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• To be aware of the long-term mental and physical effects of adverse childhood experiences
• To understand the importance of adopting a trauma-informed approach to nursing care
• To recognise how self-care can support nurses to deliver compassionate and safe nursing care
World events, such as the conflict in Ukraine, the humanitarian crisis in Afghanistan and the coronavirus disease 2019 pandemic, have highlighted the effects of trauma and adverse childhood experiences on children and young people. Adverse childhood experiences can lead to suboptimal health and risk-taking behaviours during adolescence and adulthood, while multiple adverse childhood experiences can manifest as complex trauma, toxic stress, anxiety or depression across a person’s lifespan.
This article discusses adverse childhood experiences and the concept of trauma-informed care, which involves recognising and understanding the negative events that have affected a person and how these relate to suboptimal health. The author suggests that developing resilience and using self-care strategies can support nurses to adopt a trauma-informed approach to care. This can assist them to recognise, understand and reflect on the effects of adverse childhood experiences in themselves as well as in their patients. The author also outlines a hybrid approach to debrief that can support staff to manage stressful situations and challenging workplace experiences.
Nursing Children and Young People. doi: 10.7748/ncyp.2022.e1422
Peer reviewThis article has been subject to open peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Davies JA (2022) Supporting children’s nurses to deliver trauma-informed care. Nursing Children and Young People. doi: 10.7748/ncyp.2022.e1422
Published online: 08 August 2022
Significant world events, such as the conflict in Ukraine (Ahsan 2020), the humanitarian crisis in Afghanistan (Saleem et al 2021) and the coronavirus disease 2019 (COVID-19) pandemic and associated restrictions across the globe (Douglas et al 2020), have brought into sharp focus the effects of trauma and adverse childhood experiences on the health of children and young people.
Nurses working with children, young people and their families living with trauma caused by global conflict or domestic stress will observe first-hand the harmful effects on their health. The Royal College of Nursing (RCN) (2019a) recognised that nurses and other healthcare professionals who provide trauma-informed care may experience triggers that affect their own health and well-being and that it is important for them to receive support and training to develop resilience and coping strategies.
Staff who are trauma-aware and trauma-focused in their practice can improve health outcomes for children and their families and mitigate the effects of trauma and stress by delivering care that builds on the child or young person’s resilience and coping strategies. However, to achieve this they must be able to recognise the effects of adverse childhood experiences on themselves and in their patients, practise self-care and resilience strategies and be supported by their organisations through, for example, reflective debrief sessions following stressful or traumatic workplace events or incidents.
• Adverse childhood experiences can lead to suboptimal health and risk-taking behaviours during adolescence and adulthood
• Trauma-informed care involves recognising and understanding the negative events that have affected a person and how these relate to suboptimal health
• Using a trauma-informed approach to care can support nurses to recognise, understand and reflect on the effects of complex trauma and toxic stress on children and young people
• Nurses can consider the factors that affect their own physical and mental well-being to enhance care delivery
• A hybrid approach to debrief following a traumatic or stressful workplace incident can support nurses’ well-being
Trauma arises from negative events that have physical and psychological effects on a person that they may or may not manage positively (Gerber 2019). Gerber (2019) advocated the use of a trauma-informed care model, defined as a practical, compassionate, strengths-based approach to addressing people’s health needs and deficits caused by adverse experiences. This trauma-informed care model has been described as an effective method for nurses and healthcare teams to deliver safe and appropriate care to all patients (Kimberg and Wheeler 2019).
Trauma-informed care involves recognising and understanding the negative events that affect individuals, particularly adverse childhood experiences, and how these relate to risk-taking behaviours, self-harm and suboptimal health (Ford et al 2020). Training in trauma-informed care can enable nurses to use appropriate knowledge and skills to enhance the care they provide to patients who are vulnerable because of the effects of their adverse childhood experiences (NHS Education for Scotland 2017). Effective trauma-informed care training (NHS Education for Scotland 2016) should enable participants to:
• Recognise the origins of trauma and whether adverse childhood experiences contribute to the trauma reaction.
