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TRAUMA AND RESILIENCE COMPETENCIES FOR NURSING EDUCATIONTrauma and Resilience Competencies were developed by an Expert Panel in the summer of 2018 and validated by a Delphi Survey in the fall of 2018. This project was funded by a generous grant from the George Link Foundation.Reference: Wheeler, K. & Phillips, K. (2018). Trauma & Resilience Competencies for Nursing Education. Copyright TXu002126718; available from kwheeler@fairfield.eduEXPERT PANELAudrey Beauvais?DNP, MSN, MBA, RNAssociate Dean & Associate ProfessorMarion Peckham Egan School of Nursing and Health StudiesFairfield UniversityFairfield, ConnecticutTerry Becker-Fritz, MS, RN, PMHCNSConsultant & Trainer in EMDRVirginia Ann Wolbert Burgess, DNSc, APRN, FAANProfessorBoston College Connell School of NursingBoston, MassachusettsGenevieve Chandler, Ph.D., RNAssociate ProfessorCollege of NursingUniversity of MassachusettsAmherst, MassachusettsMarion Donohoe, DNP APRN CPNP-PCAssistant ProfessorDNP-Pediatric Primary Care Nurse Practitioner Concentration CoordinatorUniversity of Tennessee Health Science CenterCollege of NursingMemphis, TennesseeLaura Cox Dzurec, Ph.D., PMHCNS-BC, ANEF, FAANSenior ScholarBoston College Connell School of NursingBoston, MassachusettsLinda Grabbe, PhD, FNP-BC, PMHNP-BCClinical Assistant ProfessorNell Hodgson Woodruff School of NursingEmory UniversityAtlanta, Georgia Elizabeth Janssen MA, NPP, PMHCNS, BCInstitute for Contemporary PsychotherapyIntegrative Trauma Treatment Program?National Institute for the PsychotherapiesNew York City, New YorkCandice Knight, PhD, EdD, APN, PMHNP-BC, PMHCNS-BCClinical Associate Professor?Program Director, Psychiatric-Mental Health Nurse Practitioner ProgramNew York UniversityNew York City, New YorkJenna LoGiudice, Ph.D., CNM, RNAssistant ProfessorMidwifery DNP Track CoordinatorMarion Peckham Egan School of Nursing and Health StudiesFairfield UniversityFairfield, ConnecticutAllyson Matney?Neal, DNP, APRN, PMHNP-BC, PMHCCNS-BC, CPNPAssistant Professor-PMH ConcentrationDepartment of Health Promotion and Disease PreventionUTHSC College of NursingMemphis, Tennessee Mary D Moller, DNP, ARNP, PMHCNS-BC, CPRP, FAANAssociate ProfessorCoordinator, PMH-DNP ProgramPacific Lutheran University School of NursingTacoma, WashingtonKathryn E. Phillips, Ph.D., MA, MSN, ANP-BCAssistant ProfessorMarion Peckham Egan School of Nursing and Health StudiesFairfield UniversityFairfield, ConnecticutCarole A. Shea, PhD, RN, CNS, FAANAdjunct FacultyMarion Peckham Egan School of Nursing and Health StudiesFairfield UniversityFairfield, ConnecticutJoyce Shea, DNSc, APRN, PMHCNS-BCAssociate Dean for Graduate Studies and Associate ProfessorMarion Peckham Egan School of Nursing and Health StudiesFairfield UniversityFairfield, Connecticut*Kathleen Wheeler Ph.D., PMHNP-BC, APRN, FAANProfessorCoordinator PMHNP ProgramMarion Peckham Egan School of Nursing and Health StudiesFairfield UniversityFairfield, Connecticut*ChairSpecial thanks to:Danielle Conklin, DNP, NP-P, PMHNP, APRNAdjunct InstructorNYU Rory Meyers College of NursingNew York City, New YorkCristina Meehan, MSN, PMHNP, RNBehavioral Health DirectorLiberty Integrated Behavioral HealthNew Britain, ConnecticutVincent Williams DNP (c), BSN, RNMarion Peckham Egan School of Nursing and Health StudiesFairfield UniversityFairfield, ConnecticutPREAMBLEThe consequences of traumatic events have been identified as a high priority public health risk by numerous national and international organizations (Copeland, Shanahan, & HInesley, 2018; U.S. Department of Health & Human Services, 2003, World Health Organization, 2013). The effects of physical trauma (suicide, homicide, unintentional physical injury) have been estimated to result in $671 billion per year in health care costs and lost productivity in the United States; and is reported to be the #1 cause of death for ages 1-46 in the United States (National Trauma Institute, n.d.). This estimate does not include the long-term costs of childhood adverse experiences which result in an exponential increase in adult onset chronic medical diseases, mental health problems, and early mortality (Felitti & Anda, 2010). The majority of people across six continents have experienced at least one traumatic event (70%) and 30% of people reported four or more traumatic events (World Mental Health Survey Consortium, 2016). This survey is consistent with exposure to traumatic events reported in the United States (Center for Disease Control and Prevention, 2010). Traumatic event exposure using?DSM-5?criteria is high (89.7%), and