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Introduction   

Typically, trauma is often associated with a sudden tissue injury caused by violence or an accident. Even though traumatic injuries are a significant global health burden, so are exposures to traumatic events. We will look at and focus on how trauma is related to one’s health and how education and prevention can impact how we handle trauma in our lives. 

The relationship between healthcare professionals and their patients is often considered very close, and this proximity can expose healthcare professionals to the distress and trauma experienced by the individuals they help (1). The desire to alleviate the pain and suffering of patients and provide empathy can enhance the connection between patients and healthcare professionals, thereby having long-term psychological impacts on healthcare professionals if left unaddressed or untreated (1). Healthcare professionals are tasked with providing care to individuals who have been affected by trauma, violence, abuse, death, etc. (1). 

Traumatic events are widespread in the United States and around the world and have a destructive impact on health. Trauma has been defined as a significant public health issue and can impact physical, social, and emotional well-being, resulting in numerous behavioral, psychological, and physical health problems. For this reason, the need to address not only trauma but also education and prevention of trauma is increasingly essential.  

This learning module will explore what is considered a traumatic event, the pathophysiology and epidemiology of trauma, the signs and symptoms of trauma, and the prevention and education of trauma. As you work through the section questions, I hope you will be able to recall a trauma you have been through or a trauma someone else you know experienced.  

Okay, let’s get started! 

Traumatic Event 

Let us first look at the definition of a traumatic event. According to the National Institute of Mental Health, a traumatic event is a shocking, scary, or dangerous experience that can affect someone emotionally or physically (2). It can be a series of events, or a single event considered hazardous, harmful, or life-threatening. 

When traumatic events take place, they can cause strong emotions such as fear and hopelessness, affecting a person’s functioning and well-being long after the event has occurred. We also must keep in mind that not everyone who experiences a traumatic event may not perceive it as being traumatic.  

Examples of traumatic events can include but are not limited to (3): 

• Natural disasters  

• • Hurricanes 

• • Earthquakes 

• • Floods 

• Acts of violence  

• • Assault 

• • Abuse 

• • • Physical  

• • • Emotional 

• • • Sexual  

• • Terror attacks  

• • Mass shootings 

• • Car crashes  

• Crime 

• Racism 

• Incest  

• Micro-aggressions 

• Neglect  

• War  

• Grief and loss  

• Medical interventions 

• Cultural, intergenerational, and historical trauma  

• Witnessing acts of violence 

• Occupational hazards  

• • Microaggressions 

• • Workplace violence  

• • Moral distress 

Trauma 

Trauma is an emotional response to a terrible event. It occurs when a person is overwhelmed by events or circumstances and responds with intense fear, horror, and helplessness (3). Trauma often has no boundaries regarding age, race, gender, socioeconomic status, ethnicity, or sexual orientation. Trauma is a common experience for adults and children in the United States and is especially prominent in those who are living with mental health disorders or substance abuse issues. Extreme stress overwhelms a person’s ability to cope. There is also said to be a direct correlation between trauma and physical health conditions such as diabetes, COPD, heart disease, cancer, and high blood pressure (30).  

Pathophysiology of Trauma (12)  

A traumatic event or series of events results in psychological changes, complex adaptations, and pathways that are all linked to harmful health conditions. Trauma is a dynamic process that involves interaction between an event or series of events and the individual’s level of vulnerability and protective factors. We will review the current factors that facilitate the process of trauma.  

Prolonged activation of these systems through chronic or repeated exposure to trauma has damaging consequences on the body. Traumatic events set off numerous biological responses that vary among individuals. The pathways between traumatic experiences and adverse health effects are complex but unquestionable and hold assurance for future treatment and care for survivors. 

• Hypothalamic-pituitary-adrenal (HPA) axis  

• • Important mediator after stress or under chronic stress  

• • Responsible for the release of stress hormones (glucocorticoids and cortisol) 

• • Chronic activation of this system will damage feedback loops that return stress hormones to their basal levels.  

