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Read the following article on developing trauma-informed practice…

Read the following article on developing trauma-informed practice in nursing and answer the following discussion questions. Please submit your answers to the dropbox. Choose one of these questions to post in the unit 7 forum for further discussion. Reply to 2 peers.

This article discusses the mental health concerns of nurses, and how the Covid-19 pandemic has helped to bring the knowledge of the effects of trauma to the forefront.  As RNs, you may find yourself in positions of leadership.  How can you, as a nurse leader, support your colleagues through mental health challenges, both past and present?

The Healers are Broken: A Call for Trauma-Informed Professional Development in Nursing[JK1] [AN2]


Discussion Questions:

  1. What are your initial thoughts and reactions to this article?
  2. Trauma, physical or psychological, can impact patients as well.  How can trauma-informed professional development for nurse help to establish trauma-informed care practices?
  3. Reflect on an experience that has resulted in lasting effects on you throughout your life (you do not need to share this experience).  Consider the 4Rs and the 6 principles presented in the article. Discuss a few of these concepts – have you encountered the implementation of these ideas by the nursing leaders in your life? What is something you will work to implement in your practice going forward?
  4. How might a person with a history of trauma have behaviour that could be interpreted as “noncompliance” or non-adherence?
  5. Answer the following hat questions:
    1. White hat: what dilemma is being presented? Were all perspectives analysed?
    2. Red hat: how did reading this make you feel?
    3. Green hat: what are some proposed solutions?

not sure we can link a PDF…we can get Shabnum to do it for spring 2023 but for this semester we can just post it seperately? [JK1]

I know how to link a pdf embedded within a word doc – I can do that for this term? [AN2]


see article below. the article needed to answer the questions above. i couldnt attach it


The Healers Are Broken

A Call for Trauma-Informed Professional Development in Nursing

Heidi Gilroy, PhD, RN, PHNA-BC, NPD-BC








he COVID-19 pandemic has brought unprece- dented attention to the general well-being of nurses and other healthcare professionals. At the begin-

ning of the pandemic, the focus was largely on the physical health and safety of healthcare workers. Concerns about the selection and availability of appropriate personal protective equipment and about protecting workers at high risk for poor outcomes from COVID-19 were widespread (Adams & Walls, 2020), and these concerns were valid. Many health- care workers contracted the virus and became ill (J. Lai, Ma et al., 2020). As the pandemic continues, it is becoming clear that the physical risks of COVID-19 represent only part of the total impactof the virus on the health and well-being ofnurses and other healthcare workers. The mental health of workers is also quickly becoming a great concern for nursing leaders.




Although data collection and analysis about healthcare workers and the effects of COVID-19 on their mental health is in its initial stages,concerning trends are developing. One study of 145 healthcare workers in Italy showed the workers caring for patientswith COVID-19 had a higherrisk of de- veloping depressive and posttraumatic stress syndrome symptoms (Di Tella et al., 2020). A study in Oman with



509 doctors and nurses also found that caring for COVID-19 patients was associated with stress and anxiety (Badahdah et al., 2020). A Chinese studywith 1,257 healthcare workers showed high levelsof mental healthissues, including more than half (50.4%) with depressive symptoms, 44.6% with anxiety symptoms, 34% reporting sleep disturbances, and 71.5% feeling distress (X. Lai, Wang et al., 2020).The front- line workers were at highest risk for poor mental health outcomes (X. Lai, Wang et al., 2020). These are just a few examples of the growing evidence of the effect of COVID-19 on healthcare workers’ mental health, and the evidence is mounting that nurses are disproportionately af- fected (Shaukat et al., 2020).

The reasons for the effects of COVID-19 on mental health are many. Social support and self-efficacy are major protective factors for many mental health issues, and COVID-19 presents a threat to both of these (Vagni et al., 2020). Healthcare workers, including nurses, may also feel socially isolated during COVID-19 because of social distanc- ing, shutdowns, or self-isolation (Barello et al., 2020), which takes away a great deal of social support. There is also evi- dence from other research about nursing during a crisis, in- cluding natural disasters, conflicts, and pandemics, that indicates that many nurses feel unpreparedprofessionally and emotionally to deal with the situation (Li et al., 2015). This is a threat to their self-efficacy, as well. Research from past outbreaks of infectious disease such as Ebola reinforce the most obvious threat to mental health, which is the fear of becoming sick or transmitting the illness to family members (Barello et al., 2020; Jalloh et al., 2018). Secondary traumatic stress is also a major factor for nurses and other healthcare professionals, as they interact with patients and families experiencing COVID-19 and their own related mental health problems (Vagni et al., 2020).



