Trigger warnings as tools for learning—theorising an evolving cultural concept

While definitions of trigger warnings vary, it is generally accepted that they caution about potential reactions arising from exposure to distressing material. Controversy surrounds use of warnings in education, with concerns noted regarding impacts on academic freedom, “coddling”, thereby undermining resilience, reinforcement of traumatised identity and enablement of avoidance. Proponents of warnings position them as accommodations for those affected by trauma, enhancing inclusion, and suggest warnings empower choice and enable informed engagement in learning. A recent meta‐analysis of warnings' efficacy demonstrated no effect on affective responses or comprehension. Findings regarding avoidance suggested warnings may increase engagement with material. Synthesis of heterogeneous results relating to context of warning application necessitates cautious interpretation of findings. Furthermore, controlled experimental designs do not reflect complex ecologies of social learning environments.


| BACKGROUND
Current operational definitions of trigger warnings vary considerably. 1,2This variation notwithstanding, it is generally accepted that 'trigger warnings' caution about a possible reaction arising from exposure to material.Reactions anticipated usually include intense physiological and psychological symptoms associated with posttraumatic stress disorder and other psychological conditions.These advisories are considered to have originated online, in feminist blogs, and were particularly associated with sexual trauma before being applied more widely, both in relation to content-type and media form. 3'Content warnings' are noted to characterise the nature of sensitive content. 2,4This term has confusingly been used as both an umbrella term, with trigger warning being considered a sub-type of content warning but also as an evolutionary term for trigger warnings themselves due to concerns about acceptability of such a term.[7] Since the adoption of trigger or content warnings on university campuses and education settings, controversy and debate have abounded, influenced in part by the variance in definition and understanding of their role.This debate has played out on social media and news outlets and in scholarly literature, in both academic opinionbased articles 8,9 and, increasingly, empirical research evidence. 1Seen by some as threats to academic freedom and free speech and as tantamount to censorship, 10,11 their presence, according to some, connotes 'coddling'6 of the 'snowflake generation', who are described as unwilling to engage with thoughts and ideas incongruent with own beliefs and likely to cause cognitive dissonance. 10Provision of warnings has been positioned as further facilitating anything from avoidance and escapism in the face of intellectual challenge 12 to enablement of 'narcissistic' behaviours. 10Longer-term concerns have included impaired resilience and compounding identities of victimhood, 12,13 with experimental evidence demonstrating that trigger warnings can reinforce centrality of trauma to identity. 14spite these publicised concerns, review of evidence from a range of academic disciplines suggests that learners often support judicious use of warnings, 1 and educators have described applying this approach. 1,15,16Proponents position warnings as an accommodation for increasing inclusivity in learning settings, 1,3,[17][18][19][20][21] by making reasonable adjustments for those with trauma histories.Far from enabling avoidance, they instead empower choice and safe, informed engagement 4,17,18,22 and encourage reflection.Warnings support gradual exposure to distressing and graphic content, as learners' coping matures, and readiness increases over time. 15,23Viewed as a concession for social justice, warnings may enhance accessibility and encourage student engagement, thereby creating more equitable learning environments. 17is debate or 'trigger warning war' 24 has become characterised by its failure to establish consensus in relation to definition, remit and function of warnings.Researchers have called for additional empirical studies on the effects of warnings and the conditions under which benefit or disbenefit accrues, so as to inform pedagogical approaches and policy 4,6,25 and to overcome this current deadlock. 17,25As a relatively recent entity in higher education, systematic reviews of the role and functions of warnings are just starting to emerge. 2,4,6Evidence in relation to warnings in healthcare professions education, a disciplinary context that regularly exposes learners to potentially-distressing subjects, remains limited. 15,23,26Evidence in relation to warnings' across other disciplines, including arts, humanities and social science 7,10,18,22,25 may aid in informing healthcare education practice.
Arising from recent scholarly work undertaken to explore the roles of trigger warnings in classroom-based healthcare education 15,26 and in response to student evaluative feedback, we have familiarity with current literature in relation to trigger warnings and trauma-informed pedagogies in higher education more generally, and this informs our narrative literature review.Seminal papers or those that we have personally identified as influential in developing and preparing our previous research 15,26 including both original research papers reporting empirical evidence and academic opinion pieces 3,17,27 were reviewed.
Two recently published systematic reviews in this area 4,6 and a previously published content analysis of online comments in response to higher education articles on trigger warnings also informed this work. 1tation chaining, the process of searching for sources cited by papers already identified and also considering sources that cite identified papers, was undertaken to identify other relevant papers.Keyword alerts for terms including 'content warning' and 'trigger warning', via Google Scholar, enabled timely identification of newly available publications including journal articles and book chapters that could inform this narrative thread whilst work was ongoing. 28This paper is therefore a contemporary critique and synthesis of this evidence base.