exposure to multiple traumatic event types is the norm (Kilpatrick et al, 2013). In the past ten years, the increasing incidence of suicide, drug related deaths, domestic violence, mass and school shootings, terrorist attacks, natural disasters due to climate change, unending wars, reported rapes on campus, and referrals for child abuse and neglect attests to the increased prevalence of trauma-related incidences and consequently the adverse effects of trauma.Only approximately 8% of people develop posttraumatic stress disorder (PTSD) (APA, 2013) after a traumatic event. However, those who have suffered adverse life experiences or stressors score significantly higher on a trauma symptom scale than those who have suffered Criterion A events, such as natural disasters, terrorist attacks, rape, and combat trauma (Mol et al., 2005). PTSD symptoms in the absence of the full disorder, or subthreshold PTSD, can still result in significant functional impairments and a greater incidence of other psychiatric disorders such as major depression, social anxiety, alcohol and drug use (McLaughlin et al., 2015; Mota et al, 2016). The long-term deleterious sequelae of traumatic events and adverse experiences on health are well documented. These events can result in profound emotional, physical, cognitive and behavioral changes. An extensive literature reveals the devastating long-term consequences across the lifespan from common and widespread adverse events in childhood (Copeland, Shanahan, & Hinesley, 2018; Felitti and Anda, 2010). In addition, there is a growing recognition of the high incidence of posttraumatic stress disorder (PTSD) after medical illness and procedures such as intensive care hospitalization (John Hopkins Medicine, 2015) and illnesses such as coronary heart disease (Vaccarino et al. 2013), myocardial infarction, cancer and stroke (American Heart Association, 2015). These studies provide compelling rationale for the need for competent healthcare providers to provide sensitive, culturally competent care aimed toward the recovery from trauma of such events. As the largest group of health professionals, nurses are not immune to the deleterious adverse effects such as distress reactions, health risk behaviors, and psychiatric disorders that are associated with the consequences of trauma. In addition to the trauma everyone is exposed to, nurses are also exposed to vicarious trauma or compassion fatigue through caring for their patients’ injury, illness and death, medical procedures, errors, and complications. Research in mirror neurons provides evidence that our brains are hardwired to respond to other’s pain and emotions (Oberman & Ramachandran, 2007). That is, the reactions experienced by the patient are shared or mirrored by the empathic nurse. Nurses also are exposed to other occupational hazards such as workplace violence, bullying, mandatory overtime and shift work, and environmental hazards. Environmental hazards can include infectious exposures during nursing care, disaster and crisis situations, chemical and radiologic hazards. A 2017 survey of employed RNs in hospitals reported that 63% experience burnout (Kronos, 2017). These unique occupational hazards for nurses require self-care and resilience skills to mitigate the effects of vicarious trauma and adverse experiences. There is minimal attention paid to the pervasive impact of trauma on physical, cognitive, emotional, and spiritual health of nurses or their patients. Resilience skills to cope with adversity and trauma, and adapt to challenges are not typically included in nursing education. Since there are evidence-based treatments (EBT) for trauma, it is imperative that individuals who suffer from psychological trauma receive these treatments (EBT) to maximize the probability of positive treatment outcomes. The Institute of Medicine (2012) supports the need for trauma education and reports a lack of education in trauma assessment and training for healthcare professionals. Despite the burgeoning scientific literature on traumatic stress, most nurses have only a cursory knowledge of care for this vulnerable population. Nursing education has not kept pace with integrating evidence-based care for trauma into curricula. A recent survey of advanced practice psychiatric nurses found that that majority of respondents did not feel that their graduate program prepared them well to treat trauma (Maybey, Wheeler, Ronconi, & Smith, 2017). The lack of trauma assessment and training in graduate programs is not unique to nursing as this content is not included in the curricula of most other