Trauma and Reflection Theoretical Framework: Trauma and Reflection Chasity L. Mullins Submitted in partial fulfillment of the requirements for NURG700: Theory and Philosophy of Nursing Practice In the Graduate Program of the Ida Moffett School of Nursing Samford University July 19, 2020 2 Theoretical Framework: Trauma and Reflection Nurses are experienced in dealing with all events patients encounter. This includes patient traumatic experiences. This trauma can fall under any domain; spiritual, psychological, emotional, and physical. But what of the trauma that the nurses themselves experience? How do they cope? Is it considered healthy coping? Are they able to recognize the everyday trauma they experience by virtue of being a nurse? This author’s DNP project topic will be centered on building resiliency and learning coping mechanisms against nurse-specific trauma. One trauma will be focused on, that of Secondary Trauma. The primary reason this topic was chosen is because often the nurse’s ability to cope with the experiences they have while providing care is not a primary concern of nursing and administrative leaders. There is the unspoken expectation that traumatic experiences are just “part of the job”. Nurses need tremendous psychosocial support in their various roles of caregiving and historically this has been found lacking. Attention needs to be given to this topic so that nurses will have the ability to build coping and resiliency skills. This DNP project will assist nurses and give them support to help protect against negative effects of Secondary Trauma. Trauma that nurses experience has been named Nurse-Specific Trauma. Trauma is defined as “experiences that cause intense physical and psychological stress reactions” (Substance Abuse and Mental Health Services Administration, 2014). Nurse-specific trauma is therefore trauma that occurs specifically to nurses. (Foli, 2019). A study was conducted by Purdue University and 372 nurses were interviewed to find out if they experienced trauma. A multitude of examples were reported. These ranged from physical assault from patients and watching patients die to insufficient resources (Foli, et al., 2020). Trauma can negatively affect everyone, and adverse outcomes have been documented because of this. One such record is the 3 groundbreaking study of Adverse Childhood Experiences funded by the Center for Disease Control and Kaiser-Permanente. The results of the study provide strong evidence that trauma can have lasting negative effects (Fellitti, et. al., 1998). Fear related to a traumatic event can also cause increased risk of heart disease (Sumner, et.al., 2020). Trauma has negative consequences for physical and mental health. Advance practice nurses in clinical practice, administration, and education need to be aware of how to support colleagues and employees and facilitate the ability to recognize nurse-specific trauma, build resiliency and coping mechanisms to be able to provide trauma informed care. Related Concepts Related concepts to the nurse specific trauma of Secondary Trauma includes posttraumatic stress, coping, reflective practice, resilience, compassion fatigue, and vicarious trauma. These concepts are frequently mentioned when exploring the topic of Secondary Trauma. Vicarious trauma, secondary traumatic stress, and compassion fatigue are conditions related specifically to those professions that work with trauma populations (Newell & MacNeil, 2010). Reflective practice involves the action of actively thinking about a situation. Coping and resiliency are attributes that can arise from the process of reflective practice. (Koshy, et. al., 2017). Familiarity with the listed concepts will allow a better understanding of Secondary Trauma and will be explored further when discussing the relationship of the concepts to the guiding theories in the following sections. Guiding Theories For development and initiation of the DNP project, two theories have been chosen. The first theory chosen is Karen Foli’s Middle Range Theory of Nurses Psychological Trauma (2019). The second theory chosen to guide the project is Galutira’s Theory of Reflective Practice 4 (2018). Both theories were chosen due to each one’s relationship with the topic of Secondary Trauma. Foli’s theory identifies and defines this type of specific trauma that nurses may experience. Secondary trauma is identified by Foli as “stress reactions and symptoms resulting from exposure to another individual’s traumatic experiences, rather than exposure to a traumatic event” (2019, p. 34). Galutira’s Theory of Reflective Practice discusses using reflection to process certain events. The use of reflection prior to, during, and after an event allows the nurse to gain new knowledge on how to manage the situation for the future. When combining both theories, an excellent theoretical framework in which to guide the DNP project emerges. Both theories are very applicable to the many encounters that nurses can experience while providing patient care; especially those that cause Secondary Trauma. Relationships of Concepts and Theories Both the Theory of Reflective Practice and the Middle Range Theory of Nurses Psychological Trauma support concepts surrounding the topic of Secondary Trauma. For example, compassion fatigue is a term used interchangeably with Secondary Trauma in some literature, but Foli’s states that compassion fatigue could potentially be a result from experiencing prolonged Secondary Trauma (2019). Additionally, post-traumatic