• Allostatic load 

• • “Allostatic” refers to the balance of the central nervous system (CNS), endocrine/metabolic, and immune systems, which are responsible for our response to stress 

• • Contributes to cardiovascular disease, metabolic disorders, and accelerated cognitive decline and is linked to lower socioeconomic status 

• • Impacted by traumatic events resulting in higher prevalence of disease, ill-health, and premature death 

• Environmental and epigenetics  

• • Traumatic events and stress can affect telomere length, resulting in increased damage to DNA during replication 

• Socioeconomic status and cortisol  

• • Those of lower socioeconomic status are exposed to more trauma and stress and are less likely to have protective resources to manage stress and the effects of trauma 

• • Cortisol affects the CNS, metabolic, and immune systems, and increased cortisol levels link traumatic events to poor health 

• Posttraumatic stress disorder (PTSD) and metabolic syndrome 

• • Poor health, chronic diseases, and allostatic load are both linked to PTSD 

• • Metabolic syndrome is a group of medical risk factors that signal abnormal underlying pathophysiological processes that increase the risk for death and chronic health problems (hypertension, type II diabetes, cardiovascular disease) 

• • PTSD is linked to an increased risk of metabolic syndrome 

• • Trauma and stress can alter neuropeptide Y, a stress-activated cardiovascular and metabolic regulating hormone 

Epidemiology of Trauma  

We will look at and focus on the most common traumatic exposure experienced by individuals. 

• Child neglect & physical abuse  

• • Parent or caregiver acts or fails to act in a way that results in physical injury to a child or adolescent 

• Child sexual abuse 

• • Interaction between a child and an adult 

• • A child is used for sexual stimulation (touching and non-touching behaviors) 

• Intimate partner violence 

• • Physical violence, sexual violence, stalking, and psychological aggression (including coercive tactics) by a current or former intimate partner  

• • spouse, boyfriend/ girlfriend, dating partner, or ongoing sexual partner 

• Sexual assault 

• • Any sexual activity where consent is not obtained or freely given  

• Community violence 

• • Exposure to intentional acts of interpersonal violence committed in public areas.  

• • Common types include individual and group conflicts 

• • • bullying, fights among gangs and other groups, shootings in schools and communities 

• • Varies by neighborhood and state  

• • Those affected by violence vary by income bracket  

• Human trafficking 

• • Action or practice of illegally transporting people from one country or area to another, typically for forced labor or commercial sexual exploitation 

• Historical trauma 

• • Increasing emotional and psychological injury because of group traumatic experiences transmitted across generations within a community 

Traumatic Stress 

Traumatic stress occurs when a person is exposed to trauma, and it can be characterized by a wide range of responses, including (8): 

• Intense and persistent distress 

• Symptoms of depression or anxiety  

• Behavioral changes  

• Difficulties controlling one’s behavior and emotions 

• Problems with interpersonal relationships  

• Disruptions in attention and learning  

• Nightmares 

• Difficulty sleeping and eating  

• Physical symptoms 

Even though healthcare professionals are resilient, repeated exposure to trauma can affect their ability to cope with stress.  

Traumatic stress can come from a variety of different sources (9): 

• Personal 

• • Grief from witnessing patients die  

• • Treating chronically ill patients  

• Interpersonal 

• • Interactions with patients or families  

• • Effective communication and psychosocial skills 

• • Caring for patients whose families have substance abuse, violence, or depression issues 

• Healthcare system  

• • Heavy workloads  

• • Long hours 

• Professional  

• • Level of self-efficacy 

• • Increased years in direct patient care 

• • Unclear caregiver boundaries 

Work-Related Stress and Trauma 

There is a debate on the correct terminology when referring to work-related trauma due to the wide range of descriptions that can often be confused with one another. We will take a closer look at the definition of each. Frequently, terms such as vicarious trauma, secondary traumatic stress, compassion fatigue, and burnout are all used interchangeably.  It is crucial to understand each term because an individual, group, or organization can experience more than one at any given time (1). Having a greater understanding of each term can help individuals and organizations identify, respond, and prevent the emotional impacts we see with work-related stress and traumas (1).  

Post-Traumatic Stress Disorder (PTSD) 

It is a psychiatric disorder/illness that occurs in some individuals who have experienced or witnessed a traumatic event. The DSM-IV defined PTSD as occurring when a “person experienced, witnessed or was confronted with an event that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. The person’s response involved intense fear, helplessness, or horror.” (4). The condition can be said to last months or years, with triggers bringing back intense memories of the trauma along with strong emotional and physical reactions (1).  

Symptoms can include but are not limited to (1): 

• Nightmares  
• Unwanted memories  
• Avoidance of situations 
• Heightened reactions 
• Anxiety 
• Depression 

Treatment can include different types of trauma-focused psychotherapy and medications to manage symptoms (1).  

Secondary Traumatic Stress (STS) 

Secondary trauma is the development of PTSD-like symptoms without directly witnessing or being involved in a trauma or traumatic event. It is composed of emotions and behaviors after exposure to someone else’s trauma. It occurs unexpectedly and suddenly, and the effects can be just as severe as those who experienced the actual trauma. Nurses and healthcare professionals who lack social support and stress relief strategies are at an increased risk of suffering from STS (9).  