Although COVID-19 is certainly highlighting the need for


                                                                                    mental health attentionfor nurses and other healthcare


Heidi Gilroy, PhD, RN, PHNA-BC, NPD-BC, is Director of Education and Magnet, Memorial HermannHealth System, Shenandoah, Texas.

The author has disclosed that she has no significant relationship with, or financial interest in, any commercial companies pertaining to this article.


NPD-BC, Memorial Hermann Health System, 9250 Pinecroft, Shenandoah, [email protected]).

DOI: 10.1097/NND.0000000000000761


workers, there is evidence that it was needed long before the COVID-19 pandemic started. A national survey of 4,267 Canadian nurses that was done before the pandemic found that nearly half (47.9%)screened positive for a men- tal health disorder (Stelnicki & Carleton, 2020). A study in the United States using data from the National Violent Death Reporting Systemfound that both male and female




Journal for Nurses in Professional Development                                                                     273


nurses had significantly higherrates of suicide(Davidson et al., 2019).A meta-analysis of nurses around the world found that more than 1 in 10 nurses have symptoms of burnout and many had issuesrelated to decreasedquality of life and compassion fatigue (Woo et al., 2020).

Even before the COVID-19 pandemic, nurses were di- rectly encountering traumatic events on a regular basis. Some are large-scale events such as the increasing number of hurricanes and natural disasters (Veenema et al., 2017). Some are individual-level traumatic events such as work- place violence (J. Liu et al., 2019). Nurses also face second- ary traumatic stress because of the nature of the work (Spranget al., 2019), regularly encountering patient deaths, victims of traumatic injury and violence, and other traumatic situations. Although COVID-19 may be more global in im- pact and longer in duration, nurses are in crisis mode fre- quently during their everyday care of patients, and they are suffering as a result (Sprang et al., 2019). Nursing leaders have a unique opportunity to help.




Professional development is an integralpart of leadership’s interactions with nursing staff, and it presents an opportunity to make a differencein the lives of nurses who may be strug- gling with burnout, depression, anxiety, or other mental health problems.The purpose of professional development, as defined by the AmericanNurses Association (2010),is to gain knowledge, skills, and attitudes for safe, qualitynursing care. The expectedoutcomes of professional development are change, learning, and professional role competence and growth (AmericanNurses Association, 2010). Although much of hospital staff and leadership are focused on patients, professional development specialists are focused on the nurse. For that reason, they might be in the best position to provide mental health interventions for nurses as part of their professional development activities, and this aligns well with the purpose and expected outcomes of professional development.




The Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) defines a trauma-informed program as one that “…realizes the widespread impact of trauma and un- derstands the 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 retraumatization.” From this definition, SAMHSA (2014) has developed the four Rs of trauma-informed care: realize, recognize, respond, and resist retraumatization.

The Four Rs


The four Rs have successfully been integrated into diverse organizations, systems, and interventions to decrease the likelihood of adverse outcomes of traumatic stress exposure (Reeves, 2015). This includes hospitals and other healthcare systems. Nurses benefitfrom the organization-wide integra- tion of trauma-informed policies, education, and other inter- ventions; however, patients are usually the primary focus instead of the nurses. In addition to existing trauma- informed care policies and general hospitalwellness efforts, integrating trauma-informed care into the professional de- velopment model of the hospitalcan promote interventions that are specifically for the benefit of nursing staff.



In order to implementtrauma-informed professional de- velopment (TIPD), nursing leadersmust first realizethe fact that many members of their staff have been exposed to traumatic events both inside and outside the hospital set- ting and that this exposure to trauma can affect the way that they behave and interact (SAMHSA, 2014). The land- mark Adverse Childhood Experiences Study (Felitti et al., 1998) revealed that a large number of Americans had been exposed to traumatic events, including physical and sexual assault, witnessing family violence, and neglect. Moreover, this study revealed that the effectsof this type of trauma could have lasting effects on physical and mental health as well as general functioning throughout the person’s lifetime, even many decades after the traumatic experi- ence had occurred (Felitti et al., 1998). Nurses may also be experiencing personaltrauma such as intimate partner violence, a death in the family, or serious illness.