mental health professions either (Courtois & Gold, 2009; DePrince & Newman, 2011). This need prompted the American Psychological Association to develop Guidelines on Trauma Competencies for Education and Training in 2015 (American Psychological Association, 2015). The prevalence of trauma and the profound physical and emotional sequelae of untreated trauma provide compelling rationale for the development of competencies for trauma and resilience for nursing education. Competencies are essential for undergraduate, graduate, psychiatric advanced practice, and other specialty roles in nursing. The following competencies in trauma and resilience for nursing education were developed in the summer of 2018 by an Expert Panel of 16 nurses who were invited because of their expertise in trauma and resilience from academia, practice and research. Following the completion of these competencies by the Expert Panel, 11 additional nursing experts in trauma were invited to validate these competencies. After 2 rounds of an eDelphi survey, the Delphi participants reached a high level of agreement on the 88 competencies. Agreement levels of 80% and above were reached on 87/88 (98.86%) competencies for relevance, 80/88 (90.91%) competencies for specificity, and 82/88 (93.18%) competencies for comprehensiveness. For competencies that scored less than 80% in agreement in any category (relevance, specificity, or comprehensiveness), reviewer comments were used to improve the competency.? These competencies serve as a guideline of minimal expectations for three levels of nursing education: 1) undergraduate, 2) graduate, and 3) psychiatric nurse practitioner programs. The proposed competencies reflect essential knowledge, skills and behaviors foundational for each level of nursing education. Each level builds on the undergraduate competencies and the psychiatric nurse practitioner level builds further on the graduate level nursing competencies. Other nursing specialties are invited to develop their own using the undergraduate and/or graduate competencies as foundational to their role/specialty. Eight domains are articulated for each level of nursing education with one supraordinate competency for each domain along with sub-competencies delineated for that domain. Each competency is identified as the knowledge, skill or attitude needed to achieve proficiency in a given area.DEFINITIONSTrauma is the experience of an event, series of events, or set of circumstances that is perceived by an individual as physically or emotionally harmful or life-threatening with adverse effects on the individual’s functioning and cognitive, physical, social, emotional, or spiritual well-being (adapted from SAMSHA, 2018).Resilience refers to the ability of an individual, family, or community to cope with adversity and trauma, and adapt to challenges through individual physical, emotional, and spiritual attributes and access to cultural and social resources (adapted from SAMSHA, 2018)Trauma Informed Care (TIC): TIC is a holistic approach to health care that fosters understanding and thoughtful responses to individuals who have experienced trauma in their lives, thus supporting their resilience and self-efficacy (Hooper, Bassuk, & Oliver, 2009).DOMAIN DEFINITIONSSelf-Resilience is the individual’s ability to cope with adversity and trauma, and adapt to challenges through physical, emotional, and spiritual resources and access to cultural and social resources. Resilience (see above definition)Knowledge refers to recognizing the epidemiology of traumatic experiences and those who are at-risk; in addition to the neurobiological, developmental, social, cultural, and psychological factors related to trauma. This domain includes the ability to evaluate the literature commensurate with level of education.?Assessment skills focus on identifying and understanding the person’s past and current adverse experiences, psychosocial and cultural history, strengths and resources, and symptoms as well as the long-term sequelae of trauma in order to develop a plan of care.Diagnosis is based on critical thinking and identifies the problem and/or disorder by a systematic analysis of the history and symptoms and is appropriate for the nurse’s level of education and specialty using either nursing diagnosis or psychiatric diagnosis.Interventions for trauma-related problems and resilience are supported by the literature and research and can include psychosocial, behavioral, pharmacological, and somatic treatments depending on the nurse’s level of education and specialty.Evaluation of the effects of interventions/treatment