NURSES EXPERIENCE psychological traumas from myriad sources that continually challenge their mental health and well-being. The looming shortage of nurses has been widely discussed, with shortfall projections ascribed to increased demand for nurses, an aging nurse workforce, and a surge in older adults needing care.1 What is often neglected in the discussion is nurse attrition: those who elect to leave the profession. In the early 2000s, researchers, including Aiken et al,2 began to collect information pertinent to job dissatisfaction and job-related burnout. Resources, such as staffing and supplies, were directly linked to nurse job dissatisfaction. Globally, nurses' work environments, including staffing ratios, appear to be tied to job dissatisfaction, burnout, and intention to leave.3,4 In the United Kingdom, the Nursing and Midwifery Council reported 5577 fewer nurses in the European Economic Area, a decrease of 87%, joined the register in 2017-2018 when compared with 2016-2017.5 In a follow-up survey, 26% of those from the United Kingdom cited staffing as the reason for leaving the register.5 As technology has advanced, so have the demands made on nurses, particularly surrounding frustrations from electronic health records.6 Since the COVID-19 pandemic, nurses' attrition is even more of a concern.
In juxtaposition to the barriers nurses face in delivering care, the act of caring is often described as a hallmark value in nursing.7 We witness the impact of the principles of Watson's7 caring science and caritas values of compassion, charity, and generosity in multiple organizations across the world. In other literature, empirical evidence shows that alexithymia, a defense mechanism used when a nurse is faced with negative and overwhelming emotions, and traumatic stress are linked to burnout symptoms.8 As the intersections of Watson's caring science are considered with the demands placed on nurses due to patient complexity, additional technologies, lack of resources, and individuals electing to leave nursing, nurses want to uphold the caritas values through quality, safe patient care, and be unable to do so.9 One mechanism to make sense of these opposing phenomena is through a new discourse to explain these tensions within the context of nurse-specific trauma.
Statements of Significance
What is known or assumed to be true about this topic?
The most frequently identified psychological traumas experienced by nurses are secondary traumatic stress, vicarious trauma, and workplace violence. However, a broader theoretical orientation to include the multiple types of nurse-specific psychological trauma has not been described. The lived experiences and needs of professional nurses, especially bedside providers, are currently overlooked, scattered, or located in anecdotal descriptions of high-pressure working conditions. These conditions are often characterized by the lack of resources and support.
What this article adds:
In this article, a comprehensive middle-range theory is presented of the various types of psychological trauma facing nurses. Moreover, a new discourse is offered for communicating such trauma so that nurses may be empowered by the ability to convey their lived experiences and the needs they have for trauma-informed care, both for themselves and for their patients. Trauma occurrence is considered avoidable and unavoidable. Trauma-informed care should be situated at the individual, professional, and organizational spaces, thus improving the quality of nurses' lives and the quality of care offered to patients.
A middle-range theory is classified as being "part of the structure of the discipline ... explicating and expanding on specific phenomena...."10(p5) Middle-range theories are compared with grand theories, which are conceptualizations that are broader and more abstract to nursing. In alignment with Kuhn,11 the purpose of this theory, the middle-range theory of nurses' psychological trauma, is to describe, explain, predict, and begin to control for the psychological trauma experienced by nurses within the contexts of both the individual and organizational spaces. According to Fawcett, this theory is a predictive theory in that it "addresses how changes in a phenomenon occur."12(p36) The middle-range theory of nurses' psychological trauma begins a conversation about potential reasons nurses experience negative outcomes such as compassion fatigue, burnout, secondary traumatic stress, posttraumatic stress disorder (PTSD), self-harm, and exit the nursing profession. While the middle-range theory was conceptualized in the prepandemic COVID-19 era,13 it is even more applicable considering the trauma created by this global natural disaster.
