Trauma-informed Care for Nursing Education: Fostering a Caring Pedagogy, Resilience & Psychological Safety

Chapter one explores the reasons why student nurses need to be educated in trauma-informed care. Trauma-informed care endeavours to help people who have experienced trauma and targets change at the organizational and clinical level with the aim of improving client/patient outcomes. Various forms of adversity that exist are presented, and we are informed that trauma is not merely a childhood occurrence but may occur at any point across the lifespan. Stereotypical biases and racial stigma experienced by the following special populations are explored, those with differing sexual orientation or gender identity, older adults, refugees and immigrants, people of colour, and Indigenous people. The role that bias and implicit bias play in structural trauma aimed at specific populations is explained. An overview is given of the following specific trauma-related responses, trauma triggers, acute stress disorder, post-traumatic stress disorder, secondary traumatic stress, vicarious traumatization, and compassion fatigue. The Four Core Assumptions of Trauma-informed Care as recommended by the Substance Abuse and Mental Health Services Administration (SAMHSA are explored, because they are foundational for providing traumaresponsive care, and consist of realizing, recognizing, responding, and resisting retraumatization. Healthcare professionals are strongly encouraged to practice in a trauma-responsive and trauma-sensitive manner. Incorporating trauma-informed approaches into the Nursing School curriculum is recommended for the following reasons. Adversity is prevalent in society, and high number of people who access health services have experienced trauma. Student nurses are not currently learning these skills in a comprehensive way in all schools. Student nurses may have a history of trauma, and they are exposed to adverse and stressful events in clinical training. Two Narrative Case Studies are presented. The first shares the story of a Counsellor who developed compassion fatigue, and the second one reveals the complexity of the trigger response. The following learning activities are suggested: connecting with the goodness in life; changing prejudices and stigma; and participating in a trauma-sensitive practice challenge. A self-care strategy that promotes self-compassion is included at the end of the chapter.

A principle-based approach to trauma-informed care is effective in promoting healing and chapter two explores the crucial aspects of each of The Six Guiding Principles of Trauma Informed Care as recommended by the Substance Abuse and Mental Health Services Administration (SAMHSA). They consist of safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and cultural, historical, and gender issues. The discussion begins by describing the physical, social, and psychological aspects of safety. They include the location of the health facility, the atmosphere of the healthcare clinic, staff attitudes, ensuring that health professionals are kept emotionally safe, and avoiding re-traumatization. It is pointed out that people who have been intentionally harmed by others do not easily trust. Therefore, trust must be earned through compassionate connection, and by protecting a person’s privacy. Transparency is highly recommended and occurs when a person is fully informed about all aspects of the plan of care. Peer support is the help received from others who have lived through similar experiences and facilitates healing. Collaboration and mutuality are suggested to create a shared environment where there is an assumption that everyone, including the client/patient, will be involved in decision-making. Empowerment, voice, and choice when consistently applied foster an environment that utilizes a person’s strengths to help them overcome adversity, gives them an opportunity to be listened to, and to make their own choices. The power of empathy and other-focused listening, and the importance of addressing cultural, historical, and gender issues are emphasized. Poor health outcomes experienced by people of the LGBTQ2S community are highly correlated with stigma. Nurses are identified as harbouring prejudicial attitudes toward members of this population, and educational efforts are strongly suggested to change these behaviours. Cultural humility is recommended as an effective way to counteract racism and power difficulties through empowerment, excellence in care, and an atmosphere of mutual respect. Self-awareness and self-reflection are recommended to incorporate cultural humility into practice. Two Narrative Case Studies are reviewed. The first one emphasizes the importance of safely conducting a client assessment, and the second one explores how peer support helps a bereaved child. Participation in these four learning activities is advised, strategies that enhance the environmental safety of a healthcare facility; when breaching confidentiality is necessary; situations that promote or impede trust; and actively communicating other-focused listening. The Chapter ends with a self-care strategy that encourages nurses to participate in mindfulness techniques to enhance the overall well-being.

