Nursing Care for Patients Who Have Experienced Trauma

Course Content

Author: Mallory Antico
Contact hours : 4 hours

Learning Objectives

  • Describe the pathophysiology of the stress response and how it relates to trauma.
  • Understand key elements in trauma-informed care.
  • Describe cultural considerations in caring for patients with trauma including identifying and mitigating implicit bias.
  • Understand Adverse Childhood Experiences and its implications on health outcomes for patients.
  • Explain vicarious trauma and describe strategies to minimize risk.
  • Compare and contrast the differences between PTSD, acute stress disorder, and acute distress response.
  • Describe nursing interventions that can be used to effectively care for patients who have experienced trauma.

Introduction

Psychological trauma refers to the emotional, cognitive, and physiological distress experienced by an individual following an overwhelming or life-threatening event. It involves the disruption of one's sense of safety, security, and well-being, leaving lasting psychological scars. Traumatic experiences can have profound effects on an individual's mental health, leading to a range of symptoms. Experiencing trauma has become incredibly common. The nursing care provided to patients with trauma plays a critical role in ensuring positive patient outcomes (Varcarolis, Fosbre, & Chiappetta, 2021). This article aims to explore the multifaceted aspects of nursing care for patients with trauma, including assessment, intervention, and ongoing support. By adopting a comprehensive approach that integrates physical, psychological, and emotional aspects of care, nurses can effectively address the complex needs of trauma patients and facilitate their journey toward recovery (Goddard, Jones, & Etcher, 2022).

Pathophysiology

The stress response is a complex physiological process that occurs in the body when an individual perceives a threat or experiences stress. It involves the activation of the autonomic nervous system and the release of stress hormones. The stress response begins with the perception of a stressor, which can be a physical or psychological threat. (Shaw, et al., 2018).

The brain's amygdala, which plays a key role in emotional processing, is responsible for detecting and assessing the threat. When the amygdala perceives a threat, it sends signals to the hypothalamus, a small region at the base of the brain. The hypothalamus acts as the command center for the stress response. The hypothalamus releases corticotropin-releasing hormone (CRH), which signals the pituitary gland to release adrenocorticotropic hormone (ACTH) into the bloodstream, where it travels to the adrenal glands. In response to ACTH, the adrenal glands secrete cortisol and epinephrine (Shaw, et al., 2018).

Cortisol, often referred to as the "stress hormone," has various effects on the body. It increases glucose production, providing the body with a quick energy source. It also enhances the availability of substances that help repair tissue damage and suppress non-essential functions like digestion and immune response. Epinephrine is another hormone released during the stress response. It acts quickly to increase heart rate, blood pressure, and respiratory rate, preparing the body for physical exertion or rapid response (Shaw, et al., 2018).

The stress response also involves the activation of the sympathetic nervous system, part of the autonomic nervous system. The sympathetic nervous system stimulates the release of adrenaline and triggers physiological changes that prepare the body for action, such as dilating the pupils, increasing blood flow to the muscles, and diverting blood away from non-essential organs. The combined effects of cortisol and epinephrine help mobilize energy resources in the body, redirecting them to the muscles and other vital organs needed for a fight, flight, or freeze response. This response is a natural survival mechanism activated in response to perceived threats or danger. When faced with a threatening or stressful situation, the body rapidly prepares itself to either confront the threat, escape from it, or freeze and assess the situation (Shaw, et al., 2018).

The fight response involves an active response to the threat. When individuals experience a fight response, they may exhibit aggression, confrontation, or assertiveness. This response is characterized by an increased heart rate, heightened alertness, and a surge of energy to prepare for a physical or verbal confrontation. The flight response involves a desire to escape or avoid the threatening situation. Individuals experiencing the flight response may feel a strong urge to flee, run away, or remove themselves from the perceived danger. Physiological changes associated with flight include increased heart rate, elevated respiration, and enhanced sensory awareness to detect potential escape routes. The freeze response is characterized by a temporary pause or immobilization in response to a perceived threat. Instead of fighting or fleeing, individuals experiencing the freeze response may feel paralyzed, and unable to move or react. This response can serve as a protective mechanism, allowing individuals to assess the situation and decide on the most appropriate action. Understanding these responses can be helpful in recognizing and managing stress or anxiety after trauma (Shaw, et al., 2018).

Once the perceived threat subsides, the parasympathetic nervous system, another branch of the autonomic nervous system, works to restore the body to its resting state. The release of cortisol and adrenaline decreases, heart rate and blood pressure normalize, and other physiological changes revert to their baseline levels. While the stress response is a vital adaptive mechanism that helps humans respond to immediate threats, it can have negative effects on physical and mental health. Managing stress and implementing effective coping strategies are essential for maintaining overall well-being (Shaw, et al., 2018).

Types of Trauma

Understanding the types and common causes of psychological trauma is crucial in comprehending its impact and developing effective interventions. Psychological trauma encompasses a broad spectrum of experiences and reactions. It occurs when an individual is exposed to an event or series of events that exceed their capacity to cope and overwhelm their ability to integrate the experience into their lives effectively. Traumatic events can be either acute or chronic, and they often involve a real or perceived threat to one's physical or psychological integrity (Orchowski & López, 2023). Types of trauma are differentiated by the timeline of symptoms and the traumatic event(s), the traumatic event(s) that initiated the trauma responses, and the ages that the event(s) occurred (Varcarolis, Fosbre, & Chiappetta, 2021).

Acute Trauma

Acute trauma refers to a single traumatic event or short series of related events that is time-limited and has an identifiable cause. It is a type of trauma that occurs suddenly and is typically characterized by its intensity and immediate impact on an individual's psychological, physiological, and emotional well-being. Acute trauma is typically referred to as acute stress reaction (ASR) or acute stress disorder (ASD) (Orchowski & López, 2023). They are both psychological conditions that can occur in response to a traumatic event but while they share similarities, there are important distinctions between the two including the time frame and duration of symptoms, the different diagnostic criteria, and the long-term impact which is summarized in table 1 (Bryant, 2023)

Table 1. Comparison between Acute Stress Reaction and Acute Stress Disorder (Bryant, 2023)


FeaturesAcute Stress Reaction (ASR)Acute Stress Disorder (ASD)
Time frame
  • Immediate
  • hortly after the event to a few weeks
  • Three days to one month
  • If symptoms persist longer than one month, diagnostic criteria for PTSD may be met
Duration
  • Transient
  • Resolves in a relatively brief period
Persistent
Diagnostic Criteria
  • No formal diagnostic criteria in DSM-5-TR
  • Often used as a descriptive term for an immediate stress response.
  • Recognized psychiatric disorder in the DSM-5-TR
  • Diagnostic criteria include the presence of dissociative symptoms, intrusive memories, avoidance behaviors, negative mood, arousal symptoms, and functional impairment
Prognosis
  • Considered a normal response to an abnormal event
  • Individuals usually recover with time and support
  • Symptoms are more severe and disruptive to daily functioning compared to ASR
  • Can be a precursor to PTSD if the symptoms persist beyond ? one month
  • Appropriate treatment can prevent the development of chronic PTSD
Treatment
First-line treatment is trauma-focused cognitive-behavioral therapy

Acute trauma can result from various incidents. Involvement in or witnessing a severe car accident, natural disaster, workplace accident, physical assault, sexual assault, or domestic violence are common causes of acute trauma. It can also be caused by witnessing or being victimized by acts of violence in public spaces, during combat or in war zones, or experiencing or witnessing a robbery or home invasion. Medical trauma is another cause of acute trauma, which occurs when a patient experiences a life-threatening medical event, has surgery or receives distressing medical news (Orchowski & López, 2023). Pregnant patients may experience birth trauma during or after delivery that can cause long-term mental health issues (Watson, et al., 2022). Coping with the sudden death of a loved one or witnessing a traumatic death are other causes of acute trauma (Orchowski & López, 2023).

While acute trauma can have a profound immediate impact, not everyone who experiences such events will develop long-term psychological difficulties. Most individuals are resilient and can recover with time and support from family, friends, and professionals. However, for some individuals, acute trauma can lead to ongoing psychological difficulties, such as post-traumatic stress disorder (PTSD), anxiety disorders, or depression. Seeking professional help and support is recommended for those who continue to struggle with the aftermath of acute trauma (Orchowski & López, 2023).

Chronic Trauma

Chronic trauma occurs when an individual is exposed to prolonged and repetitive traumatic experiences, often in interpersonal relationships. Unlike acute trauma, which involves a single or limited number of traumatic incidents, chronic trauma is characterized by ongoing, persistent, and often cumulative exposure to distressing or harmful events that can occur in various contexts (Orchowski & López, 2023).

Enduring physical, sexual, or emotional abuse, neglect, or chronic exposure to domestic or intimate partner violence can cause chronic trauma. Additionally, being exposed to prolonged periods of violence, armed conflict, living in war-torn regions, or experiencing discrimination, racism, sexism, or other forms of systemic oppression can cause chronic trauma. Chronic trauma can also be caused by being subjected to prolonged periods of exploitation, forced labor, or sex trafficking, dealing with long-term or life-threatening medical conditions, repeated medical procedures, or ongoing medical treatments, and working in high-stress professions where exposure to traumatic events is frequent (Orchowski & López, 2023).

Complex Trauma

Complex trauma refers to exposure to multiple and/or chronic traumatic experiences, typically during childhood, within the context of an interpersonal relationship. It can involve a combination of physical, emotional, and sexual abuse, neglect, and witnessing domestic violence. Complex trauma often leads to significant and long-lasting psychological and interpersonal difficulties (Orchowski & López, 2023).

Complex trauma can lead to a fragmented and unstable sense of self. Dissociation is a coping mechanism commonly observed in complex trauma survivors. It involves a detachment from one's thoughts, feelings, memories, or surroundings as a way to escape or cope with overwhelming distress. Dissociation can manifest as feeling disconnected from oneself or observing experiences as if detached from the body. Complex trauma can also manifest somatically, resulting in physical symptoms and health issues that have no apparent medical cause. These symptoms may include chronic pain, headaches, gastrointestinal problems, or other unexplained physical ailments. Individuals who have experienced complex trauma may be at a higher risk of revictimization, as they may have difficulty recognizing and establishing healthy boundaries. They may be more susceptible to abusive relationships or engaging in high-risk behaviors that perpetuate trauma. The manifestations of complex trauma can vary greatly between individuals. Factors such as the severity, duration, and timing of the traumatic experiences, as well as the presence of supportive relationships and resources, can influence the specific manifestations observed in each person (Orchowski & López, 2023).

Childhood Trauma

Children who endure physical, sexual, or emotional abuse or neglect are at high risk of developing psychological trauma. These early traumatic experiences can have lasting effects on their development and physical and mental health. Adverse Childhood Experiences (ACEs) are traumatic experiences that occur during childhood and can have a significant impact on a person's well-being throughout their lifespan. ACEs refer to a range of experiences that can be categorized into three main types: abuse (physical, emotional, or sexual), neglect (physical or emotional), and household dysfunction (for example, witnessing domestic violence, substance abuse, mental illness, parental separation, or incarceration) (Goddard, Jones, & Janicek, 2022).

The ACEs study, conducted by the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente, has demonstrated a strong correlation between ACEs and negative health outcomes including various physical health issues later in life. These may include chronic conditions such as heart disease, obesity, diabetes, respiratory problems, liver disease, and autoimmune disorders. ACEs can have long-term effects on the body's stress response systems, leading to chronic inflammation, hormonal dysregulation, and increased susceptibility to illnesses (Goddard, Jones, & Janicek, 2022).

ACEs significantly increase the risk of developing mental health disorders, including depression, anxiety, PTSD, substance abuse, and suicidal ideation or attempts. The trauma experienced during childhood can shape brain development and lead to altered neural pathways, impacting emotional regulation, impulse control, and the ability to cope with stress. They are associated with an increased likelihood of engaging in high-risk behaviors such as smoking, substance abuse, risky sexual behaviors, and self-harming behaviors, which can have detrimental effects on physical and mental health, as well as contribute to the cycle of trauma and adversity (Goddard, Jones, & Janicek, 2022).