Although a leader often knows the traumatic events that a nurse experiences during the workday, they are likely not to know about all of the traumas that the nurse has ex- perienced over a lifetime or is experiencing. Also, this is important because the numberof traumas that someone experiences can increasetheir risk for poor outcomesof trauma exposure and make reactions to trauma more com- plicated (Cloitre et al., 2009). Because it is not appropriate for leaders to screen for childhood or lifetime trauma, part of the “realize” step of TIPD is to develop, plan, and imple- ment professional development activities in such a way that it can be appropriate for all individuals, whether they are experiencing trauma or not. The other part is to be aware that the ultimateoutcome of this type of approach has the potential to help not only the nursebut also all of the nurse’s colleagues and patients.



The signs of traumatic stress exposure can often mimic be- havioral problems, which can present a challenge to leaders as they manage professional development activities. Individ- uals who are experiencingposttraumatic stress syndrome



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may experience intrusive thoughts about the event (night- mares, flashbacks), hyperarousal (easily startled, overly vigilant), avoidance(pushing out memories, avoiding the location where the trauma happened), and mood and cog- nitive alterations (angry outbursts, confusion, errors; Foster et al., 2017). Some behavioral issues such as verbal aggres- sion toward colleagues, repeated medication errors, or falling asleep on the job may actually be related to symptomology related to traumatic stress exposure (Foster et al., 2017). A leader can learn to recognize the signs and differentiate them from behavioral issues as part of a trauma-informed approach.

Another part of recognition is to be aware of risk factors for poor outcomes of traumatic stress exposure. Nurses who work in certain specialty units that may be exposed to more traumatic events, such as intensive care units or mental health units, are more likely to have poor health outcomes. During the COVID-19 pandemic, this includes nurses working in units dedicated to the care of patients with COVID-19, as well (Kim et al., 2020). Leaders from these areas must be even more attentive to potential signs and symptoms of posttraumatic stress as other leaders.



Responding to trauma exposure in nurses in an evidence- based way is the next importantaspect of implementing TIPD. Although TIPD is a new concept, we can learn from interventions aimed at decreasing burnout, increasing pro- tective factors, and improving well-being for nurses and other healthcare professionals. These interventions range from system-wide approaches, such as creating self-care plans with nurses and facilitating advisorycouncils to as- sess and bring forward ideas for wellness activities that would be accessible and acceptable to the nurses that they represent (Brand et al., 2017), to one-on-one interventions, such as mindfulness teaching (Lomas et al., 2019). Al- though hospitalsoften have dedicated wellness teams that may include psychologists or psychiatrists, there is evi- dence that nurses, including professional development specialists, can also intervene to assist in preventing poor outcomes related to trauma exposure and promote recov- ery (Brand et al., 2017).

Integrating knowledge of the effects of traumaand evi- dence from previous research and intervention studies from other fields will also enhance the response. For exam- ple, we know there are certain risk factorsfor poor mental health outcomes for nurses who have been exposed to trauma. Chen et al. (2021) found that nurses working in critical care units had greater risk for developing posttrau- matic stress disorder. Professional development specialists may want to use this type of evidence to aim interventions at groups at highest risk. Social support is shown to be an effective protective factor against poor outcomes of trauma exposure across disciplines. For healthcare professionals,


social support combined with humor, venting, and accep- tance is especially helpful(Brooks et al., 2019). A profes- sional development specialist can integrate this evidence into their TIPD by making sure that their educational of- ferings include time for this type of activity, especially those activities that may remind nursesof difficult situa- tions or memories.


Resist           retraumatization Individuals with a history of trauma may find coping with new trauma more difficult than those without a history of trauma (Cloitre et al., 2009). That is why resisting retraumatization is so important. An example from the literature of a potentially traumatizing professional development activity is the educa- tion that follows a medication error. Some nurses who make errors experience second victim distress, especially if a patient dies or is injured as a result of the error. Approaches that take into account the educational and accountability needs of the situation as well as the emotional well-being of the nurse who made the error decrease the distress felt as a result of the trauma (Quillivan et al., 2016).

Although the evidence about retraumatization through

education is limited in other areas, it is reasonable to as- sume that it would be based on what we know about posttrauma experiential avoidance and its connection with poor outcomes (Miller et al., 2020; Seçer et al., 2020). For example, it may be difficultfor some nursesto be in places where traumatizing events happened (such as in the pa- tient room where an individual died) or in situations that remind them of a traumatizing event (such as a mock code). During the COVID-19 pandemic, education re- lated to personal protective equipment has the capacity to retraumatize because of its connection with anxiety and fear. Althoughavoiding situations wherethe nurse is reminded of a traumatic situation is not helpful for pre- vention or recovery (Miller et al., 2020), leaders should be aware of the potential of retraumatization in those in- stances and plan for a trauma-informed response.