Chapter three explores client-centered, person-centered, and resiliencefocussed approaches to trauma-informed care, and although they differ somewhat, all three are strength-based and share the common goal of helping people who have experienced adversity. Client-centered care places the person and their capacity for growth and change at the heart of all that occurs. This approach prioritizes respect for the self-worth of every human being and promotes the practice of unconditional positive regard. The quality of the therapeutic relationship between the nurse and client/patient is important, as is the nurse’s ability to apply professional knowledge and competence to the care they provide. A unique aspect of person-centered care is that it provides services to people with acute and chronic health issues that are holistic, and recovery-orientated. Collaboration and effective communication skills are essential features of this approach. Positive ways to offer person-centered care to people from these populations are reviewed, the elderly, those with a disability, people with dementia, palliative care patients, and persons suffering from mental illness and substance use. Specific components of recovery-oriented care that are included in the discussion are a person’s capacity for change and courage, their responsibility for their growth, and the importance of finding purpose in their lives. Resilience is identified as the is the ability to carry on and bounce back to original functioning after experiencing a trauma. We are made aware that a resilient person becomes stronger despite adversity because they utilize positive emotions, develop a sturdy mindset, a renewed commitment to life, and welcome challenges. The remainder of the discussion focuses on how to safely conduct screening for trauma for everyone including survivors of interpersonal violence (IPV). Two Narrative Case Studies are presented. The first one demonstrates that when a client/patient crosses a professional boundary, a problem is created for the nurse. The second Case Study explores how a survivor of interpersonal violence (IPV) may require advocacy to help them stay safe. The following four learning activities are recommended, how to practice unconditional positive regard; exploring helpful strategies to utilize when conducting trauma screening; dispelling myths associated with IPV; and how to implement survivor-centered approaches when caring for someone who has experienced IPV. At the end of the Chapter, a self-care strategy is recommended that challenges nurses to set aside time to focus more on being present.

The aim of Chapter Four is to demonstrate that living a better life after adversity is possible when adequate support is offered. Therefore, positive psychology and post-traumatic growth are two recovery-focused trauma-informed approaches that are highly recommended to help people who have experienced adversity. Positive psychology studies human well-being and optimal functioning. Post-traumatic growth refers to positive changes in someone’s coping that occur from sorting through their experience of trauma. Three different responses to traumatic stress are explained. For instance, certain people bounce right back after an adverse event, others develop maladaptive functioning, and a third reaction results in post-traumatic growth. The particular response that a person experiences is somewhat context-dependent. After trauma occurs, positive changes in brain function are made possible through neuroplasticity. Positive Psychology and trauma-informed care share the common goal of helping people to live better lives, but they also differ. For instance, positive psychology strategies are designed to be used by everyone and are therefore not limited to those who have experienced trauma. The five key elements of well-being theory called PERMA are presented, such as positive emotions, engagement, relationships, meaning, and accomplishment. Positive emotions are deemed essential for life satisfaction. Work-related well-being was later developed and called PERMA+4 and is associated with physical health, mindset, work environment, and economic security. Flourishing is a central component of well-being theory and consists of the capacity to be satisfied with one’s life achievements and being involved in something that is meaningful. The following strategies are known to facilitate well-being, being grateful, a positive attitude, random acts of kindness, and positive psychotherapy. Positive psychotherapy is an effective method to treat trauma because it focuses on a person’s strengths and weaknesses but also uses a person’s character signature strengths to help them move forward. Appreciation for life, new possibilities, relating to others, personal strength, and spiritual change are the five domains of post-traumatic growth. Meaningmaking, instillation of hope, and self-compassion are identified as additional lifeenhancing responses to adversity. Two Narrative Case Studies are presented. The first one identifies how a student nurse felt unprepared to discuss spiritual issues with her patient. The second case study demonstrates how nurturing mindful self-compassion helps a teen to heal from childhood trauma. The following three learning activities are suggested, debating the value of positive emotions, understanding the 24 signature strengths of positive psychotherapy, and lessons learned from those who have experienced post-traumatic growth. The chapter ends by recommending specific gratitude-enhancing self-care strategies.