ACEs can impact social functioning and the ability to form healthy relationships because individuals may struggle with trust, attachment, and interpersonal difficulties. This can lead to isolation, challenges in establishing support networks, and a higher likelihood of experiencing interpersonal violence or abusive relationships (Goddard, Jones, & Janicek, 2022).

ACEs can impact cognitive development and academic achievement. Children exposed to chronic stress and trauma may experience difficulties with attention, learning, memory, and executive functioning. This can hinder educational progress and limit future opportunities. ACEs can affect not only the individual who experienced them but also future generations (see section on generational trauma). Pregnant individuals who have a history of ACEs may face increased risks of complications during pregnancy, such as preterm birth, low birth weight, and maternal mental health issues. These factors can further impact the health and development of the child (Goddard, Jones, & Janicek, 2022).

The impact of ACEs is not deterministic, and individuals can build resilience and overcome the negative effects through supportive relationships, access to resources, and appropriate interventions. Recognizing the prevalence and impact of ACEs has led to the development of trauma-informed approaches in healthcare, education, and social services, which aim to promote healing, resilience, and prevention through early intervention and comprehensive support (Goddard, Jones, & Janicek, 2022).

Generational Trauma

Generational trauma, also known as transgenerational trauma or historical trauma, refers to when the psychological and emotional impact of traumatic events can be passed down from one generation to the next, even if subsequent generations did not directly experience the original trauma. Generational trauma often stems from collective or cultural traumas that have had a profound and enduring impact on a specific group or community (Yehuda & Lehrner, 2018).

Generational trauma typically originates from significant historical events or systematic oppressions, such as colonization, slavery, genocide, war, forced displacement, or other forms of mass violence or injustice. These traumatic experiences have long-lasting effects on the affected communities and can shape their collective identity and well-being. Trauma can be transmitted across generations through various mechanisms, including narratives, family dynamics, cultural practices, beliefs, and behaviors. It may be indirectly transmitted through family stories, cultural rituals, or societal patterns that reflect the impact of the original trauma. Recent research suggests that trauma can have an impact on the expression of genes, potentially leading to changes in the genetic material passed down to future generations. These epigenetic changes can influence an individual's vulnerability to trauma-related conditions and may contribute to the intergenerational transmission of trauma (Yehuda & Lehrner, 2018).

Generational trauma can affect the collective identity, cultural practices, and worldview of affected communities. It can contribute to a sense of collective grief, loss, and ongoing psychological distress, which can shape the social, emotional, and behavioral patterns of subsequent generations. Recognizing and addressing generational trauma is crucial for healing and promoting resilience within affected communities. This includes acknowledging the historical context, validating the experiences of individuals and communities, and implementing trauma-informed approaches to promote healing and well-being (Yehuda & Lehrner, 2018).

Cultural practices, rituals, storytelling, and community support systems can play a vital role in healing generational trauma. Emphasizing the strengths and resilience of the community and empowering individuals to reclaim their cultural heritage can be important components of the healing process. It's important to approach the topic of generational trauma with sensitivity and cultural humility, recognizing that the experiences and effects of trauma may vary across different communities and cultural contexts. Mental health professionals and community leaders with expertise in trauma-informed care can play a significant role in supporting affected communities in their healing journey (Yehuda & Lehrner, 2018).

Vicarious Trauma

Vicarious trauma, also known as secondary traumatic stress or compassion fatigue, refers to the emotional and psychological impact experienced by individuals who are regularly exposed to the trauma experiences of others. When individuals empathetically absorb the emotional and psychological pain of others, they may start to exhibit their own trauma-like symptoms. Professionals who work with trauma survivors often develop deep connections and empathy for their patients or the individuals they serve. This empathetic engagement can lead to an emotional investment in the stories and experiences of those who have been traumatized. This exposure to others' trauma narratives and experiences can gradually erode their emotional well-being and resilience. There are several key features of vicarious trauma.

Vicarious trauma can manifest through various symptoms and reactions, which can resemble those experienced by individuals who have directly experienced trauma. Typically vicarious trauma is a result of prolonged exposure to traumatic stories and experiences rather than a single incident. Over time, the accumulation of exposure to multiple traumatic narratives can impact the professional's psychological well-being and resilience.

Professionals may experience transference, where their own unresolved personal trauma or experiences become activated or triggered by their patients' trauma. Countertransference occurs when professionals project their own unresolved emotions or reactions onto their patients. These dynamics can intensify the impact of vicarious trauma and can impair how the person performs in their role. It may lead to decreased job satisfaction, burnout, decreased empathy, diminished emotional resilience, reduced productivity, and compromised quality of care or services provided.

Recognizing and addressing vicarious trauma is essential for professionals to maintain their well-being and continue providing effective support to trauma survivors. Self-care strategies, such as seeking support from colleagues or a therapist, practicing stress management techniques, setting boundaries, engaging in activities that promote well-being, and cultivating a healthy work-life balance, can help mitigate the effects of vicarious trauma. It's crucial for professionals working in trauma-related fields to prioritize their own self-care, engage in regular supervision or consultation, and access resources that support their well-being. Organizations and institutions can play a significant role by implementing trauma-informed policies and practices that acknowledge and address the potential impact of vicarious trauma on their staff members.

Assessment of Trauma

Diagnosing trauma involves a comprehensive assessment that considers various factors and criteria by a qualified mental health professional, such as a psychologist or psychiatrist. The diagnostic process typically includes a lengthy interview, a trauma history assessment, and a review of trauma-related symptoms. The clinician then differentiates between trauma symptoms and other mental health conditions (which often have overlapping presentations) and relates their findings to the diagnostic criteria in the most recent Diagnostic and Statistical Manual (DSM) of Mental Health Disorders. In some cases, psychological assessments, such as self-report questionnaires or structured interviews, may be utilized to supplement the diagnostic process. These assessments can provide additional information about trauma-related symptoms, emotional functioning, attachment styles, and cognitive patterns (Orchowski & López, 2023; Varcarolis, Fosbre, & Chiappetta, 2021).

The clinical interview is used to gather detailed information about the individual's personal and trauma history. This interview aims to assess the presence of multiple and chronic traumatic experiences within the context of interpersonal relationships. The clinician explores the individual's history of trauma, including the types, frequency, duration, and severity of traumatic events experienced. They also consider the developmental timing of the trauma and any ongoing trauma-related stressors. The individual's symptoms and difficulties associated with complex trauma are then reviewed, including an exploration of emotional dysregulation, disturbed self-identity, attachment difficulties, cognitive and behavioral challenges, dissociation, and somatic symptoms (Orchowski & López, 2023; Varcarolis, Fosbre, & Chiappetta, 2021).

Some types of trauma, such as complex trauma, do not have a specific diagnosis in the DSM; however, its effects may be captured by other diagnoses such as Post-Traumatic Stress Disorder (PTSD) or Disruptive Mood Dysregulation Disorder (DMDD), among others. The mental health professional considers and differentiates complex trauma from other mental health disorders that may share similar symptoms. They assess the presence of comorbid conditions, such as anxiety disorders, depressive disorders, personality disorders, or substance use disorders (Orchowski & López, 2023).

Cultural Considerations in Trauma Assessment

When caring for patients with trauma, it is essential to consider cultural factors that can influence their experiences and responses. Cultural considerations help healthcare providers deliver care that is sensitive, respectful, and aligned with the patient's cultural background. Different cultures may have unique beliefs and values regarding trauma, mental health, and help-seeking behaviors. It is important to understand and respect these beliefs to provide culturally appropriate care. For example, some cultures may emphasize the importance of familial support and community involvement in healing, while others may have specific rituals or spiritual practices related to trauma recovery (Hankerson, et al., 2022).

Language barriers can impact the patient's ability to express their traumatic experiences and understand the care being provided. Healthcare providers should ensure effective communication by using interpreters or translators when necessary. Additionally, cultural nuances in communication styles, such as direct or indirect communication, should be considered (Hankerson, et al., 2022).

Cultural attitudes towards mental health and trauma may influence how patients perceive and seek help. The stigma surrounding mental health issues can be prevalent in certain cultures, making it important to approach discussions about trauma and mental health sensitively. Educating patients and their families about trauma and its impact can help reduce stigma and encourage help-seeking behaviors (Hankerson, et al., 2022).

In many cultures, the family and community play a significant role in the individual's recovery from trauma. Involving family members in the care process, with the patient's consent, can provide support and facilitate healing. Understanding the patient's social support network and involving trusted individuals in treatment planning can be beneficial. Different cultures may have unique ways of expressing and coping with trauma. For example, some cultures may emphasize storytelling, art, music, or traditional healing practices as therapeutic outlets. Healthcare providers can support and incorporate culturally appropriate coping mechanisms into the patient's care plan (Hankerson, et al., 2022).

Religion and spirituality can be important sources of support and resilience for individuals with trauma. Healthcare providers should be respectful of the patient's religious and spiritual beliefs and consider incorporating these beliefs into their care, if appropriate. This may involve collaborating with spiritual leaders or offering opportunities for prayer, meditation, or other spiritual practices (Hankerson, et al., 2022).

Systemic racism refers to the ingrained and pervasive structures, policies, and practices within a society that systematically disadvantage and oppress individuals and communities based on their racial or ethnic background. It perpetuates inequalities and creates significant challenges for marginalized communities. The effects of systemic racism can contribute to trauma in various ways. Marginalized communities have often experienced a long history of oppression, discrimination, and violence due to systemic racism. This collective trauma can be passed down through generations, leading to a sense of ongoing distress and a diminished sense of safety and well-being (Hankerson, et al., 2022).

Systemic racism manifests in unequal access to resources, opportunities, and quality services, such as healthcare, education, employment, and housing. These disparities can create chronic stress, economic challenges, and barriers to upward social mobility, contributing to psychological and emotional distress. Individuals from marginalized communities often face daily experiences of racial discrimination and microaggressions, which are subtle or indirect forms of bias and prejudice. These repeated experiences can lead to feelings of invalidation, hypervigilance, anxiety, and a diminished sense of self-worth, contributing to trauma (Hankerson, et al., 2022).

Marginalized communities are disproportionately exposed to incidents of racial violence, police brutality, and hate crimes, either directly or through media coverage. Witnessing or hearing about such incidents can cause vicarious trauma, leading to emotional distress, fear, anger, and a heightened sense of vulnerability within the community. Intersectionality recognizes that individuals can experience multiple forms of oppression simultaneously based on their intersecting identities, such as race, gender, sexual orientation, or socioeconomic status. The compounded effects of systemic racism with other forms of discrimination can intensify the trauma experienced by marginalized communities (Hankerson, et al., 2022).

Erasure and devaluation of cultural practices, traditions, and histories of marginalized communities can cause disconnection from cultural roots can result in identity conflicts, feelings of alienation, and a loss of community support systems, further exacerbating trauma. Systemic racism contributes to significant health disparities in marginalized communities. Limited access to quality healthcare, racial bias in medical settings, and the stressors associated with systemic racism can lead to higher rates of chronic health conditions, including hypertension, diabetes, and mental health disorders, all of which can contribute to trauma (Hankerson, et al., 2022).

Addressing the trauma experienced by marginalized communities requires comprehensive and systemic efforts to dismantle structural racism, promote equity, and foster inclusive environments. It involves acknowledging historical injustices, amplifying marginalized voices, advocating for policy changes, promoting culturally responsive care, and ensuring access to trauma-informed services and resources that address the unique needs of these communities (Hankerson, et al., 2022).

Bias can significantly affect culturally responsive care provided to patients who have experienced trauma. Implicit bias refers to unconscious attitudes and stereotypes that can influence the decisions and actions of nurses. It can lead to unintended negative consequences for patients, particularly those who have experienced trauma. Because implicit bias often goes unrecognized by the individual, it is especially important to understand how to recognize it and decrease its effects. Implicit bias can lead nurses to misinterpret symptoms or downplay the severity of a patient's condition which can result in delayed or inadequate treatment (Gopal, et al., 2021).

Implicit biases can also affect the way nurses interact with trauma patients. It may cause nurses to stereotype patients based on their race, gender, or other characteristics leading to stigmatization and a failure to provide individualized care. There may be a reluctance to address the unique needs of different patient populations which may lead to unequal treatment in terms of pain management, access to resources, and referrals for mental health services (Gopal, et al., 2021).