Risk factors for developing STS include (9):  

• Working closely with clients who have experienced trauma  
• Personal stressors  
• Interpersonal stressors   
• Healthcare system stressors   
• Professional stressors   
• Lack of social support  
• Lack of stress relief management techniques  

The effects of STS include (9):  

• Poor problem solving  
• Poor decision making  
• Poor concentration   
• Difficulty sleeping  
• Intrusive thoughts about patients  
• Irritability  
• Fear for the future   
• Diminished activity level   

Definitions and Examples of STS: 

Vicarious Trauma 

This type of trauma occurs from repeated exposure to other people’s trauma. It can be described as a snowballing ‘negative transformation’ that impacts nurses’ and healthcare professionals’ physical and mental health (1). It affects all aspects of one’s personal and work life. It accumulates over time, interrupting everyday life, and has the potential to alter an individual’s personality and belief system drastically (1).  

Compassion Fatigue 

Compassion fatigue is a type of indirect trauma specific to healthcare professionals. It is often caused by the emotional toll of working with those who have experienced trauma rather than from exposure to the actual trauma itself (1). To classify or create distance from the emotional experience of patients, healthcare professionals can develop emotional exhaustion, depersonalization, and a lack of empathy (1).  

Signs of compassion fatigue can include (6): 

• Physical and emotional exhaustion 
• Increased anxiety  
• Anger  
• Irritability  
• Intimacy issues  
• Irrational fears  
• Decreased sympathy or empathy toward coworkers and patients  
• Increased use of sick time or higher rates of absenteeism  

Risk factors for developing compassion fatigue include (6):  

• Younger  
• Inexperienced (2-5 years) 
• Working in medical-surgical and pediatric inpatient departments  
• Outpatient home health  
• Practicing in rural settings  
• Increased patient-to-nurse staffing ratios 
• Workplace incivility 

Compassion fatigue in younger nurses and healthcare professionals can decrease retention, increase turnover, and leave the profession entirely (6).  

Burnout 

Excessive and prolonged stress is thought to cause burnout, resulting in emotional and psychological exhaustion related to an individual or their work environment (1). Burnout is also a byproduct of compassion fatigue, affecting 40-75% of healthcare professionals (6). It can often be corrected by changing work environments or simply adjusting one’s schedule (1).  

Symptoms of burnout include (6): 

• Feelings of hopelessness  
• Emotional exhaustion  
• Lack of self-efficacy 
• Depersonalization  
• Decreased productivity in the workplace 

Risk factors for developing burnout (6): 

• Working in high-acuity, high-intensity environments 

• • Critical care, oncology, emergency nursing 

Traumatic Countertransference  

Traumatic countertransference occurs when a nurse or healthcare professional relates to a patient in a way that unconsciously connects the patient with an existing relationship in their own life (1). This can occur in any situation where a connection is developed between people based on empathy; it can happen in any setting, not just medical (1).  

This type of trauma can be harmful in many ways because, as a healthcare professional, the relationship with patients and families should always be professional with appropriate boundaries (1). It should not be a relationship based on or influenced by the idea that the patient reminds the nurse or healthcare professional of, let us say, their mother or child (1).  

Trauma Statistics 

Let us look at how common trauma is in the United States. According to the National Council for Mental Wellbeing, 70% of adults, about 223.4 million people in the United States, have experienced some traumatic event at least once in their lives (3). 55-90% of the general population have experienced at least one adverse childhood trauma (5). Of the 55%-90% who have experienced childhood trauma, some experience five or more traumatic events in their lifetime (5). While 14% have reported experiencing community violence, which includes racism, and 23% report suffering from PTSD (5). 

Nurses and healthcare professionals are not immune to trauma or traumatic stress. Current literature suggests nurses and healthcare providers experience the same amount of trauma as the general population, with some studies suggesting they experience higher rates of trauma than the general population. Nurses and healthcare providers who have a history of childhood trauma and work in a high-acuity setting are at an increased risk of being traumatized through exposure to specific situations, leading to anxiety, depression, PTSD, compassion fatigue, and burnout (5). 

When looking at rates among healthcare workers, the prevalence is not well known, but rates tend to be higher in those working in the emergency departments, oncology, pediatrics, and hospice (5). 