| Evidence for the efficacy of trigger warnings
Efforts continue to establish-or disestablish-evidence for efficacy of trigger warnings in relation to impacts on recipients' psychological reactions.A recent meta-analysis combined evidence from 12 experimental studies of the comparative impacts of warnings (vs control). 6tcomes assessed include self-rated positive or negative emotions, anxiety, intrusions, physiological responses and avoidance behaviour in response to the warning itself (i.e., anticipatory affect) or the 'warned about' content (i.e., response affect). 60][31] Pooled outcomes demonstrated no effect on response affect or comprehension.A counterintuitive increase in anticipatory affect (i.e., participant affect measured after receiving a warning, but before exposure to the relevant stimulus) was observed.There was no increased tendency to avoidance, and, in some cases, a counterintuitive increase in engagement with material was noted.Short-term responses, generally over a single timepoint, were measured.Across pooled studies, participants included are often those from non-traumatised populations, and studies did not consistently consider differences among particular subgroups or according to trauma history.

| Evidence for efficacy aligned to education contexts
Although a small number of studies in this review appeared to evaluate warnings as a general 'community-based clinical intervention for emotional well-being', 14 several others appeared to reference learning conditions, demonstrating focus on the increasing use of warnings in learning settings.Experiment tasks or stimulus material 31 were chosen to reflect curricular content, 5,32,33 or study participants reflected student populations. 6,31Findings from studies that were educationally situated suggest warnings have neutral effect 14,31 or decrease tendency towards avoidance 33 and that warnings only slightly improved comprehension.Synthesis of heterogeneous results in relation to context of warning application requires cautious interpretation of findings.A further consideration not explored is that of recipients' intention and motivation in a learning context.Current methodologies fail to expose the impact of these motivations and intentions in learner recipients' response to warnings, it being plausible that learner motivation mediates impacts of warnings.

| Limitations of the evidence; generalisability to social learning contexts
Although controlled settings are necessary for experimental studies, these are not reflective of social learning environments, 7 thus compromising ecological validity, 33 that is, the applicability and generalisability of results to real-life settings. 34Researchers, while discrediting a therapeutic role of warnings, concede that educators may choose to employ warnings for other reasons not investigated by them. 5,6Warnings-and any conclusions derived-are detached and decontextualized from the wider social context, learning environment and relationships therein. 6,7In assessing efficacy, actual performance within the complexity of real-world learning settings and learners' needs and appreciation of warnings, that is, effectiveness, 35 may be overlooked.Current evidence does not suggest warnings have significant deleterious effects and that they may enable engagement by some traumatised populations.However, failure to consider learner motivations and other impacts of learning environments and challenges of interpretation of heterogeneous studies necessitate contextualised reconsideration of impacts.

