COVID-19: Outcomes for trauma-impacted nurses and nursing students.

Introduction

Suppose you wake up one day, and all your plans are hindered, postponed, and potentially suspended. Your future, the future of your family, and life as you know it is changed. Although the COVID-19 pandemic did not occur overnight, the impact on nursing and nursing education appeared to have happened abruptly. During the pandemic, nurses and nursing students voiced concern for themselves, families, patients, communities, and the future (McClunie-Trust, 2020). The actions taken to flatten the curve can have an unprecedented impact on a specific sect of nurses and nursing students who have been survivors of trauma or acute childhood experiences (ACE).

Nurses and nursing students as individuals are not immune to traumatic experiences in their formative years. Nursing school is a high stake, stressful environment, and the opportunity to be re-traumatized is high. In addition, cognitive processes impact students who have experienced ACE events. Conversely, practicing professional nurses will be exposed to high-stress events, such as death, patient trauma, and COVID-19, which has the potential to re-traumatize the nurse and influence the care provided.

Background

Nursing is a people-oriented career. Whether nurses are providing care to patients or nursing faculty, educating the next generation of nurses, people are involved. The certainty of nurses connecting with people assures that some will display behaviors and actions based on past-lived experiences. The relationship between adverse childhood experiences and subsequent health and success of the adult is highlighted in a hallmark study by Felitti et al. (2019). Detrimental childhood experiences are associated with poor decision-making and damaging behaviors in adulthood. Exposure to child abuse, family violence, sexual trauma, or alcoholism as a child is linked to unfavorable physical and social outcomes as an adult. ACEs have dose-related effects on adult well-being, indicating more events, the greater the effect (Keesler, 2018). The more adverse events, the higher the risk to adult well-being. There are significant neurological, physiological, psychological, and cognitive effects of chronic exposure to trauma (McConnico et al., 2016).

The neuroscientific underpinnings related to individuals subjected to traumatic experiences as a child has cumulative effects on the person as an adult. Nurses and nursing students who have experienced ACE events have overcome some of the impacts by achieving a level of success required for nursing. However, exposure to the circumstances present during the COVID-19 pandemic may predispose this sect of nurses and nursing students to re-traumatization.

Impact

High-stress events are often triggers for re-traumatization (Franic et al., 2014). COVID-19 pandemic responses included sheltering at home, closing business, social distancing, self-quarantine, and disruption in schools. The uncertainty and fear produced anxiety for most. For nurses and nursing students who are survivors of ACE events, the ability to cope may be compromised. A case study conducted by Franic et al. (2014) found that fifteen years after a traumatic event was experienced, intense emotions and feelings triggered psychological disruption in the person.

Nursing

The awareness and implication of ACE trauma necessitate moving the effects of the trauma from an individual issue to a societal issue. In a time where nurses are often referred to as heroes, it is important to take note that some of the heroes may be experiencing re-traumatization. Nursing's obligation as essential health-care workers has placed some nurses on the front lines in the COVID-19 pandemic. The situations, circumstances, and experiences during COVID-19 can lead to the re-traumatized nurse to a feeling of a lack of control. A study of pediatric nurses found stressful and traumatic situations could produce feelings of compassion fatigue, burnout, and vicarious traumatization in the nurse (Kleis and Kellog, 2020). The impact of a re-traumatized nurse experiencing compassion fatigue and burnout is counter to organizational goals and high-quality health care.

Higher education

The hyperarousal associated with re-traumatization student ACE survivors can influence and potentially adversely affect the student's overall success in obtaining a nursing degree. Students who have experienced trauma have adaptive processes that are different from traditional college students. A controlled study related to ACEs aided in the fundamental understanding that there are changes in the lateral and ventromedial fronto-limbic brain area (Hart and Rubia, 2012). This specific area controls emotional regulation and behavior. The COVID-19 pandemic altered educational course for the student nurse. Many students were included in the sect of front-line health care workers who witnessed the impact of the pandemic. Others had their clinical experiences blocked and had limited experiences with the crisis. In both cases, anxiety, uncertainty, and concern for their individual and family health and future prosperity produced a state of increased anxiety and stress. The potential impact on the student who has experienced ACE events can be a hesitancy to continue their education, exaggerated feelings of hopelessness, and feeling a total loss of control, thus influencing the student's confidence and performance.

Implications

In nursing, the needs of those who have experienced ACEs are addressed through the provision of Trauma-Informed care. This care modality aims to create an environment that does not re-traumatize a patient. This type of care consists of health care professionals realizing the widespread impact of trauma related to ACEs, recognizing the signs and symptoms of trauma, responding by fully integrating knowledge about trauma into policies, procedures, and practice, and resisting re-traumatization (SAMHSA, 2014). It is essential to create a Trauma-informed care culture that is sensitive to the needs of patients, their families, and other health care professionals.

