comprises five domains (Bruce et al., 2018): 11 items evaluating providers’ knowledge regarding TIC; 9 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. All items were measured using a five-point Likert scale ranging from “strongly disagree” to “strongly agree” (Additional file 1). Cronbach’s alpha coefficients for the TIC Provider Survey range from 0.78–0.92 across the five domains (Ghosh et al., 2023; King et al., 2021). The survey has also been validated for use by different healthcare providers, such as nurses, physicians, and social workers (Ghosh et al., 2023; King et al., 2021).\u003c/p\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using SPSS software version 31 for Windows. Descriptive statistics (i.e., means, standard deviations, and frequencies) were calculated for demographic information and the main outcomes. Variables of interest (i.e., TIC knowledge, opinions, competencies, barriers, and recent practices) were compared among work settings using a one-way analysis of variance, and post-hoc analyses were conducted using the Games-Howell test because Levene’s test identified unequal variances among groups. Multiple regression analysis was also performed to evaluate whether nurses’ knowledge, opinions, barriers, and practices regarding TIC in chronic pain management affect TIC competencies. A \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.05 was considered significant for all analyses.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 272 nurses participated in the study. Most participants were aged 25\u0026ndash;30 years (58.1%), Saudi (91.2%), and female (81.6%). Regarding educational level, 75.7% had a bachelor\u0026rsquo;s degree, and 32.4% had two to five years of experience. Participants were primarily employed in medical-surgical units (27.2%) or emergency departments (27.2%), and 36.8% of nurses reported having undergone TIC training (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics (N\u0026thinsp;=\u0026thinsp;272)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150 (58.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (21.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36\u0026ndash;40 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (17.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;41 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (2.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e222 (81.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (18.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNationality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaudi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (8.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Saudi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e248 (91.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssociate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (16.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e206 (75.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhD/MSN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (7.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (32.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (13.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (29.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork setting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical-surgical unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (27.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (14.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (27.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental health unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOB unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (9.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePediatric unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (16.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceived formal training for TIC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (36.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e172 (63.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eSD, standard deviation; PhD, Doctor of Philosophy; MSN, Masters in Nursing Science; ICU, intensive care unit; OR, operating room; ED, emergency department; OB, obstetric; TIC, trauma-informed care\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eNurses’ knowledge\u003c/h3\u003e\n\u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, nurses who worked in ORs and mental health units reported the highest knowledge levels, whereas those who worked in pediatric units had the lowest knowledge of TIC. Knowledge scores differed significantly among work settings (F(6,265)\u0026thinsp;=\u0026thinsp;4.01, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, η\u0026sup2; = 0.08, moderate effect size). However, there were no significant pairwise differences.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean scores of nurses\u0026rsquo; knowledge, opinions, competencies, barriers, and recent practices of trauma-informed care by work setting (N\u0026thinsp;=\u0026thinsp;272)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork setting/ units\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOpinions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCompetencies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRecent practices in the past 6 months\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical-surgical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e18.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e16.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e15.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e18.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e16.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e13.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e8.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e21.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e23.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e17.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e18.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e17.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e8.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e7.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e20.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e20.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e21.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e9.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e8.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e16.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e15.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e17.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e4.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePediatric\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e16.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e11.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e10.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c6\"\u003e \u003cp\u003e5.