| The context of healthcare education
A systematic review exploring a typology of warnings acknowledges their inconsistent application and highlights that frameworks in different sectors have evolved organically and often in disciplinary, legal, and geographical silos. 2 Sectors and disciplines assert individual assumptions and priorities.Researchers note that in the arts sector, provocation arising from works is valued and intended, and here, warnings support optionality.Contrast this with healthcare settings where desire and responsibility to reduce patient harm associated with potential retraumatisation or 'triggering' those with trauma, histories prevail. 36We assert that needs in healthcare education and training contexts are subtly different still.In professional programmes of study, optionality is reduced to enable acquisition of core competencies.Furthermore, less perceptible learning environment features and pedagogies, including accommodations towards wellbeing, inclusion and social justice, contribute powerfully to belonging and professional identity formation of healthcare professional learners. 37,38evalent pre-existing trauma experiences among healthcare learners are recognised, 39,40 and healthcare learners also come from increasingly diverse and traditionally under-represented backgrounds. 41,42Risks of primary and vicarious traumatisation are recognised and unavoidable in healthcare education. 43,44Recent experiences from the global pandemic have expedited acknowledgement of secondary traumatisation as an entity experienced by healthcare professionals. 45To support preparedness for prevalent, pervasive trauma-related issues in professional practice, traumainformed competencies for medical education have been defined. 46In this context and in recognition of learners' holistic developmental needs, including skills for professional self-care, warnings have been proposed as teaching tools for enhancing awareness and understanding of trauma. 15,23,47 discussed, a significant reservation regarding the role of trigger warnings relates to that of learners 'acting in bad faith' 48 and exploiting trigger warnings to selectively avoid challenging content. 1,10,49en examined, this hypothesis does not appear to be supported.
Research among educators 15,18,50 and students 7,25,26,51,52 from various disciplines finds limited evidence of this behaviour, demonstrating that blanket avoidance of subjects is not the primary educator intention or student expectation relating to warnings.Neither is there evidence of desire for omission of topics from syllabi. 7,26,51Spencer and Kulbaga argues that the limits of acceptable speech have already extended considerably, inviting discussion of diverse topics not previously considered suitable for examination in classrooms. 17In the context of healthcare education, including the wider societal expectations of healthcare professionals, issues affecting minoritised groups, inequities and abuse are increasingly explored. 27Of great concern to both educators 12,15,18 and students, 7,23,25,26 was the fact that compared with controlled classroom settings, in unpredictable professional (clinical) environments, avoidance and selective engagement would not be possible.Whereas some learners expected unmoderated, authentic experiential learning, in readiness for future practice, others elsewhere identified that warnings facilitated engagement, 15,25,48 by enabling learners' self-preparation and establishing an appropriate mindset.
Here, consideration of the timing and circumstances of engagement with distressing content was recommended, particularly in respect of designated learning settings, which were anticipated by learners as safer and more nurturing and learner-centred compared with workplace settings.

| Wider roles of warnings
Experimental efforts to derive empirical evidence for warnings appear reductive when applied to multifaceted social ecosystems where professional learning and identity formation occur.Some researchers have not provided initial definition of trigger warnings to enable identification of participants' own constructs and authentic responses regarding the potential role of warnings. 15,23For some, warnings convey an important organisational signal regarding the value of self-care and learner wellbeing. 1,4,7,8,15,17,26,47Wider pedagogical benefits include enhancing awareness of trauma and empathy development among those not directly affected by trauma-related issues. 17,50We argue that the value of warnings may lie in their use as tools to support safe engagement within the learning environment, both at the level of the individual learner, and in enhancing observed organisational culture.We consider both trigger and content warnings, characterised by their intent to support recipient informed self-preparation for distressing content 6 and to enhance inclusion in learning, and we capture these under the collective term 'warnings'.We acknowledge that formats of forewarnings vary 2,6 and endorse specification in their construction, for example, conveying acceptance of responses and reinforcing importance of pursuing wellbeing, 15,17,47,53 to enhance their utility.In the following discussion, building on suggestions from Bryce et al, we review theories of adult learning salient to healthcare professional education and conditions recommended for professional learning. 4Reflecting on the evidence presented earlier, we consider how warnings may be applied and function within these theoretical frameworks to promote effective learning.

| Learner participation, meaningful engagement
Knowles's principles of andragogy describe a guiding premise for adult learning. 54Knowles gave primacy to the role of the independent adult learner and underlined the importance of their direct participation in the learning process, including in identifying own learning needs and ways to independently address these.Experiential learning requires engaged presence in a concrete experience, in which the learner is actively involved. 55A key requisite for learning is the learner's ability to perceive and attend to a relevant internally or externally generated stimulus. 56,57Critical reflection underpins the experiential learning process that is initiated only by this active participation and engagement.The learner reflects during, as well as after the experience, allowing interpretation and integration into existing knowledge and generation of new knowledge.Educators and learners both have rationalised the use of trigger warnings as promoters of active participation in planning for and engagement in learning. 3,15,17,20,25,26,58In their systematic review, Bryce et al identify learning settings where trigger warnings enable safe and informed active engagement. 4ncerns regarding selective avoidance and non-participation are discredited in a number of studies, as discussed earlier.Warnings are means to confer a degree of control and ownership of the learning process, fundamental principles in andragogy 54 and socially constructivist learning, 59 and they alert the learner to reflect on their needs in a given context and on how to address or manage these.