NURSES AS THE FOCUS OF THEORETICAL SPACE
Theorists who examine the interrelationships of the metaparadigm of nursing, person, health, environment, and nursing14,15 typically focus on the person/patient and health as the geopolitical spaces of conceptualization. The act of caregiving, of situating the patient as the center of activities, is common. Nursing is itself defined in relation to the patient and the environment in grand theories,16,17 as well as middle-range theories and specific clinical contexts.18 A notable exception is the work of Conti-O'Hare,19 in which the nurse is situated as both wounded individual and a healer as described in the Nurse as Wounded Healer theory. The middle-range theory of nurses' psychological trauma aligns with Conti-O'Hare's19 work. In the Nurse as Wounded Healer, the nurse as healer is emphasized and prioritized, as is the integration of the nurse's trauma into the role of healer.19 Conti-O'Hare frames the archetype of the nurse as a wounded healer from "the transcendence of old wounds"20(p76) that enables the nurse to enhance patient care and competence. Further application of the Nurse as Wounded Healer to nurses' PTSD reveals self-healing as a path to transforming and transcendence of trauma.21
The theory under discussion is related, but unique, because the primary focus is the well-being of the nurse within the lens of psychological trauma in its myriad forms (ie, humankind as well as nurse-specific and nurse-patient-specific traumas). In contrast to the work of Conti-O'Hare,19,20 the trauma described here is viewed as both avoidable and unavoidable, and the nurse and trauma are both located in the individual, professional, and organizational spaces. The current theory ascribes to the reciprocal interaction worldview in that reality is relative and context dependent. Nurses interact with their environments in reciprocal ways.12 Furthermore, the current theory widens the remedies of trauma beyond interventions designed to build individual-level nurse resiliency and extends further to examine organizational culpabilities and strategies to provide a trauma-informed environment for nurses. Therefore, and in this way, the theory outlines paths to prevention, praxis, and ways to mitigate nurse-specific trauma.
PSYCHOLOGICAL TRAUMA
Acceptance of a definition of psychological trauma is necessary to understand the middle-range theory of nurses' psychological trauma. Psychological trauma is described by the Substance Abuse and Mental Health Administration (SAMHSA) in a 3Es model22:
...experiences that cause intense physical and psychological stress reactions. It can refer to a single event, multiple events, or a set of circumstances that is experienced by an individual as physically and emotionally harmful or threatening and that has lasting adverse effects on the individual's physical, social, emotional, or spiritual well-being.21
There is an Event, something that happens and causes a cascade of biological and psychological responses.22 This Event is interpreted by each individual as an Experience, which may result in the lasting Effects of the psychological injury.22 Included in Effects is the potential for PTSD as well as posttraumatic growth. Psychological trauma resides within us as an internal force that must be reckoned with. Humankind trauma is injury that affects individuals, regardless of professional titles. Such trauma may occur early in life when we are most vulnerable and may be linked to adverse childhood experiences23 that transmute into early trauma. Trauma may also occur later in our lives when, for example, we endure the loss of significant others, crimes against us (violent and nonviolent), and other unpredictable events that cause psychological injuries. Trauma also creates neurobiological changes in the individual as the brain reacts to the psychological injury.
When resilience is framed as an internal presence, nurses are often called upon to build and use coping skills, and otherwise nurse "heal thyself," in response to trauma. This approach is only one dimension of recovery from trauma. This conclusion is based on the fact that the sources of trauma nurses face are frequently out of their control. However, they may be avoidable and under the control of those making decisions in health care organizations that affect nurses' work environments. Within a theoretical perspective, evidence of how nursing leadership can provide critical support to nurses within the Nursing as Caring framework is clear: "She ministers to the nurses in her charge daily in ways small and large...."24(p3) In this description, nurses are then seen as both a recipient of care and a renderer of patient care by their leaders. In contrast, if organizational leadership, including and beyond nursing leadership, does not provide the necessary environment to minimize nurses' exposure to trauma, nurses may be on a continuous loop of recovery, with some leaving the place of employment and even the profession.25
Types of nurses' psychological traumas
