Awareness and organizational response

ALMOST ONE IN THREE nurses experiences a trauma-related mental health condition, according to Caruso and colleagues. Since the COVID-19 pandemic, the impact of mental health issues has gained attention; however, evidence in the nursing literature suggests that nurses have long experienced more trauma-related symptoms than the general population.

Ignoring the mental health of nurses has far-reaching implications not just for nurses, but also for patients and healthcare organizations. To avoid the negative consequences of trauma, nurses and their employers must understand what it is and how we can help ourselves and our colleagues recover after distressing events.

Trauma defined

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma as resulting from, “an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life-threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” The important elements of trauma include the event, the experience of the event, and the effects.

With physical trauma, we can clearly see the three elements and how they’re related. In a car accident, for example, you have a singular event with cars colliding. All passengers are present for the same event, but their experiences vary depending on several factors, including the type of car they’re in, whether they wore a seatbelt, and their previous health status. An infant properly restrained in a car seat in the back of one vehicle may have no injuries at all, while an unrestrained driver in the other vehicle may have critical injuries.

The same holds true for emotional trauma. We may all experience the same event, such as the recent COVID-19 pandemic, but our experiences vary. Some nurses, for example, may have had mental health challenges before the pandemic or may have worked on a unit with a greater likelihood of patient death or personal exposure to the virus.

The impact on bystanders represents another area of possible significant difference between physical and emotional trauma. Witnesses to a car accident, for instance, experience no physical injuries, but may develop symptoms of emotional trauma. Even after the event, individuals who interact with traumatized people may develop symptoms. Bock and colleagues define this as secondary trauma, which remains common among nurses.

Some researchers, including Švorcová, report heritable DNA changes related to emotional trauma. They suggest that emotional trauma experienced by an individual may lead to effects in their children and grandchildren. For example, some offspring of individuals who lived through the Holocaust or serious famines report experiencing health effects of the traumatic event, even though they weren’t yet born.

Types of trauma

Trauma can result in post-traumatic stress disorder (PTSD), which the American Psychiatric Association (APA) defines as “a psychiatric condition that can develop after experiencing or witnessing a traumatic event that involves actual or threatened death, serious injury, or sexual violence.”

Exposure to trauma can occur through direct experience, witnessing the event in-person, learning that the event happened to a loved one, or repeated exposure to the details of the event. Nurses may work in traumatic situations where patients are dying, seriously injured, or have been victims of violence.

Wolfe and colleagues note that nurses who work in hospital settings frequently experience PTSD, either through direct exposure (for example, workplace violence or threats of workplace violence) or indirect exposure (such as a sexual assault nurse examiner hearing the graphic details of rape or an emergency department nurse seeing the effects of serious injuries).

Many nurses also encounter trauma outside of the work setting. Nurses may experience intimate partner violence or the illness or death of a loved one. These all represent traumatic events.

Historical trauma

The APA’s definition of trauma doesn’t include all events that may contribute to trauma symptoms. Historical trauma, for example, involves emotional pain and trauma across generations. According to Brave Heart and colleagues, Native Americans first described historical trauma resulting from losses imposed by outsiders and interruptions in the practice of important customs. Ortega-Williams and colleagues note that many ethnic and racial groups experience historical trauma with resulting mental and physical health issues. Nurses who are members of marginalized groups also may experience this type of trauma with resulting symptoms.

Collective trauma

Collective trauma, an event or series of events that affects a group of people, can occur during natural disasters like hurricanes or violent events like school shootings. The most recent Diagnostic and Statistical Manual of Mental Disorders eliminated media exposure to traumatic events in its definition of trauma that leads to PTSD; however, research indicates that effects of collective trauma exist. For example, a study by Holman and colleagues found that participants who spent more time viewing media reports of terrorist attacks experienced more trauma symptoms than those who didn’t watch these reports. Kalsched describes the COVID-19 pandemic as collective trauma, with implications for people around the world. Nurses may experience collective trauma when they help to care for victims of terrorist events, natural disasters, and pandemics.

Childhood trauma

Felitti and colleagues’ landmark Adverse Childhood Experiences Study linked the experience of violence in the home, neglect, and other household dysfunction to both physical and mental health issues throughout the lifespan. According to Cooke and colleagues, childhood trauma can have profound effects on genetic, physiologic, and neurologic development. Varcarolis and Fosbre suggest that nurses who experienced childhood trauma may struggle to overcome traumatic event exposure in the workplace.

Symptoms of trauma

The body typically responds to stress with fight or flight, which dates back to our ancestors’ responses to the many dangers they faced. For example, upon encountering a tiger, the individual’s body has an involuntary reaction (run away or confront the tiger). Varcarolis and Fosbre point to another response—freezing—where individuals who can’t escape or fight remain motionless.

Although most people won’t encounter a tiger in their work now, examples of that stress response exist. A person may react with anger or defensiveness in a one-on-one meeting with a boss in which they’re receiving negative feedback—they’re in fight mode due to a perceived threat. A person also may avoid a boss (flight) if they anticipate negative feedback. Or an employee might freeze during a feedback session, unable to say or do anything in response.

During a traumatic event, these responses can lead to many of the symptoms related to PTSD and other trauma-related conditions. Varcarolis and Fosbre describe these symptoms as falling into four categories: alterations in arousal, avoidance, cognition and mood changes, and re-experiencing symptoms. (See Trauma symptoms.)