Patients who have experienced trauma may already have a heightened sense of mistrust in the healthcare system due to their experiences. Implicit biases displayed by nurses can reinforce this mistrust, making it more difficult for patients to engage in treatment and follow medical recommendations. Nurses may be less empathetic or understanding towards patients they hold biases against, which can make it difficult for patients to feel comfortable sharing their traumatic experiences or seeking help. Its effect on communication includes the use of insensitive language and failure to ask essential questions related to the patient's trauma history, leading to a breakdown in the therapeutic relationship (Gopal, et al., 2021).

Cultural considerations should be integrated into trauma-informed care practices. This involves recognizing and addressing cultural barriers, biases, and power dynamics that may impact the patient's care experience. It requires cultural humility, ongoing learning, and a commitment to providing care that is sensitive to diverse cultural backgrounds. Each patient's cultural background is unique, and it is important to approach care with an individualized and culturally responsive mindset. Taking the time to understand and respect cultural considerations can enhance the therapeutic relationship, promote patient trust, and improve treatment outcomes for patients with trauma. Trauma can be challenging to diagnose accurately due to its unique nature and the diverse ways it manifests in individuals. Therefore, a comprehensive understanding of the individual's experiences and symptoms is crucial for effective treatment planning and support (Gopalkrishnan, 2018)

Psychological Emotional and Physiological Impact of Trauma

When individuals experience trauma, they can have immediate and long-term reactions that vary based on the nature of the traumatic event, the individual's response, their support system, and other factors (Orchowski & López, 2023).

Immediate Impacts

In the immediate aftermath of trauma, individuals may feel a sense of disbelief or shock. They may struggle to process what has happened and have difficulty comprehending the magnitude of the event. Trauma often triggers a heightened state of fear and anxiety. Individuals may feel constantly on edge, have intense feelings of apprehension, and be hypervigilant for potential threats or danger (Orchowski & López, 2023).

Trauma can evoke a wide range of intense emotions, including sadness, anger, guilt, shame, helplessness, or a sense of numbness. These emotions may fluctuate and be overwhelming, making it challenging to regulate one's emotional state. In addition to psychological symptoms, trauma can elicit physical manifestations, such as rapid heartbeat, sweating, trembling, difficulty breathing, headaches, gastrointestinal distress, or fatigue. These physiological responses are part of the body's natural stress response system (Orchowski & López, 2023).

Intrusive thoughts, which are unwanted thoughts that make a person uncomfortable, may occur that include memories or images of the traumatic event. Flashbacks can occur, where the survivor feels as though they are actually reliving the trauma, complete with vivid sensory perceptions. Some individuals may instinctively avoid reminders of the trauma, including places, people, or activities that trigger distressing memories or emotions. Avoidance can also extend to emotional numbing, where individuals disconnect from their emotions to cope with the overwhelming feelings associated with the trauma (Orchowski & López, 2023).

Long-Term Impact

Over time, the reaction to the trauma can change. Trauma can increase the risk of developing mood disorders, such as depression, and anxiety disorders, such as generalized anxiety disorder or panic disorder. These conditions can persist long after the traumatic event and significantly impact daily functioning. Some individuals may turn to alcohol, drugs, or other substances as a means to cope with the distressing emotions and memories associated with the trauma. Substance abuse can develop as a maladaptive coping mechanism and may further complicate the recovery process (Orchowski & López, 2023).

Some individuals may engage in other self-destructive behaviors, such as self-harm, risky sexual behavior, or reckless activities, as a way to cope with the trauma or regain a sense of control. Trauma can strain interpersonal relationships. Individuals may struggle with trust, intimacy, communication, and emotional regulation, which can lead to challenges in maintaining healthy and supportive relationships. Exposure to trauma and chronic stress can contribute to various physical health conditions, including cardiovascular problems, immune system dysfunction, gastrointestinal issues, and chronic pain. For some individuals, the immediate reactions may develop into diagnosable PTSD (Orchowski & López, 2023).

Post-Traumatic Stress Disorder (PTSD)

PTSD and trauma are related concepts but have distinct differences. Trauma refers to the psychological and emotional response to a distressing or overwhelming event or series of events. It is the experience itself, such as a natural disaster, physical or sexual assault, or witnessing a violent incident. Trauma can have a significant impact on an individual's mental and emotional well-being, often leading to a range of symptoms and difficulties. PTSD, on the other hand, is a specific mental health disorder that can develop following exposure to a traumatic event. It is characterized by a set of symptoms that persist for an extended period after the traumatic experience has occurred. Not everyone who experiences trauma will develop PTSD, but those with PTSD have experienced trauma and exhibit specific symptom patterns (Sareen, 2023).

To be diagnosed with PTSD, an individual must meet specific criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 TR). PTSD has several key features. First, the person has experienced, witnessed, or been confronted with an event involving actual or threatened death, serious injury, or sexual violence. The individual also experiences intrusive and distressing memories, flashbacks, or nightmares related to the traumatic event. They may also experience intense psychological distress or physiological reactions when exposed to cues that remind them of the trauma. The person actively avoids reminders or triggers associated with the traumatic event, such as avoiding specific places, people, or activities. They may also experience emotional numbness or a diminished interest in activities they previously enjoyed (Sareen, 2023).

As a result, the individual may have persistent negative thoughts and beliefs about themselves, others, or the world. They may experience feelings of guilt, shame, or a diminished ability to experience positive emotions. Symptoms such as hyperarousal and reactivity may occur. Patients may experience heightened irritability, angry outbursts, hypervigilance, exaggerated startle response, and problems with concentration and sleep. For an individual to receive a diagnosis of PTSD, these symptoms must persist for at least one month and cause significant distress or impairment in various areas of their life. Complex trauma refers to the exposure of an individual, typically during childhood, to multiple and/or chronic traumatic experiences within the context of an interpersonal relationship. Unlike a single traumatic event, complex trauma involves ongoing and repeated traumatization over an extended period. These traumatic experiences are typically severe, and pervasive, and occur within the individual's caregiving system or close relationships (Sareen, 2023).

First-line treatment of PTSD is trauma-focused therapies such as cognitive-behavioral therapy (CBT), prolonged exposure therapy, and eye movement desensitization and reprocessing (EMDR) therapy. It's important to note that while these reactions are common, each individual's response to trauma is unique. Not everyone who experiences trauma will develop long-term difficulties, and many individuals demonstrate remarkable resilience and are able to recover with appropriate support and interventions. Seeking professional help, such as therapy or counseling, can be beneficial in processing the trauma and promoting healing (Sareen, 2023).

Pediatric Presentation

Children present with varying symptoms after trauma depending on the developmental stage that they are in. Nurses who work in the pediatric population should be vigilant of signs of trauma in children. An overview of pediatric symptoms at different ages can be found in Table 2.

Table 2. Manifestations of trauma in the pediatric population (Goddard, Jones, & Janicek, 2022).


Developmental StageTrauma Manifestation
Preschooler
  • Withdrawn
  • Restlessness
  • Irritability
  • Inconsolable
  • Re-enacting of trauma in play
  • Regression
  • Loss of previously achieved milestones
  • Temper tantrums
  • Attachment issues
  • Difficulty focusing and concentrating
  • Poor skill development
School-aged
  • Difficulty with school work
  • Conduct issues
  • Challenges authority
  • Trouble with criticism
  • Clinging to adults or teachers
  • Excessive worry or anxiety
  • Hyperactivity
  • Inattention
  • Attendance issues
  • Anger outbursts and/or aggression
  • Distrust of others
Early Adolescent
  • Feelings of inadequacy or guilt
  • Preoccupation with appearance
  • Conduct issues
  • Irritability
  • Discomfort with feelings
  • Vengeful
  • Hyperactivity
  • Difficulty with schoolwork
  • Inattention
  • Startles easily
Adolescent
  • Regression
  • Excessive worrying or anxiety
  • Emotional dysregulation
  • Conduct issues
  • Withdrawal from activities
  • Absenteeism
  • Changes in academic performance
  • Inattention
  • Hyperactivity
  • Difficulty trusting others, with authority, or receiving criticism
  • Thoughts about death and dying

Approaches to Treatment of Trauma

Stress Reduction Techniques

Stress reduction techniques can help individuals manage and reduce the negative impact of stress on their physical and mental well-being. These techniques aim to promote relaxation, enhance resilience, and restore balance in the body and mind. Deep breathing exercises, such as diaphragmatic breathing or belly breathing, involve taking slow, deep breaths, filling the lungs with air, and exhaling slowly. Deep breathing helps activate the body's relaxation response, reducing stress and promoting a sense of calm (Varcarolis, Fosbre, & Chiappetta, 2021). Progressive Muscle Relaxation (PMR) involves systematically tensing and then relaxing different muscle groups in the body. By progressively releasing muscle tension, individuals can experience physical relaxation and a reduction in overall stress levels. Mindfulness meditation involves paying attention to the present moment, non-judgmentally and with full awareness. By focusing on the present and letting go of ruminations or worries about the past or future, mindfulness meditation can reduce stress and promote a sense of clarity and calm (Varcarolis, Fosbre, & Chiappetta, 2021).

Regular physical activity, such as aerobic exercises, yoga, or walking, can help reduce stress levels. Exercise releases endorphins, which are natural mood-boosting chemicals in the body, and promotes a sense of well-being. It also helps to improve sleep quality and overall physical health. Engaging in meaningful social connections and seeking support from others can be an effective stress reduction technique. Sharing concerns, feelings, and experiences with trusted friends, family, or support groups can provide emotional validation, perspective, and a sense of belonging (Varcarolis, Fosbre, & Chiappetta, 2021).

Effective time management and prioritization techniques can help individuals feel more in control of their lives, reduce overwhelm, and manage stress. This may include setting realistic goals, creating schedules, delegating tasks, and practicing self-care. Various relaxation techniques, such as guided imagery, visualization, or listening to calming music, can induce a relaxation response and reduce stress. These techniques help shift focus away from stressors and promote a sense of peace and tranquility. Engaging in self-care activities that promote physical, mental, and emotional well-being is essential for stress reduction. This may include practicing good sleep hygiene, maintaining a balanced diet, engaging in hobbies or activities that bring joy, and setting aside time for relaxation and self-reflection. Different techniques work for different individuals, and it may require some trial and error to find the strategies that work best (Varcarolis, Fosbre, & Chiappetta, 2021).

Trauma-Focused Therapies

Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT)

TF-CBT is an evidence-based treatment approach specifically designed to address the needs of children, adolescents, adults, and their families who have experienced trauma. It integrates principles of cognitive-behavioral therapy (CBT) with trauma-focused interventions to help individuals process traumatic experiences, manage distressing symptoms, and build resilience. TF-CBT aims to reduce trauma-related symptoms, improve overall functioning, and promote post-traumatic growth. TF-CBT may also incorporate the additional therapies below (Stein, 2023).

TF-CBT teaches individuals practical skills to enhance personal safety and reduce the risk of re-traumatization. This may include assertiveness training, boundary-setting, and recognizing and avoiding potentially harmful situations. In pediatrics, TF-CBT recognizes the crucial role of caregivers in supporting their child's recovery. The therapy involves teaching loved ones skills to manage their own distress, provide emotional support, and create a safe and nurturing environment for the patient's healing (Stein, 2023).

TF-CBT incorporates graded exposure techniques to help individuals confront trauma-related triggers in a controlled and gradual manner. This gradual exposure helps reduce avoidance and anxiety while promoting adaptive coping strategies. TF-CBT focuses on fostering resilience, promoting healthy development, and planning for the future. This may involve setting goals, identifying strengths and resources, and enhancing protective factors to support the child's long-term well-being (Stein, 2023).

TF-CBT is typically conducted by trained mental health professionals, such as psychologists, social workers, or counselors. The therapy is tailored to meet the specific needs and developmental level of the patient, and it often involves collaboration with the family or caregivers. TF-CBT has been shown to be effective in reducing trauma-related symptoms and improving functioning in those who have experienced various types of trauma (Stein, 2023).

Cognitive Processing Therapy

Cognitive Processing Therapy is a type of evidence-based therapy that focuses on helping individuals develop a better understanding of their thoughts and beliefs related to the traumatic event(s) and how these thoughts contribute to their distressing symptoms. The main goal of Cognitive Processing Therapy is to help individuals challenge and modify maladaptive thoughts and beliefs that have developed as a result of the trauma. By addressing these cognitive distortions, individuals can reduce their emotional distress and improve their overall well-being (Stein, 2023).