The middle-range theory of nurses' psychological trauma conceptualizes 7 traumas that may be experienced as nurses render care: (1) vicarious and secondary trauma; (2) historical and intergenerational trauma; (3) workplace violence; (4) system/treatment-induced trauma; (5) insufficient resource trauma9; (6) second-victim trauma; and (7) trauma from disasters (Figure; Table 1). These types of nurse-specific trauma are created through the daily, routine acts of caring for others, or in periods of crisis and in times of heightened vulnerability and suffering. Vicarious trauma is the type of psychological injury that results from empathy and co-experiencing the patient's suffering that can affect the caregiver's view of the world. Secondary traumatic stress is experienced by direct care providers as they co-live the trauma of another. Concept attributes of secondary traumatic stress have been associated with "posttraumatic stress disorder-like symptoms," including avoidance, intrusion, and arousal.27(pp149,151) In a review of secondary traumatic stress literature, Misouridou28 describes nurses' responses to being exposed to those who have experienced trauma and how nurses may struggle with processing these emotions. Nurses' reactions may be intense and varied, from becoming disengaged to becoming overinvolved and losing sight of professional boundaries in caring for patients with trauma.28
Although distinct, concepts associated with vicarious trauma and secondary traumatic stress are compassion fatigue and burnout. While burnout and compassion fatigue share stress and exhaustion as attributes, compassion fatigue also includes ineffective coping and a lack of empathy toward others.29 The question remains as to whether there is a temporal component to trauma, burnout, and compassion fatigue, with trauma being a precursor of the latter two. Recent literature suggests that distinct types of nurse-specific traumas may precede burnout and compassion fatigue. In a 2011 review article by Beck,30 compassion fatigue is equated with secondary traumatic stress and the terms are used interchangeably. In this review,30 compassion fatigue/secondary traumatic stress is seen as having sudden onset while burnout has a gradual, insidious development. Recent literature tends to see the concepts of secondary traumatic stress and compassion fatigue as distinct. In a concept analysis conducted by Wynn,29 an attribute unique to burnout is the stress associated with the work environment, such as excessive workloads and inadequate support. In contrast, secondary traumatic stress originates with the nurse-patient relationship and is an attribute of compassion fatigue.29 Antecedents of burnout are described as workplace driven, whereas antecedents of compassion fatigue include burnout and the "large degree of emotional trauma" that leads to stress."29(p64) Comparisons of these phenomena are ongoing and necessary.
The second type of nurse-specific trauma in the theory is historical and intergenerational trauma. Intergenerational trauma may be specific to a population or group, including nurses as an oppressed group, which is passed down through generations and influenced by historical events and contexts of power. Based on the work conducted by Kellermann31 with survivors of the Holocaust, the transmission of trauma becomes clearer: descriptions of trauma are passed down from parent to child. Groups who have long endured racial and ethnic disparities have also experienced intergenerational trauma, a topic that is also timely. Nurses themselves may be viewed as an oppressed group, passing down this oppression to new nurses in the form of bullying and incivility.13 How this translates to us as nurses is aided by the work of Paulo Freire.32 Freire's32 theory of how oppressed peoples, when confronted with authority, are silent and silenced. Nurses, who are historically employees of an organization, may be situated within a hegemonic domain where they are grouped and anonymized. They become an oppressed group caring for patients who themselves are oppressed.33
Symptoms of oppression, incivility, and bullying within nursing may be viewed as types of workplace violence. Workplace aggression includes both bullying and violence-related acts toward nurses.34 To aid in differentiating these 2 concepts is that in most instances, workplace violence is characterized by physical acts. Overt violence against nurses by patients and families results in trauma, both physical and psychological. In reviewing the literature on bullying, lateral violence, and incivility, Crawford and colleagues35 emphasize the organizational unit being just and fair, as well as the critical role of nurse leaders in providing such an environment. While not entirely avoidable, given patient and family roles in workplace aggression, a just culture practiced by nursing leaders can be a mitigator for nonviolent forms of workplace aggression and thus psychological trauma.
System-induced or treatment-induced trauma occurs when nurses co-experience the psychological injuries the patient experiences because of the care they and other health professionals are rendering. This type of trauma may be categorized as nurse-patient-specific trauma and overlaps with vicarious and secondary trauma in that the nurse is witnessing and living through the trauma of the patient, in this instance because of the care being received. Prepandemic, we know patients were traumatized as a result of care given.36,37 Given the isolation from family, friends, and health care providers, who must limit time spent in direct contact with them, patients who are diagnosed with the SARS-CoV-2 virus infection, experience medically induced trauma. To date, we have multiple anecdotal accounts that describe the trauma that both patients and nurses endure within the context of the COVID-19 pandemic due to the medical treatment environment.