| Self-directedness through incremental exposure
Underlying these learner-centred participatory models of adult learning is self-direction.Self-direction in learning has been categorised as both a personal trait and an ability, which may be situationdependent 60 and which on first pass appears to be at odds with the notion of educators forewarning of troubling subjects.Candy identified three features of self-directed learning: autonomy, autodidaxy (self-led learning) and learner control. 61Within this framework, Grow sees self-directed learning as indicative of the degree of choice that learners have within a learning situation. 60This assertion is reminiscent of discussions of choice, agency and empowerment conferred through the use of warnings. 1,4,8,18,22,26Here, warnings respect learner autonomy, promote involvement and signal acceptance of differential learner needs and responses.Grow describes four stages through which learners gradually (though not necessarily linearly) transition, before finally developing self-directedness.Throughout this graded process, the importance of accessible scaffolding is noted by both Candy and Grow. 60,61Graded approaches to use and withdrawal of trigger warnings have emerged as key considerations in how they are practically operationalised and effectively used, 15,26 often in the context of spiral curricula. 62Incremental exposure to, and exploration of, troubling subjects indicates the potential for change in readiness for learning. 23,51Learners desire safe exploration of these issues, allowing acquisition of abilities and skills to manage them. 7,26,51Medical educators consider the medical school environment as 'a halfway house', 15 where warnings can be used during early exposures to distressing content, as an interim measure while students develop self-regulation and coping skills.Medical students noted that in under-taking a journey to professionalisation, learners commence as novices, with the ultimate aspiration of acquiring incremental professional preparedness.Here, warnings could accommodate individual needs.These temporary dependencies need not be considered pedagogically destructive. 63Transformative learning too is characterised by changed readiness via movement through a 'cumulative' series of phases by an individual, and here, change is noted as a factor of time and other developments in the individual's life and the readiness of the individual to engage in critical reflection. 64

| Perspective transformation towards humanistic professionalisation
Cognitive, constructivist and social learning theories have all been applied in elucidating the development of clinical learners to becoming novice clinical professionals. 65This professional transition and development have also been conceptualised as a transformative process. 65,66A uniquely adult learning theory, grounded in human communication, transformative learning theory emanates from the work of Mezirow, taking account of other established learning theories. 67,68Transformative learning theory has been explored in a range of disciplines 69 and has assumed a place as an influential construct in contemporary healthcare education. 66Transformative learning challenges students to assess their values and perspectives, through critical reflection, and requires both intentional cognitive and affective action. 66,69Learning is understood as the process of using a prior interpretation upon which to develop a new or revised understanding of one's experience. 70,71Perspective transformation is affected through occurrence of a critical event, which is shaped by context and reflection, resulting in changed meaning.Learners are subsequently transformed by the experience, leading to new ways of being in the world. 66,72

| Creating conditions for transformative learning and how warnings support this
Transformative learning requires experience at its essence, followed by critical reflection and rational discourse. 73Transformation requires the occurrence of a troubling, or at least stimulating, event, where the experience is at odds with one's established frameworks for understanding and encourages examination of alternative perspectives and critical reflection on these. 69Taylor highlighted the need for learners to engage in 'intense shared experiential activity', 72 occasionally termed a 'disorienting dilemma'. 67This experience may be one curated by the educator or incidental to the learning environment, or may be a felt experience, unique to the learner and situated in own biography.In addition to major episodic or 'epochal' dissonance, progressive or 'cumulative' series of events can also produce shifts in perspectives. 65Such experiences and the resulting discourse create relevance and meaning to those involved.1][52] By using warnings during exposure to impactful subjects, educators supported students to prepare themselves and aimed to enable engagement and participation while still acknowledging and accepting that strong emotional responses can occur. 65,74e context in which learning occurs is also noted as significant for transformative learning.Contextual factors identified in individual studies include those pertaining directly to the learning environment and atmosphere curated by the educator. 73Critical reflection on experiences or 'dilemmas' is a precursory component of transformation and can be promoted by educators who are trusting, empathic and caring and through establishing a sense of safety. 72These conditions are notably manifested in arguments for using warnings. 15,17,26rsonal and social factors are also noted as playing an influencing role in transformative learning. 66Salient factors may include individual's current personal and professional context, as well as previous formative life experiences, including family and social history. 64,75e significance of these contextual factors is reflected in the rationale described by educators and learners for role of warnings, 1,15,17,26 where warnings were used to convey awareness, empathy and acceptance of different backgrounds and histories, and how these may be referenced directly or indirectly in the learning environment.

