Exposure to traumatic stress can have a life-altering negative impact on student nurses. Traumatic stress can challenge effective coping, emotional regulation, and the ability to focus, retain, and recall nursing concepts. According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2014), the “3 E” conceptualization of trauma are Event (single or cumulative), Experience (neglect, abuse, betrayal), and Effects (anxiety, loneliness, depression, feeling unsafe ) are manifested in various ways in people with exposure to trauma.
An individualized student-centered approach is crucial in understanding and adapting teaching pedagogy in nursing education to realize, recognize, respond, and resist re-traumatization (SAMHSA, 2014)in student nurses with a history of traumatic stress.
This article discusses the concept of trauma-informed pedagogy in nursing education and its significance in promoting equity and inclusion. Trauma-informed pedagogy suggests that past experiences can negatively impact health outcomes and learning (Garfin D. R. et al., 2018). As a result, educators must be able to identify signs of trauma and adapt their teaching methods to meet their students’ unique needs. It discusses the impact of trauma on nursing students’ physical and mental health functioning, and it then delves into implementing principles of trauma-informed pedagogy in the classroom.
Background/Significance
Trauma is defined as an event or set of circumstances that an individual experiences as physically or emotionally harmful or threatening, resulting in lasting adverse effects on their functioning and well-being (Bremner, J. D. 2006). College students, despite their excitement to succeed, often experience severe psychological distress, with 70% reporting such distress. Additionally, 35% of students were diagnosed with anxiety, and 29% had depression (American College Health Association, 2022).
Transgender and LGBTQIA students report higher levels of mental health issues than their straight counterparts. Microaggressions are also experienced by underrepresented students, creating a sense of unsafety on campus. Evidence suggests that Colleges should pivot to a learning space that promotes inclusion and equity. Only 40% of college students think colleges are doing enough to support mental health (Veneable, M.A., & Pietrucha, M. E., 2022).
The Universal Design for Learning ( UDL) recognizes that every student has different learning needs, and a one-size-fits-all approach is an ineffective instructional strategy. Similarly, implementing trauma-informed pedagogy principles within the nursing curriculum is a significant step toward meeting every student’s learning needs and experiences, promoting accessibility, equity, and inclusion in nursing education.
How Traumatic Stress Affects the Brain
Traumatic experiences can affect the brain’s development, structure, and function. It is critical to understand normal brain development to distinguish brain abnormalities. The areas of the brain responsible for stress responses are the amygdala, hippocampus, and pre-frontal cortex (Bremner, J. D., 2006). When an individual is exposed to traumatic stress, there is an increase in the level of cortisol and norepinephrine. Repeated exposure to stress increases the level of cortisol and norepinephrine and affects normal brain functioning and stress regulation, resulting in pathophysiological change(Bremner, J. D. 2006).
Students who are affected by traumatic stress may have difficulty learning concepts, focusing, and retaining information, resulting in course failures and higher attrition rates compared to their peers who have not experienced trauma. Traumatic experiences can cause anxiety and depression in some students. Past and current data suggest that trauma-informed care is critical for the promotion of equity in people with a history of trauma (Han et al., 2021).
Students’ sense of safety is disrupted, and the cumulative effects are difficulty adjusting to college experience, low grades, and high attrition rates. According to (Corello J., 2018), educators should adopt trauma-informed teaching and be compassionate and consistent in the learning environment. Despite the impact traumatic experience has on the brain, there is hope and possibility for students to be successful.
Implications for Nurse Educators
In the Four “Rs in the Trauma-informed approach to teaching student nurses(SMASHA, 2014), the nurse educator must convey empathy, possibilities, and hope to student nurses and focus on “what happened to you, instead of what is wrong with you’. Implementing trauma-informed principles is an issue of equity and inclusion and must be viewed through the lens of disability.
Realization
Research suggests that 66%-85% of youth report exposure to traumatic events by the time they enter college (Read et al., 2011). Additionally, approximately three-quarters of college students, 77 %, experienced moderate to severe psychological distress (ACHA, 2022). Understanding that traumatic experiences can affect the development, structure, and function of the brain, the nurse educator must acknowledge that trauma happened and provide a trusting teaching environment that emphasizes hope and transformation.
