Exploring Provider Perspectives on Gaps in Trauma-Informed Care Delivery Within the Acute Care Surgery Timeline at a Federally Qualified Health Center: Human-Centered Design Study

Introduction

Exposure to trauma within hospital populations is both widespread and complex, often stemming from chronic stressors that accumulate over time. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), individual trauma “results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being.” [1] Importantly, trauma is not limited to individual experience, as it can also be transmitted at the community and societal levels, including across generations. This is especially true for patients at Federally Qualified Health Centers (FQHCs), which are health care settings that receive federal funding to provide health care services to underserved populations, regardless of patients’ financial capacity. At these institutions, the patient population has an increased risk of trauma exposure due to socioeconomic challenges such as poverty, housing instability, and limited access to education [2]. One study found that approximately 80% of patients in safety-net hospitals have experienced 2 or more traumatic events, with 33% experiencing 5 or more [3]. Across trauma centers nationwide, the Improving Social Determinants to Attenuate Violence Workgroup within the American College of Surgeons has been actively addressing the root causes and impacts of trauma by promoting trauma-informed care (TIC) practices and curricular changes [4].

TIC is a strengths-based framework that is grounded in an understanding of trauma and the response to its impact, emphasizing the physical, psychological, and emotional safety of survivors to rebuild a sense of control and empowerment. According to the SAMHSA, TIC is a framework that health care systems can use to identify histories of traumatic experiences among patients and staff and enhance workflows by focusing efforts on developing policies and practices that prevent retraumatization [1]. In primary care settings, TIC has been used to improve provider and staff training, trauma screening protocols, trauma-informed interventions and resources, and staff burnout prevention [5]. Studies have shown that these practices allow providers to create a more comprehensive understanding of their patients’ histories, with visit lengths increasing by 5 minutes or less, 91% of the time [6]. However, in emergent settings (such as perioperative care, the emergency department, and the intensive care unit), time and workflow constraints pose additional obstacles to implementing TIC [7].

Surgical procedures are highly vulnerable experiences for patients, particularly regarding time-sensitive decision-making and bodily autonomy. The indications for surgical interventions, as well as the interventions themselves, carry the risk of causing psychological trauma in the preoperative, operative, and recovery periods. These environments place patients with unfamiliar providers, allot a limited time for decision-making, and compel patients to yield control to the health care system [8]. Frameworks and tools to understand and respond to this are critical for mitigating negative impacts and increasing opportunities for building patient-provider trust, facilitating patient-centered decision-making, and improving follow-up postoperatively with better outcomes. Although there has been an increase in research on TIC regarding patients, there has been little exploration into the insights of providers who deliver this care.

The research aim was to understand how to better adapt and implement TIC practices, education, and interventions in emergency care settings, particularly in FQHC surgical units, using interdisciplinary collaboration and design. While traditional qualitative research typically focuses on observing and understanding an environment, human-centered design (HCD) methodology was chosen to actively explore the perspectives and challenges of implementing TIC with the intent to create practical interventions [9]. HCD places users at the center of the design space, working toward co-designing solutions that incorporate the voices of stakeholders [10]. This methodology involves 3 phases: inspiration, ideation, and implementation. Each phase offers a stepwise approach to identifying the needs of the users, generating meaningful solutions, and turning these ideas into applicable outcomes. HCD has been used to develop prototypes in communities facing systemic barriers due to the prioritization of equal partnerships between stakeholders and researchers [11]. It has been used to improve documentation of geriatric care, reduce perinatal inequities, and design interventions for youth with HIV [10,12,13]. Incorporating users into the research team increases the likelihood of use, enhances accessibility, and improves the feasibility of the developed prototypes [14]. This paper focuses on the first inspiration phase, where an iterative process consolidates information gathered from interviews, ultimately laying the foundation for the development of interventions in subsequent phases.

Methods

Ethical Considerations

This study was approved by the University of California, San Francisco Institutional Review Board (IRB #22‐36409). The IRB approved a waiver of signed consent; participants were provided with an information sheet describing the study, and they verbally confirmed their agreement to participate over Zoom (Zoom Communications, Inc) prior to their interview. Participants were informed of their right to decline participation or withdraw at any time. Interview recordings were deidentified to protect participant privacy and confidentiality, and no identifying information is included in this manuscript.