• Develop the ability to self-assess adverse childhood experience status.
• Demonstrate sensitivity to others who are affected by trauma and adverse childhood experiences.
• Develop self-awareness of personal stress responses.
• Identify the effects of personal experiences on personal coping abilities and resilience.
• Assess a person’s health behaviours and health status by asking ‘What happened to you?’ not ‘What’s wrong with you?’
• Deliver holistic patient care using reflection and debrief (reflective activity in teams) techniques.
Kessler et al (2015) advocated debrief as a positive technique to support healthcare staff’s mental well-being following stressful and traumatic events, particularly in emergency departments. However, Greenberg et al (2020) suggested that single session psychological debrief approaches should not be used as they may cause additional harm. It is the author’s opinion that improvements in care, and staff’s ability to manage stressful situations and toxic experiences in the workplace, could be achieved by implementing a hybrid approach to debrief. The benefits of this and the practical steps required for effective debrief following stressful or traumatic events in the workplace are discussed later in the article.
Harmful events experienced by children are termed adverse childhood experiences and include emotional, physical or sexual abuse, emotional or physical neglect, violence against the child’s mother, loss of a parent (for any reason) and living with household members who are substance misusers, have a mental health condition or have been imprisoned (Felitti et al 1998). Being subjected to four or more adverse childhood experiences may manifest as complex trauma, toxic stress, anxiety and depression at any point across the person’s lifespan (Felitti et al 1998).
Complex trauma refers to the effects of ongoing and repeated traumatic circumstances, for example childhood abuse or neglect (NHS Education for Scotland 2017), while toxic stress refers to prolonged or permanent abnormal physiological responses to stressors (Franke 2014). The physical effects of complex trauma and toxic stress on a child’s brain are evident in changes to the cerebral cortex, limbic system, diencephalon, cerebellum and brainstem which interpret and process sensory information (Perry 2002). The areas of the brain responsible for the development of ‘caring’ behaviour and some cognitive capacities may sustain long-term damage in those who have experienced adverse childhood experiences (Perry 2002). In addition, increased cortisol levels caused by negative stressors can cause the brain to ‘expect’ stress and trauma (NHS Education for Scotland 2017). This can result in brain and behaviour changes leading to risk-taking, addiction, self-harm and self-neglect which, in turn, can lead to chronic ill health and risk of premature death (World Health Organization 2007, McDonald et al 2019).
The effects of complex trauma and toxic stress are significant and may be irreversible (Ford et al 2020). For example, a retrospective study involving a prison population of male adults found a correlation between adverse childhood experiences and lifetime mental ill health, self-harm or attempted suicide and suboptimal mental well-being (Ford et al 2020). The long-term physical health consequences of adverse childhood experiences can include functional limitations, physical changes and damage to major organs and systems of the body which can impair their effectiveness and result in conditions such as diabetes and heart disease (Monnat and Chandler 2015).
There is a risk that adverse childhood experiences can limit the life chances of a second generation of children. For example, a US study of mothers who had had adverse childhood experiences reported that their parenting skills negatively affected their children’s optimal development (Sun et al 2017). This is supported by learning from a pilot evaluation of a programme undertaken in Wales in which health visitors asked parents and caregivers about their adverse childhood experiences and the potential effects on their health and well-being and on that of their children (Hardcastle and Bellis 2021). One of the findings from the pilot evaluation was that 18% of those with the highest level of exposure to adverse childhood experiences were receiving intensive health visiting support.
Healthcare professionals have a responsibility to be aware of the effects of adverse childhood experiences on their patients and to mitigate the risks of these on all aspects of children’s lives (Hardcastle et al 2020). The Nursing and Midwifery Council (NMC) (2018a) requires nurses to recognise and assess people at risk of harm, and situations that may place them at risk of harm, and to ensure prompt action is taken to safeguard those who are vulnerable. Nurses are also required to assess risks to patient safety and manage these during the delivery of care.