| Supporting transformative development
Establishing learner's preparedness for transformative learning experiences is required, and role of warnings in enabling self-preparation has been described earlier.The task then becomes to support the learner.Taylor cautions that support in the form of 'comfort' does not facilitate transformation, and he instead advises supporting learner's tolerance of discomfort and enabling recognition of learner's own narrative.Support in transformative learning can occur as 'validation' of learners' feelings. 70Beverly et al identified trigger warnings as indicators of respect and empathy for medical students, and in this way, warnings can serve as educator's 'confirmation' of students' feelings. 23Here, 'confirmation' refers to the transactional process by which teachers communicate to students that they are valuable and significant.Such confirmation enhances student participation, leading to greater cognitive and affective learning.Medical educators' use of warnings role-modelled empathy and sought to normalise and signal acceptability of emotional responses, 15,74 once again demonstrating parallels with professional development arising from transformative learning. 65,69The discussions that follow consider strategies and skills for coping with emotional responses.

| Ensuing emotional responses
In Mezirow's original works, the roles of rationality and critical reflection are emphasised, according to some, at the expense of focus on emotions intrinsic to the process. 76Learning through reflection requires returning to and reviewing experience, attending to the feelings evoked and re-evaluation and integration of the experience.Emotions drive processes of critical reflection, and thus, attention to harnessing and managing these is warranted.Rationality, devoid of emotion, does not support effective reasoning.Taylor highlights the role of emotions and affective learning as central to relational knowing and transformative learning.He quotes Mezirow's assertions that 'effective participation in discourse and in transformative learning requires emotional maturity, awareness, empathy, and control….[and]   knowing and managing one's emotions, motivating oneself, recognizing emotions in others and handling relationships-as well as clear thinking'. 70In order to develop critically reflective capacity, the learner must be able to recognise, acknowledge and process feelings and emotions as integral aspects of the learning experience. 73,77Emotions and feelings experienced by learners not only stimulate reflection, but also serve as the focus of reflection itself.In depth, exploration of feelings enhances self-awareness and changes in meaning making.Reluctance or refusal to engage with such feelings may inhibit learning, 66,70,72,78 particularly where unanticipated personal responses arise; whereas, processing emotional responses was noted to be therapeutic and enabling, by expanding the scope of critical reflection. 72Warnings may enable working with, and through sensitive subjects and emotions arising, students acquire necessary critical skills for future professions. 65,79

| Emotional literacy for transformative learning
Although considerable opinion maintains that adult learners can recognise and manage own emotional responses, 10,25,80 authoritative scholarly reviews of transformative learning highlight gaps in current pedagogical approaches.In their review of transformative learning for healthcare professions education, Van Schalkwyk et al reflect on the need for educators' sensitivity to students' potential emotional and cognitive responses and call for the provision guidance for managing such scenarios in supporting transformative learning. 66Taylor notes a paucity of knowledge on how to engage emotions in practice and in critical reflection, 70 identifying a need to address this gap and acknowledging the critical role of emotions.Here, he advocates for attention to emotional literacy and intelligence as additional strategies for fostering transformative learning. 73Emotional literacy promotes development of self-awareness and recognition of emotions, controlling emotional responses, understanding underlying causes, distinguishing feelings from actions and the ability to empathise.Selfknowledge and self-efficacy, and particularly greater mastery over oneself, were identified within a typology of transformative outcomes. 69These processes of recognising, accepting and learning to manage responses reflect those explored in narratives and rationales for use of warning. 4,15Wider purported pedagogical benefits included enhancing empathy for experiences of others. 17We propose warnings as tools for supporting emotional literacy, itself being a condition for fostering effective transformative learning.

| Acknowledging power differentials in the learning environment
Ensuring an emotionally secure environment presents a challenge of balancing the need to promote experiences that stimulate transformations in thinking and knowing, while still creating a safe, nonthreatening environment.Knowles's assumptions that all learners approach learning from similar contexts, 56 and Mezirow's assumed conditions overlook the 'distorting effect' of power in interactions 72 and thus may curtail rational discourse.Learners have previously described that educators are perceived to control session content, establishing a power differential between educator and learner. 7,26nsiderations of unspoken hierarchies and marginalisation is all the more relevant in increasingly diverse classrooms.This dynamic entrains a responsibility of educators to consider overt and implicit hierarchies and societal impacts beyond the classroom settings and how these all may impact learners' needs.Warnings have been positioned as tools for social justice. 17In discussing power differentials, warnings-supporting informed student approaches and actionswere proposed as a way of levelling hierarchies and redistributing power between educator and learner. 7,26The role and relevance of trigger warnings to theories of adult learning as explored in the preceding discussion are summarised in Table 1.These considerations, mechanisms and outcomes explored are depicted in Figure 1 as a conceptual model to position warnings as tools in learning.