Students and practicing nurses are at risk of developing empathy-based stress conditions related to caring for people who have been traumatized. Caring is a known factor in all suggested interventions for empathy-based stress conditions. Therefore, Chapter Five explores ways to mitigate the negative effects of secondary traumatic stress and compassion fatigue through employing a caring pedagogy and resilience. Caring pedagogy in nursing education is important because it incorporates caring components into the delivery of the core curriculum, creates a community of learning that prioritizes students, is inclusive, and engaging, and protects the emotional integrity of student nurses. Noddings’ elements of moral education such as modeling, dialogue, practice, and confirmation are identified as essential to a caring learning environment. For example, student nurses can learn what it means to care by observing the behavior of their instructor, by a dynamic exchange of ideas, by prioritizing caring, and by encouraging the best in others. A learning environment that is caring must also be based on civility and is the shared responsibility of both faculty and students. Selfcare is identified as a known strategy to reduce the emotional stress experienced by nurses and student nurses. Watson’s Caritas processes are subsequently recommended as the basis for self-care and consist of demonstrating sensitivity toward oneself and everyone else, through spiritual practices that support loving, caring relationships. Resilience consists of the ability to quickly return to normal functioning after experiencing adversity. Resilience skills can be learned through the development of protective factors and mechanisms and may prevent empathy-based stress conditions related to trauma, can assist a trauma survivor to bounce back more quickly, and teach people how to deal with the stress of everyday life. The following ways to cultivate resilience in nurses are presented, building positive nurturing relationships and networks; maintaining positivity; developing emotional insight; achieving life balance and spirituality; and becoming more reflective. Three strategies to foster resilience in nursing education include resilience training in the school curriculum; prioritizing role modelling; and enabling generativity. Two Narrative Case Studies are presented. The first one tells the story of how a Psychiatric Nurse developed the signs of secondary traumatic stress after one of her clients ended their life through suicide. The second one describes how a student nurse was unaware that she was experiencing emotional strain. The following four learning activities are proposed, sharing examples of being cared for; exploring ways to enhance learning; nurturing caring experiences in educational settings; and implementing Watson’s caring processes and strategies to enhance selfcare. The Chapter ends by recommending a self-care challenge that promotes emotional appraisal to manage negative emotions.

Chapter Six presents an overview of how trauma-informed educational processes ensure that student nurses feel safe and supported in an ideal learning environment. Strategies that promote psychological safety are recommended followed by measures to foster compassion satisfaction and joy in work. Psychological safety consists of a civil and respectful place for learning to occur. Compassion satisfaction is derived from the gratification experienced by caregivers when caring for others, and joy in work consists of positive components in the work environment. Nursing students are a risk group for trauma, and they identify the following situations as sources of trauma, individual-related interpersonal experiences; those related to their role as students; trauma related to institutional and organizational exposure; and stressors associated with the community. <i>The Four Core Assumptions of Trauma-informed Care</i>  are used as a guide to implementing psychological safety in nursing school and include specific measures for the classroom, simulation, and clinical settings. Those directly related to high-fidelity simulation include actions to make students feel safe before, during, and after each session. The positive feelings and six core assumptions associated with compassion satisfaction, and the role that self-compassion and worklife balance play are featured. Key aspects of the work environment that have the greatest impact on the well-being of nurses working in critical care consist of adequate staffing, meaningful recognition, and effective decision-making. Student nurses with a history of trauma can experience compassion satisfaction if they are able to identify with some of the positive aspects associated with being a trauma survivor. If new nurses are adequately supported by their employers they experience less stress, and increased fulfillment in their jobs. There are valuable justifications for creating joy in work. A focus on joy enhances the work experience, increases employee engagement, benefits the organization, and improves patient outcomes. Making the workplace happy is a shared responsibility, where everyone is expected to do their best work. Meaningful connection to other people is important where teamwork, cooperation, and a sense of camaraderie are ideal. Two specific forms of governance that promote joy in work are participatory and servant leadership. Psychological personal protective equipment (PPE) consists of individual and system-wide measures that support and safeguard the mental health of employees. Two Narrative Case Studies were presented.

In the first one, a student nurse became re-traumatized when listening to a detailed story of someone’s traumatic experience. The second Narrative Case Study revealed how a new nurse considered leaving his high-acuity job because of a lack of appreciation. The following five learning activities were proposed, exploring assumptions about constructive feedback; ways to professionally express appreciation; understanding how you handle mistakes; creating a self-inventory to assess work-life balance; and incorporating the ten characteristics of servant leadership into practice. At the end of the Chapter, specific strategies were recommended to build college students’ self-confidence.