Study Setting and Participant Selection

This is an exploratory qualitative research study conducted at an FQHC in Northern California between 2022 and 2023 to understand clinicians’ perspectives on TIC within the acute surgical care setting.

Purposeful sampling [15] was used to recruit 18 stakeholders who represent the spectrum of providers with varying levels of experience and roles who work within emergency surgical care, from arrival at the emergency department to discharge. These included physicians and surgeons who direct clinical decision-making, nurses who provide continuous bedside care, social workers who address psychosocial needs, psychologists who support patients experiencing acute distress, and de-escalation staff who manage crisis situations. This diversity of roles was intentional in order to capture the fundamentally team-based nature of TIC. Individuals were recruited through provider and staff referrals at an FQHC emergency department and medical-surgical inpatient floors. No formal exclusion criteria were applied beyond failure to meet the inclusion criteria; all individuals who were referred and contacted by the research team agreed to participate and provided informed consent prior to their interviews. Interviews lasted approximately an hour and were conducted virtually through Zoom to accommodate clinical schedules and COVID-19 precautions in place at the time. Interviews were audio-recorded, deidentified for participant confidentiality, and transcribed for analysis.

Qualitative Data Collection

Consistent with the HCD Inspiration phase, semistructured interviews were conducted using open-ended questions to elicit narratives identifying individual and systems-level challenges to providing TIC [16]. Interview guides were developed based on existing TIC literature and the SAMHSA framework [1,5], covering topics such as staff training, screening protocols, TIC interventions, and TIC implementation. These topics were used to understand our subjects’ perspectives on how TIC manifests in their daily work and the challenges they have encountered in its implementation. While all participants were asked the same core questions regarding their understanding of TIC, how they apply it in their daily work, and the barriers they encounter, role-specific probing questions were included to elicit contextually relevant examples.

Qualitative Data Analysis

A general inductive approach to thematic analysis [17] was conducted to identify key themes and exemplar quotes from deidentified interview transcript data. Two interview transcripts were selected by the interviewers for their representation of the sample’s diversity and the range of themes identified across all interviews. These transcripts were independently coded by 2 researchers (coder initials: AM and NR) to develop the initial codebook. To establish intercoder reliability, the researchers engaged in regular discussions after coding the representative interviews to ensure agreement on theme definitions and coding decisions. Once the initial codebook was defined, these researchers independently coded the transcripts using Dedoose (SocioCultural Research Consultants, LLC), a qualitative data analysis software, which facilitated the organization and analysis of the data [18]. Consistent with an inductive thematic analysis approach, the final codebook (Multimedia Appendix 1) was continuously refined throughout the analysis. Any new codes that needed to be added or existing codes that required redefinition were revised collaboratively by the team and applied consistently across all interviews. After interviewing 18 individuals, thematic saturation was achieved, and recruitment ceased. Thematic saturation was indicated by a lack of emergence of novel themes in new interview data; additionally, the number of interviews exceeded the commonly cited new information threshold of 10‐12 participants [19]. Themes, defined as inductively identified patterns of meaning derived from the interview data, were reassessed across the full set of interviews. Representative quotes were identified for each theme as empirical evidence of the observed patterns. Together, the themes and supporting quotes provided the foundation for insight statement development. Themes sharing common patterns or stakeholder concerns were grouped and synthesized into insight statements that captured the underlying tensions between stakeholder needs and systemic constraints. Each draft insight statement was written in actionable, user-centered language and iteratively reviewed and refined against supporting themes and quotes to ensure it remained grounded in the data. These insight statements define the user’s core motivations and needs, providing directed guidance for creating design opportunities (Figure 1). The design opportunities serve as starting points for potential interventions to address the issues identified under the insight statements. These inspiration phase activities are illustrated in Figure 1. Prototype development and iterative refinement, which comprise the subsequent ideation phase, will be addressed in future work.

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Results

Qualitative Data Analysis

Eighteen interviews were conducted with a heterogeneous sample of individuals who work across the spectrum of emergency surgery, including physicians, nurses, social workers, psychologists, and de-escalation staff (Table 1). Thematic analysis of these interviews revealed 21 themes, organized under 7 overarching insight statements. These are presented alongside supporting quotes and design opportunities that highlight the obstacles and tensions involved in delivering TIC (Textbox 1).