Realizing that trauma affects the student’s ability to function optimally, the nurse educator must stay involved in world events that may be traumatic to students: for instance, racism, disability, COVID-19, sexism, sexual harassment, and sexual orientation. Modeling emotional intelligence skills, self-reflection, and situational awareness, the nurse educator can convey trust and transparency when discussing and understanding sensitive topics in the classroom.
Recognize
The nursing process is a framework taught in nursing education to provide care for diverse populations. It begins with an assessment. Likewise, the nurse educator must be able to recognize signs of traumatic stress and respond with empathy, kindness, and understanding. Some signs and symptoms are difficulty focusing on a topic, lack of engagement, absenteeism, anxiety, low grades, and difficulty adjusting to the college environment.
It is essential to acknowledge that the traumatic event happened, and an evidence-based action plan is activated to promote healing and agency to enhance academic success. The nurse educator must be knowledgeable about topics or events that may trigger traumatic stress and develop a lesson plan or teaching strategies to avoid triggers—for instance, disparities in healthcare outcomes for minorities. Nurse educators must adopt several strategies to effectively support students’ learning experiences in teaching sensitive topics. To this end, the nurse educator should consider the value of establishing eye contact with students and facilitating opportunities for them to share their lived experiences. The nurse educator must also demonstrate a genuine interest in the student experience. By applying these strategies, nurse educators can foster an environment that supports students’ learning journey and promotes their well-being.
Respond
When a student goes through a traumatic experience, their sense of safety can be severely affected. As a nurse educator, it is essential to demonstrate emotional intelligence while conversing with such students regarding traumatic stress. Using the student’s name and giving them enough time to contemplate and respond is crucial. In addition, the nurse educator should offer their presence to show kindness and compassion, which can provide comfort and support for the student.
As a nurse faculty member, you can support your student’s academic journey by referring them to the Office of Accessibility and Disability. The office provides essential services to students with disabilities, ensuring they have the resources to succeed in their studies. Letting your students know you are available for office hours and phone calls is essential, as this can help them feel more comfortable and supported.
Creating a respectful and inclusive learning environment is crucial to the success of all students. You can do this by promoting a culture of civility and respect in your classroom and being mindful of your students’ diverse needs. If a student is experiencing anxiety or stress, consider extending assignment due dates to help alleviate their concerns.
Finally, it is essential to recognize that some students may have a history of trauma that could impact their ability to learn. To increase the accessibility and inclusion of these students, incorporate multiple teaching modalities that address the cognitive, psychomotor, and affective domains of learning. Doing so can help ensure that all your students can succeed.
Resist re-traumatization
In a nursing education culture that prioritizes diversity, equity, and inclusion, it is essential to recognize that some college students may have experienced trauma. By intentionally incorporating transformative, trauma-informed practices into nursing education, we can foster a sense of human dignity, promote academic growth, and help students thrive. To prevent re-traumatization, faculty and peers must have zero tolerance for discrimination against students. The learning environment must prioritize civility, human caring, compassion, and consistency (Corello, 2018) while avoiding punitive measures and implementing clear policies and procedures. Sensitive topics should be approached with empathy and understanding, and training modules focused on trauma and its effects can help create awareness and build a strong sense of community.
Conclusion
Integrating trauma-informed practices into nursing education requires comprehensive changes across multiple levels, from micro to macro systems. At the micro level, nurse faculty must demonstrate empathy, benevolence, courtesy, and honor towards individuals who have survived trauma. They must also remain watchful in recognizing, validating, and averting re-traumatization for student nurses who have experienced trauma. By nurturing a learning environment that fosters personal development and transformation, faculty and students can collaborate to establish a warm and accommodating community open to everyone.
References:
1. American College Health Association -National College Health. (2022). Assessment III: Undergraduate Student Reference Group Executive Summary Spring 2022. Silver Spring, MD: American College Health Association.
2. Bremer, J. D. (2006). Traumatic stress: effects on the brain. Dialogues in Clinical Neuroscience, 8(4), 445-61.
3. Carello, J. & Thompson, P. (Eds). (2021). Lessons from the pandemic: Trauma-informed approaches to college, crisis, change. Palgrave Macmillan.