Symptoms and Behaviors of Trauma 

The human response to stress and trauma is involuntary and unconscious. However, the chemical and biological processes that cause a person to experience stress and trauma are the same (1).  The stress from trauma is not subjective to rational processing, and therefore, two people can perceive and react differently to the same traumatic event (1). Not all who are exposed to trauma will suffer from symptoms or experience difficulties. Most people, however, will experience the following (10): 

• Intrusions 
• Nightmares 
• Startle reactions 
• Numbness  

If symptoms are left untreated, they can develop into mental health disorders, detachment and social isolation, emotional distress, and substance abuse (1). Symptoms of trauma include but are not limited to (3): 

• Headaches, backaches, stomachaches, etc.  
• Rashes  
• Sudden sweating and/or heart palpitations 
• Changes in sleep patterns, appetite, interest in sex  
• Constipation or diarrhea 
• Easily startled by noises or unexpected  
• More susceptible to colds and illnesses  
• Increased use of alcohol or drugs and/or overeating 
• Fear, depression, anxiety, irritability, grief 
• Outbursts of anger or rage  
• Emotional swings 
• Nightmares and flashbacks (re-experiencing the trauma) 
• Tendency to isolate self or feelings of detachment  
• Difficulty trusting and/or feelings of betrayal 
• Self-blame, survivor guilt, or shame 
• Diminished interest in everyday activities 

Coping Strategies  

Healthy ways of coping can help reduce stress and improve well-being. Some coping strategies include (3):  

• Acknowledge that you have been through traumatic events  
• Connect with others, especially those who have shared the stressful event or experienced other trauma 
• Exercise  
  • Jogging 
  • Aerobics 
  • Bicycling 
  • Walking 
  • Relax 
  • Yoga 
  • Stretching 
• Massage 
• Meditation 
• Deep muscle relaxation 
• Take up music, art, or other diversions 
• Maintain a balanced diet and sleep cycles 
  • Avoid over-using stimulants like coffee, sugar, or nicotine 
• Commit to something personally meaningful and vital every day  
• Write about your experience for yourself or share with others 
• Avoid alcohol or drugs 
• Spend time with supportive friends and family  
• Set realistic goals and focus on what you can manage 
• Stay informed  
• Avoid too much exposure to the news  
• Take breaks 

Effects of Trauma  

The effects of trauma can place a heavy burden on individuals, families, and communities. Although many people who experience trauma will go on living their lives as usual without lasting adverse effects, others will have difficulties and experience traumatic stress reactions associated with trauma (7).  

How someone responds to a trauma is personal. If a person has a robust support system, little to no past traumatic experiences, and resilient qualities, the trauma may not affect their mental health (7). Research has shown us that those who experience trauma are more likely to suffer from both behavioral health and chronic physical health problems (7).  

Treatments  

Traditional  

• Cognitive Behavioral Therapy (CBT) 
• Eye Movement Desensitization and Reprocessing (EMDR) Therapy  
• Talk Therapy  
• Group Therapy  

(3) 

Alternative  

• Energy processing 
• Hypnotherapy  
• Neuro-linguistic programming 
• Massage therapy  
• Pet or equine therapy  
• Trauma and recovery peer support groups  
• Wellness recovery action planning (WRAP) 

(3) 

Management  

Nurse leaders are often not always prepared with a background in trauma and how to manage those who have experienced trauma. Nurses who have experienced past trauma along with work-related stressors usually result in compassion fatigue, burnout, and secondary traumatic stress (6). Nurse leader engagement and trauma-informed leadership approaches are imperative to mitigate and mediate the effects of trauma on nurses and patients (6).  

Prevention and Protection  

Prevention focuses on promoting well-being and resilience to reduce the burden of mental health problems for individuals, families, and communities (8). Prevention involves strengthening protective factors, skills, and social connections while reducing risk factors and stressors (8). Prevention can lessen the adverse long-term outcomes for individuals and communities suffering from trauma (8).  

Exposure to stressful working conditions can directly influence an individual’s health and safety. Coping with work stressors requires protective measures from individuals and the professional organization they work for (1). Certain areas are essential to help manage trauma and steps organizations or hospitals need to take to protect their healthcare providers. 

Support Systems (9) 

One protective factor that is common with trauma is the lack of support from family and friends, along with having few support systems in place.  Often, those who have a support system are less likely to experience the long-term effects of trauma. There are a variety of support systems individuals can utilize, such as:  

• Informal support 
  • Talking with a trusted colleague, friend, or family member 
• Therapy 
  • Cognitive Behavioral Therapy  
  • Family therapy  
• Group support 
  • Structured group meeting with a mental health specialist 

It becomes crucial for individuals and organizations to strengthen their relationships with coworkers and enhance a healthy work environment through organizational team building.  