stress is often mentioned as a result Secondary Trauma. Vicarious trauma occurs when one is exposed to the actual trauma with the patient, where secondary trauma can occur in this manner or without the nurse being exposed to the actual trauma (Tend, n. d.). Since they are very similar in definition, both concepts are used interchangeably. Coping and Resiliency are concepts often found in literature discussing trauma, so it is not surprising these two concepts are associated with nurse-specific trauma. Reflective Practice as a concept is used by many professions to process specific events as well as enhance learning 5 and think proactively on how to cope with patient encounters. Over time, this will help to build resiliency (Koshy, et.al., 2017). The concept of Reflective Practice has been shown in other studies as a possible strategy to assist in recovery from traumatic experience. Whereas avoiding any type of coping or implementing any method of coping was shown to cause persistent trauma and not to build resiliency skills (Niiyama, et. al., 2009). Definition of Key Terms Specific terms related to the DNP project are trauma, secondary trauma, nurse-specific trauma, cope, resilient, trauma informed care, and reflection. Trauma is defined as “an injury to living tissue cause by an extrinsic agent; an emotional upset; a disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury” (Merriam-Webster, n.d.). Secondary trauma is defined in literature as “trauma experienced by a professional providing care to victims of trauma repeatedly” (Quitangon, 2019). Nurse specific trauma is defined as psychological trauma experienced by the nurse that relate directly to the role of the nurse (Foli, et. al., 2020). The definition of cope (coping) is “to deal with and attempt to overcome problems and difficulties” (Merriam-Webster, n.d.). Resilient (resiliency) is defined as “an ability to recover from or adjust easily to misfortune or change” (Merriam-Webster, n.d.). One of the multiple definitions of the term reflection is “a thought, idea, or opinion formed, or a remark made as a result of meditation” (Merriam-Webster, n. d.). Finally, the term trauma informed care is defined as “clinical interventions for trauma responses” (Substance Abuse and Mental Health Services Administration, 2014). Assumptions The initial assumption made in relation to the DNP project is that nurses will experience some type or types of nurse-specific trauma during their career. A second assumption made is 6 that nurses will experience Secondary Trauma specifically. A third assumption made is that nurses will embrace the opportunity of cultivating coping and resiliency methods. The final assumption made is the intervention of reflective practice will be supported by nursing leadership and hospital administration. Variables There are important variables to consider for implementation of the DNP project. One significant variable is the sample size of nurses to participate in this project along with any specific specialization they may have. Another variable is the type of educational techniques to be used to teach the nurses how to engage in reflective practice. A third variable is the type of tool to evaluate the effectiveness of utilizing reflective practice. Finally, because this DNP project will be conducted as research, IRB approval from both the university and hospital organization will need to be obtained. Schematic Design 7 The theory of reflective practice as a framework for reflection on nurse specific secondary trauma. Adapted from Theory of Reflective Practice, by G.M Galutira, 2018, International Journal of Nursing Science. Theoretical Framework Evaluation The Middle Range Theory of Nurses Psychological Trauma (Foli, 2019) is vital in the development of the theoretical framework. This theory identifies the main topic, Secondary Trauma, of which the DNP project will focus. Without the foundation of this theory, the framework would not be solid and able to be built upon. The Theory of Reflective Practice (Galutira, 2018) guides the methods and timing of reflection associated with the trauma. It also guides the DNP project to evaluate for both positive and negative outcomes that could occur because of implementing this theory. Both theories combine beautifully to create a specific approach that will enable further research into all the identified nurse-specific traumas. Conclusion Nurse specific trauma has been occurring almost as long as nursing has been a profession. Solid documentation of this exists as far back as World War II (Lucchesi, 2019). The purpose of this DNP project is to implement the method of reflective practice to assist with building coping and resiliency strategies for the nurse specific trauma, secondary trauma. By combining the theories of Nurse’s Psychological Trauma and Theory of Reflective practice, specific interventions and methods can be researched to determine which best assists nurses in developing coping and resiliency skills. These theoretical frameworks will allow for a foundation to be built to create therapeutic interventions and to further study additional nurse specific traumas in the future. Four decades have passed since the phenomena was first identified and it is now getting the attention it should (Figley, 2002). As world events continue to impact the 8 methods in which nursing care is delivered, the occurrence of nurse specific traumas will only increase. 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