Cognitive processing therapy interventions begin with providing education to patients and their caregivers about trauma, its effects, and common trauma-related symptoms. Psychoeducation helps normalize their experiences, reduces shame, and enhances their understanding of trauma's impact on their thoughts, feelings, and behaviors. Cognitive restructuring is a technique that involves identifying and challenging unhelpful or distorted thoughts related to the trauma. The therapist guides individuals to examine the evidence supporting and contradicting these thoughts. Through this process, individuals can develop more balanced and realistic beliefs about the traumatic event and its aftermath (Stein, 2023).

Another technique used in cognitive processing therapy is Socratic questioning, which is when the therapist uses probing questions to help individuals explore the accuracy and validity of their thoughts and beliefs. This process encourages critical thinking and assists individuals in examining the evidence and alternative perspectives. Patients may be asked to write about their trauma and related thoughts and feelings. These written accounts help individuals process and organize their thoughts, increase self-awareness, and identify patterns or themes that contribute to their distress.

Cognitive processing therapy may include exposure techniques to help individuals confront and process their traumatic memories in a safe and controlled manner. This can involve recounting the traumatic event(s) in detail or engaging in imaginal exposure exercises (Stein, 2023) and is described further in the exposure techniques section of this article. Individuals are typically assigned homework exercises between therapy sessions to practice applying cognitive restructuring techniques and challenging their unhelpful thoughts and beliefs. These assignments help reinforce the skills learned in therapy and encourage active engagement in the treatment process (Stein, 2023).

Cognitive Processing Therapy is typically conducted in a structured format and the number of sessions may vary depending on individual needs and progress. It is important to work with a trained therapist who is experienced in trauma treatment and specifically trained in CPT to ensure the proper implementation of the therapy. It has been shown to be effective in reducing PTSD symptoms and improving overall functioning in individuals who have experienced various types of trauma (Stein, 2023).

Exposure Therapy

Exposure therapy is when patients gradually are exposed to traumatic memories or experiences to allow them to reprocess their trauma. There are different types of exposure therapy. In written exposure therapy individuals are encouraged to gradually and safely confront their traumatic memories through the creation of a trauma narrative. The therapist helps them express their trauma experiences using verbal and/or written formats. The narrative is revisited and revised over time to foster processing and desensitization. This component of TF-CBT helps individuals identify and challenge unhelpful or distorted thoughts related to the trauma. By replacing negative or self-blaming beliefs with more accurate and adaptive thoughts, individuals can reduce emotional distress and promote healthier coping strategies (Stein, 2023).

Prolonged exposure therapy is another type. It usually lasts around 12 sessions and teaches patients how to retrain their breathing, common reactions to trauma, and how to process trauma. These techniques involve recounting the traumatic event(s) in a safe and controlled environment, allowing for the emotional processing of the memories. Individuals are guided to confront situations or cues in their daily lives that remind them of the trauma. This exposure helps reduce avoidance behaviors and fear responses associated with trauma triggers, enabling individuals to regain a sense of control and mastery over their environment (Stein, 2023).

Somatic Therapy

Somatic therapy is an approach that recognizes the connection between the mind and body in healing trauma. It focuses on integrating the experiences of the body, sensations, movement, and the physiological responses associated with trauma. Somatic therapy acknowledges that trauma is not only stored in memories and thoughts but also in the physical body (Stein, 2023).

In the context of trauma, somatic therapy aims to help individuals access and release the unresolved physical and emotional tension that may be held in their bodies. It recognizes that trauma can disrupt the body's natural self-regulating mechanisms and can result in symptoms. Therapists help individuals develop greater awareness of their bodily sensations, including tension, pain, and other physical sensations associated with trauma. This increased awareness allows individuals to better understand their bodies' responses to trauma triggers and stressors (Stein, 2023).

Focused breathing exercises are used to help individuals regulate their nervous system and increase their ability to self-soothe. Techniques such as deep breathing, diaphragmatic breathing, or breath awareness can promote relaxation and grounding. Therapists may incorporate gentle movements, such as yoga, dance, or tai chi, to help individuals reconnect with their bodies and release tension. Expressive arts techniques, such as drawing, painting, or sculpting, can also facilitate the exploration and expression of emotions associated with trauma. Somatic experiencing is an approach that focuses on renegotiating and resolving trauma-related physiological responses. It involves tracking bodily sensations, allowing the body to complete interrupted fight, flight, or freeze responses, and supporting the individual in integrating and processing their traumatic experiences (Stein, 2023).

Sensorimotor psychotherapy combines somatic and cognitive approaches to address trauma. It helps individuals develop awareness of bodily sensations, explore movement patterns, and address the somatic manifestations of trauma while also incorporating talk therapy techniques. Somatic therapy may also incorporate mindfulness practices, such as body scans or mindful movement, which can help individuals develop present-moment awareness and cultivate a sense of grounding. These techniques promote self-regulation and support individuals in managing distressing symptoms related to trauma. Somatic therapy can be effective in helping individuals release physical and emotional tension, restore a sense of safety and control over their bodies, and develop greater resilience in coping with trauma-related symptoms. It can be used in conjunction with other therapeutic approaches to support the overall healing process (Stein, 2023).

Psychodynamic Therapy

Psychodynamic therapy is a form of talk therapy that focuses on exploring and understanding the unconscious processes and patterns of behavior that influence a person's thoughts, emotions, and actions. It is rooted in psychodynamic theory, which emphasizes the role of unconscious thoughts and early life experiences in shaping one's psychological well-being and functioning. In psychodynamic therapy, the therapist and patient work together to uncover and address underlying conflicts, unresolved issues, and unconscious motivations that may be contributing to the patient's current difficulties or distress (Stein, 2023).

The primary goals of psychodynamic therapy include gaining insight into unconscious dynamics, resolving internal conflicts, and promoting psychological growth and self-awareness. It emphasizes the exploration of unconscious thoughts, feelings, and memories that may be influencing the patient's thoughts, emotions, and behaviors. Through open-ended discussions, the therapist helps the patient uncover and make sense of unconscious material (Stein, 2023).

Defense mechanisms are psychological strategies that individuals use unconsciously to protect themselves from anxiety or emotional distress. Psychodynamic therapy aims to identify and analyze defense mechanisms that may be hindering the patient's ability to address underlying issues. By understanding and working through these defense mechanisms, the patient can gain greater insight into their thoughts and behaviors. A summary of defense mechanisms and their descriptions can be found in Table 3 (Stein, 2023).

Psychodynamic therapy recognizes the significance of early life experiences, including childhood relationships and family dynamics, in shaping one's personality and functioning. The therapist helps the patient explore and make connections between past experiences and present difficulties, fostering insight into the origins of patterns and behaviors. The therapist may offer interpretations and insights to help the patient understand unconscious motivations, conflicts, and unresolved issues. These interpretations aim to bring awareness to unconscious processes and facilitate personal growth and change. This process often includes examining recurring themes and patterns, processing and expressing emotions, and developing healthier coping strategies (Stein, 2023).

Psychodynamic therapy is typically conducted over a more extended period compared to some other forms of therapy. It allows for a deeper exploration of underlying dynamics and patterns, giving the patient time to develop insights and make lasting changes. Psychodynamic therapy can be effective for a range of mental health concerns, including unresolved trauma. The therapeutic relationship between the therapist and patient plays a central role in the process, providing a safe and supportive environment for exploration and growth (Stein, 2023).

Table 3. Common defense mechanisms and their definitions (Varcarolis, Fosbre, & Chiappetta, 2021).


Defense MechanismDescription
RepressionInvolves pushing distressing or threatening thoughts, memories, or feelings into the unconscious mind, making them inaccessible to conscious awareness. It serves as a way to protect oneself from the discomfort or pain associated with the repressed material.
DenialThe refusal to acknowledge or accept reality, often in the face of overwhelming evidence. It allows individuals to avoid or minimize threatening or distressing information, protecting them from the anxiety or emotional turmoil associated with it.
ProjectionInvolves attributing one's own unacceptable or unwanted thoughts, feelings, or traits to others. By projecting these internal experiences onto someone else, individuals avoid acknowledging or confronting them in themselves.
RationalizationThe process of creating logical or plausible explanations to justify or make acceptable one's thoughts, feelings, or behaviors that may otherwise be seen as undesirable or socially unacceptable. It helps individuals maintain self-esteem and alleviate guilt or shame.
DisplacementInvolves redirecting one's emotions or impulses from their original target to a less threatening or safer substitute target. For example, a person who is angry with their boss may take out their frustration on a family member or engage in aggressive behavior towards an unrelated person or object.
SublimationThe channeling of unacceptable or socially inappropriate impulses or desires into socially acceptable and constructive outlets. It involves transforming negative or disruptive energy into productive or creative activities. For example, an individual with aggressive impulses may channel their energy into competitive sports or artistic pursuits.
RegressionInvolves reverting to earlier, more childlike patterns of behavior in response to stress or frustration. It can manifest as behaviors and reactions that were characteristic of an earlier developmental stage. For instance, an adult may resort to tantrums or become overly dependent on others during times of distress.
IntellectualizationCharacterized by excessive focus on logical and intellectual aspects while avoiding or minimizing emotional or personal significance. It involves distancing oneself from emotions and dealing with distressing situations in a detached and analytical manner.
Reaction FormationExpression of thoughts, feelings, or behaviors that are the opposite of one's true impulses or desires. It involves presenting oneself in a way that contradicts one's internal conflicts or unacceptable feelings. For example, a person who experiences unconscious same-sex attractions may exhibit exaggerated homophobic behaviors or beliefs.
SuppressionA conscious effort to deliberately push away or avoid unwanted thoughts, feelings, or memories. Unlike repression, which occurs at an unconscious level, suppression involves a conscious decision to not think about or dwell on certain information or experiences.

Eye Movement Desensitization and Reprocessing (EMDR)

EMDR is a therapeutic approach developed by Francine Shapiro in the late 1980s. It is primarily used to treat PTSD and other trauma-related disorders. EMDR integrates elements of CBT with bilateral stimulation techniques to help individuals process and resolve traumatic experiences. The therapist conducts a comprehensive assessment to gather information about the individual's trauma history, current symptoms, treatment goals, and the patient’s readiness to engage in EMDR. They must ensure the patient has adequate coping skills and stability to manage the emotional intensity that may arise during the process (Stein, 2023).

Bilateral stimulation involves activating both sides of the brain through alternating sensory stimulation. This can be achieved through eye movements, auditory tones, tactile tapping, or other bilateral stimulation techniques. The individual's attention is directed back and forth between the therapist's hand movements or other forms of bilateral stimulation. The therapist and individual work collaboratively to identify specific traumatic memories or distressing events that are targeted for reprocessing during EMDR. These memories are chosen based on their relevance to the individual's symptoms and treatment goals (Stein, 2023).

The desensitization phase involves recalling the targeted traumatic memory while simultaneously focusing on the bilateral stimulation. The individual is guided to hold the memory in mind while allowing associated thoughts, emotions, and physical sensations to emerge. The bilateral stimulation helps facilitate the processing of the memory and reduces its emotional intensity. Throughout the desensitization phase, the therapist guides the individual to identify negative beliefs or thoughts associated with the traumatic memory. The individual is then prompted to replace these negative beliefs with more positive and adaptive cognitions. This cognitive restructuring aims to create a more balanced and realistic perspective on the traumatic event (Stein, 2023).

The installation phase involves strengthening positive beliefs or affirmations identified during cognitive restructuring. The therapist guides the individual to focus on positive beliefs while engaging in bilateral stimulation, reinforcing a sense of empowerment and self-efficacy. After the desensitization and cognitive restructuring phases, the therapist helps the individual scan their body for any remaining physical sensations or tension related to the trauma. Bilateral stimulation is continued as needed to facilitate the release and resolution of any residual distress. At the end of each EMDR session, the therapist ensures that the individual is in a calm and stable state before concluding the session. This may involve relaxation exercises, grounding techniques, or other interventions to promote emotional stability and a sense of closure (Stein, 2023).