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eICU, intensive care unit; OR, operating room; ED, emergency department; OB, obstetric\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eNurses’ opinions\u003c/h3\u003e\n\u003cp\u003eNurses who worked in ORs had the most favorable opinion of TIC, followed by those who worked in mental health units and EDs. In contrast, nurses who worked in pediatric units had the lowest opinion scores. Opinions toward TIC varied significantly according to work setting (F(6,265)\u0026thinsp;=\u0026thinsp;7.45, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, η\u0026sup2; = 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 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Nurses who worked in ORs scored significantly higher than those who worked in all other units except mental health units.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eNurses\u0026rsquo; competencies\u003c/h2\u003e \u003cp\u003eNurses who worked in mental health units demonstrated the highest competence in TIC, followed by nurses who worked in ORs and medical-surgical units. Pediatric nurses had the lowest competency scores. There was a significant difference in competency scores among work settings (F(6,265)\u0026thinsp;=\u0026thinsp;4.95, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, η\u0026sup2; = 0.10). Post hoc comparisons showed that nurses who worked in mental health settings had significantly higher competence than those who worked in pediatric units, OB units, EDs, and ICUs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eBarriers to TIC\u003c/h2\u003e \u003cp\u003eMean scores for barriers to TIC were similar across work settings, which indicated that challenges to TIC implementation were consistent across the various work settings. There were no significant differences in the perceived barriers to implementing TIC by work setting (F(6,265)\u0026thinsp;=\u0026thinsp;0.74, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.61, η\u0026sup2; = 0.02).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRecent TIC practices\u003c/h2\u003e \u003cp\u003eThe highest levels of recent TIC practices were reported by nurses who worked in ICUs, mental health units, and Eds, whereas the lowest levels were observed in those who worked in ORs and pediatric units. Significant differences were found in recent TIC practices among work settings (F(6, 265)\u0026thinsp;=\u0026thinsp;7.78, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, η\u0026sup2; = 0.15). Post hoc tests revealed that nurses who worked in pediatric units reported a significantly lower level of recent TIC practices than those who worked in OB units, EDs, ICUs, and mental health units (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eThe multiple regression analysis showed that the overall model was significant (F\u0026thinsp;=\u0026thinsp;48.03, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, R\u0026thinsp;=\u0026thinsp;0.52) and indicated that 52% of the variance explained TIC competence. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, greater knowledge (β\u0026thinsp;=\u0026thinsp;0.32, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.43, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), positive opinions (β\u0026thinsp;=\u0026thinsp;0.28, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.80, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and fewer barriers (β\u0026thinsp;=\u0026thinsp;0.19, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.91, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were significant positive predictors of TIC competence. However, past TIC training did not have a significant effect on TIC competence (β\u0026thinsp;=\u0026thinsp;0.06, \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.43, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.15).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe impact of nurses\u0026rsquo; knowledge, opinions, and recent practices of TIC on their competencies in TIC\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpinions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecent practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eSD, standard deviation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to assess nurses\u0026rsquo; 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 on nurses\u0026rsquo; 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 (Ayhan et al., 2024; Bruce et al., 2018). 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 practice, which may reflect limited training and education regarding TIC (Goddard et al., 2022; \u0026Ouml;zbay et al., 2023).\u003c/p\u003e \u003cp\u003eWe also found that nurses working in ORs and mental health units held more favorable opinions of TIC than those in pediatric and OB units. Research has shown that when staff members witness the positive effects of TIC on patients' well-being and on collaboration during operations, they frequently express appreciation for TIC (Goldstein et al., 2024; Ross et al., 2025). 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 (Anderson et al., 2023). Variations in nurses\u0026rsquo; opinions about TIC across different work settings (Qin et al., 2025) highlight the importance of fostering positive attitudes through reflective practice, modeling, and leadership engagement.\u003c/p\u003e \u003cp\u003eNurses who work in mental health units demonstrated the highest level of competence, followed by those working in ORs and medical-surgical units. This finding is consistent with previous research reporting a link between TIC proficiency, experience-based learning, supervision, and continued reflective practice (Qin et al., 2025). 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 (Williams et al., 2025).\u003c/p\u003e \u003cp\u003eWe 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 (Alhalal \u0026amp; Alhalal, 2025). 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 (Goldstein et al., 2024).\u003c/p\u003e \u003cp\u003eNurses working in ICUs, EDs, and mental health settings had the highest level of recent TIC practices, which is likely attributed to the frequent exposure to patients presenting with acute distress or complex trauma histories. Nurses in these settings will often apply TIC principles, such as safety, trust, and empowerment, during crisis care (Anderson et al., 2023). 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 (Qin et al., 2025).\u003c/p\u003e \u003cp\u003eFinally, we evaluated whether nurses\u0026rsquo; knowledge, opinions, and practices of TIC in chronic pain management influence their competencies. We found that lower perceived barriers were all significant predictors of competence in TIC. This supports the idea that cognitive understanding, attitudinal readiness, and organizational support all contribute to improving TIC skills (Zhang et al., 2025). However, practicing TIC did not significantly improve nurses\u0026rsquo; competencies, suggesting that current routine approaches alone, without structured guidance or reinforcement through formal competency-based assessments, are inadequate for improving TIC competencies (Holod et al., 2025).