assesses the interaction of the person and the environment for indicators of improving or worsening.Ethics/Culture/Policy includes professional values and issues relevant to the context and care of trauma survivors.ReferencesAmerican Heart Association. (2015, June 29). PTSD, traumatic experiences may raise heart attack, stroke risk in women. Science Daily. Retrieved from Psychological Association. (2015). Guidelines on trauma competencies for education and training. Retrieved from , C., Bromet, E., Karam, E., Kessler, R., McLaughlin, K., Ruscio, A….Koenen, K. (2016). The epidemiology of traumatic event exposure worldwide: Results from the World Mental Health Survey Consortium. Psychological Medicine, 46(2), 327-343. doi: 10.1017/S003329175001981Centers for Disease Control and Prevention. (2010). Adverse childhood experiences reported by adults—Five states 2009. Morbidity and Mortality Weekly Report, 59(49), 1609-1613.Copeland, W., Shanahan, L., & Hinesley, J. (2018) Association of Childhood Trauma exposure with adult psychiatric disorders and functional outcomes., JAMA Netw Open.?2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493Courtois, C. A., & Gold, S. N. (2009). The need for inclusion of psychological trauma in the professional curriculum: A call to action. Psychological Trauma: Theory, Research, Practice, and Policy, 1, 3-23. doi:10.1037/ a0015224DePrince, A., & Newman, E. (2011). Special issue editorial: The art and science of trauma-focused training and education. Psychological Trauma: Theory, Research, Practice, and Policy, 3, 213-214. doi:10.1037/ a0024640Felitti, V. J., & Anda, R. F. (2010). The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: Implication for healthcare. In R. A. Lanius, E. Vermetten, & C. Pain (2010), The impact of early life trauma on health and disease: The hidden epidemic (pp. 77-87). New York, NY: Cambridge University Hooper, Bassuk, & Oliver (2009). Shelter from the storm: Trauma-informed care in homeless settings. The Open Health Services and Policy Journal, 2, 131-151.Institute of Medicine. (2012). Treatment for posttraumatic stress disorder in military and veterans. Washington, DC: Author.Johns Hopkins Medicine. (2015). PTSD common in ICU survivors. Retrieved form , D.K., Resnick, H.S., Milanak, M.E., Miller, M.W., Keyes, K.M., & Friedman, M.J. (2014). ?National Estimates of Exposure to Traumatic Events and PTSD Prevalence Using?DSM-IV?and?DSM-5?Criteria, Journal of Traumatic Stress, Oct; 26(5): 537–547.?doi:??[ HYPERLINK "" \t "pmc_ext" 10.1002/jts.21848]Kronos (2017). Employment engagement in nursing. Retrieved from , L. J., Wheeler, K., Ronconi, J. M., & Smith, J. A. (2017). What do psychiatric nurses know about trauma treatment? A national survey of psychiatric advanced practicenurses. Retrieved from , K. A., Koenen, K. C., Friedman, M. J., Ruscio,A. M., Karam, E. G., Shahly, V., . . . Kessler, R. C. (2015). Subthreshold posttraumatic stress disorder in the World Health Organization World Mental Health Surveys. Biological Psychiatry, 77(4), 375-384. doi:10.1016/j.biopsych.2014.03.028Mol, S., Arntz, A., Metsemakers, J., Dinant, G.-J., Vilters-Van Montfort, P., & Knottnerus, A. (2005). Symptoms of post-traumatic stress disorder after non-traumatic events: Events from an open population study. British Journal of Psychiatry, 186, 494-499.Mota, N.P., Tsai, J., Sareen, Jitender, Marx, B.P., Wisco, B.E., Harpaz-Rotem, L, Southwick, S.M., Krystal, J.H., & Pietrzak, R.H., (2016) High burden of subthreshold DSM5 post-traumatic stress disorder in U.S. military veterans., World Psychiatry, Trauma Institute (n.d.). Trauma statistics & facts. Retrieved July 6, 2018 from, L.M. & Ramachandran, V.S. (2007). The stimulating social mind: The role of the mirror neuron system and simulation in the social and communicative deficits of autism spectrum disorder, Psychological Bulletin, 133(2), 310-327.? HYPERLINK "" \t "_blank" (n.d) Trauma and Violence. Retrieved November 17, 2018 from . Department of Health and Human Services. (2003). President’s New Freedom Commission: Achieving the promise: Transforming mental health in America. Final report. Rockville, MD: Author.Vaccarino, V., Goldberg, J., Rooks, C., Shah, A. J., Veledar, E., Faber, T., . . . Bremner, J. D. (2013). Post-traumatic stress disorder and incidence of coronary heart disease: A twinstudy. Journal of the American College of Cardiology, 62, 970-978.World Health Organization. (2013). Guidelines for the management of conditions specifically related to stress. Retrieved from who.int/mental_health/emergencies/stress_guidelines/en/ASSUMPTIONSMost