Resilience is a concept that describes an individual’s ability to manage challenging and stressful situations and responses to trauma (RCN 2019a). The RCN (2019a) resource Healthy Workplace, Healthy You recognised that nurses are not immune to the effects of adverse childhood experiences or personal or occupational trauma and emphasised the importance of nurses reflecting on their own well-being and developing their resilience. There is, however, growing debate about the interpretation of the term resilience in relation to healthcare and healthcare staff amid concern that it places responsibility for managing adverse experiences on the person themselves rather than on the organisational mechanisms that could support them (Dall’Ora 2021).
The RCN (2021) and the King’s Fund (Charles and Ewbank 2021) identified the importance of nurses’ well-being and the development of resilience to support recovery from the traumatic effects of working during the COVID-19 pandemic. Before the pandemic, the NHS England (2019) Interim NHS People Plan emphasised the need for improvements to ensure the health service is a safe and attractive place in which to work. These improvements included development of a culture of positive leadership across the health service and valuing staff by developing multi-professional relationships and strengthening how teams support each other, for example by reviewing adverse events together using improvement and root cause analysis models and professional reflection and debrief techniques (West et al 2020). One of the aims of these suggested improvements was to enhance nurses’ well-being and increase their resilience.
An RCN employment survey of 8,307 members explored a range of factors about work and working conditions (RCN 2019b). The findings highlighted that some nurses experienced moral distress due to their inability to provide the quality of care they wished to and that some experienced conflict in the workplace through physical or verbal abuse and bullying. In the author’s opinion, these findings support the argument that for nurses who have had adverse childhood experiences there is a risk that an unexpected and possibly negative response could be triggered while caring for patients who have had similar experiences and are living with the effects. The RCN (2019a) suggested that self-care strategies such as mindfulness and practical techniques such as exercise could support nurses to manage their stress responses and assist with the recognition of post-traumatic stress disorder. Greenberg et al (2020), meanwhile, discussed employers’ duty of care to provide appropriate care through occupational health departments and human resources services to protect the mental health of staff who have had to manage the challenges of working through the COVID-19 pandemic. In the author’s opinion, developing and sustaining resilience is the responsibility of individuals and their employers.
Greenberg et al (2020) advocated for managing trauma and the mental health challenges experienced by staff during the COVID-19 pandemic through reinforcing the value of healthcare teams as essential to care provision. A sustainable system of emotional support must be in place to monitor staff well-being. The trauma-informed approach (Greenberg et al 2020) in conjunction with reflective practice (Nicol and Dosser 2016, NMC 2018a) can assist nurses to develop personal resilience and subsequently deliver trauma-informed care. The trauma-informed approach acknowledges and supports the recognition of adverse childhood experiences and emphasises the need for increased self-awareness and self-reflection to develop resilience and to deliver care safely, effectively and compassionately for patients, including those who are affected by adverse childhood experiences.
The RCN (2015) Healthy You Assessment Worksheet – www.rcn.org.uk/professional-development/publications/pub-005539 – is a self-assessment tool that provides an overview of strategies that can assist in maintaining nurses’ health and gauge their current level of self-care. The author of this article has developed an ABCDE mnemonic for the recognition and delivery of trauma-informed care and self-care which may assist nurses to develop personal resilience and increase their confidence in delivering trauma-informed care.
It is important to acknowledge a recent experience of trauma or a trigger related to adverse childhood experiences. This could be working relationships, the effect of COVID-19 and the associated restrictions, grief and loss, social and financial issues, exam pressures or other significant life changes, such as moving house.
Staff must be aware of the effects of adverse childhood experiences and ask themselves and their patients ‘What happened?’ (not ‘What’s wrong?’) followed by ‘What next?’