The fifth type of trauma is insufficient resource trauma. Revealed in an empirical study by Foli et al,9 insufficient resource trauma occurs when there are inadequate resources available for the nurses to render safe, competent, quality care, and the care that they know should be rendered.9 There is an element of time, or the lack of time, lurking within this trauma. Nurses lack the resource of time to deliver patient care, often psychosocial care. In a grounded theory study, Williams reports, "When nurses worked within the constraints of insufficient time they were unable to consistently provide quality nursing care to all their patients."38(p811) Furthermore, Williams38 notes that when quality care was not delivered, nurses experienced stress and dissatisfaction. Knowing that they are providing less than quality care erodes the nurse's soul. Their values are not upheld, values that are embedded as part of their identity as nurses and buttressed by the American Nurses Association (ANA) Code of Ethics.39 In building a healthy nurse workforce, nurses' self-care is often emphasized.40 However, the reality for some nurses is that self-care is neglected with little time for hydration and nourishment on the typical 12-hour shifts and often due to insufficient resources.
Second-victim trauma is the sixth type of psychological injury and refers to the provider who becomes victimized and traumatized after an adverse event or medical error has occurred.41,42 Evidence of lingering effects of medical errors has been revealed on the basis of reports from nurses who made errors; however, the phenomenon was more complex than a nurse making a mistake and experiencing trauma. First, the trauma appeared to be, at times, unrelated to the patient outcome or harm; second, the trauma seemed to be linked to whether the nurse felt they had acted as a strong advocate for the patient.9 Guilt and symptoms of PTSD were described by the nurse.9
Trauma from disasters is the final type of psychological trauma experienced by nurses. Disasters may take many forms: natural versus man-made and acute versus long term. Disasters disrupt the functioning of a community or society and interact with "conditions of exposure, vulnerability and capacity...."43 Nurses, as the largest health care workforce, are often first responders when disasters occur. The ANA44 brief on nurses responding during disasters was written before the COVID-19 pandemic disaster. The ANA44 brief, however, discusses the obligations of the nurse in prophetic terms as the balance between caring for patients and self is weighed: "During these times of pandemics or natural catastrophes, nurses and other health care providers must decide how much high-quality care they can provide to others while also taking care of themselves."(p1) Triage decisions within an environment of insufficient resources, the constant potential for self-endangerment, and the exhausting need to care for critically ill patients create an experience of psychological trauma for nurses nested in the backdrop of a disaster.
In Table 2,26 the concepts that surround the middle-range theory of nurses' psychological trauma are presented. These concepts add to the discourse that is needed to describe the work of nurses and the individual histories that shape them. Nurse-specific and nurse-patient-specific traumas are not mutually exclusive; however, the focus of the trauma varies with each concept (ie, nurse-specific trauma focuses on the nurse, whereas nurse-patient-specific trauma focuses on the patient).
OUTCOMES OF PSYCHOLOGICAL TRAUMA
As mentioned earlier, staff and professional turnover may be a negative outcome as the nurse experiences and endures traumatic experiences. Mental health distress may arise, including depression, anxiety, and PTSD.9 The Effects22 of nurses' psychological trauma may result in a continuum of behaviors, such as alexithymia and disengagement to hypervigilance and overinvolvement.27,28 There is a loss of something when trauma is experienced.13 Links between psychological trauma and nurses' alcohol and substance use have been found.45 More research is needed to support these findings that trauma from lateral violence in the workplace, and humankind trauma (adverse childhood events and life events) appears to be predictors of nurses' alcohol and substance use.45
Other outcomes of trauma may be positive and lead to psychological growth. Since the COVID-19 pandemic, discussions about nurse resilience have exponentially increased. From phone "apps" to mindfulness, nurses are educated and, in subtle messaging with subtexts, instructed to become more resilient. Resilience is a complex phenomenon that exists in response to an adversity or trauma.46 Similar to buried seeds, with some individuals' seeds in more fertile ground than others, with enough water and nutrients, their seeds can grow. But there is more to this concept: a genetic predisposition that benefits individuals during and after interactions between individuals and their environments.47 In the current theory, then, "Resiliency may be viewed as a trait, a process, a defense mechanism, or an outcome, depending upon the context, resources available, and the individual."13(p107) As the COVID-19 pandemic has shown the world, resiliency is reinforced and perhaps instigated by system and organizational recognition; organizational and nursing praxis must ensure nurses' exposure to avoidable trauma is minimized or negated. For example, sufficient resources can avoid certain nurse-specific traumas. The middle-range theory of nurses' psychological trauma has been applied as a framework of understanding to the COVID-19-induced trauma experienced by emergency department nurses.48 Amberson asserts that this theory can be used as a mechanism "to name our experiences"48(p363) and thereby offers examples of each type of psychological trauma as mapped to emergency nursing and COVID-19.