Stress Relief Strategies  

Those who use appropriate coping strategies reduce stress and the effects of trauma. The most common stress-relieving activities are exercise and hobbies. Those who exercise and participate in outside hobbies are more likely to use medication to cope and less likely to use drugs and alcohol. One common coping strategy is informal or formal debriefings following the exposure to a trauma. Those suffering from a traumatic event should seek appropriate counseling and use stress management techniques. (9) 

Education  

Healthcare providers need to be educated about the signs, symptoms, and risks that are associated with stress and trauma. Learning about ways to prevent stress and the longer-term effects of trauma will help to increase resilience among individuals and healthcare professionals. One example is to teach healthcare providers working with trauma patients how to display empathy while avoiding compassion for the emotional toxicity that leads to stress and long-term complications of being exposed to those suffering from trauma. (9) 

Self-care  

Self-care is a well-known way to combat the daily stressors we encounter. Self-care and self-confidence can act as a buffer between experiencing a stressful or traumatic event and suffering the symptoms of trauma.  

Taking care of your body, emotions, and mind is essential with self-care methods. 

• Self-reflection 
• Self-monitoring 
• Journaling 
• Avoiding negative thoughts  
• Following basic health principles 
• Meditation 
• Relaxation  
• Reflecting on the rewards in life 

(9) 

Individual Strategies  

Individual strategies to avoid work-related stress and trauma include: 

• Positive work/life balance  
  • Boundary setting 
• Maintaining personal and social connections 
• Pursuing hobbies or interests outside of work  
• Motivation to learn and grow professionally and personally  
• Relaxation techniques or reflective practices  
• Avoid relying on substances to decompress  
• Lean into your social support network  
• Seek mental support from professionals 

(1) 

Organizational Strategies  

The most important thing organizations can do to help prevent and protect their employees from trauma and stress is to focus on prevention efforts. The first step in this is recognizing and understanding the consequences trauma and stress have on providers. Prevention efforts will help promote an individual’s overall health and well-being. Unfortunately, trauma and stress are a hazard for those who work in the healthcare profession; therefore, organizations need to develop ways for individuals to combat work-related stress and trauma regularly (1).  Organizations play a crucial role in prevention and mental health promotion. Healthcare organizations are responsible for building support resources for healthcare professionals to help address work-related stress and trauma at the origin rather than managing the symptoms after the fact (1).  

Healthcare organizations should have policies and procedures in place that recognize and prevent risk factors for work-related stress and trauma. Wellbeing and employee assistance programs implemented throughout organizations help reduce stress and trauma’s impact on healthcare professionals (1).  

Potential prevention strategies in organizations include (1): 

• Balancing workloads/caseloads 
• Offering additional leave time  
• Offering counseling services/resources 
• Encourage and allow for personal care  
• Education on mental health  
• Education about mental health resources/services 

Public Health Strategies  

Public health strategies should be aimed at preventing or diminishing the mental health problems and conditions that come along with being exposed to trauma and the stress caused by traumatic events. Strategies are active on all levels: individual, family, community, and society (10).  

• Preventing danger 
  • Stopping or avoiding exposure to events  
• Creating awareness and recognition 
  • Education on the impact of trauma 
  • Monuments or silent journeys 
  • Public health campaigns 
• Strengthening resilience  
  • Increasing self-efficacy  
• Counseling  
  • Debriefing  
• Reconciliation  
  • Programs to reconcile people to restore trust, connectedness, and social cohesion 
• Policymaking  
  • Policies to prevent traumatic events  
  • Understand risk and protective factors  
  • Provide early intervention services  
  • Shape societal norms to eliminate stigma 
    • Priority on improving mental health  
    • Trained researchers and professionals  
    • Supporting international collaborations 
    • Encouraging scientists to share expertise  

Conclusion

Trauma and toxic stress are a growing public health concern with increasing risks to morbidity and mortality rates across the globe. While trauma is a part of the human experience, exposure to traumatic events is abundant worldwide and has a well-established harmful impact on health. 

Trauma can take many forms, and its impact varies based on the impacted individual’s unique life circumstances, environment, and resilience. Unlike the usual stresses of our daily lives, traumatic experiences occur outside the realm of everyday experience, thereby threatening one’s life or bodily integrity and invoking intense feelings of helplessness, powerlessness, and terror. These events overwhelm the ordinary systems of care that give people a sense of control, connection, and meaning, thereby giving them a sense of loss of control.  

Healthcare professionals, administrators, and leaders have a critical role in responding by identifying and preventing poor health outcomes for individuals throughout the community. As with any other highly contagious disease, it is recommended that foundational knowledge and understanding of trauma be part of education at all levels and disciplines (12). This must be paired with universal trauma precautions to prevent re-traumatization and relieve the transmission and spread between individuals, within families, among communities, and in the healthcare workforce (12). 

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