One of the critical steps nurses can take in this endeavor is to obtain specific training in Trauma-informed care. The training will help nurses understand what patients and families are experiencing and feeling, and guides them in promoting best care practices. As trauma can evolve from a vast array of life events, training would include tools that enable nurses to adapt to diverse patient populations and communities. Another component of training would consist of strategies that help nurses develop skills to deal with personal and professional stressors (Eslami Akbar et al., 2015).

The provision of Trauma-informed care has been reported to yield many benefits for nurses. In one study, a Trauma-informed approach taken by nurses within their practice enhanced job satisfaction, reduced risk for burnout, and improved patient experiences and outcomes (Schulman and Menschner, 2018). Hospitals and other health care organizations that employ nurses would be ideal locations for setting up nursing task forces that would facilitate Trauma-informed care practices. Representatives from each facility unit would be trained to serve on the task force and they would monitor their respective units for factors that affect job satisfaction, staff stress levels, and burnout. In addition, they would also assess patient satisfaction scores to determine what kinds of interventions are needed to improve nursing care. Taskforce members would be considered “super users” and would provide anticipatory guidance if there were any noted personal concerns among nurses, and would provide the resources needed to support them, such as debriefing sessions. The implementation of a Trauma-informed care task force may potentially prompt discussions about ACEs and other trauma components that would help to destigmatize the conversations about stressors that have a significant impact on mental health and well-being.

With higher education, it is crucial to not only provide guidance and training to students regarding their nursing practice but also to support them in times of crisis. With the emergence of the COVID 19 pandemic, students may have been placed in a position to choose between the safety of family and pursuing careers. Nursing schools should have policies and procedures in place to protect the students and the faculty as they navigate through the myriad of challenges resulting from major life events. Policies outlining alternative plans to facilitate completion of academic requirements by students during stressful life events would minimize hardships inherent to difficult circumstances. These protocols would have tools in place to assess both the students' and faculty members' stress levels and coping abilities. Within specific parameters, de-escalation strategies to mitigate emotional distress would be put in place to minimize the adverse effects of stress and trauma events as they occur.

As a mitigation component, nursing schools can incorporate self-care strategies into the nursing curriculum. One example of a self-care strategy would be Mindfulness-based stress reduction (MBSR). This intervention has had positive results with new nurses. It has been recommended for widespread inclusion in nursing school curricula (Marthiensen et al., 2019). Another mitigation technique would be to create an environment within nursing programs that build on a hybrid model of course content delivery that combines virtual and face-to-face instruction. The hybrid model of delivery can include virtual simulations, hands-on simulation, and clinical practice. The hybrid model would facilitate transition from face-to-face classroom instruction to an online format during times of national or global emergencies. Finally, it would be essential to develop and implement a training course for nurse educators that teach about the six core values of Trauma-Informed Practice. These core values include Safety, Trustworthiness, Choice/Control, Collaboration/Mutuality, Empowerment, and Cultural/Historical/Gender Issues (SAMHSA, 2014). See Table 1 for a list of symptoms and strategies.

Table 1

Symptoms and strategies for trauma-impacted nurses and students.

	Symptoms	Strategies
Nurses	• Symptoms of burnout: fatigue, feelings of under appreciation, lack of interest, emotionality • Lack of engagement • Attendance issues • Tardiness • Decline in attentiveness- may impact care provided	• Train nurses in trauma-informed care • Educate on stress reducing strategies for both personal and professional stress • Set up hospital task forces to facilitate trauma-informed practices • Implementation of “super-users” • Supportive environment for nurses during crises • Flexible policies related attendance and time-off
Nursing students	• Fear • Emotionality • Late assignments • Lack of engagement • Questioning of career choice • Emotionality • Loss of confidence • Feelings of hopelessness • Decline in attentiveness- may be less productive	• Train nurses/students in trauma-informed care • Educate on stress reducing strategies for both personal and professional stress • Set up hospital and nursing faculty task forces to facilitate trauma-informed practices • Implementation of “super-users” both in nursing and among nursing students • Support nurses and students during crises • Alternative plans for course completion

Conclusion

Nursing and nursing education is entering a new era. The context in which nursing practice occurs is evolving. We cannot function in the same manner to be successful moving forward. In nursing education, we must educate students on the impact of trauma-experiences or ACE events both in their personal lives and in their professional lives. The new norm will be different for nurses and nursing students. Nursing educators and administrators need knowledge on how to transition nurses to this new norm. In situations where there is a possibility of re-traumatization, strategies to mitigate detrimental outcomes need to be enacted. This will not be easy, and the impact of the pandemic on those that have already been subjected to ACE events will require special care and attention to ensure that they are successful.

Credit statement

Karen Fowler: conceptualization, writing - review-editing; Melissa Wholeben: resources, writing.

Funding source

None.

Ethical approval

Not research, none.

Declaration of competing interest

None to declare.