4. Garfin, D. R., Thompson, R. R., & Holman, E. A. (2018). Acute stress and subsequent health outcomes: A systematic review. Journal of Psychosomatic Research, 112, 107-113. doi: 10.1016/j.jpsychores.2018.05.017
6. Han, H. R., Miller, H. N., Nkimbeng, M., Budhathoki, C., Mikhael, T., Rivers, E., Gray, J., Trimble, K., Chow, S., Wilson, P. (2021). Trauma-informed interventions: A systematic review. PLoS One, 16(6), e0253209. Doi: 10.1371/journal.pone.0253209
7. Kubala, J. (2020). Of Trauma and Triggers: Pedagogy and Affective Circulations in Feminist Formations, 32(2), 183-206.
8. Read, J. P., Wardell, J. D., Vermont, L. N., Colder, Ouimette, P., & White, J. (2012). Transition and change: Prospective effects of posttraumatic stress on smoking trajectories in the first year of college. Health Psychology, 32(7), 757-767.
9. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. (2014). HHS Publication No. (SMA) 14-4884. Substance Abuse and Mental Health Services Administration, Rockville, MD.
10. Veneable , M. A., & Pietrucha, M,E. (2022). 2022 College Mental Health Report, Best Colleges.
In the world of nursing, consistent rates of students graduating from nursing programs, becoming licensed, and successfully entering the workforce are critical to the long-term viability of the nursing profession and the healthcare system itself. As the true lifeblood of healthcare delivery, nurses are central to patient care, from long-term and public health to acute care and home health. In that regard, nursing education is a pipeline to the future.
Nursing School Capacity
In May 2023, the American Association of Colleges of Nursing (AACN) released data showing that student enrollment in entry-level baccalaureate nursing programs
decreased by 1.4% in 2022, the first decrease in 20 years. Overall, 844 colleges and universities offer a BSN education, and many turned away thousands of qualified candidates due to a lack of clinical training sites and faculty. In 2022, 66,261 candidates were rejected, and in 2021 applications by 76,140 candidates were turned down.
Alongside these disappointing numbers in the entry-level BSN category, the AACN identified other factors:
Enrollment in RN to BSN bridge programs has been declining over the last 4 years.
Master’s programs have seen a 9.4% decrease since 2021.
Nursing PhD program enrollment shrank 4.1% from 2021 to 2022.
DNP program enrollment is at a virtual standstill.
When it comes to nursing school capacity, there’s plenty of evidence that something isn’t right. This statement from an October 2021 article by National Public Radio says a great deal about one major hurdle: “One of the biggest bottlenecks in the system is long-standing: There are not enough people who teach nursing. Educators in the field must have advanced degrees yet typically earn about half that of a nurse working the hospital floor.”
Becker’s Hospital Review reported in August 2023 that the California Hospital Association and the Service Employees International Union (SEIU) have teamed up to introduce a bill that would hold community colleges accountable for reserving 15% of enrollment slots for healthcare workers looking to advance their education and move into higher-paying career tracks like nursing. Whether this bill can make it through Congress and become law is unknown.
The U.S. Department of Labor has issued $78 million in grants to expand nursing school enrollment in 17 states. The state of Maryland has awarded its nursing program grants to boost schools and address the long-standing and worrisome nursing shortage. New Mexico is also expanding its nursing school capacity through support for increased enrollment.
While legislation, grants, and expanding nursing school capacity are all valuable strategies to increase the nursing workforce, we can also keep more grassroots efforts in our sights.
In families from many different backgrounds, a multigenerational tradition of service in the nursing profession is often the norm. Aunts, mothers, fathers, siblings, and others can profoundly influence younger generations’ career choices. When the value of being a nurse is communicated from generation to generation, a familial line of nurses can extend over many decades as additional family members join the profession.
As nurses, speaking proudly of the profession and our work can generate interest in those considering their options. While twenty-first-century nursing and healthcare have enormous challenges, we can also tell the story of how nursing provides endless opportunities and flexibility. Of course, there is the potential to travel and see other parts of the country and see one’s education through to a terminal degree such as a PhD or DNP.
In communicating about the possibilities to be found in nursing, we can point out that, contrary to what the public and the media might think, not all nurses work in the hospital. There are expanding opportunities in the pharmaceutical, biotech, and medical device industries; public health; informatics; nurse entrepreneurship; medical writing; legal nurse consulting; nurse coaching; research; and many other fascinating areas. In the interest of our profession’s growth, we paint an expansive picture for those who think of nursing as solely hospital based.