| A conceptual model
Noting the limited authenticity and transactional nature of experimentally evaluated trigger warnings, we propose a conceptual model that brings together salient features of learning experiences and environments.In curating a learning environment and culture, a warning is provided to the learner, enabling informed engagement and active participation in an intense, experiential activity.With time, iterative and incremental exposure to content occurs.By considering and accommodating the learner, and explicitly valuing their wellbeing, an empathic and inclusive environment and ethos is created.The learner as an active and engaged participant may ultimately undergo gradual transformation, enhancing capacity for self-care, self-regulation and emotional literacy.

| DISCUSSION
In the preceding overview, we have reviewed what is currently known and practised relating to warnings in learning and applied this to a range of theories of adult learning, with particular emphasis on muchprized transformative learning.These suggested parallels remain tentative and exploratory.Authoritative and comprehensive reviews of learning frameworks have usefully informed learning practice and approaches; however, significant limitations in exploring widely interpreted entities such as transformative learning still frustrate definitive answers, for example, how to effectively engage emotions in transformative learning, learner's responsibilities in transformative learning and peripheral effects of this learning on others. 70Practical, pedagogical and ethical issues relating to eliciting and managing emotional responses in learning settings are unaddressed in established discourses.As a relatively recent entity in education, warnings and their purported and intended effects are still revealing themselves.We highlight substantial limitations in current experimental evidence for the efficacy of warnings, including synthesis of heterogeneous results relating to context of warning application and omission of possible mediating effects of recipients' intention and motivation in learning contexts.The application of warnings is not experienced uniformly. 25eir effects, although resistant to empirical measurement, may have relevance to these gaps in theoretical frameworks.
T A B L E 1 Theories of adult learning and the role and relevance of trigger warnings.

Adult learning theory
Role and relevance of trigger warnings

Knowles's principles of andragogy
Active participation Knowles's principles underline the importance of direct participation in the learning process.Neither educators 13,16,50 nor learners [23][24][25]51,52 view warnings primarily as mechanisms for avoidance. Educaors and learners rationalise the use of trigger warnings as promoters of active participation in learning.3,15,17,20,25,26,58 Warnings are means to confer a degree of control and ownership of the learning process, which are fundamental principles in andragogy.54 Self-directed learning Choice Self-directed learning is characterised by the degree of choice that learners have within a learning situation.60 This factor relates to discussions of choice, agency and empowerment conferred through use of warnings.Warnings demonstrate respect for learner autonomy, promote involvement and signal acceptance of differential learner needs.1,4,6,16,20,24 Graded exposure Although some learners expect unmoderated learning experiences, others identify that warnings scaffold and facilitate engagement by enabling selfpreparation.17,25 Warnings can support gradual exposure to distressing content, as learners' coping matures over time. Some learners desirsafe exploration of issues, allowing acquisition of abilities and skills to manage them.7,26,51 Educators view the medical school as a 'halfway house' where warnings are interim measures as students develop coping skills.15 Transformative learning 'Intense shared experiential activity' Transformative learning requires engagement in 'intense shared experiential activity'. 72y using warnings during exposure to impactful subjects, educators support students to prepare themselves while acknowledging and accepting that strong emotional responses can occur. 65,74This normalises such responses. 15,17,26nditions and contextual factors Learning context is significant in transformative learning and may include the learning environment curated by the educator 73 and individual's current and past personal and professional context. 64,66,75hese factors are reflected in the rationale for warnings described by educators and learners. 1,15,17,26Warnings convey awareness, empathy and acceptance of different histories, and how these may be referenced in the learning environment.