In a related concept, posttraumatic growth offers the individual a positive outcome from psychological trauma. The individual moves into a psychological space that was absent prior to the presence of trauma.49,50 The individual is able to value what has been experienced, how coping was used, and, yet, the individual may still feel distress.49,50 Increased compassion toward others is an outcome related to posttraumatic growth and related to trauma-informed care.
Trauma-informed care
As an individual becomes stronger through resilience and posttraumatic growth, there is potential for compassion toward others. The middle-range theory of nurses' psychological trauma creates inclusivity of trauma-informed care to encompass nurses, other health care workers, patients, and significant others. In a synthesis of literature on trauma-informed care, Reeves51 derived themes, which include a trusting provider-patient relationship. Such a relationship may build organically when nurses' experiences and behaviors are viewed within a trauma-informed lens and there is a given mutuality of nurse as receiver and giver of care.
One framework of trauma-informed care exists in SAMHSA's 6 key principles: (1) safety; (2) trustworthiness and transparency; (3) peer support; (4) collaboration and mutuality; (5) empowerment, voice, and choice; and (6) cultural, historical, and gender issues.22 While each of these components characterizes an approach designed to mitigate re-traumatization and provide appropriate responses to trauma, providing for psychological and physical safety surpasses the others. Feeling safe opens opportunities for trustworthiness, support, mutuality, empowerment, and understanding that cultural, historical, and gender issues will be accounted for. Imagine the nurse whose career is marked by knowing their voice will be heard without judgment, reprisals, or retributions. Think of the empowerment and trust offered to self, peers, and patients when the nurse is free from the distractions of inadequate resources and concerns about workplace violence. There is now a space for posttraumatic healing and growth.
ASSUMPTIONS AND THEORETICAL STATEMENTS
Assumptions that underlie the theory should be stated. The first assumption is that due to gender, hegemonic, and historical factors, as well as the nature of the work of nurses, the theory presents nurse-specific and nurse-patient-specific traumas that are unique to the world of nursing. While certain traumas, such as second-victim trauma may be experienced by others, such as physicians, the current theory forwards how such trauma is experienced by nurses. Related to this assumption is that by being aware of and understanding nurse-specific and nurse-patient-specific traumas, student nurses, newly graduated nurses, and practicing/veteran nurses may use a discourse surrounding the traumatic event, process the traumatic experience, and mitigate the effects of the traumas.
The second assumption is that while nurses are exposed to trauma, select nurses may reject the notion of having endured trauma.9 Individuals may have experienced minimal humankind traumas, and they may feel safe, secure, and resilience. Nurses render care in a variety of settings, some removed from direct patient care, thereby avoiding co-living patients' sufferings. Furthermore, there may be degrees of trauma exposure; yet, as previously discussed, the individual's Experiences and Effects from trauma vary and are unique.22 Therefore, the description and application of this theory may not be endorsed by every individual who is a professional nurse and, instead, by those who recognize trauma have experienced traumatic events and are recovering from psychological trauma.
The third assumption is that individuals, groups and leaders, and organizations have the moral and social responsibility to operationalize policies, procedures, and resources to avoid those nurse-specific traumas that may be circumvented. While resiliency is an individual undertaking, building and maintaining resiliency are contextual and occur within a social milieu.
With these assumptions in place, the conceptual model of nurses' psychological trauma is based on the following 6 statements.26 Note that nurse-specific traumas are differentiated from the traumas facing humankind, such as acute, chronic, complex, and developmental traumas. The theoretical statements provide relationships between concepts and how humankind and nurse-specific/nurse-patient-specific traumas influence the nurse as a person and as a professional.
Statement 126
The traumas may be nurse-focused (ie, nurse-specific) or patient-focused (ie, nurse-patient-specific) and may overlap. For example, when a medical error occurs, there may be second-victim trauma to the nurse and medically induced trauma to the patient. These psychological forces are differentiated from the traumas facing humankind, such as acute, chronic, complex, and developmental traumas.
