A Middle-Range Theory of Nurses’ Psychological Trauma

The current ANS featured article is titled “A Middle-Range Theory of Nurses’ Psychological Trauma” by
Karen J. Foli, PhD, RN, FAAN. We are offering continuing education credit for this article, so you can also access the CE test and apply for credit! And, you can download this article at no cost while it is featured! Here is a message from Dr. Foli about her work:

Many years ago, I became a registered nurse. Despite the decades that have passed, I still recall my active clinical days and, most often, the satisfaction that came from either direct patient care or supervising others in rendering care. I practiced in psychiatric nursing, long-term care (direct care provider, nurse manager, and consultant), hospital-based rehabilitation, and as a clinical instructor. But there are also distinct memories that were born from traumatic experiences as a nurse, ones that I believe are specific and essential to being a nurse. Some examples of what I remember…

• My visceral reaction to knowing the added workload from a peer who called off sick and wondering how I would get “it” all done. (Insufficient resource trauma – personnel)
• Being completely unprepared as a baby was delivered in the hallway of an operating room suite while the mother awaited an unnecessary C-section. I can feel the newborn’s soft head as I frantically tried to suction her nose. (Insufficient resource trauma – knowledge).
• Being verbally abused by patients, especially an older adult, Agnes, a patient confined to a wheelchair because of advanced rheumatoid arthritis. (Workplace violence)
• Grieving from the passing of a patient with advanced metastatic breast cancer, Carol, who had resided on my long-term care unit for months. The tears that suddenly appeared and that I couldn’t seem to control as I walked down the hallway outside her room. (Secondary traumatic stress)
• Witnessing the toll of patient suffering that medical intervention caused and contributed to patient suffering. One of my patients was a Vietnam veteran and had received electroconvulsive therapy for major depression; suddenly, he couldn’t remember my name. (System-induced trauma)
• Recalling a medication error I made and, then another one, on the rehab unit where I worked because I was so rattled and distracted about whether I had harmed the patient. (Second-victim trauma)
• Training in the operating room by a nurse who expressed impatience at my slow uptake of information and wondering if I would ever be competent as a nurse (Historical trauma)

Above I have described six of the seven nurse-specific traumas that I present in my middle-range theory, which are described in detail in my article. The seventh is nurse-specific trauma from disasters, experienced by so many nurses today due to the pandemic: deciding who receives what treatment and being exposed to and endangered by the virus as frontline workers. Although I have offered personal examples, I believe these traumas are universal phenomenon in the practice of nursing.

This paper expands on my theory as outlined in my book, The Influence of Psychological Trauma in Nursing (Foli & Thompson, 2019). As a nursologist and active researcher, I uncovered the concept of “insufficient resource trauma” after the book was published in data I had collected (see Foli et al., 2020). Nurses related the lack of time, personnel, and knowledge prevented them from carrying out their moral responsibilities as professional nurses.

I will close with two additional points that also directs us toward praxis: some traumas in nursing practice are avoidable and others are not. Secondary trauma, for example, may be unavoidable as we connect with patients in their most vulnerable moments. Insufficient resource trauma, I assert, is avoidable, which brings me to my second point. While resiliency in nurses should be encouraged and is a good thing, the environment provided to nurses has to be committed to allowing nurses to become resilient. In a chronically, insufficiently, resourced environment, nurses will struggle to become and maintain resiliency. Nursing care isn’t provided in a vacuum; the organizational context must be considered.

About a month ago, I was asked to present my theory to senior, public health nursing students in post-clinical debriefing sessions. It was an honor to listen to their narratives and hear them speak about what had happened to them. Even with this focus to my work, I was amazed at the traumatic events these young adults had witnessed and endured. I could see them trying to make sense of it; some students were vocal, one sobbed, and some seem paralyzed. Their primary clinical instructor was masterful and demonstrated a safe, compassionate space for them. She followed up with several to ensure they were all right. The experience was a gift to me, albeit bittersweet, in validating my work and understanding the responsibility of how fragile nurses are as we recall past traumas. Although nurse-specific traumas have surged with the COVID-19 pandemic, these traumas are old acquaintances.

References

Foli, K. J., Reddick, B., Zhang, L., & Krcelich, K. (2020). Nurses’ psychological trauma: “They leave me lying awake at night.” Archives of Psychiatric Nursing, 34(3), 86-95.  http://doi.org/10.1016/j.apnu.2020.04.011

Foli, K. J. & Thompson, J. R. (2019). The influence of psychological trauma in nursing. Sigma Theta Tau International Publishing.