Insight 1: TIC Requires Additional Time for Provider Education and Clinical Implementation, Which the Productivity-Driven Hospital Workflow Does Not Accommodate

A total of 10 (56%) interview participants stated that an assembly-line structure of hospital workflows does not adapt effectively to the diverse trauma-informed needs of providers and patients. Providers experience a persistent tension between their desire to deliver holistic, person-centered care and the time constraints imposed by a productivity-driven environment. This tension limits opportunities to develop personalized care plans, build meaningful provider-patient relationships, and engage patients in the deeper conversations necessary to uncover past experiences, apprehensions, and emotional needs prior to care. When a fast-paced, profit-driven hospital structure systematically prioritizes efficiency over emotional engagement, the psychological and relational dimensions of patient care are consistently overlooked.

Design opportunity 1: Integrate TIC training into hospital workflows and medical education to support productivity while respecting time constraints.

Interventions to improve TIC within a production-oriented hospital work environment should focus on uplifting patient experiences without coming at the expense of providers’ time and mental capacity. These could include integrating training into previously scheduled didactic time or providing support systems that alleviate the burden on providers, reducing the need for them to manage TIC independently.

Insight 2: Providers Who Do Not Receive Support to Address Their Own Vicarious Trauma and Burnout Do Not Have the Personal Resources to Prioritize TIC

Providers working in high-trauma environments face a continuous cycle of emotional suppression that erodes their well-being and long-term commitment to the field. A prominent pattern across interviews was that acute care requires providers to set aside their own emotional responses to deliver consistent care to each patient, yet they often lack adequate opportunities for recovery or resolution. For providers working primarily in acute care settings, where patient encounters are concentrated in moments of crisis, limited visibility into patient recovery and positive outcomes can deepen this emotional toll and distort their broader sense of purpose in their work. When burnout takes hold, providers lose the capacity for empathy, compassion, and sustained attention that TIC demands. The consequences extend beyond individual providers: when providers lack the personal resources to sustain trauma-informed practices, patients feel the absence of compassion in their care, perceiving themselves as unseen or a burden within the health care system. Together, these conditions make it increasingly difficult for providers to sustain the personal and professional resources necessary to prioritize TIC.

Design opportunity 2: Create supportive structures for providers to process vicarious trauma and mitigate burnout, enabling them to sustain and prioritize TIC.

Interventions that provide both the time and resources necessary to reflect on challenging experiences in the hospital setting are crucial. Providing structured opportunities for debriefing, peer support, or access to mental health resources can help mitigate the stress and burnout associated with these experiences. These support mechanisms offer providers the opportunity to improve personal resilience and to engage in their careers with greater compassion and empathy.

Insight 3: TIC Training Is Too Inconsistent to Be Widely Adopted and Too Generic to Address Specialty-Specific Needs, Making It Difficult for Clinicians to Apply in Real-World Care

Interviews revealed both an appreciation for TIC and notable gaps in the current structure and delivery of training. Providers described the need for a standardized foundational curriculum that establishes clear expectations and a shared framework, with the understanding that evidence-based deviations from that standard are appropriate when supported by data. However, foundational knowledge alone was not considered sufficient in practice. One provider who had participated in formal TIC training found that certain recommended approaches, such as asking open-ended questions or engaging patients in a trauma-informed manner, felt unrealistic within the time constraints of their specialty. This highlighted a broader need for training that accounts for the specific demands of different clinical settings while allowing providers the flexibility to adapt their approach to each unique patient situation. Further complicating adoption, TIC is not consistently incorporated into formal health care education. Seven (39%) interviewees described their trauma-informed practices as largely intuitive or drawn from personal and patient experiences rather than structured instruction, reflecting a broader gap between what training prepares them for and what they encounter in clinical practice.

Design opportunity 3: Design a flexible TIC training model that combines a standardized core curriculum with specialty-specific modules, enabling both broad adoption and practical implementation across diverse clinical settings.

Improvements to TIC training should focus on teaching and requiring core components that allow for personalized education, making it easier to meet the differing demands of each specialty and provider role. This could include adding unique modules and courses for learners at all levels of training and across fields.