people have experienced trauma.Trauma can include any situation where the person perceives overwhelming helplessness.Traumatic events affect the victim as well as the helpers (vicarious trauma).There is both explicit and implicit bias in acknowledging trauma. Implicit bias prevents the person from recognizing the impact that trauma has on one’s own as well as other’s well-being and physical health.Trauma can include big “T” traumas such as natural disasters, war, and accidents; as well as small “t” traumas such as invasive dental or medical procedures, routine surgeries, workplace and personal bullying; and cumulative trauma such as poverty, racism domestic violence, multiple deployments, and transgenerational trauma.Many chronic health conditions are a result of adverse childhood experiences.Nurses at every level of practice encounter those who have suffered trauma.To provide compassionate care, nurses need self-awareness and knowledge of both resilience and petencies provide knowledge, attitudes or skills needed to address the care of oneself and those who have been impacted by trauma.DELPHI PANELSusie Adams, PhD, RN, PMHNP, FAANP, FAANProfessor of NursingFaculty Scholar for Community Engaged Behavioral HealthVanderbilt University School of NursingNashville, TNKathleen R Delaney, PhD, PMHNP, FAANRush College of NursingProfessor?Program DirectorPsychiatric Mental Health Nurse Practitioner ProgramChicago, Il.Heather Frye, APRN, PMHNP-BC, MSNPennsylvania College of Health SciencesLancaster, PASusan Glodstein, DNP, RN, PMHNP, BC, PMHCNS,BCClinical Assistant Professor?Stony Brook University?Stony Brook, NYCynthia Handrup, DNP,?APN, PMHCNS-BCClinical Assistant Professor?College of Nursing, HSSUniversity of Illinois at ChicagoChicago, IlSara Jones, PhD, APRN, PMHNP-BCAssistant Professor & Specialty CoordinatorPsychiatric Mental Health NursingUniversity of Arkansas for Medical SciencesLittle Rock, AkBarbara J Limandri, PhD, APRN, BCPortland Dialectical Behavior Therapy InstitutePortland Oregon Pamela Lusk, DNP, RN, FAANPClinical Associate ProfessorThe Ohio State University College of NursingColumbus, OhioDonna Rolin, PhD, APRN,?PMHCNS-BC, PMHNP-BCClinical Associate ProfessorDirector of Psychiatric Mental Health?Nurse Practitioner?Graduate ProgramUniversity of Texas at?Austin, School of NursingKathy Steele, MN, CSConsultant & AuthorAtlanta, GeorgiaDonna M Zucker PhD , RN, FAANProfessorUniversity of Massachusetts AmherstTRAUMA & RESILIENCE COMPETENCIES FOR UNDERGRADUATE NURSING EDUCATIONThese competencies are foundational to Trauma and Resilience Competencies for Graduate Nursing and Specialty Competencies.DomainCompetency K/S/A*ContentSelf Resilience1) Demonstrate participation in and maintenance of self-care, managing stress, and supportive relationships with others.K, SSelf-care, work/life balance, bullying, workplace Incivility, lateral violence, vicarious trauma1a) Assess one’s own stress, resilience & strengths on an ongoing basis. SSelf-care log, reflective exercises, Impact of Event Scale, Life Change Units, Compassion Fatigue, burnout, vicarious trauma1b) Examine one’s own attitudes, beliefs, values, bias, and expectations about individuals with a history of trauma.ASelf awareness, diversity and equity awareness, reflective exercises and journal1c) Identify reactions that the nurse may experience while working with an individual with a history of trauma.K, AMindfulness, reflective journalingResilience2) Incorporate a strength- based approach in working with patients, families, and communities affected by trauma.K, AComponents of resilience,somatic mindfulness,resilience narrativesABC’s (active coping, building strength, cognitive awareness and social support)2a) Demonstrate the ability to teach traumatized patients skills to enhance resilience.SCommunity Resilience Model (CRM)Stress Appraisal2b) Describe the role of resilience in patient’s ability to manage traumatic experiences.KCRM2c) Incorporate prevention, early intervention, rehabilitation, and recovery/resilience-oriented approaches to care.K, SRecovery and resilience-oriented approaches to care2d) Recognize how the Social Determinants of Health facilitate resilience.KTrauma-informed systems of careKnowledge3) Explain the effects of adverse childhood experiences on risk related morbidity and mortality.KNeurobiological changes that occur as a result of trauma, HPA dysregulation3a) Summarize the basic pathophysiology of trauma responses.KEpigenetics, toxic stress, HPA dysregulation3b) Describe clinical manifestation of acute and chronic trauma for individuals and families.KPhysical & psychological signs and symptoms of trauma3c) Recognize challenging behaviors such as (substance use, violence, suicide and/or other self-destructive behaviors) as often attempts to cope with the sequelae of past trauma experiences.K, SSubstance use (eg. alcohol, marijuana, opioids, ect), suicide risk and protective factors, anger and aggression management3d) Describe the traumatic sequelae resulting from experiences of abuse, bullying, neglect, military trauma, accidental events, medical procedures and illness, suicide attempts, torture, natural disasters etc.KStress and coping, Crisis managementAssessment4) Assess patients by asking if they have experienced adverse experiences e.g. neglect, substance use in a caregiver, physical or sexual abuse, and how that has affected their health.K, SStigma, self-stigmapatient narrative4a) Identify developmental, cultural, family, and gender issues related to trauma.STheories of development, cultural competence, Biopsychosocial assessment4b) Identify and use assessment tools for trauma and resilience.K, Se.g. Life Events Checklist, Connor-Davidson Resilience Scale (CD-RISC)4c) Recognize the strengths and vulnerabilities of clients across the lifespan affected by trauma and stress.KStrength-based approach to care4d) Identify behavioral, emotional, cognitive, and physical symptoms resulting from abuse, neglect, military trauma, accidental events, medical procedures, medical illness, suicide attempts, natural disasters, torture etc.K, SMood swings, depression, flashbacks, anxiety, pain, repetitive behaviors, acting out, nightmaresDiagnosis5) Identify nursing diagnoses for those who have experienced trauma. K, Se.g. Powerlessness, Hopelessness,Ineffective copingInterventions6) Apply best practices in providing holistic care to individuals and families with a history of trauma.A, SIndividual and community resources, barriers to access resources, trauma-informed care6a) Collaborate with the interprofessional team, patient, family members, and/or significant others to develop a trauma-informed plan of care.K, SABCs-DEFs (distress, emotional support, and family needs),person-centered care, shared decision making, recovery-oriented practice6b) Provide a therapeutic environment in which the patient feels emotionally safe and supported.STherapeutic communication, relationship & milieu6c) Deliver efficient, safe, and compassionate care to patients and families of diverse ethnic and cultural backgrounds with a history of trauma.S, ASuicide assessment, Cultural competence6d) Implement a trauma informed teaching plan that recognizes strengths, builds resilience and promotes hopefulness.SIdentifying triggers,coping skills (eg. grounding practice, self soothing techniques)6e) Demonstrate the ability to tolerate trauma victims’ intense affect.SSelf-care practices6f) Promote the safety of patients in emotionally dysregulated states.SSafe care environment, patient rights6g) Provide age-appropriate trauma-informed care in a culturally and ethnically sensitive manner.K, S, ATrauma in global contextacculturation process,refugees, race-based trauma, oppression, culturally resonant practicesEvaluation7) Involve the client with a history of trauma in evaluating progress toward measurable individualized goals.K, SSMART objectives7a) Evaluate the impact of trauma on the family system.SIntergenerational/transgenerational traumaEthics/Culture/Policy8) Advocate for the patient/family /community with a history of trauma.A#Me too Movementorganizational/institutional culture,institutional betrayal, sociocultural trauma, gun violence, gender, differences in the experience of trauma. LBGTQ community trauma8a) Identify the legal, ethical, cultural, spiritual, and social issues involved in the care of patients with a history of trauma.K, S, ASeclusion and restraints, trauma informed care, HIPPAsafety and security, informed consent8b) Describe state and national health care policies related to the care of patients with a history of trauma.KMandated reporters, least restrictive practice, ACE, state policies,relationship between health care providers and law enforcement, APNA Scope & Standards of Practice for Psychiatric-Mental Health Nursing8c) Demonstrate ethical principles and decision-making relevant for trauma survivors.S, AEthical principles (e.g. beneficence, autonomy), Code of Ethics for Nurses, State nurse practice acts*Knowledge/Skills/AttitudeFaculty ResourcesChandler, G., Roberts, S., and Chiodo, L. (2015) Resilience Intervention for Young adults with adverse childhood experiences. Journal of the American Psychiatric