In subsequent sessions, the therapist assesses the individual's progress, reviews the impact of previous EMDR sessions, and identifies any remaining targets for reprocessing. EMDR continues until the individual's distress related to the targeted memories significantly decreases, and positive cognitive and emotional changes are consolidated. EMDR is typically conducted by trained mental health professionals who have received specific training in the EMDR approach. While the exact mechanisms of EMDR are still being researched, it is believed that the bilateral stimulation used in EMDR helps facilitate the adaptive processing of traumatic memories, leading to reduced distress and symptom improvement. EMDR has been widely studied and has shown effectiveness in treating PTSD and other trauma-related disorders (Stein, 2023).

Pharmacological Interventions

There are several medications that may be used to help manage specific symptoms associated with trauma-related disorders. It is important to note that medication should always be prescribed and monitored by a qualified healthcare professional, such as a psychiatrist or a prescribing provider. The choice of medication depends on the individual's specific symptoms, overall health, and any other existing medical conditions (Orchowski & López, 2023).

Selective Serotonin Reuptake Inhibitors (SSRIs) are a class of antidepressant medications commonly used in the treatment of trauma-related disorders such as PTSD. Examples of SSRIs include sertraline (Zoloft), paroxetine (Paxil), and fluoxetine (Prozac). SSRIs can help reduce symptoms of anxiety, depression, and intrusive thoughts commonly associated with trauma. Serotonin-norepinephrine reuptake Inhibitors (SNRIs) are another class of antidepressants that work by increasing the levels of serotonin and norepinephrine in the brain. They are sometimes prescribed for trauma-related disorders when SSRIs alone do not provide sufficient relief. Examples of SNRIs include venlafaxine (Effexor) and duloxetine (Cymbalta) (Orchowski & López, 2023).

Benzodiazepines are a class of medications that are sometimes prescribed for short-term use to manage acute anxiety symptoms associated with trauma. They work by enhancing the effects of the neurotransmitter gamma-aminobutyric acid (GABA), which helps reduce anxiety. However, long-term use of benzodiazepines is generally discouraged due to the risk of dependence and potential negative effects on memory and cognition. Prazosin is an alpha-1 adrenergic antagonist that is sometimes prescribed to manage nightmares and sleep disturbances in individuals with PTSD. It may help reduce the intensity and frequency of nightmares and improve sleep quality. Some anticonvulsant medications, such as topiramate (Topamax) or lamotrigine (Lamictal), may be used off-label to help manage symptoms of irritability, anger, or emotional dysregulation associated with trauma-related disorders (Orchowski & López, 2023).

Beta-blockers, such as propranolol, are sometimes prescribed to help manage the physiological symptoms of anxiety, such as rapid heartbeat, trembling, and sweating. They are occasionally used on an as-needed basis to reduce the intensity of anxiety during specific triggering situations, such as public speaking or exposure therapy sessions. It's important to remember that medication alone is not considered a comprehensive treatment for trauma-related disorders. It is often recommended to combine medication with psychotherapy, such as trauma-focused therapy, cognitive-behavioral therapy (CBT), or eye movement desensitization and reprocessing (EMDR), for optimal results. The specific treatment plan should be tailored to the individual's needs and preferences, and regular monitoring and evaluation should be conducted to assess the effectiveness and potential side effects of any medications prescribed (Orchowski & López, 2023).

Alternative and Complementary Therapies

Alternative and complementary therapies can be valuable adjuncts to traditional treatments for trauma. While they may not replace evidence-based therapies, these approaches can offer additional support and promote overall well-being. Practices such as mindfulness meditation, yoga, and tai chi can help individuals develop an awareness of their present-moment experiences and cultivate a sense of calm and relaxation. Mindfulness-based interventions have been shown to reduce symptoms of anxiety, depression, and emotional distress associated with trauma (Orchowski & López, 2023).

Art therapy involves engaging in creative processes, such as painting, drawing, or sculpture, to express and explore emotions and experiences related to trauma. It can provide a nonverbal outlet for processing and communicating feelings, as well as promoting self-expression, self-discovery, and emotional healing. Equine-assisted therapy involves interacting with horses under the guidance of a trained therapist. Working with horses can help individuals develop trust, improve emotional regulation, enhance communication skills, and promote self-confidence. The presence of horses can create a safe and supportive environment for trauma survivors (Orchowski & López, 2023).

Music therapy utilizes music and sound as therapeutic tools to address emotional, cognitive, and physical needs. Listening to or creating music can help individuals express their emotions, reduce stress, promote relaxation, and facilitate emotional processing. Music therapy can be particularly beneficial for individuals who struggle with verbal expression or have difficulty accessing their emotions directly.

Massage therapy and bodywork techniques, such as acupuncture, acupressure, or somatic experiencing, can help individuals release physical tension, reduce stress, and promote relaxation. These approaches focus on the mind-body connection and can help individuals reconnect with their bodies and regain a sense of safety and grounding (Orchowski & López, 2023).

Some individuals may explore the use of herbal remedies or dietary supplements to support their mental and emotional well-being. However, it is essential to consult with a healthcare professional before starting any herbal remedies or supplements to ensure they are safe and appropriate for the individual's specific needs and potential interactions with other medications. Techniques such as breathing exercises, guided imagery, and progressive muscle relaxation can help individuals regulate their physiological responses, reduce anxiety, and promote relaxation. These techniques can be incorporated into daily self-care routines and can provide individuals with practical tools to manage stress and traumatic triggers (Orchowski & López, 2023). While alternative and complementary therapies can be beneficial, these therapies should be used in conjunction with evidence-based treatments for trauma under the supervision of a trained healthcare provider. The integration of multiple approaches can provide a comprehensive and holistic approach to healing from trauma.

Nursing Implications in Trauma Care

In collaboration with the interdisciplinary team, there are many ways that nurses can support patients who are dealing with psychological trauma (Varcarolis, Fosbre, & Chiappetta, 2021).

Care During Acute Trauma

When a patient has just experienced a traumatic event, the nurse should identify if the patient has been physically hurt and if so, get medical attention for those injuries. The nurse should talk to the person, but should not pressure them to talk. The patient should be reassured that they will get the help they need. Reassure them that there are many responses to trauma and that what they are feeling or experiencing is a normal reaction to a traumatic event. After the period of crisis has passed, the patient should be given resources to help them seek care if they need help processing their trauma (O’Kane, 2021).

There are also more structured interventions that can occur after a group of people have all experienced a traumatic event. CISD is a psychological intervention designed to support individuals who have experienced a traumatic event. It aims to help individuals process their emotional reactions, reduce the impact of the trauma, and promote recovery. CISD is typically conducted in a group format and involves several phases. This should occur between one to three hours after the event. This strategy can also be used when the healthcare team experiences trauma. It consists of several phases, starting with the pre-briefing. In the pre-briefing, the facilitator introduces the purpose and structure of the debriefing session, clarifies confidentiality and ground rules, and explains the debriefing process. Participants are encouraged to share their experiences and emotions openly and honestly (Orchowski & López, 2023; Varcarolis, Fosbre, & Chiappetta, 2021).

Next, during the fact phase, participants are invited to describe the objective details of the traumatic event. This phase allows individuals to provide a chronological account of the event, focusing on facts rather than emotions. The facilitator may ask clarifying questions to ensure a comprehensive understanding. The next phase is the thought phase, where participants are encouraged to share their thoughts, beliefs, and cognitive reactions related to the traumatic event. This includes their interpretations, self-blame, guilt, or any distorted thinking patterns that may have emerged. The facilitator helps individuals identify and challenge any irrational or unhelpful thoughts (Orchowski & López, 2023; Varcarolis, Fosbre, & Chiappetta, 2021).

After the thought phase is the reaction phase, where participants have the opportunity to express their emotional and physical reactions to the traumatic event. They may discuss their feelings of fear, anger, sadness, guilt, or other emotions that have arisen as a result of the experience. The facilitator validates and normalizes these reactions, creating a safe space for individuals to share openly. The symptom phase follows, where the participants are asked to discuss any physical or psychological symptoms they may be experiencing since the traumatic event. This may include sleep disturbances, nightmares, intrusive thoughts, irritability, or other signs of distress. The facilitator provides psychoeducation about common stress reactions and coping strategies (Orchowski & López, 2023; Varcarolis, Fosbre, & Chiappetta, 2021).

In the teaching phase, the facilitator provides information and guidance on stress management techniques, coping strategies, and self-care practices. This may include deep breathing exercises, relaxation techniques, grounding exercises, and referrals to additional resources or support services. The final portion is the re-entry phase, where participants discuss their thoughts and concerns about returning to their regular activities and routines. The facilitator addresses any challenges or fears associated with re-engaging in daily life and provides guidance on gradual re-entry and self-care during the recovery process (Orchowski & López, 2023; Varcarolis, Fosbre, & Chiappetta, 2021).

CISD is primarily designed as an immediate intervention to support individuals in the aftermath of a critical incident. If individuals continue to experience significant distress or symptoms, they are encouraged to seek further professional help for more comprehensive treatment. CISD should be conducted by trained professionals who are knowledgeable about trauma and its impact. Their role is to facilitate a supportive and safe environment for participants to process their experiences and provide appropriate guidance and resources for further support if needed (Orchowski & López, 2023; Varcarolis, Fosbre, & Chiappetta, 2021).

Psychological First Aid is another acute trauma intervention that is designed to improve outcomes immediately after a traumatic event to offer support by fostering safety, calmness, social connectedness, and optimism. It is a flexible and practical approach that focuses on promoting safety, comfort, and emotional well-being in the immediate aftermath of a crisis. It is typically provided by trained mental health professionals, healthcare providers, or individuals with relevant crisis response training. The first step of PFA is to ensure the physical and emotional safety of the individual. The provider creates a calm and supportive environment, establishes rapport, and demonstrates empathy and a non-judgmental attitude. This helps the individual feel heard, understood, and respected. Then the provider assesses the individual's immediate needs and concerns, including physical safety, medical attention, basic necessities (such as food, water, or shelter), and emotional well-being. This assessment helps identify the most pressing needs and prioritize interventions accordingly (Orchowski & López, 2023; Varcarolis, Fosbre, & Chiappetta, 2021).

The next step provides stabilization and practical assistance which involves providing support and assistance to meet the individual's immediate needs. This may include arranging for medical care, connecting the person with necessary resources (e.g., food, clothing, temporary shelter), and facilitating communication with loved ones or support systems. Next, the provider uses active listening and validation to create a space for the individual to share their experiences and emotions without judgment. They listen attentively, acknowledge the person's feelings, and validate their reactions as normal and understandable given the circumstances. The provider offers emotional support and reassurance to the individual. This includes offering comfort, empathy, and understanding. They may provide information about common stress reactions and normalize the individual's emotional responses to the traumatic event (Orchowski & López, 2023; Varcarolis, Fosbre, & Chiappetta, 2021).

Then, accurate and relevant information about the situation, available resources, and potential next steps are provided. The provider offers clear explanations and answers questions to reduce uncertainty and help the individual make informed decisions. They also provide guidance on coping strategies and self-care practices. This may involve teaching relaxation techniques, deep breathing exercises, or grounding exercises to help manage stress and anxiety. The provider may also encourage the individual to engage in healthy self-care activities such as maintaining a regular sleep routine, eating nutritious food, and seeking social support. If necessary, the provider may make referrals to additional support services or mental health professionals for ongoing care. They may provide information about local resources, support groups, or counseling services to ensure the individual has access to continued assistance if needed. Psychological First Aid aims to provide immediate support and promote resilience in the early stages of a crisis. It helps individuals cope with the immediate impact of the event and lays the foundation for further recovery and long-term healing (Orchowski & López, 2023; Varcarolis, Fosbre, & Chiappetta, 2021).

Therapeutic Communication

Therapeutic communication refers to a set of communication techniques and strategies that can be used by nurses to establish and maintain a strong professional relationship with patients or patients. The goal of therapeutic communication is to facilitate effective and meaningful exchanges of information, promote trust, understanding, and emotional support, and enhance the overall therapeutic process (Varcarolis, Fosbre, & Chiappetta, 2021).