The Six Principles

SAMHSA (2014) gives six principles to guide trauma- informed care: safety,trustworthiness and transparency, peer support, collaboration, empowerment, and cultural issues. These principles can be integrated into professional development practices to create TIPD.



Nurses must feel physically and psychologically safe dur- ingprofessional development activities (SAMHSA, 2014). The scope and standards of practice of nursing profes- sional development highlight the importance of respect, cultural appropriateness, and sensitivity in professional de- velopment (American Nurses Association, 2010). These features help to promote psychological safety. Physical



Journal for Nurses in Professional Development                                                                     275


safety, however, may be outside the normal scope for leaders planning professional development activities. It is an extremely important part of TIPD. Things that promote feelings of physical safety may include security officers, well-lit walkways, and clean and maintained equipment and rooms (SAMHSA, 2014). Physical safety during the COVID-19 pandemic also includes options for social distancing and virtual professional development activities.


Trustworthiness and transparency

Trustworthiness and transparency in professional develop- ment is vital becausenurses must believethat the informa- tion and education given to them is true, appropriate for their practice, and based on evidence (American Nurses Association, 2010). Duringcrises, including the COVID-19 pandemic, information and evidence changes quickly, and leaders engagedin TIPD must have a strategy to set expec- tations for nurses that there may be misinformation given or that information may change, communicate correct and up-to-date information as it is available, and hold nursesac- countable only for the information that they have been given (B. F. Liu et al., 2018). Althoughthis is especially im- portant during crises, this effort toward trustworthiness and transparency is important all of the time in TIPD.


Peer support

Social support is a powerful protective factor against poor outcomes of trauma exposure before, during, and after traumatic events (Vogt et al., 2007). Professional develop- ment activities are an excellent opportunity to integrate new staff into the unit or strengthen relationships with ex- perienced nurses. Leaders should purposely facilitate the type of interactions that enhance relationship building to maximize the benefit. COVID-19 has made peer support more difficult because of infection control limitations on meetings and other interactions. Using technology to facil- itate the peer support is an important adaptation for TIPD.



Leaders engaged in professional development must also be mindful of power structures. Collaboration in TIPD can be enhanced by having nurses of all experience levels and back- grounds assisting in the development of professional devel- opment activities. According to SAMHSA (2014, p. 11), “… healing happens in relationships and in the meaningful sharing of power and decision-making.” When nurses have a say in their professional development, they can help themselves and their colleagues to encounter and re- spond to traumatic events.



Empowerment takes collaboration a step further and re- quires the leader to recognize and build on the experience and strengths of the individuals who are sharingin the


planning. This is a usualmodel of nursing professional de- velopment: individuals with more clinical experience teaching those who have less. However, it may be helpful in TIPD to include individuals who have been exposed to trauma to share their experience and teach coping mecha- nisms that have worked for them. Education related to emergency situations, such as mock codes, or psychosocial issues, such as bereavement, are great opportunities to em- power all staff by allowing individual nurses to share their coping strategies. In the future, it may be helpful for individ- uals who experienced trauma related to COVID-19 to share that experience with new nurses to empower both the ex- perienced and the new nurse.


Cultural issues

Biases based on race, sexual orientation, gender, age, reli- gion, ethnicity or nationality, and gender identity are an- other important principle for responding to trauma in professional development activities. The COVID-19 pan- demic, as well as socioeconomic issues and the protests of the killing of several unarmed Black men, highlighted disparities that remain in the United States and in the healthcare system (Galea & Abdala, 2020). Staff members may have differentresponses to these events, and those re- sponses highlight the lasting effects of discrimination on processing trauma. Discrimination is traumatic (SAMHSA, 2014). Leaders must engage in professional development that is culturally appropriate and free of bias to avoid further traumatization for nurses across all cultural backgrounds.




One example of a functioning TIPD activity is an orienta- tion program for new graduate nurses in three pediatric critical care units at a single hospital. This program was ini- tiated because of the high trauma exposure for these spe- cialty nurses (Berger et al., 2015). The program started with training for leaders, preceptors, and new graduate nurses in trauma-informed care principles. Although the training was specialized for each role, all three training courses providedinformation on the four Rs of trauma- informed care (SAMHSA, 2014) and specifically how trauma burden can affect nurses. The leader orientation included the six principles (SAMHSA, 2014), with ideas for imple- mentation in the training of the new graduate nurses.