Pipeline to the Future
Whether a new graduate nurse eventually becomes an operating room nurse, a biotech research nurse, or a self-employed legal nurse consultant, the nursing school remains the pipeline through which that individual must pass to realize their dream. No matter how one person’s professional journey unfolds, it all begins with admission to an accredited nursing program, successfully graduating and passing the NCLEX®, and then receiving a license to practice. The nursing school is the funnel for future nurses of every stripe and interest.
When nursing school capacity is hobbled, our profession and society suffer. Decreased graduation rates translate to a shrinking nursing workforce, staffing shortages, nurses working under stress, and the potential for compromised patient safety and outcomes. Burned-out nurses are more likely to leave the profession and less likely to encourage younger generations to pursue the same career path.
Addressing decreased nursing school capacity is paramount, and we can use our collective genius to find solutions, whether through grants, legislation, and public relations or the direct recruitment of faculty through the offer of increased salaries and improved work conditions.
We must use every available means to secure the flow of fresh talent through the pipeline to the future. Our society and the lives of those within it depend on the quality and quantity of the nursing workforce, and it’s our responsibility to see that the pipeline remains filled with the talented nurses of tomorrow.
In today’s climate, nursing is everywhere. It’s in the news and social media, but the coverage is rarely positive. Nursing has been America’s most trusted profession for years, but COVID-19 changed the perception of nursing.
No longer are nurses viewed as the safe harbor for patients who were battered by the winds and wrath of an industrial health care complex. Instead, nurses are publicly placed on trial for system errors and named in lawsuits for medical malpractice. What does the future of nursing look like in America? No one knows for certain, but I do know
who can reframe the perception of nursing, and that is the nurse educator.
Soul of Nursing
The nurse educator is truly the master of the soul of nursing. Still, they are rarely esteemed for the critical work accomplished. The nurse educator takes the raw material of an eager student and pours endless knowledge and skills to form the building blocks of a nurse. There is not a single nurse in existence who has not passed through the skilled hands of a nurse educator. The educator can genuinely alter the perception of a new nurse before the nurse even realizes they have been altered. The nurse educator can transfer tolerance and understanding through their formative teachings, prejudice, and judgment. The responsibility to develop the future of the entire profession rests on a select few, rarely acknowledged, who guard our profession with love and passion.
Passion
It is passion that drives the nurse educator. It surely is not the ability to earn a high income. According to the Bureau of Labor Statistics, the average nurse educator earns an annual income of $78,000. For a job that requires an advanced degree, any nurse educator could be better served with more lucrative uses of their degree, such as a nurse practitioner or joining an organization’s nursing leadership. It’s not the hours that drive the nurse educator. Is getting Christmas off a perk? Absolutely! Is waking up to 13 texts from a student who could not upload an assignment a benefit! Absolutely not. As a nurse educator, the breaks from classes are spent reworking material, developing new experiences, and continuing to grow professionally. It is truly a passion and a calling that drives the nurse educator.
Need for Nursing Faculty
Why should every nurse be aware of the need for nursing faculty? According to the American Association of Colleges of Nursing, a faculty vacancy rate of 8.8% nationwide has remained. This has resulted in a horrendous outcome of over 91,000 qualified applicants being turned away from nursing programs. Turning away applicants continues to exacerbate the nursing shortage. With the current projection from NCSBN of close to one-fifth of the nursing workforce looking to exit in the next five years, every applicant to a nursing school is a building block to the solution.
Know Your Influence
So why consider nursing education? The nurse educator is an artist. They take a piece of unformed clay and place pressure to mold and change the clay into a beautiful vase. With every student, educators leave a tiny part of themselves to transform a corner of the world. As a bedside nurse, I touch a few lives every shift. But if, as an educator, I have taught the floor of nurses, my reach is far greater than I will ever know. Knowing that your influence can affect the health care of a region, state, or nation is a pride and privilege few know. Nursing education is a beautiful profession that is far too often overlooked but should be dutifully considered.
The Office of Minority Health, a division of the U.S. Department of Health and Human Services, designates each July as Minority Mental Health Awareness Month. By calling attention to the specifics of mental health in minority communities, the awareness campaign helps spread information about the importance of good mental health practices, shares resources for finding help, and removes some of the stigma around seeking treatment for conditions including depression or anxiety.