Reflect on coping and resilience strategies and which might be most effective in a particular situation. Strategies might include accessing self-help videos or mindfulness techniques.
Think about who to speak to and who might be able to provide appropriate support, for example your GP, support services such as helplines or talking therapies.
Evaluate the effectiveness of the action taken, become self-aware enough to recognise when you are coping well and to know when you need extra support to continue to manage your life effectively, to work safely and meet the requirements of the NMC (2018b) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates.
The aim of debrief is to include and support everyone involved in an incident and to discuss the positive and negative aspects. Guided reflection and support can assist each participant to recognise the effects of the incident, the emotions they experienced and the actions and resilience required to manage future incidents. The author suggests that implementing a hybrid approach that involves ‘hot’ and ‘cold’ debriefs can support staff to manage stressful situations and challenging workplace experiences which, in turn, can lead to improvements in patient care.
A hot debrief involves reflection, occurs immediately after an incident or traumatic event and includes all those involved. Participants reflect on what happened before and during the event and discuss what went well and what could have been done better (Kessler et al 2015). They then discuss and scrutinise the positive and negative elements of the incident. Care is taken to encourage an open and honest discussion and not to apportion blame. The purpose of a hot debrief is to provide immediate support to enable staff to manage their emotions directly following an incident. This is important when service delivery must continue (Kessler et al 2015).
A cold debrief, which either follows a hot debrief or is a stand-alone event, is arranged within a few weeks of an incident and also involves reflection. Additional staff, for example paramedics, are invited to attend alongside those involved or affected by the incident. The aim is to learn from the incident. An open, honest discussion is supported by a designated person and the principle of no blame is adhered to. Quality improvement tools, for example the NHS England (2015) serious incident framework or the NHS England and NHS Improvement (2021) cause and effect (fishbone) diagrams, can be used to identify contributing factors. Participants examine systems of work and human factors, the care environment, equipment and any other factors that may have contributed to the incident. They then assess the risk of a similar incident occurring in the future and complete a time-critical action plan to prevent this.
Two important aims of a cold debrief are to identify training that may be required and to share learning points, for example through an anonymised briefing note to staff involved and/or through communities of practice, to reduce risk and improve safety. This can assist in increasing staff confidence to deliver safe, effective, person-centred care, particularly when training issues are identified and addressed. Enabling staff to maximise training opportunities in safe learning environments is supported by the RCN (2021) and the NMC (2018a).
The following checklist can support a hybrid approach to debrief:
• Consider and agree on what sort of events or incidents will trigger debriefs.
• Develop a standardised format for debriefs.
• Determine methods for sharing the outcomes of debriefs throughout the service and organisation.
• Determine who should participate, including those involved in the incident and additional staff such as paramedics and/or managers.
• Decide who should facilitate the debrief.
• Determine that the timing of the debrief is suitable for participants.
• Select a comfortable environment for the debrief to take place.
• Determine the objectives for each debrief.
• Consider using a debriefing tool or script, for example a serious incident framework (NHS England 2015) or cause and effect (fishbone) diagrams (NHS England and NHS Improvement 2021).
• Develop and implement action plans for improvement based on the outcomes of the debrief.
Developing resilience and using a trauma-informed approach to care can support nurses to recognise, understand and reflect on the effects of complex trauma and toxic stress on children and young people. Nurses can consider the factors that affect their own physical and mental well-being using the ABCDE approach outlined in this article to enhance the delivery of care. Staff health and well-being is fundamental to the effectiveness and safety of care and can be supported through implementation of a hybrid approach to debrief following a traumatic or stressful workplace incident or event.
Adverse Childhood Experiences (ACEs). Preventing Early Trauma to Improve Adult Health:
cdc.gov/vitalsigns/aces/pdf/vs-1105-aces-H.pdf
Eight Elements of Workplace Wellbeing:
nhsemployers.org/articles/eight-elements-workplace-wellbeing
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