Introduction

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.

Trauma-informed care

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:

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.

Adverse childhood experiences

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).

Resilience

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.

Debrief: a hybrid approach

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.

Conclusion

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.