Nurses Association, 21(6), 406-416. Chandler, G, Kalmakis, K. & Murtha, T. (2018). Screening adults with substance abuse disorder for adverse childhood experiences. Journal of Addictions Nursing, 29(3), 172-178.Delaney, K. & Ferguson, J. (2014). Peplau and the brain: Why Interpersonal Neuroscience provides a useful language for the relationship process, 4(8), 145-152. doi:? Felitti, V. J. & Anda, R.F. (2010) The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: Implications for healthcare, Chapter 8 in The impact of earl life trauma on health and disease, Ed. R.A. Lanius, E. Vermetten & C. Pain. N.Y.: Cambridge.Hampkins, S. (2014). Art of narrative psychiatry. New York: Oxford University Press. Kalmakis, K., & Chandler, G. (2014) Health consequences of adverse childhood experiences: a systematic review. Journal of the American Association of Nurse Practitioners. 27 (8), 458-465. doi: 10.1002-2327-6924.12215 Kalmakis, K., Shafer, M, Chandler, G, Aponte, E. & Roberts, S. (2018). Screening for childhood adversity among adult primary care patients. Journal of the American Association of Nurse Practitioners 30, 193-200. doi:#10.1097/JXX.0000000000000033.Leitch, L. PACES McCallister, M. (2007). Solution focused nursing. New York: Palgrave MacMillan.Miller-Karas, E. (2015). Building Resilience to Trauma, N.Y.: Routledge.Waite, R., Gerrity, P., & Arango, R. (2010) Assessment for and response to adverse childhood experiences. Journal of Psychological Nursing and Mental Health Service, 48(12), 51-61.Wheeler, K. (2010). A relationship-based model for psychiatric nursing practice, Perspectives in Psychiatric Care 47(1), 151-159, doi: 10.1111/j.1744-6163.2010.00285.TRAUMA & RESILIENCE COMPETENCIES FOR GRADUATE NURSING EDUCATIONThe Undergraduate Trauma & Resilience Competencies for Nursing Education are foundational to the following Graduate Nursing Competencies.DomainCompetencyK/S/A*ContentSelf Resilience1) Develop and utilize a repertoire of resilience skills for oneself.K, SSelf care practices, mindfulness, reflective journaling, breathing exercises, thought stopping, physical exercise, sleep, nutrition, work/life balance, family and professional support systems, secondary traumatic stress, vicarious traumatization, self care log1a) Identify one’s own past traumatic events, vicarious trauma, and triggers through self-reflection. K, AJournal,Impact of Event ScaleLife Change UnitsCompassion FatigueBurnoutResilience2) Facilitate the development of resilience skills for individuals, families and communities.SCommunity Resilience Model (CRM)stress appraisal, self regulation, patient, families and community resourcesKnowledge3) Describe the physical and psychological complexities of trauma, including the impact of trauma on developmental milestones.KNeurobiological changes that occur as a result of trauma, HPA dysregulation, principles of trauma and informed care. TIC. Van der Kolk’s. CDC/ACES information on violence prevention. neurobiology. Dan Siegel, effective communication skills regarding trauma, epigenetics, toxic stress. 3a) Describe how cumulative trauma such as racism, poverty, and gender violence dysregulates the nervous system.Kinter-generational family violence and abuse, developmental trauma, attachment theory, mind-body science3b) Describe the prevalence, range, and presentation of trauma symptoms, including dissociative symptoms.KDissociative disorders, Trauma and stressor related disorders (DSM 5)3c) Examine chronic disease through a trauma informed lens.KACE, physical & psychological signs and symptoms of traumaSubstance use (eg. Alcohol, marijuana, opioids, etc.)Assessment4) Conduct a trauma-informed history and assessment on every patient.K, SACE; PCL-C; TSI; IES; strengths and difficulties, and SBIRT4a) Assess patient’s resilience through history and by administering evidence-based tools.K, SCD-RISC, BRS, RSA, SPF4b) Assess family dynamics affected by trauma.SStigma, self-stigma, patient narrative, intergenerational violence, transmission of trauma and violence Diagnosis5) Diagnose unresolved trauma and co-occurring mental health problems as appropriate to nursing role. K, SDevelopmental traumatology, complex trauma, single and cumulative trauma, DSM-5Interventions6) Provide trauma informed developmentally appropriate education regarding the connection between symptoms and trauma history. K, SBasic stress reduction, mindfulness practices, distress tolerance, CRM, triggers, physical and emotional intervention for wellness, universal precautions. 