Insight 4: Hospital Architecture, Security Measures, and Compliance Are Meant to Ensure Safety, but Instead Make Patients Who Have Experienced Trauma Feel Unsafe, Undermining the Goals of TIC

Providers described a fundamental tension between hospital safety requirements and the goal of making patients feel safe. One interviewee described how the physical layout of hospitals, from security checkpoints to locked entry points, and a uniformed police presence, can mirror environments associated with incarceration, creating a sense of threat for patients before care even begins. While providers recognized that law enforcement presence is sometimes warranted given safety risks, they also acknowledged that it introduces an inherent contradiction in a space meant for healing, particularly for patients whose histories include negative interactions with law enforcement. Rather than defaulting to security personnel, providers called for greater investment in de-escalation approaches that address the root of patient distress. This tension extended into clinical decision-making as well. Providers described situations in which standard hospital protocols were applied without consideration of a patient’s trauma history, such as the use of restraints on a patient with a documented history of sex trafficking or incarceration. Together, these dynamics place providers in the difficult position of navigating between institutional compliance and their commitment to TIC.

Design opportunity 4: Create physical hospital environments that balance structural requirements, security, and compliance with trauma-informed design principles to ensure a psychological sense of safety for patients.

A third of participants remarked in their interviews that to prevent retraumatizing patients, it is essential to have surroundings where both providers and patients feel safe, highlighting how TIC can be built into the design, structure, and regulations of the environment as well.

Insight 5: When Translation Is Inconsistent or Lacks Cultural Nuance, Providers Struggle to Build Trust and Worry They Are Delivering Lower-Quality Care to Non–English-Speaking Patients

Language and cultural barriers emerged as a source of stress for providers, complicating their ability to build trust and ensure that patients fully understood their care. Providers noted that even when translation services were used consistently, they did not always result in genuine mutual understanding between patients and providers. Interviewees highlighted that cultural understanding is not always guaranteed when using these services and that, without sufficient time, it becomes more challenging to build trust and communicate clearly. Due to the heightened time constraints associated with using translators, many providers shared their discontent with the quality of their appointments, expressing that they felt they were providing suboptimal care to patients who speak languages other than the providers’ own.

Design opportunity 5: Enhance the quality and consistency of translation services to help providers deliver clear, compassionate, and patient-centered care to non–English-speaking patients.

Overall, providers emphasized in their interviews the difficulty and importance of holding nuanced care conversations with non–English-speaking patients to account for the emotional, psychological, and cultural elements that are essential to build the trust required for TIC. Interventions should be designed to address these communication gaps between providers, translators, and patients to foster stronger relationships and improve collaboration.

Insight 6: Providers Earn Patient Trust Through Involving Them in Their Care, but Medicine’s Hierarchical Structures Can Impede This Trauma-Informed Approach

The hospital experience can be disorienting for patients, who often find themselves distanced from their sense of control, comfort, and familiar coping mechanisms. Providers described how simply acknowledging this discomfort can be a foundational step in building trust and creating space for collaboration. Providers noted that when patients are treated as active participants in their own care rather than passive recipients of it, they are more likely to engage with and follow through on their care plans. However, structural barriers consistently undermined this approach. One provider described, for example, a culture of deference within hospital hierarchies that discouraged staff from questioning decisions even when doing so was in the patient’s best interest. Another interviewee described a system too rigid to accommodate meaningful patient input, one that defaulted to talking at patients rather than with them, and limited the kind of shared decision-making that TIC requires. These examples point to a broader disconnect between what providers recognize as effective, trust-building practice and what the current structure of hospital care allows them to do.

Design opportunity 6: Integrate diverse team viewpoints to address patient concerns and foster improved communication and stronger relationships.

Relationships between patients and provider care teams require interventions that support ongoing communication and provide avenues for voicing opinions and concerns. Since TIC relies on a team-based approach, fostering these relationships will enhance its efficiency and implementation.

Insight 7: The More Deeply Providers Care About Their Patients and Mission, the More Likely They Are to Struggle to Sustain Their Sense of Purpose Over Time in High-Demand Safety-Net Settings

Ten (56%) providers described choosing to work at this safety-net hospital as a deliberate values-driven decision, motivated by a belief that quality health care should be accessible to everyone regardless of their financial or social circumstances. For some, this commitment was deeply personal, rooted in their own experiences of loss, inadequate support, or systemic failure, and shaped by a determination to ensure their patients did not experience the same. Yet sustaining that commitment has come at a significant cost. The emotional weight of the work, compounded by institutional barriers that discourage advocacy and resist change, has prompted some providers to consider leaving. One provider described how attempting to address these issues from within had at times led to conflict with hospital administration, making an already difficult environment even harder to navigate. Together, these experiences reflect a deeper tension between the passion that draws providers to this work and the conditions of a system that too often fails to sustain them within it.