In addition to education, the orientation aimed to limit anxiety-producing scenarios that did not add value to the orientation. The goal of this part of the programwas to re- sist retraumatization. For example, great care was taken to avoid changing preceptors or shifts without advanced no- tice. Although in the past, patient assignments were made on the basis of nursing skill and orientation objectives, more thought was also given to the emotional capacity of the new graduate nurse. For example, a nurse in the first few weeks of orientation would not be given a patient



276                                                                                                                                                              September/October 2022


who had just experienced open heart surgeryor a patient who had severe traumatic abuse, as these cases may be es- pecially traumaticfor nurses and family members (Berger et al., 2015). As the nurses learned the clinicalskills as well as the coping skills necessary to take care of these types of patients, they were given these assignments.

Other measures were implemented to reduce anxiety as well. The new graduate nurses had a 2-week check-in form that included a well-being scale and a measure of cognitive load (Tubbs-Cooley et al., 2018).Although the new graduateswere meeting with a professional develop- ment specialist regularly, a low score on the well-being scale or a high score on the cognitive load scale triggered immediate contact.Because of previousfeedback about anxiety related to the use of equipment, new graduates were also given the opportunity to handle equipmentlike pressure tubing for arterial lines or external ventricular drain setups in low-stress simulation environments instead of high-stress patient care environments. In addition, new graduate nurses were invited to join the hospital-wide wellness committee where they were able to share their own ideas for coping mechanisms and learn from more ex- perienced staff.

This project was implemented before the COVID-19pan- demic began. The TIPD principles already applied made it easier to quickly reactto the trauma of the pandemic. Leaders realized that the new graduate nurses would lose the peer support of meeting in person on a regular basis, and that this would take away a major protective factor for them. The leaders mobilized the clinical education resource nurse, which is a nurse who splits their time between bedside and education, to spend an hour every 2 weeks with the new graduate nurses and model coping skills.

This project was meant to test the feasibility of TIPD in new graduate education and not necessarily the outcomes. The program was viewed positively by the leaders, precep- tors, and new graduate nurses,and previous researchon trauma-informed care would lead us to believe that these in- terventions would have a positive impact. However, future research must empirically test these assumptions.


Limitations and Barriers

Using TIPD in professional development practice is not without its limitations and barriers. First, it requires some education for leaders and professional development special- ists. Many hospitals already have trauma-informed care as part of their policies and procedures, and a recent survey of healthcare providers from an urban medical center showed 75% were able to correctly answer questions about trauma-informed care and 89% had a favorable view of it (Bruce et al., 2018). With a baseline level of knowledge about trauma-informed care, it may be easier to train for TIPD.

Another limitation is that TIPD may increasethe cost of professional development programs if specialists need


more time and resources to complete training while integrat- ing trauma-informed principles. The return on investment, however, is compelling. Because poor mental health in nurses is associated with errors and decreased patientsatis- faction (Gärtner et al., 2010),there is valuein protecting the mental health of nurses (Noben et al., 2014).



Although the COVID-19 pandemic has highlighted the need for interventions to protect nursing staff from the harmful effects of traumatic stress, the evidence proves that nurses have long been experiencing poor outcomes re- lated to trauma exposure. Nursing leaders focus on patient outcomes because that is the primary focus of our work as nurses. They focus on fiscal responsibility because we would not be able to continue to care for patients outside a self-sustaining business organization. The purpose of this article is to arguethat nursing leadersalso must focus on the mental health and well-being of nurses in order to sup- port the best possible outcomes for the nurses themselves, organization, and patients.

This is an initial presentation of the potential for TIPD to address some of the mental health and well-being needs of nurses while accomplishing the task of educating and de- veloping nurses with some ideas for implementation. More work is neededto identify interventions that conform to the ideas and principles of TIPD and to test their efficacy, especially during the COVID-19 pandemic, as it givesus the opportunity to test interventions around the world. Re- search should include randomized controlled trials of spe- cific TIPD interventions as well as holistic programs aimed at reducing the impact of trauma exposure to determine if these interventions affect the long-term risk of posttraumatic stress disorder and other trauma-related poor outcomes. Re- search should also include members of other healthcare dis- ciplines. Whereas nurses may have increased risk for poor outcomes, others are also exposed.TIPD developed for nurses may serve as a model for other disciplines.

There is sufficient evidence to suggest that trauma- informed care is a helpful tool in populations at risk for trauma exposure and its sequelae (SAMHSA, 2014). Follow- ing the general principles will help leadersto realize the im- pact of trauma, recognize the effects of trauma, respondin an evidence-based way, and resist retraumatization.



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