As the COVID pandemic has retreated, many folks are left with lingering feelings of trauma, particularly in minority communities that were impacted more than others. Many people lost loved ones during the past few years and others are coping with the lingering health impacts of having had COVID or caring for those who did. The pandemic exposed glaring health disparities in which racial and ethnic minority patients had less access to high-quality health care, more severe illness, and higher numbers of severe COVID.
Beyond healthcare and within a society that has structural racism, the pandemic caused far-reaching impacts from a disease that upended employment, income, insurance coverage, childcare, transportation, and family structure. The long-term impacts of the trauma people experienced, and are still experiencing, is something that will influence minority mental health for years to come.
During Minority Mental Health Awareness Month, nurses can help spread information about the importance of good mental health by discussing it with patients. They can offer resources, talk about how mental health changes physical health, and normalize discussions around emotions and trauma.
Because nurses educate patients, they can call attention to symptoms that patients might associate with mental health struggles including
new or marked sadness or crying
changes in eating (too little or too much)
changes in sleep patterns (difficulty falling asleep or getting out of bed)
lack of interest in hobbies, relationships, work
thoughts of suicide
They can also verbalize symptoms that aren’t always recognized as symptoms of something like depression or anxiety including
anger and rage
increased substance use and abuse
new or increased compulsive actions (checking locks, food patterns)
Talking about minority mental health with nurses encourages patients to recognize their feelings, be attentive to changes, and understand that they aren’t alone. These efforts might not always seem significant, but nurses can keep in mind that their conversation about mental health might be the only time a patient discusses their concerns. Some minority communities have such a barrier to openly discussing mental health that it is a subject that is just never brought up.
When nurses identify symptoms, highlight resources, make connections for therapy or medication providers, and show support, patients feel seen and heard. Emphasizing that mental health is a physical condition and that effective treatment is available is a beacon of hope for people who are feeling like they aren’t sure what to do. Nurses can make a meaningful difference to patients with a caring conversation about minority mental health and some resources to get started.
With all that nurses do for our patients, it is only fitting that we do just as much for them, supporting nurses as they grow in their VA career.
Whether at the bedside of a Veteran or working in an outpatient clinic, our nurses deliver quality care and lead the way in innovating how we provide nursing care. Nurses also develop patient safety initiatives, conduct research to improve care delivery, and help guide the next generation of nurses.
Academic partnerships
VA and schools of nursing around the country offer academic affiliations. These collaborative efforts between VA facilities and the country’s finest nursing schools provide students with clinical experiences that specifically address the unique needs of Veteran population and prepare them to excel in careers at VA.
These partnerships offer nursing students a comprehensive and intensive four-year clinical training. The programs create a stronger, mutually beneficial relationship between nursing schools and VA facilities by giving students the opportunity to engage with faculty and ultimately provide better patient care as they put classroom concepts into practice.
By the end of the program, graduates are fully accustomed to the culture and mission at VA and ready to care for our Veterans.
Transition to practice
For over a decade, VA has promoted Registered Nurse Transition-to-Practice (RNTTP) residency programs to provide a transition from school to the more complex clinical environment for RNs with less than one year of experience.
The comprehensive 12-month curriculum explores the clinical, leadership and professional dimensions of nursing at VA. Post-graduate RNs perform the typical roles, duties, patient care activities and procedures that are carried out by nurses on our team.
Availability varies by location, so contact the nurse educator or nurse recruiter at a facility near you for more information.
Financial aid
VA offers eligible employees and students nursing scholarships to advance their education and skills training through the following programs:
The National Nursing Education Initiative (NNEI), a component of the Employee Incentive Scholarship Program, funds the pursuit of bachelor’s and advanced degrees for VA RNs.
The VA National Education for Employees Program (VANEEP) is offered to employees in a clinical program pursuing first-time licensure in a clinical occupation. Participants can earn their degree faster by attending school full time, with VA covering not only some education costs but also replacement salary while they are enrolled.
The VA Learning Opportunities Residency (VALOR) program provides an opportunity for outstanding college nursing students to develop clinical competencies at an approved VA Medical Center. VALOR is designed to increase participants’ clinical skills, clinical judgement and critical thinking while caring for our nation’s Veterans. This program provides opportunities for learning with a qualified RN preceptor. Students must have completed their junior year in an accredited baccalaureate nursing program. VALOR students are offered up to 800 hours of salary dollars.
Work at VA
Are you ready to help us heal and care for Veterans so they can thrive in life after military service? Apply for a job as a VA nurse.