Design opportunity 7: Create systems and support structures that help providers at safety-net hospitals sustain their sense of mission and commitment to public health, despite the demands of patient care.

Interventions that help sustain the drive and morale of safety-net hospital workers include methods that support providers in furthering their interests in the field of public health and offer recognition for the work they do.

Discussion

This study demonstrates that the successful implementation of TIC in acute care settings is not limited by provider willingness, but by structural conditions that constrain their ability to incorporate TIC into clinical care. Time-pressured workflows, insufficient staffing, productivity-driven priorities, and limited access to tailored training collectively create an environment where TIC is difficult to operationalize, even when providers recognize its importance. These constraints contribute to and are exacerbated by burnout and unaddressed moral distress, further reducing providers’ capacity to consistently deliver TIC. In response, many clinicians rely on personal intuition and prior experiences rather than formal training, highlighting a gap between institutional preparation and real-world demands. Additionally, features of the care environment such as rigid protocols and security presence may inadvertently undermine patients’ sense of safety, directly subverting the goals of TIC. Despite these barriers, providers consistently express a strong commitment to their patients and communities, suggesting that effective solutions must align system design with this intrinsic motivation to enable sustainable, trauma-informed practice.

These findings highlight a self-reinforcing cycle in which exposure to patient trauma and moral distress diminishes providers’ capacity to deliver TIC, thereby contributing to further patient trauma and adversely affecting patient outcomes. Repeated exposure to patient trauma can lead to secondary traumatic stress among providers, reducing their ability to consistently deliver compassionate, TIC [21]. The tension between providers’ strong desire to deliver TIC and the real-world constraints that prevent them from practicing in alignment with their values results in further moral injury, which is a critical and underrecognized barrier to TIC [22]. The resulting threats to workforce wellbeing constitute a patient safety concern, as they are associated with decreased quality of care, increased medical errors, and reduced patient satisfaction [23]. Collectively, these findings underscore that workforce wellbeing and TIC are essential and interdependent, serving as foundational prerequisites for the delivery of safe, equitable, and TIC.

These findings also demonstrate how the unique context of high-acuity, team-based emergency surgery amplifies known barriers to TIC implementation. The need for rapid decision-making and tightly coordinated multidisciplinary care intensifies the tension between efficiency and human-centered care, making consistent application of TIC particularly challenging [24]. The trifecta of burnout, inadequate support, and structural barriers undermines the reliable integration of TIC principles in high-stakes surgical care, at a time when patients are especially vulnerable to trauma.

Despite these challenges, the foundational goals of TIC, originally developed to recognize and respond to trauma, remain highly relevant given the pervasive prevalence of trauma [1]. A trauma-informed approach is particularly critical in FQHC settings, where patients are disproportionately affected by prior traumatic experiences [3]. Although neither safety-net hospitals nor TIC alone can resolve structural inequities in health care, both are grounded in a shared commitment to advancing health equity and ensuring access to compassionate, patient-centered care.

While our data provide valuable insights, it is important to acknowledge limitations in our study design. The scope of this study only included participants from one FQHC in California. Our study population was recruited primarily through participant referrals, which limited our ability to obtain a sample that reflects the full diversity of the hospital’s occupational demographics. This may reflect self-selection bias inherent to voluntary recruitment methods, as individuals with a preexisting interest in TIC may have been more likely to participate. Additionally, our sample included a substantial proportion of attending physicians. While trainees and other providers are often more directly involved in the initial management of trauma patients, attending physicians play a key role in shaping departmental culture and the adoption of trauma-informed practices. Future studies should incorporate more trainees in their study populations to better understand frontline implementation. Our data may be transferable but not generalizable to other hospital systems, as health care providers’ experiences may vary across different geographical locations and workplace environments.

Future work will also focus on understanding the perspectives of patients receiving treatment from acute care surgery teams, gathering data on their perceptions of how TIC is delivered in the hospital setting, and identifying which support systems enhance this type of care. Using data from both provider and patient perspectives will enable a more holistic understanding that will allow future researchers to develop prototypes to further improve TIC implementation in FQHCs. By understanding this context, we can gain valuable insights into how to improve the effectiveness and accessibility of TIC, thereby creating the steps necessary to begin the next stage of HCD, the ideation phase. In this phase, prototypes will be developed to address these issues, ultimately improving patient outcomes and fostering a more supportive health care environment.