Safety is an important word in the hospital setting. We have white papers, evidence-based recommendations, and even communication tools aimed at enhancing safety. One of the most recognizable tools for communicating safety is the CUS tool (Agency for Healthcare Research and Quality, n.d.). Using the CUS tool, the individual who recognizes a potential safety risk makes the following statements:
"I am concerned."
"I am uncomfortable."
"This is a safety issue."
The tool is meant to be used to guide conversations and alert others to something they may not have noticed that puts someone in danger.
I have been working in health care for more than 20 years and have spent most of that time involved in education and professional development. As I look back on my time in nursing, I realize there is so much to celebrate, such as an increased focus on health equity and patient outcomes. We have made great strides in the care we provide and our professional image in society; however, I feel the need to start a conversation about safety for nurses.
I am concerned.
A meta-analysis of research from 2020 indicated that approximately 30% of nurses had posttraumatic stress disorder (Caruso et al., 2021). A separate meta-analysis indicated that healthcare workers, including nurses, also have high levels of anxiety, depression, acute stress, and sleep disorders (Marvaldi et al., 2021). Although there certainly has been more attention paid to mental health since the COVID-19 pandemic began, evidence spanning decades shows increased mental health conditions among nurses compared to the general population including depression and suicide (Brandford & Reed, 2016; Davidson et al., 2019). Nurses are hurting, and repeated exposure to traumatic events is likely a major contributor.
I am uncomfortable.
We have evidence-based tools to address psychological distress and trauma-related issues in nurses. The Substance Abuse and Mental Health Services Administration (2014) has created a framework for providing healing environments for individuals who have experienced trauma called the trauma-informed approach. This approach encourages organizations to use the 4 Rs: realize how common and impactful trauma is, recognize the signs of trauma, respond to trauma in evidence-based ways, and resist retraumatization. Trauma-informed organizations should also integrate the six principles: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment and choice; and cultural, historical, and gender issues.
The trauma-informed approach is used in many settings, including hospitals. Its application is usually intended to help patients who have experienced a traumatic event and has indirect benefits on healthcare workers as well. The trauma-informed professional development framework is a new model that combines the principles of the trauma-informed approach and the nursing professional development model to directly aim interventions at healthcare workers, including nurses. Directing trauma-informed interventions specifically toward healthcare workers is essential to help with the trauma burden and mental health challenges that nurses are dealing with now.
This is a safety issue.
I have spent the past few years talking about trauma-informed professional development in different settings across the country, and I have had the honor to hear from many nurses about the importance of this work. One area that has received the most comment and attention is the principle of safety. A great deal of work has been done to address physical and psychological safety in the workplace for nurses, and a great deal of work still needs to be done. There is a third kind of safety, however, that does not receive as much attention. It is difficult to find it anywhere in the literature. When I talk about it with nurses, though, they understand exactly what I mean.
The type of safety that nurses are clamoring for now, in addition to physical and psychological safety, is professional safety. In essence, a nurse wants to be confident that they can provide the highest quality care to every single patient that they are assigned to care for. They want to feel comfortable that they are in an environment that supports their ability to provide nursing care with the knowledge, skills, and resources that are necessary. They want to be sure that they will not lose their license and livelihood because of something beyond their control.
Nurses have shared with me many current and serious threats to professional safety. First, medical knowledge is increasing at a faster pace than ever. In many cases, the knowledge that a nurse is receiving in a class or learning activity is already out of date. Second, the medical complexity of patients is increasing. This complexity requires nurses to manage not just one but many conditions at once. Nurses must learn the equipment and medication required to manage all of them. We also have new and emerging conditions, like COVID-19, which require nurses to care for patients that require different care than they are accustomed to providing. Third, the nursing shortage has meant staffing challenges for many hospitals. Nurses may be asked to float or cover units that they are not familiar with because there is not enough staff.
Threats to professional safety are threats to nurses' mental health. It makes it more challenging for a nurse to recover after being exposed to a traumatic event. Imagine that a nurse is caring for a patient in a unit they are unfamiliar with or with a heavier patient load than usual. Imagine they are feeling insecure about their ability to effectively care for the patient who is in front of them. Then, imagine if a traumatic event happened, such as a death or near-death of a patient or a violent attack by a patient. That feeling of insecurity or lack of professional safety is likely to make it more difficult for the nurse to cope and heal after the traumatic event.
Nursing professional development practitioners (NPDs) can help with professional safety. Although we may not be able to help with the contextual factors that may make nurses feel professionally unsafe, we can address self-efficacy through trauma-informed professional development activities. Experiences of personal mastery of nursing skills and social support can build self-efficacy (Bandura, 1997). So, for example, frequent contact with an NPD during nursing orientation to review skills can help with both personal mastery and social support for a newly licensed nurse. Performing with a group of coworkers in an escape room scenario can help an experienced nurse feel a greater sense of connection with colleagues and teach skills at the same time, which increases self-efficacy. Just-in-time education from an NPD for a nurse who is floating to an unfamiliar unit can provide needed information and presence to enhance self-efficacy as well.
Beyond clinical skills, the NPD can also teach positive coping strategies, thereby increasing a nurse's coping self-efficacy. Coping self-efficacy has been shown to enhance trauma recovery after a traumatic event (Bosmans & van der Velden, 2017), so this intervention can be very powerful both in the short and long term.
I am hopeful.
The statement, "I am hopeful" is not a part of the CUS communication tool, but I think it is necessary to end this editorial with hope. I am hopeful for many reasons. The COVID-19 pandemic has brought about a new awareness not only of the importance of nurses but also the importance of keeping nurses healthy and safe. In addition, there is increasing recognition of the role of the NPD in providing safe and effective care across specialties and practice areas. As our specialty grows, we will be able to partner with learners not just for learning, change, role competence, and growth but also for professional safety and overall wellness through trauma-informed professional development.
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