Some of these symptoms present challenges for nurses in their efforts to care for patients safely and effectively. For example, re-experience symptoms and alterations in arousal can disrupt sleep. If being at the hospital reminds a nurse of a traumatic event, they may experience avoidance symptoms that make it difficult for them to work. Cognition and mood changes may cause a nurse to doubt their own abilities.

Copeland and colleagues note that these symptoms are associated with poor functioning in the workplace, which some may mistake for behavioral problems or incompetence. A nurse may call in sick more frequently because of avoidance symptoms. They may make an error because of cognition and mood changes, and alterations in arousal may create friction with team members.

The importance of awareness

In addition to the nurses’ mission to help others, we also have a responsibility to help ourselves and our colleagues. In fact, Provisions 5 and 6 of the American Nurses Association (ANA) Code of Ethics for Nurses call on us to treat our colleagues respectfully and fairly and to care for ourselves. Awareness of the impact of trauma can help us in these efforts.

Almost everyone experiences some symptoms after exposure to a traumatic event. Several protective factors—such as self-efficacy and social support—can help us work through them. However, long-lasting or particularly distressing symptoms require diagnosis and treatment by a trained professional. Varcarolis and Fosbre recommend that nurses troubled by their trauma symptoms access mental health services.

An awareness of one’s own trauma burden and family history plays an important role in self-care. According to Hamby and colleagues, cumulative trauma can have profound consequences. For instance, a nurse with a history of childhood or historical trauma has a higher risk of developing a trauma-related condition after a new traumatic event compared to colleagues without that history. Varcarolis and Fosbre also note that mental health conditions resulting from trauma may have a genetic component. Individuals with a family history of conditions like PTSD may be at greater risk for trauma-related symptoms.

Peer support can serve as a major protective factor. According to SAMHSA, peer support works best when the other person also has experienced trauma and can relate to what the individual is going through. Even for those working with a mental health professional, reaching out to friends and family can offer additional support.

Awareness of trauma symptoms can help nurses serve as formal or informal peer support for their colleagues and friends who show signs of trauma. Connors and colleagues describe formal peer support as an intervention that’s activated after a traumatic event, including after medical errors or adverse events. Many healthcare facilities have adopted this type of formal peer response, which Carbone and colleagues report can help decrease the risk of symptoms after trauma.

Organizational response

Healthcare organizations play an important role in addressing symptoms of trauma experienced by nurses at work. The SAMHSA trauma-informed approach—which assumes organizations will realize the widespread impact of trauma, recognize signs and symptoms, respond with evidence-based strategies, and resist re-traumatization—has been used successfully in various settings, including prisons, schools, women’s shelters, and hospitals. Within the hospital setting, trauma-informed care aims to provide a healing environment for patients who’ve experienced trauma.

When applied to nurses who’ve experienced trauma, the trauma-informed approach’s six principles also come into play: safety; trustworthiness and transparency; peer support; empowerment, voice, and choice; collaboration and mutuality; and cultural, historical, and gender issues. (See Trauma-informed approach in action.)

Bosse and colleagues have described the application of trauma-informed education (using the same trauma-informed approach assumptions and principles) in undergraduate nursing programs to address trauma exposure among nurses in training. Similarly, Gilroy and colleagues note the use of trauma-informed professional development in conjunction with the nursing professional development practice model to address trauma among practicing nurses.

In their efforts to adhere to the trauma-informed approach principle related to cultural, historical, and gender issues, organizations also must address implicit and explicit bias. As Hamed and colleagues reported, many nurses from marginalized groups experience direct bias, and they witness the effects of bias on patients who also are members of marginalized groups. These experiences can contribute to historical trauma and challenges to recovery after additional traumatic events.

Post-traumatic growth

Tedeschi and Calhoun report that not all consequences of traumatic event exposure are negative. They coined the term post-traumatic growth to describe enhancements in personal relationships, appreciation for life, personal strength, new possibilities, and spirituality. Hensen and colleagues compare this growth to the aftermath of an earthquake, which includes rebuilding and the potential for greater resilience and strength.

Post-traumatic growth may explain why 40% of nursing students in a national survey conducted by Clark and Aboueissa reported a high number of traumatic events in childhood compared to 12.5% to 13.3% of the general population. Perhaps their response to trauma becomes a desire and capacity to help.

Post-traumatic growth and negative symptoms of trauma can occur at the same time, requiring diagnosis and treatment from a healthcare professional. Hensen and colleagues note that many of the same sources of support (such as peers) that protect against the symptoms of trauma exposure also can help to increase the likelihood of post-traumatic growth.

Recognition, solutions

More nurses and healthcare leaders recognize the seriousness of mental health issues among nurses as well as the need for comprehensive solutions. Evidence of this recognition appears in ANA’s new definition of a healthy nurse: “A healthy nurse is one who prioritizes striving toward positive physical, mental, social, environmental, and professional wellbeing.”

The mental and physical health consequences of trauma exposure can take nurses away from patient care, where we’re desperately needed. We can help by caring for ourselves and each other and advocating for healthcare leaders to use a trauma-informed approach, which benefits not just patients but also nurses.

Heidi Gilroy is the director of nursing practice at Memorial Hermann The Woodlands Medical Center in The Woodlands, Texas.

American Nurse Journal. 2025; 20(10). Doi: 10.51256/ANJ102522

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Additional resource

The American Nurses Foundation’s Nurse Well-Being: Building Peer and Leadership Support serves as a model for peer support (nursingworld.org/foundation/programs/nurse-wellbeing)

Key words: trauma, mental health, trauma-informed care