Supporting transformative development
Warnings convey an important organisational signal regarding value of self-care and learner wellbeing. 1,4,7,15,17,47upport in transformative learning is characterised as 'validation' of learners' feelings and empathy towards others. 70rigger warnings can indicate respect and empathy for students and can serve as educator's 'confirmation' of students' feelings. 23ducators described efforts to normalise emotional responses. 15,74

Emotional responses
To develop critical reflective capacity, learners must recognise and process emotions, as integral aspects of learning experiences. 73,77eluctance or refusal to engage with such feelings may inhibit learning. 66,70,72,78otional literacy Emotional literacy and intelligence are recommended to enable transformative learning.73 Emotional literacy promotes development of self-awareness, understanding underlying cause of emotional responses, distinguishing feelings from actions and empathic ability.Recognising, accepting and learning to manage responses are all explored in narratives and rationales for use of warning.4,15 Knowles's principles of andragogy, transformative learning

Acknowledging power differentials in the learning environment
Warnings are viewed as an accommodation for those with trauma histories and as a means for inclusion in learning settings, 1,3,17,[19][20][21] thereby creating more just learning environments. 17Learners perceive that educators control session content, establishing a power differential between educator and learner. 7,26Unspoken hierarchies are relevant in diverse classrooms.Educators should consider hierarchies and how these may impact on learners.Warnings are proposed as a way of levelling hierarchies and redistributing power between educator and learner. 7,15any scholars are at pains to distinguish between traumarelated responses and offence or discomfort. 48,81We too support this distinction, but we do so with awareness of recently emergent traumatic stressors including experiences of racism, inequalities and other collective traumas. 82Cebulla et al identified learner disquiet in relation not only to discussions of canonical traumas, but also in relation to social class and inequality. 7Concerns widely articulated include the impracticality of predicting all potential triggers.Researchers have cautioned that classrooms should not become proxy therapeutic settings 25,84 ; however, any presumed buffer between professional learning environments and 'the Outside World' proves to be ill-defined and far from impenetrable. 27Classrooms are never devoid of personal experiences and histories, despite educators' apparent obliviousness to personal relevance of the discussions they facilitate. 7,26Engagement with and reflection on experiences and emotions is intrinsic to many adult learning paradigms.With growing recognition of societal issues and their salience in health professional education, we posit that safe and supported discussion of challenging issues, including those with potential personal relevance to learners, should be promoted. 85,86Preparation and intentionality, through deployment of warnings by informed and skilled educators, can support learning here.
We have described how warnings may augment other learning strategies through enhanced preparedness for necessary engagement with content, processes (attending to stimuli, managing emotions) and responses.Burch et al suggest that resource is misappropriated in promoting warnings and would be better diverted to teaching critical skills. 10We suggest that these are not mutually exclusive scenarios.
We highlight the limitations of attempted disaggregation of rationality from emotions and assert that warnings can indeed support critical thinking.'Safe' classes have been reported as being more academically challenging, 87 where safety was conferred by the role-modelled characteristics of instructor, peers and the classroom environment and where students were secure in expressing honest opinions and listening to others and experienced greater intellectual challenge and stretch.Liberatory learning environments emphasise knowledge cocreation through learner and educator collaboration.This results in learner empowerment and encourages metacognition, reflection and development of trust and empathy. 85,88ylor concludes that truly fostering transformative learning requires more than perfunctory use of designated instructional strategies.In learning settings, warnings are contextualised by other supports (academic, peer and pastoral).As is noted, 4,7,17 warnings are not a silver bullet for navigating contentious subjects and emotional responses in professional learning, nor should they act as substitutes for wellbeing supports.Limitations associated with current evidence means it fails to truly illuminate the potential of warnings.Educator development and guidance should support awareness and empower F I G U R E 1 A conceptual model for the role of warnings in fostering effective learning and learning environments.[Color figure can be viewed at wileyonlinelibrary.com]educators to assess 'ecologies of their classrooms', and to identify the most aligned learning strategies.3,7Systematically implemented trauma-informed pedagogies, including informative forewarnings that encourage preparedness, inclusion and promote care of self and others, can create effective transformative professional learning environments.Where such pedagogies are promoted and embedded within learning environments, trauma-related impacts and concerns can be managed within an ethic of care that resists retraumatisation and supports strengths-based approaches, empowerment and choice.3,58AUTHOR CONTRIBUTIONS Helen Anne Nolan conceived and developed the idea for the paper, reviewed and summarised the extant literature, drafted the early versions of the manuscript and made subsequent critical revisions for important intellectual content.Lesley Roberts reviewed and advised on the study methodology, reviewed the early versions of the manuscript and made substantial contributions to the content and direction of the manuscript.Both authors approved the final version of the manuscript and agreed to be accountable for all aspects of the work including questions related to the accuracy or integrity of the work.