\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has limitations that should be acknowledged. First, the data were collected using self-reported surveys, which may have introduced bias and overestimated competencies. The sample sizes for some subgroups (i.e., the OR and mental health unit nurse groups) were relatively small compared with others, which may have limited the statistical power for the pairwise group comparisons. However, we addressed this issue by using the Games-Howell post hoc test, which is robust against differences in variance and group sizes. Additionally, the study was conducted within a specific geographic region, which limits the generalizability of our findings to other cultural contexts. To gain a clearer understanding of how nurses\u0026rsquo; TIC skills develop over time, future studies should use longitudinal or mixed methods designs, recruit from more diverse populations, and incorporate objective measures or performance assessments.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study identified significant disparities in nurses\u0026rsquo; knowledge, opinions, competencies, and practices regarding TIC across various clinical contexts. Nurses working in mental health units and ORs had superior knowledge and competence of 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. 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 the management of 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 healthcare environments.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dataset used and analyzed during the current study is available from the corresponding author on\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ereasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declares that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAK contributed to the study\u0026rsquo;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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author would like to thank the nursing managers and staff nurses from the participating hospitals for their participation in this study. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlmalki MT, BinBaz SS, Alamri SS, Alghamdi HH, El-Kabbani AO, Mulhem A, Alzubaidi AA, Altowairqi SA, Alrbeeai AT, Alharthi HA, W. 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Nurse Educ Pract. 2025;82:104233. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.nepr.2024.104233\u003c/span\u003e\u003cspan address=\"10.1016/j.nepr.2024.104233\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams R. Communication strategies to support people experiencing mental health issues. \u003cem\u003eNursing standard (Royal College of Nursing (Great Britain)\u003c/em\u003e: 1987), 2025; 40(1), 56\u0026ndash;61. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7748/ns.2024.e12297\u003c/span\u003e\u003cspan address=\"10.7748/ns.2024.e12297\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang D, Songwathana P, Vachprasit R, Holroyd E. Knowledge, attitude, and practice regarding trauma-informed care among nursing students in Eastern China: A cross-sectional study. Belitung Nurs J. 2025;11(4):443\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.33546/bnj.3947\u003c/span\u003e\u003cspan address=\"10.33546/bnj.3947\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Trauma-informed care, Competency, Barriers, Experiences, Chronic pain, Nurses","lastPublishedDoi":"10.21203/rs.3.rs-8882700/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8882700/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eChronic 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 re-traumatization and to encourage individuals to better engage with therapy. Currently, there is a lack of empirical data regarding the TIC competencies of nurses in the management of chronic pain in Saudi Arabia.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eTherefore, this study aimed to: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) assess nurses\u0026rsquo; knowledge, opinions, competencies, barriers, and practices related to TIC in chronic pain management across work settings, and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) examine how these factors influence overall TIC competence in chronic pain management.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a cross-sectional study using an online survey distributed to 272 nurses working in hospitals in the (xxx). We collected data using the TIC Provider Survey to evaluate nurses\u0026rsquo; competencies, barriers, and experiences in TIC over three months. Multiple regression analysis was used to evaluate whether years of nursing practice experience influence nurses\u0026rsquo; knowledge, attitudes, competencies, and practices related to TIC in chronic pain management.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOverall knowledge levels varied significantly across work settings, with nurses in operating rooms and mental health units scoring the highest, and those in pediatric units the lowest. Pediatric nurses had the lowest opinion scores for TIC, and OR nurses had the highest. Mental health nurses were the most competent, followed by OR nurses, medical-surgical unit nurses, and pediatric nurses. No major differences were found in TIC implementation barriers across work settings. Greater knowledge of TIC, more positive opinions of TIC, and fewer barriers to TIC were predictive of TIC competence. However, prior training was not a significant predictor.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOur findings highlight the variability in nurses\u0026rsquo; knowledge, opinions, and practices regarding TIC across different work settings. Specifically, mental health and OR nurses demonstrated higher competence than pediatric nurses. To improve competence in TIC and ensure its consistent implementation in nursing practice, addressing barriers, fostering positive attitudes, and enhancing education are crucial.\u003c/p\u003e","manuscriptTitle":"Nurses' Competencies, Barriers, and Experience in Trauma-Informed Care: A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-11 16:54:41","doi":"10.21203/rs.3.rs-8882700/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-27T08:01:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-24T02:20:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159214024965523102318764115402922006377","date":"2026-03-16T18:57:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-14T11:59:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50160041296979713739195692971542411421","date":"2026-03-08T18:28:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-06T13:51:42+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-26T13:32:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-19T11:48:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-19T11:48:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-02-14T22:04:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3a2acd43-ab6e-40e4-bc80-18d53146e3c8","owner":[],"postedDate":"March 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-16T16:23:28+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-11 16:54:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8882700","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8882700","identity":"rs-8882700","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}