Statement 226
Each individual perceives trauma in a unique way because the Events, Experiences, and Effects of the traumatic event(s) are exclusive to the person.21 Nurses' genetic/biological, familial, psychological, cultural, spiritual, and environmental facets influence how traumatic events are processed, how they are experienced, and the lingering effects that may be present.
Statement 326
Select nurse-specific traumas are threaded into the work of the nurse and may be unavoidable at the individual level. These include vicarious/secondary trauma and patients' medically induced traumas. Other traumas, including workplace violence and insufficient resource trauma, may be mitigated or prevented by the environments produced by systems and organizations. System forces create environments that increase or decrease the risk for nurse-specific traumas.
Statement 426
Nurse-specific traumas stimulate neurobiological changes in the nurse and, if not lessened, may create an allostatic load, leading to negative outcomes. Nurses' decreased physical and mental health (eg, depression, anxiety, and substance use), unsafe patient care lacking in quality, and leaving organizations and the profession are examples of negative outcomes.
Statement 526
Resiliency and posttraumatic growth act as buffers and potential outcomes to nurse-specific psychological traumas. Positive and negative individual outcomes are possible, and both may simultaneously be present.
Statement 626
Trauma-informed self-care may lessen the impact of individual nurse-specific traumas. Similarly, trauma-informed patient care may lessen the impact of nurse-patient-specific traumas. System and organizational strategies designed to provide safe working conditions and sufficient resources, which add to individual resources and praxis, may reduce the impact of nurse-specific psychological traumas.
DISCUSSION
Therefore, within the context of praxis, how do we, as a profession, create a caregiving environment that buffers nurses from avoidable trauma and lends nurses much needed support when unavoidable trauma is endured? The Nursing Manifesto52 presents us with several possibilities. First, the sovereignty of nursing must be aligned with institutional practices. In a study based on the Nursing Manifesto, Jarrin describes major themes in answer to the question of "What is it like to practice nursing today?"53(pE76) Threats to the nurse-patient relationship are those that are out of the nurse's control, including "a lack of resources combined with policies that are cost-centered rather than patient-centered."53(pE76) From the Nursing Manifesto Project:
Organizations are not changing because people in organizations are not changing. We seek to inspire and excite the desire for claiming personal and professional sovereignty. We are seeking no less than fundamental change in a movement that awakens us to the possibilities for transformation of individual and collective consciousness and to that which restrains us. This is the meaning of realizing sovereignty.54
Through this middle-range theory of nurses' psychological trauma, nurses can unmask the subtexts and discourses that create a false sense of culpability when faced with traumatic experiences. To assume a nurse who has experienced psychological trauma-as an independent being-needs to build resiliency and recovery-as an independent being-is an oversimplification. Building resiliency is necessary but, in isolation, is not sufficient. Resiliency and recovery are not accomplished in a vacuum or through token gestures by an organization. Such eudemonic interventions must intentionally move individuals who are working as professional nurses in organizations toward posttraumatic growth and healing. Our sovereignty as nurses will begin to undo a learned, professional helplessness.
Nurses' sovereignty encourages support, identity, and transformation of what is and has existed-systems that no longer function to achieve the goals in our profession or of our health care delivery services. The middle-range theory, which needs to be further empirically tested, allows us some sense of prospicience. We are at a juncture in time that has magnified our lens of understanding the work of nurses. With nurses guiding and directing such efforts, we cannot and should not ignore this opportunity; if we allow this point in time to pass and continue the health care business as usual, the losses will be surely not only with nurses but also with patients and, ultimately, with those who have held health care institutional power for so long.
CONCLUSION
As a function of our humble beginnings as caregivers in the home, or our historically gendered roles, or by being the largest, and often anonymized, health care professional workforce, nurses are viewed as trustworthy, strong, ever-present, and maternal, yet frequently overlooked as needing support. When such support is recognized, nurses are often singularly charged with building resiliency to offset psychological distress. The COVID-19 pandemic has changed these impressions and created new discourses in favor of nurses' well-being. The recent historical events have created new contexts that call for society to recognize the space of human suffering for nurses and other health care professionals. Perhaps, the articulation of this middle-range theory of nurses' psychological trauma will provide an opening for real change in nurses' health and well-being. The evidence for nurses' psychological trauma existed long before the COVID-19 pandemic, a disaster that has only offered clarity and forced us to come to terms with a crisis of caring for the caregivers.
REFERENCES