There are several key principles and techniques of therapeutic communication. Therapeutic communication emphasizes active listening, which involves fully focusing on and comprehending what the individual is saying. It includes maintaining eye contact, nodding or providing verbal cues to indicate understanding, and avoiding interruptions. Active listening helps individuals feel heard, validated, and understood (Varcarolis, Fosbre, & Chiappetta, 2021).

Demonstrating empathy involves understanding and acknowledging the emotions and experiences of the patient. It involves putting oneself in the other person's shoes, showing genuine concern, and providing non-judgmental support. Empathy helps create a safe and supportive environment, allowing individuals to express their feelings and concerns openly (Varcarolis, Fosbre, & Chiappetta, 2021).

Open-ended questions encourage individuals to provide more detailed and reflective responses, rather than simple "yes" or "no" answers. These questions promote conversation and exploration of thoughts and feelings. For example, instead of asking, "Did that make you sad?" the nurse might ask, "How did that experience make you feel?" Offering validation and support is essential in therapeutic communication. Validating someone's experiences and emotions helps them feel understood and accepted. Providing support and encouragement can enhance self-esteem and motivation for change (Varcarolis, Fosbre, & Chiappetta, 2021).

Reflective responses involve paraphrasing or summarizing what the individual has expressed to ensure accurate understanding. It demonstrates active listening and validates the person's experiences. Reflective responses can be used to clarify information and encourage further exploration of thoughts and feelings. Clarifying and summarizing information can help ensure mutual understanding and prevent miscommunication. It involves restating or paraphrasing important points and checking with the individual if the understanding is accurate. Summarizing the discussion at appropriate intervals can help reinforce key insights and promote a sense of progress (Varcarolis, Fosbre, & Chiappetta, 2021).

Non-verbal cues, such as facial expressions, body language, and tone of voice, play a significant role in therapeutic communication. Maintaining a calm and open body posture, maintaining appropriate eye contact, and using a warm and gentle tone can help convey empathy, understanding, and acceptance. Silence can be a powerful therapeutic communication technique. It allows individuals to process their thoughts, reflect on their experiences, and express themselves at their own pace. Using appropriate periods of silence can create space for individuals to gather their thoughts, share deeper insights, or express emotions that they may find difficult to verbalize (Varcarolis, Fosbre, & Chiappetta, 2021).

Offering validation and support is essential in therapeutic communication. Validating someone's experiences and emotions helps them feel understood and accepted. Providing support and encouragement can enhance self-esteem and motivation for change. Create a safe and non-judgmental space for the person to express themselves freely. Refrain from criticizing or blaming them for their emotions or experiences. Accept their feelings without minimizing or dismissing them (Varcarolis, Fosbre, & Chiappetta, 2021).

Maintaining confidentiality is an essential aspect of therapeutic communication. Respecting the privacy and confidentiality of the individual's personal information promotes trust and a safe environment for open and honest communication. Being aware of and respectful of the individual's cultural background, beliefs, and values is crucial in therapeutic communication. Cultural sensitivity helps establish trust and prevents misunderstandings or misinterpretations that could hinder effective communication (Varcarolis, Fosbre, & Chiappetta, 2021).

Deescalation

There are times when patients who have experienced trauma present with anger or agitation. The nurse may need to initiate de-escalation techniques if the patient is showing signs of anger such as being verbally threatening, overly sarcastic, or withdrawn. Physically the nurse may notice furrowed eyebrows, a tense jaw or grinding teeth, pacing, or dilated pupils. The patient may be yelling or speaking quietly and they may make eye contact for longer than what would be expected (O’Kane, 2021).

To escalate the situation, the nurse should aim to bring the tension down to the point that a discussion can occur. This starts with controlling one’s own reaction. Keeping oneself calm is of the utmost importance. Maintain a relaxed posture and make intermittent eye contact. Then the nurse should assess the safety of the situation. Leaving a little distance between the nurse and the patient can create a feeling of safety. The patient should never be in front of the exit so that the nurse can leave if needed. Avoid de-escalation alone, have another person standing by in case the patient is violent. Security may get involved, but realize that this may escalate a patient further and security should be used with caution. The use of other healthcare workers is much less threatening. If the patient is in a noisy or busy area, try to get them to a quieter space. When the patient is able to begin to talk, the nurse can explore what the patient wants or needs. Offer appropriate choices whenever possible, always using empathy and respect in communication. Then come to a flexible resolution (O’Kane, 2021).

Caring for Someone Engaging in Self-Harm

Self-harm is a term that describes non-suicidal intentional injurious behaviors that a person does to themselves. Common self-harm behaviors can include cutting, burning or scalding, hair pulling, skin carving, or picking scabs. When the nurse is caring for someone who self-harms, they should know that these patients are at higher risk of suicide so they should be assessed for suicide risk. If the physical harm is not life-threatening, the nurse can keep the patient safe and offer calm, honest, compassionate communication. The patient’s pain should be acknowledged and treated and they should be set up with follow-up with an appropriate mental health professional (O’Kane, 2021).

Caring for Someone Who is Suicidal

If someone is suicidal, actions really depend on the setting. The first thing the nurse should do is establish safety. The nurse should know if the patient has a plan on how to kill themselves if they have access to any weapons at home or with them, and if they are on medications and where they are. They should be assessed for the frequency and nature of suicidal thoughts if they have taken any drugs or alcohol, and how much. In some cases, emergency services may be called. The nurse can help individuals who are or have been suicidal create a plan on what to do when they feel that way. The nurse should acknowledge their distress calmly while keeping them safe and arranging for follow-up (O’Kane, 2021).

Caring for Someone Who is Having a Panic Attack

A panic attack is when an individual experiences intense fear that is usually triggered by negative thoughts. While physically they are harmless, they can be incredibly frightening. Usually, they go away without medical attention. Sometimes patients may say they feel like they're dying or having a heart attack so the nurse must rule out cardiac issues. The nurse should then encourage the person to take slow, deep breaths while calmly reminding the person that the feelings will pass and cannot harm them. It is really important to acknowledge their distress and not be dismissive of their symptoms. Try to move the person to a quiet and private place and stay with them until they remain calm (O’Kane, 2021).

Care Coordination and Interdisciplinary Collaboration

Patients who have experienced trauma may have multiple needs from friends, family, and the healthcare team. They may require referrals to other services or different resources to assist them. The nurse often coordinates and implements the plan of care to move toward recovery. This involves communicating between the patient, their loved ones, and other healthcare workers.

Social Support

Social support can be incredibly beneficial for individuals who have experienced trauma. When a person has experienced trauma, it is common to feel isolated, misunderstood, or overwhelmed by their emotions. Social support can provide emotional validation, connection, companionship, and empathy. Having a network of supportive loved ones who listen, validate their feelings, and offer understanding can help those who have experienced trauma feel less alone and provide a sense of comfort. Trauma can also erode a person's sense of safety and trust in others. Building a support network with others who are trustworthy and reliable can help restore a sense of safety and security. Knowing that there are people who genuinely care and have their best interests at heart can be reassuring and promote healing (Varcarolis, Fosbre, & Chiappetta, 2021).

A support system can offer practical assistance as well. This may include helping with daily tasks, providing transportation to appointments, offering financial assistance or resources, or simply being there to lend a helping hand when needed. Practical support can alleviate stress and allow individuals to focus on their healing and recovery. Connecting with others who have gone through similar traumatic experiences can be especially valuable. Peer support groups or networks provide a safe space for individuals to share their stories, exchange insights, and learn from others who have navigated similar challenges and nurses play an important role in connecting patients with area support groups. Peer support can foster a sense of validation, normalization, and inspiration for recovery. Individuals within the group may have knowledge of therapy options, support groups, self-help resources, or other services that can aid in the healing process. Sharing these resources can empower individuals to seek appropriate help and support (Varcarolis, Fosbre, & Chiappetta, 2021).

Sleep

Patients with trauma may have difficulty falling asleep, or staying asleep, or they may experience nightmares. Nurses can teach patients habits that can help patients sleepbetter, such as maintaining a consistent bedtime schedule, performing a soothing bedtime routine, or avoiding screen time and rigorous exercise before bed. Children who have experienced trauma and have sleep difficulties may benefit from using a night list, reassurance when feeling scared, or using a transitional object such as a plush toy or special blanket (Goddard, Jones, & Janicek, 2022).

Pediatric Considerations

General Guidelines

Supporting a child who has experienced trauma requires a sensitive and nurturing approach. Establish a safe and predictable environment for the child. Ensure they have a secure physical space, consistent routines, and clear boundaries. This stability can help them feel secure and reduce anxiety. Develop a trusting and supportive relationship with the child. Show them empathy, respect, and patience. Building trust takes time, so allow the child to gradually open up at their own pace (Goddard, Jones, & Janicek, 2022).

Create opportunities for the child to express their feelings and thoughts. Practice active listening by giving them your full attention, maintaining eye contact, and validating their emotions. Avoid judgment or criticism and provide reassurance that it's safe for them to share. Much like adults, children need validation of their emotions by acknowledging their experiences and feelings. Let them know that their reactions are normal given what they have been through. Help them identify and label their emotions, and reassure them that it's okay to feel the way they do.

Provide honest and age-appropriate information about trauma. Help the child understand that what they experienced was not their fault. Use language and explanations that they can comprehend, and be prepared to answer their questions honestly. Children often find it easier to express themselves through play, art, or other creative activities. Provide them with opportunities to engage in activities that allow them to process their emotions and experiences. This can include drawing, painting, storytelling, or playing with toys. Help the child regain a sense of control and empowerment. Involve them in decision-making when appropriate, and give them choices within reasonable limits. Encourage their strengths and abilities, and provide opportunities for them to develop new skills (Goddard, Jones, & Janicek, 2022).

Collaboration

Pediatric patients usually require additional collaboration with caregivers and school personnel. The healthcare team should work collaboratively with the child's caregivers by sharing information, strategies, and resources to ensure consistent support across different environments. Maintain open lines of communication to address any concerns or updates (Goddard, Jones, & Janicek, 2022).

Altered Elimination

Pediatric patients may experience changes in their bowel and bladder patterns after trauma including constipation, encopresis, or enuresis. Nurses can teach children and their families to eliminate negative associations around toileting and use positive strategies such as a reward system for sitting on the toilet or staying dry at night, using a game or activity only used in the bathroom to encourage them to go, and scheduling voiding every two hours (Goddard, Jones, & Janicek, 2022).

Challenging Behaviors in Children and Adolescents

Children and adolescents who have experienced trauma often experience undesirable behaviors that can be challenging for their caregivers to deal with. Nurses who work with this population can recommend positive parenting practices that build resiliency and use non-physical punishment. It is crucially important for parents to view these behaviors through the lens of a trauma response instead of intentional misbehavior. Nurses can help facilitate the necessary referrals to other members of the interdisciplinary team for intensive support in navigating these issues (Goddard, Jones, & Janicek, 2022).

Perinatal Considerations

General Guidelines

Supporting a pregnant person who has experienced trauma requires sensitivity, compassion, and understanding of their unique needs. Pregnancy can be an especially vulnerable time for individuals and it is important to recognize and address issues with trauma to ensure the safety and well-being of the pregnant person and their unborn child. In addition to the other strategies used for adult patients, there are some specialized considerations in the perinatal period (Goddard, Jones, & Janicek, 2022).

Recognize that trauma can affect a person's sense of control and autonomy. Respect their boundaries and decisions regarding their pregnancy and birth preferences. Support their choices and empower them to make informed decisions about their care. Offer access to accurate and relevant information about pregnancy, childbirth, and potential challenges or triggers associated with their trauma. Help them understand the available options for prenatal care, childbirth, and postpartum support. Encourage them to ask questions and seek clarification as needed (Goddard, Jones, & Janicek, 2022).

Help the pregnant person find healthcare providers who have experience working with trauma survivors. Seek professionals who can offer sensitive and trauma-informed care during prenatal visits, childbirth, and postpartum care. Collaborate with healthcare providers to ensure consistent and supportive care. Be available to provide emotional support throughout the pregnancy journey. Listen actively, offer validation and reassurance, and provide a non-judgmental space for the pregnant person to express their concerns and fears. Offer encouragement and remind them of their strengths and resilience. Support them in setting boundaries and finding time for self-care amidst the demands of pregnancy. Providing a compassionate and non-judgmental presence can make a significant difference in their journey toward healing and a healthy pregnancy (Goddard, Jones, & Janicek, 2022).

