Simple nurse actions can ensure patients feel safe and empowered.
- Trauma-informed care is a core component of nursing practice.
- Nurses must implement universal strategies to prevent retraumatizing patients.
- Nursing school curricula should include education about trauma.
Childhood trauma (adverse childhood experiences [ACEs]) can result in severe mental and physical consequences that reverberate throughout a person’s life. Despite the widespread occurrence of ACEs, most nurses remain unaware of their long-term, negative effects. Many nursing tasks—touching a patient’s body, asking questions about past sexual history or abuse—can trigger retraumatization. If you routinely implement trauma-informed care (TIC), you can help reduce the risk of re-traumatizing patients. (See About trauma.)
The prevalence of trauma requires screening of all patients in all healthcare settings. Universal trauma screening increases the chances of a patient reporting their trauma history. According to Palmieri and Valentine, 82% of sexual assault and intimate partner violence survivors would report a traumatic event with appropriate screening measures; whereas, only 24% would disclose their trauma history if not properly screened. Many patients may not disclose trauma information out of fear of retraumatization. Proper screening can help patients feel more comfortable and provide them with the support they need.
However, trauma screening doesn’t occur during most healthcare visits and a substantial amount of trauma history goes unnoticed. This lack of screening and education about the importance of TIC makes nurses’ bedside behavior critical to preventing patient retraumatization.
Trauma and the brain
Trauma’s main effect on the brain involves the hippocampus (the memory center), the amygdala (the fear center), and the prefrontal cortex (the center that regulates emotions and controls functions). They work simultaneously to manage stress. When an individual thinks about a past traumatic event, the amygdala is activated while the prefrontal cortex is suppressed. This results in the body being overcome with fear but unable to control the feeling.
As the brain’s memory center, the hippocampus also is responsible for distinguishing between the present and the past. When having a traumatic thought, the hippocampus becomes less active, and the brain can’t distinguish between actual trauma and a memory. The brain perceives the memory as an actual threat, placing it in an elevated alert state, and making the person feel trapped in their own, never-ending emotions.
The effects of ACEs can manifest throughout an individual’s life, from childhood through adolescence and into adulthood.
Childhood trauma increases the risk of developing psychological distress, anxiety, and depression. These conditions can present as physical symptoms (stomachaches, headaches), disruptive behavior (including unexplained anger), lack of focus, obsessive worrying, irritability, sleep disturbances, and appetite changes. The effects of trauma make it hard for children to form and maintain relationships with peers and may prevent them from succeeding in school. Some children can move into adolescence without any effects from their past trauma, but most experience several challenges.
For adolescents, childhood trauma may remain a constant and disturbing memory that leads to depression and anxiety. They may find it hard to talk about their past trauma because they can’t trust others or they feel different from those who haven’t had similar experiences. Some adolescents suffer from post-traumatic stress disorder (PTSD), and most don’t receive the treatment they need.
Adolescents may use drugs or alcohol to repress traumatic memories. Substance use disorders among adolescents are linked to higher rates of school failure, a lack of social skills, low activity participation, memory-related issues, increased suicide rates, liver dysfunction, and death from alcohol poisoning.
In addition, traumatized adolescents may exhibit reckless behavior, such as driving carelessly, having unprotected sex with multiple partners, and participating in violent activity. All of these behaviors can result in life-changing outcomes, including sexually transmitted infection, pregnancy, incarceration, physical injury, or death. Campbell and colleagues state that female adolescents who are sexually victimized have substantially higher risks for sexual or physical abuse in adulthood. Although the percentage of sexual abuse remains higher in females, the risk for experiencing abuse in adulthood also increases when a male has been sexually abused as a child.
Adults who’ve experienced childhood trauma have higher risks for depression, anxiety, and PTSD. Adolescent risky behaviors may worsen, and substance use disorder may become more prevalent. Increased behaviors in adulthood amplify the risk for their detrimental consequences.
Some adults may not display the typical behavioral signs of distress; however, repressed trauma may manifest in conditions that require medical attention, including asthma, severe migraines, depression, pulmonary disease, obesity, cancer, and inflammatory diseases. Those with past trauma also are significantly more likely than those without to seek mental and physical healthcare later in life.
By taking a TIC approach, you assume that all patients have experienced past trauma and tailor your behavior to prevent retraumatization. TIC emphasizes physical, psychological, and emotional safety. It creates opportunities to rebuild a patient’s sense of control and empowerment by ensuring they feel safe and comfortable, respecting personal space, using nonthreatening body language, paying attention to patient cues, and communicating clearly. TIC promotes an environment of healing by reducing distress and providing emotional support and resources. (See 5 key ingredients of TIC.)
Reducing the risk for retraumatization
Retraumatization occurs when an individual consciously or unconsciously re-experiences a previous trauma, which can be triggered by a similar environment, a smell, an image, a new relationship that mimics a previous one, or a healthcare visit. Everyday nursing actions can help reduce the risk for retraumatization. For every patient interaction, introduce yourself and explain your role, use open and nonthreatening body language, assure patients that you’ll protect their privacy, and describe care and assessments, especially before touching the patient. Always use clear, simple explanations for discharge and treatment instructions, as well as teach-back to confirm patients understand. (See Preventing retraumatization.)
Enhance patient safety and comfort
Frequently, universal trauma screening isn’t implemented during patient encounters, making bedside TIC crucial to ensure patients who’ve experienced trauma feel safe. Consistent trauma screening for all patients, trauma and TIC education implemented in nursing education curriculum, and workplace retraining can help healthcare providers better understand the effects of ACEs and enhance patient comfort, safety, and sense of control during healthcare encounters.
Ally Buettel is an RN at NYU Langone Health in Mineola, New York. Marissa D. Abram is an assistant professor at Adelphi University College of Nursing and Public Health in Garden City, New York.
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Key words: trauma-informed care, adverse childhood experiences, trauma-informed nursing