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Why Creating a Trauma-Informed Environment is Crucial to Helping Traumatized Nurses Heal

Analysis  |  By Carol Davis  
   October 18, 2021

Without appropriate trauma support, nurses will continue to flee the profession, researcher says.

Nurses are struggling so much with their own psychological stress and trauma from the harsh effects of the COVID-19 pandemic and the conditions it has caused, that their hospitals and health systems must provide the necessary support to heal, a trauma researcher says.

But they can't do it alone.

Leaders are called upon to step up and to really be aware of this, to familiarize themselves with the literature on being trauma-informed individually as a leader, as well having an organization be trauma-informed," says Karen J. Foli, PhD, RN, FAAN, an associate professor and director of the PhD in Nursing program at Purdue University School of Nursing

Providing a supportive environment

While it is critical for traumatized nurses to recover and establish resiliency, doing so requires support by hospitals and health systems, Foli says.

"There's such a drive right now … to cultivate nurses being resilient individuals, and that isn't necessarily wrong, but it is not the complete picture," Foli says. "For a nurse to be resilient, she or he has to have an environment that will support not only establishing resiliency, but the maintenance of resiliency. But when you have conditions that are ripe for psychological distress and or trauma, resiliency is very hard to cultivate."

For nurse and hospital leaders to help their nurses handle and heal from trauma, they must create a trauma-informed culture.

A trauma-informed program, system, or person has a knowledge and understanding of trauma and its far-reaching effects, which, in some nurses is caused by seeing patients die; tending to patients who can't get relief from symptoms; patient and family aggression; feeling overextended because of inadequate nurse-to-patient ratios; frustration; and helplessness, according to the study, Secondary Posttraumatic Stress and Nurses’ Emotional Responses to Patient’s Trauma published in the April/May 2017 issue of Journal of Trauma Nursing.

"In terms of mental health resources, it's not a one-and-done thing," Foli says. "I spoke at Kaiser Permanente a couple of years ago, pre-pandemic, and nurses were saying, 'You know, it's great to have a quiet room, it's great to have aromatherapy, but it's not enough.' If you have a cumulative distressing environment where there are few resources or little awareness of what's going on and what nurses are experiencing, you're going to have these nurses leave the workforce and that's what we're seeing."

Indeed, 22% of nurses indicated in a recent McKinsey survey that they are considering leaving their current position of providing direct patient care.

Of that 22%, some 60% said they were more likely to leave since the pandemic began because of such factors as insufficient staffing, workload, and the emotional toll, according to the survey.

Creating a trauma-informed environment

Creating a trauma-informed environment begins by asking the right questions and listening, Foli says.

"[Leaders] have to be trauma-informed in what they ask," Foli says. "For example, one of the ways to find out what's going on is to ask, "What happened to you?" versus "What is wrong with you?" There's a big difference in how we phrase those two questions, with the latter inferring that it's more or less your fault."

If hospitals and health systems don't address trauma, nurses will continue to leave the profession in droves, further contributing to the worsening staffing shortage, Foli says.

"Resiliency is a very complicated concept and if you look at the literature, some would argue that there's perhaps a familial or even a genetic predisposition for some of us to be resilient," she says. "But regardless, when you talk about nurse resiliency, again, it puts the burden or the responsibility on the individual nurse when in fact, the whole organization really needs to look at what they can do to support resiliency."

The 3 'E's' of trauma

Unaddressed trauma can significantly increase the risk of mental and substance use disorders, along with chronic physical diseases, but with proper support and intervention, people can overcome traumatic experiences, according to the Substance Abuse and Mental Health Services Administration (SAMHSA)—the agency within the U.S. Department of Health and Human Services with the mission to reduce the impact of mental illness and substance abuse.

To provide a framework for treating trauma, SAMHSA created a concept it calls The Three 'E's" of Trauma:

Events—Circumstances that may include the threat of physical or psychological harm. These could include violence, natural disasters, or pandemics. Such events may occur once or repeatedly over time.

Experience—An individual’s experience of these events determines whether it is a traumatic event. A particular event may be traumatic for one, but not for another.

Effects—Long-lasting adverse effects of the event are a critical component of trauma. Effects may begin immediately or be delayed, and the duration can be short- or long-term.

"If there was ever an organization that included trauma, with or without a pandemic, it's a healthcare organization," Foli says. "Your patients are in crisis because they're there for life-threatening or life-saving treatments [and] we as nurses, who are rendering care to these vulnerable individuals through our empathy and our caring, co-exist and co-live that trauma with them. Nurses that have that empathetic caring nature will have that secondary traumatic stress, so it's in the air we breathe."

But understanding trauma is not enough to successfully treat it, according to SAMHSA, so it created a trauma-informed approach, which is based on a set of four assumptions and six key principles.

The four assumptions—also known as "The 4 R's"—are described by SAMHSA in this way: "A program, organization, or system that is trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; and responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization."

SAMHSA's six key principles of a trauma-informed approach are:

  1. Safety
  2. Trustworthiness and transparency
  3. Peer support
  4. Collaboration and mutuality
  5. Empowerment, voice, and choice
  6. Cultural, historical, and gender issues

"It's really a time of upheaval in the nursing profession," Foli says. "There are ways we can make it better for nurses, but until there's this awareness that these environments are ripe for trauma and that their support have to be given to nurses as professionals, then we will come up short."

“If you have a cumulative distressing environment where there are few resources or little awareness of what's going on and what nurses are experiencing, you're going to have these nurses leave the workforce and that's what we're seeing.”

Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.


22% of nurses are considering leaving the workforce because of working conditions.

Being trauma-informed means understanding trauma and its far-reaching effects.

Adequately addressing trauma in nurses is the duty of hospitals and health systems.

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