Intimate Partner Violence

The risk for intimate partner violence increases significantly during pregnancy, Nurses should be aware of the signs of intimate partner violence, which may include physical, emotional, or sexual abuse, controlling behaviors, isolation, or threats. The nurse should establish a safe and non-judgmental space for the pregnant person to disclose any traumatic experiences. Privacy and confidentiality must be respected in order for there to be an environment of safety. The patient should know that the nurse is available to listen and support them without pressuring them to share if they are not ready (Varcarolis, Fosbre, & Chiappetta, 2021).

The nurse can offer various resources about intimate partner violence and its impact on pregnancy. Educational materials can be provided or the patient can be connected to reliable resources that can help them understand their rights, available support services, and options for safety planning. Ensure they have access to helplines, local shelters, counseling services, or legal support if needed (Varcarolis, Fosbre, & Chiappetta, 2021).

The nurse should use open-ended questions to assess the level of danger they may be facing and evaluate their immediate safety and the safety of their unborn child. Develop a safety plan together, which may include identifying safe places to go, emergency contact numbers, and strategies for reducing risk. Collaboration with other professionals, such as social workers, counselors, and legal experts, helps to ensure a comprehensive approach. Information is shared with their consent to facilitate coordinated care and support (Varcarolis, Fosbre, & Chiappetta, 2021).

If the pregnant person discloses instances of violence, the nurse should document the information accurately and securely, following appropriate guidelines and legal requirements. If necessary and with their consent, report the violence to the appropriate authorities to ensure their safety. The pregnant person's autonomy should always be respected and they should be supported in making their own decisions regarding their safety and well-being. It is important to avoid pressuring them to take actions they are not ready for but offer guidance and support when they express a desire for change. Maintain regular contact and follow up with the pregnant person to ensure their well-being. Continue providing support throughout their pregnancy and beyond, connecting them with appropriate resources as needed (Varcarolis, Fosbre, & Chiappetta, 2021).

Birth Trauma

Birth trauma is any physical or psychological distress that is experienced during and after childbirth. Patients may feel afraid, helpless, or unsupported during childbirth. After the birth, they may experience feelings of guilt, numbness, or a loss of control. Birth trauma is very common in the United States and occurs when the childbirth experience is not what was hoped for. Birth complications, such as vaginal tearing, episiotomy, hemorrhage, emergency Cesarean birth, or the use of forceps or other medical devices can also cause trauma. Birth injury in the infant is a significant source of trauma as is when the baby requires medical attention after the delivery. Lastly, not receiving care or support from the healthcare team can be incredibly traumatic (March of Dimes, 2023).

Patients often expect childbirth to be a joyous occasion, and when birth trauma occurs it can be very difficult to seek support. One way of coping with birth trauma is to journal about the birth story, reframing the experience to give it a new meaning. A person can even share their story with other parents to make connections. This can help birth trauma survivors regain a sense of personal identity and control (March of Dimes, 2023).

Birth trauma, long-term mental health issues, and death are significantly higher in Black birthing people than in any other population in the United States. The reasons for this disparity are complex but include the history of generational trauma, the unrelenting experience of racism at the systemic level, decreased access to health services, and mistreatment by the healthcare workforce. Nurses are positioned to be advocates for change and can help Black pregnant, birthing, or postpartum patients engage in empowerment and advocacy. Nurses should specifically seek to listen carefully to Black patients, validating their experiences and meeting their medical needs by providing needed resources. Better representation in the workforce and medical research is another important factor in addressing the disparity (Chatlani, 2022).

LGBTQIA+ Individuals

LGBTQIA+ individuals may be at a higher risk for experiencing trauma due to various factors, including social, cultural, and systemic dynamics. They often face discrimination and stigma in many areas of their lives, including family, education, employment, healthcare, and society at large.

Experiencing prejudice, rejection, or violence based on their sexual orientation, gender identity, or gender expression can have a profound impact on their mental and emotional well-being, potentially leading to trauma (APA, 2023). LGBTQIA+ individuals may experience minority stress, which refers to the unique stressors and challenges faced by individuals from marginalized groups. This stress can stem from the fear of discrimination, concealing one's sexual orientation or gender identity, navigating societal norms, and internalized homophobia or transphobia. Over time, chronic exposure to minority stress can contribute to trauma. They are also at an increased risk of experiencing victimization and violence, including hate crimes, bullying, harassment, and intimate partner violence. These traumatic events can have long-lasting psychological and emotional effects, leading to PTSD or other trauma-related conditions (APA, 2023).

Many LGBTQIA+ individuals face rejection from their families and communities, which can result in a sense of loss, isolation, and emotional trauma. Being rejected by loved ones or not having a supportive social network can contribute to feelings of shame, low self-worth, and increased vulnerability to trauma. LGBTQIA+ individuals who belong to other marginalized groups, such as people of color, individuals with disabilities, or those with low socioeconomic status, may face intersecting forms of oppression. These intersecting identities can compound the risk of experiencing trauma due to the cumulative effects of discrimination, marginalization, and systemic injustices (APA, 2023).

LGBTQ+ individuals may face barriers to accessing affirming and competent healthcare services. This can lead to inadequate or discriminatory treatment, resulting in traumatic experiences within healthcare settings. Lack of appropriate mental health support or resources can further contribute to the risk of trauma. It's important to recognize that trauma experiences among LGBTQIA+ individuals can be complex and varied. Providing trauma-informed care that considers their unique experiences and needs is crucial for promoting healing and resilience. By fostering inclusive and affirming environments, challenging discrimination and stigma, and promoting access to supportive resources, nurses can work towards reducing the risk of trauma among LGBTQIA+ individuals and promote their overall well-being (APA, 2023).

Prevention of Vicarious Trauma

Preventing vicarious trauma is imperative for those who work closely with trauma survivors. There are strategies that can help prevent vicarious trauma. Paying attention to one’s own reactions and emotions when working with trauma survivors, acknowledging any signs of distress, and intervening with healthy coping strategies can prevent vicarious trauma from developing. Prioritizing self-care activities that promote well-being, such as engaging in hobbies, practicing relaxation techniques, getting regular exercise, maintaining a healthy lifestyle, and ensuring sufficient rest and sleep can make nurses more resilient (Varcarolis, Fosbre, & Chiappetta, 2021).

Those who care for trauma survivors should make sure they take adequate breaks and set boundaries to avoid burnout. Clear boundaries should be established in both work and personal lives. Limits can be defined around the amount of time and energy that is devoted to work. Taking regular time off to rest, relax, and engage in activities that bring joy helps to prevent constant exposure to trauma-related content (Varcarolis, Fosbre, & Chiappetta, 2021).

Peer support groups or debriefing sessions can also be helpful for sharing experiences, seeking advice, and receiving validation from others who understand the demands of the work. Supervisors should provide a safe space to discuss challenging cases, process emotions, and gain guidance. Continuously investing in professional growth by staying up to date on trauma-informed practices, attending workshops or training, and engaging in ongoing learning can help individuals feel more competent and effective in their role, reducing the risk of feeling overwhelmed or helpless (Varcarolis, Fosbre, & Chiappetta, 2021).

Recognizing that nurses are human and that it is normal to be affected by the stories and experiences of trauma survivors self-compassion is a must. Those who work with patients who have experienced trauma should treat themselves with the same empathy and understanding as would be extended to others. Self-compassion techniques, such as positive self-talk, mindfulness, and self-care rituals can help. Maintaining a strong support network outside of the work environment by cultivating relationships with family, friends, and loved ones can provide emotional support and understanding. Nurturing relationships creates a sense of connection and belonging (Varcarolis, Fosbre, & Chiappetta, 2021).

Those who experience significant distress or difficulty coping with vicarious trauma should seek professional support by consulting with a mental health professional who specializes in trauma or compassion fatigue. They can provide guidance, therapeutic interventions, and strategies tailored to specific needs. By prioritizing one’s own mental health, one can continue to support others effectively while minimizing the risk of experiencing vicarious trauma (Varcarolis, Fosbre, & Chiappetta, 2021).

Trauma-Informed Approaches

Trauma-Informed Approaches to Healthcare

Trauma-informed care is an approach to providing services and support that recognizes the widespread impact of trauma and integrates this understanding into all aspects of care delivery. It involves creating a safe and supportive environment that promotes healing and recovery for individuals who have experienced trauma. Providing trauma-informed care requires knowledge and understanding of the impact of trauma on individuals' lives. This includes recognizing the potential triggers, responses, and coping mechanisms associated with trauma. For instance, a mental health professional may understand that individuals with a history of trauma may experience heightened anxiety during certain therapy sessions and be prepared to provide additional support and reassurance (Goddard, Jones, & Etcher, 2022).

Key principles of trauma-informed care include safety, trust, choice, empowerment, collaboration, and cultural responsiveness. Ensuring physical and emotional safety is a fundamental principle of trauma-informed care. This includes creating an environment where individuals feel safe, respected, and in control of their own experiences. For example, healthcare providers can explain procedures and obtain consent before conducting examinations, providing individuals with a sense of autonomy and control (Goddard, Jones, & Etcher, 2022).

Building trust is essential in trauma-informed care. Providers should be transparent in their intentions, communication, and decision-making processes. For instance, therapists can openly discuss treatment goals, methods, and potential challenges with their patients, fostering a collaborative and trusting therapeutic relationship (Goddard, Jones, & Etcher, 2022).

Trauma-informed care emphasizes empowering individuals and promoting their choice and autonomy. It involves collaborating with individuals in decision-making processes related to their care. For instance, allowing survivors of trauma to have agency in choosing treatment modalities, setting goals, or deciding on the pace of their recovery journey. It recognizes that individuals are experts in their own experiences. Providers actively involve individuals in their care planning and treatment, valuing their input and experiences. For example, in a school setting, educators can work collaboratively with students who have experienced trauma to identify and implement strategies that support their academic and emotional well-being (Goddard, Jones, & Etcher, 2022).

Trauma-informed care recognizes and respects the cultural background and diversity of individuals. Providers should be culturally sensitive and adapt their approach to meet the unique needs and preferences of different cultural groups. For example, a domestic violence shelter may provide trauma-informed services that are tailored to the specific cultural practices, beliefs, and traditions of the residents (Goddard, Jones, & Etcher, 2022).

Trauma-informed care acknowledges and builds upon the strengths and resilience of individuals. It focuses on promoting recovery, growth, and empowerment. For instance, a support group for survivors of trauma may emphasize participants' strengths and accomplishments, fostering a sense of resilience and hope. Implementing trauma-informed care requires training, organizational commitment, and ongoing evaluation to ensure its effective implementation. By integrating these principles into various settings such as healthcare, education, social services, and mental health, trauma-informed care creates an environment that supports healing, recovery, and overall well-being for individuals impacted by trauma (Goddard, Jones, & Etcher, 2022).

Trauma-Informed Approaches in Schools

Trauma-informed approaches are effective in other areas as well. They can be beneficially implemented in schools to create supportive and inclusive environments for individuals who have experienced trauma. Schools can prioritize physical and emotional safety by establishing clear rules, routines, and expectations. They can also foster a positive and supportive school climate through practices like peer mentoring, conflict resolution programs, and anti-bullying initiatives (Schulman & Menschner, 2018).

Policies that consider the needs of students who have experienced trauma can be developed. This may involve flexible attendance policies, trauma-informed discipline practices, and accommodations for students with trauma-related difficulties, such as allowing breaks or providing additional support. Educators can incorporate trauma-informed strategies within the classroom, such as providing predictable routines, offering choices, using calming techniques, and implementing sensory-friendly environments. They can also utilize trauma-sensitive teaching approaches that promote a sense of safety, connection, and empowerment. Integrating social-emotional learning (SEL) programs into the curriculum helps students develop skills in self-awareness, self-regulation, empathy, and healthy relationship-building. SEL provides a foundation for trauma-informed practices by fostering emotional well-being and resilience. Schools can provide professional development opportunities for teachers and staff to enhance their understanding of trauma and develop skills to support traumatized students. Collaboration between educators, counselors, and other support staff is crucial in implementing trauma-informed approaches effectively (Schulman & Menschner, 2018).

Trauma-Informed Approaches in Workplaces

Trauma-informed approaches can also be implemented in workplaces by organizations by offering a safe and supportive work environment, using human resources and leadership practices consistent with trauma-informed principles, offering training and education, and prioritizing employee well-being and self-care (Schulman & Menschner, 2018).

Employers can create a work environment that emphasizes physical and emotional safety, respect, and inclusivity. This includes providing clear policies against harassment and discrimination, fostering open communication, and promoting work-life balance. Human resources departments can adopt trauma-informed approaches in areas such as recruitment, hiring, and onboarding. This may involve training HR staff to recognize and support employees who have experienced trauma and ensuring that policies and procedures are sensitive to trauma-related needs (Schulman & Menschner, 2018).

Employers can offer trauma-informed training for managers and staff members to develop awareness and understanding of trauma and its impact in the workplace. This training can cover topics such as recognizing trauma-related signs, responding empathetically, and promoting a supportive work environment. Supervisors can adopt trauma-informed approaches in their interactions with employees. This includes providing clear expectations, offering constructive feedback, and recognizing the potential impact of trauma on an employee's performance and well-being. Providing flexible work arrangements, such as flexible schedules or remote work options, can support employees who may need additional flexibility due to trauma-related challenges. This can help create a sense of control and reduce potential triggers or stressors (Schulman & Menschner, 2018).

Employers can promote employee well-being by implementing self-care initiatives, such as wellness programs, access to mental health resources, and encouraging a healthy work-life balance. This can support employees in managing the effects of trauma and maintaining their overall well-being. Employee Assistance Programs (EAPs) can offer confidential counseling and support services for employees who have experienced trauma. These programs provide access to resources, referrals to mental health professionals, and confidential avenues for employees to seek assistance (Schulman & Menschner, 2018).

Implementing trauma-informed practices in workplaces requires a collaborative effort that involves leadership commitment, staff training, policy development, and ongoing evaluation. By creating environments that acknowledge and respond to the impact of trauma, employers can support the healing and well-being of students and employees who have experienced trauma (Schulman & Menschner, 2018).

Implementing Trauma-Informed Practices

Organizational Level

Implementing trauma-informed practices in an organization, whether in healthcare delivery, in workplaces, or schools, involves a systematic approach that encompasses organizational policies, staff training, and changes in service delivery. First and foremost, true trauma-informed organizations must have commitment and support from organizational leadership to prioritize trauma-informed care. This commitment should be reflected in mission statements, policies, and decision-making processes (Schulman & Menschner, 2018).

There are many key steps to consider when implementing trauma-informed practices, which usually starts with an organizational assessment, where an assessment of the organization's current practices and policies to identify areas that may need improvement to align with trauma-informed principles. This assessment may include evaluating physical and emotional safety measures, staff training, communication protocols, and patient engagement strategies (Schulman & Menschner, 2018).

Comprehensive training should be provided to all staff members to enhance their understanding of trauma and its impact. This training should cover topics such as trauma-informed care principles, trauma awareness, trauma responses, and self-care strategies. Ensure ongoing training opportunities and resources are available to support staff in implementing trauma-informed practices. Physical and emotional safety measures must be established within the organization. This may involve creating welcoming and calming spaces, ensuring privacy and confidentiality, and implementing procedures that prioritize patient comfort and autonomy (Schulman & Menschner, 2018).

Protocols to screen and assess individuals for trauma history and related symptoms are often used to help inform treatment planning and ensure appropriate support is provided. Validated trauma screening tools and assessment measures should be used to gather comprehensive information.

Individuals should be actively involved in their care planning and decision-making processes. Encourage their participation, listen to their needs and preferences, and seek their feedback on the services provided. Foster a collaborative and respectful relationship between patients and staff. Service delivery approaches should be adapted to align with trauma-informed care principles. This may involve using trauma-sensitive language, providing options and choices, incorporating trauma-focused interventions, and utilizing evidence-based practices for trauma recovery (Schulman & Menschner, 2018).

Trauma-informed organizations and the individuals who work in them should recognize the potential impact of working with individuals who have experienced trauma on staff members. Strategies should be implemented to support staff well-being, including opportunities for self-care, debriefing sessions, supervision, and access to resources for secondary trauma support. Organizations should regularly evaluate the effectiveness of trauma-informed practices and seek feedback from patients, staff, and stakeholders to identify areas for improvement and make necessary adjustments (Schulman & Menschner, 2018).

Trauma-informed organizations should collaborate with other organizations and community stakeholders to promote a trauma-informed approach across systems. This can involve sharing resources, coordinating services, and advocating for policies that support trauma-informed care. Implementing trauma-informed practices is an ongoing process that requires a commitment to learning, growth, and continuous improvement. It is essential to regularly assess and adapt your approach based on emerging research and feedback from patients and staff (Schulman & Menschner, 2018).

Nursing Care

Nurses play a critical role in implementing trauma-informed care within healthcare settings and there are several ways that they can incorporate trauma-informed practices into the care that they provide. Nurses should start by seeking out comprehensive and ongoing education and training on trauma-informed care that includes understanding the impact of trauma, recognizing trauma-related signs and symptoms, and developing skills to respond sensitively and effectively to individuals who have experienced trauma (Varcarolis, Fosbre, & Chiappetta, 2021).

Nurses can create a safe and trusting environment for patients by ensuring physical safety, privacy, and confidentiality. This can be done by communicating openly and honestly with patients, explaining procedures, and obtaining their informed consent. They should allow patients to express their needs and preferences, and respect their boundaries. Nurses should use trauma-informed communication strategies when interacting with patients. This involves using clear and non-threatening language, practicing active listening, and allowing patients to share their experiences at their own pace. Avoid judgment or blame and offer validation and empathy (Varcarolis, Fosbre, & Chiappetta, 2021).

Trauma-informed nurses must be aware of potential triggers that may retraumatize patients and take steps to minimize their exposure. This may involve being mindful of sensory triggers, such as loud noises or invasive procedures, and providing options to enhance patient comfort and control during their care. Patients should be encouraged to take an active role in their care planning process. Nurses should collaborate with patients to set goals, develop treatment plans, and make decisions about their healthcare. Nurses should provide information in a clear and understandable manner that is culturally responsive and sensitive to the patient’s individualized needs (Varcarolis, Fosbre, & Chiappetta, 2021).

Nurses can offer emotional support to patients who have experienced trauma by showing empathy, validating their experiences, and providing resources for emotional support and coping strategies. Additionally, they can encourage self-care practices and provide information about community support services that can aid in the patient’s healing journey. Patient information should also be documented in a trauma-informed manner. Use language that is objective and free of judgment or assumptions. Focus on strengths and resilience, as well as patient goals and preferences, when documenting care plans and progress. Nurses should work collaboratively with other healthcare professionals and interdisciplinary teams to ensure a trauma-informed approach is integrated across all aspects of patient care. They can share knowledge and insights, advocate for trauma-informed practices, and contribute to the development of policies and procedures that support trauma-informed care within the healthcare setting (Varcarolis, Fosbre, & Chiappetta, 2021).

Nurses should be mindful of their own triggers and emotional reactions when working with patients who have experienced trauma. They should maintain professional boundaries, seek supervision or support when needed, and engage in self-care practices to ensure personal well-being. By integrating trauma-informed principles into their practice, nurses can create a supportive and healing environment that promotes the well-being and recovery of patients who have experienced trauma (Varcarolis, Fosbre, & Chiappetta, 2021).

Providing effective nursing care for patients who have experienced psychological trauma requires a holistic and patient-centered approach. By addressing the physical, psychological, and emotional needs of patients who have experienced trauma, nurses can play a pivotal role in promoting recovery and improving outcomes. Implementing evidence-based nursing interventions can make a significant difference in the lives of those affected by trauma.

References

American Psychological Association (APA). (2023). Stress & Trauma Toolkit for Treating LGBTQ in a Changing Political and Social Environment. Retrieved on April 5, 2023

from https://www.psychiatry.org/psychiatrists/diversity/education/stress-and-trauma/lgbtq

 Bryant, R. (2023). Treatment of acute stress disorder in adults. Up to Date. Retrieved on April 4, 2023 from https://www.uptodate.com/contents/treatment-of-acute-stress-disorder-in-adults

 Chatlani, S. (2022). Focusing on maternity and postpartum care for Black mothers leads to better outcomes. American Psychological Association. Retrieved on April 6, 2023 from https://www.apa.org/monitor/2022/10/better-care-black-mothers

 

Goddard, A., Janicek, E., & Etcher, L. (2022). Trauma-informed care for the pediatric nurse. Journal of pediatric nursing, 62, 1–9. https://doi.org/10.1016/j.pedn.2021.11.003

 

Goddard, A., Jones, R., & Etcher, L. (2022). Trauma informed care in nursing: A concept analysis.

 Nursing outlook, 70(3), 429–439. https://doi.org/10.1016/j.outlook.2021.12.010 Gopal, D. P., Chetty, U., O'Donnell, P., Gajria, C., & Blackadder-Weinstein, J. (2021). Implicit bias

in healthcare: clinical practice, research and decision making. Future healthcare journal, 8(1), 40–48. https://doi.org/10.7861/fhj.2020-0233

 

Gopalkrishnan N. (2018). Cultural Diversity and Mental Health: Considerations for Policy and Practice. Frontiers in public health, 6, 179. https://doi.org/10.3389/fpubh.2018.00179

 

Hankerson, S. H., Moise, N., Wilson, D., Waller, B. Y., Arnold, K. T., Duarte, C., Lugo-Candelas, C., Weissman, M. M., Wainberg, M., Yehuda, R., & Shim, R. (2022). The Intergenerational Impact of Structural Racism and Cumulative Trauma on Depression. The American journal of psychiatry, 179(6), 434–440. https://doi.org/10.1176/appi.ajp.21101000

 


Jitender S. (2023). Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis. Up to Date. Retrieved on April

24, 2023 from https://www.uptodate.com/contents/posttraumatic-stress-disorder-in-adults-epidemiology-pathophysiology-clinical-manifestations-course-assessment-and-diagnosis

 

March of Dimes. (2023). Birth trauma frequently asked questions. Retrieved on April 7, 2023 from https://www.marchofdimes.org/find-support/topics/postpartum/birth-trauma-frequently-asked-questions

 


O’Kane, D. (2021). Mental health: A pocket guide (4th ed.). pp. 87-102. Elsevier.

 

Orchowski, L. M. & López, G. (2023). Clinical overview: Acute stress disorder. Clinical Key for Nursing. Retrieved on May 1, 2023 from https://www.clinicalkey.com/nursing/#!/content/derived_clinical_overview/76-s2.0-B97  80323755733000317

 

Schulman & Menschner. (2018). Laying the groundwork for trauma-informed care. Center for Health Care Strategies. Retrieved on April 1, 2023 from https://www.traumainformedcare.chcs.org/wp-content/uploads/Brief-Laying-the-Groun dwork-for-TIC_11.10.20.pdf

 

Shaw, W., Labott-Smith, S., Burg, M. M., Hostinar, C., Alen, N., van Tilburg, M. A. L., Berntson, G. G., Tovian, S. M., & Spirito, M. (2018). Stress effects on the body. American Psychological Association. Retrieved from https://www.apa.org/topics/stress/body


 

Stein, M. B. & Norman, S. (2023). Psychotherapy and psychosocial interventions for posttraumatic stress disorder in adults. Retrieved on April 23, 2023 from https://www.uptodate.com/contents/management-of-posttraumatic-stress-disorder-in-adults

 

Varcarolis, E. M., Fosbre, C. D., & Chiappetta, L. (2021). Essentials of psychiatric-mental health nursing: A communication approach to evidence-based care. Fourth edition. St. Louis, Missouri, Elsevier.

 

Watson, K., White, C., Hall, H., & Hewitt, A. (2021). Women's experiences of birth trauma: A scoping review. Women and birth : journal of the Australian College of Midwives, 34(5), 417–424. https://doi.org/10.1016/j.wombi.2020.09.016

 

Yehuda, R., & Lehrner, A. (2018). Intergenerational transmission of trauma effects: putative role of epigenetic mechanisms. World psychiatry : official journal of the World Psychiatric Association (WPA), 17(3), 243–257. https://doi.org/10.1002/wps.20568