6a) Provide medication management with a consideration for trauma symptoms as appropriate to nursing role.A, SABCs-DEFs (distress emotional support, and family needs), person-centered care, shared decision making, recovery-oriented practice.6b) Share community- based trauma informed resources with patients as appropriate.SIndividual and community resources, barriers to access resources6c) Offer strategies to prevent and manage iatrogenic medical and vicarious traumaSIdentifying triggers. coping skills eg. grounding practice, self soothing techniques6d) Stabilize and refer for trauma psychotherapy as needed.S, ATherapeutic communication6e) Engage in disciplinary and interdisciplinary collaboration regarding traumatized individuals, families, and communities.K, SEvaluation7) Measure patient change in trauma symptoms and resilience utilizing established tools.K, SSMART objectivesBDI, STAI, HDR, WHO well-being measure, PHQ-9, CDRISC, etc.Ethics/Culture/Policy8) Educate others on how to change systems of care to a trauma informed model.K, STherapeutic relationship, therapeutic milieu, restraint-free8a) Appraise cultural norms related to physical, spiritual, and emotional manifestations of trauma.K, AMandated reporters, least restrictive practice. ACE, state policies,relationship between health care providers and law enforcement 8b) Identify the forensic/legal implications of documentation relating to trauma.K, AIntergenerational/transgenerational trauma#Me too movementorganizational/institutional culture,institutional betrayal, sociocultural trauma, gun violence, gender differences in the experience of trauma, LBGTQ community trauma, rape trauma kits8c) Follow local, state, and federal guidelines related to mandatory reporting, involuntary commitment, and mental health laws appropriate to the advanced nursing practitioner.K, AStandards of practice, nursing ethics policy, dynamics of HI/SI, Rights, social justice, social determinants of mental health, LGBTQ, refugee and immigrant populations, medically underserved areas/HPSAs, shared governance, ACEs, bullying, mandatory reporting, involuntary commitment, and mental health laws, seclusion and restraints,trauma informed care, HIPPA,safety and security, informed consent*Knowledge/Skills/AttitudeFaculty ResourcesAhern, N. R., Ark, P., & Byers, J. (2008). Resilience and coping strategies in adolescents. Pediatric Nursing, 20(10), 32-36. Anda, R. F., Fleisher, V. I., Felitti, V. J., Edwards, V. J., Whitfield, C. L., Dube, S. R., & Williamson, D. F. (2004). Childhood abuse, household dysfunction, and indicators of impaired adult worker performance. The Permanente Journal, 8(1), 30-38. Ayers, S. (2017). Birth trauma and post-traumatic stress disorder: The importance of risk and resiience. Journal of Reproductive & Infant Psychology, 35(5), 427-430. HYPERLINK "" \t "10.1080/02646838.2017.1386874" \o "" , M. S., Loomis, J. (2017). Enhancing care models to capture trauma. Journal of Psychosocial Nursing and Mental Health Services, 55(4), 29-36. Coughlin, M. (2014). Transformative nursing in the NICU: Trauma-informed age-appropriate care. New York, NY: Springer Publishing Company, LLC. Feczer, D., & Bjorklund, P. (2009). Forever changed: Posttraumatic stress disorder in female military veterans, A case report. Perspectives in Psychiatric Care, 45(4), 278-291. Finkelhor, D. (2018, Screening for adverse childhood experiences (ACEs): Cautions and suggestions, Child Abuse & Neglect, 85, 174-179.Hornor, G. (2018). Resilience. Journal of Pediatric Healthcare, 31(3), 384-390. HYPERLINK "" \t "10.1016/j.pedhc.2016.09.005" \o "" , K. A., Chandler, G. E. (2015). Health consequences of adverse childhood experiences: A systematic review. Journal of the American Association of Nurse Practitioners, 27, 457-465. Kalmakis, K. A., Chandler, G. E., Roberts, S. J., & Leung, K. (2017). Nurse practitioner screening for childhood adversity among adult primary care patients: A mixed-method study. Journal of the American Association of Nurse Practitioners, 29, 35-45.Kalmakis, K. A., Shafer, M. B., Chandler, G. E., Aponte, E. V., & Roberts, S. J. (2018). Screening for childhood adversity among adult primary care patients. Journal of the American Association of Nurse Practitioners, 30(4), 193-200. Miller-Karas, E. (2015). Building Resilience to Trauma, N.Y.: Routledge.Molitierno, T. (2018). Trauma-informed care as part of nursing school curricula. Journal of Psychosocial Nursing and Mental Health Services, 56(5), 5-6. Raja, S., Hoersch, M., Rajagopalan, C. F., & Chang, P. (2014). Treating patients with traumatic life experiences: Providing trauma-informed care. JADA, 143(3), 238-245. doi: 10.14219/jada.2013.30Scudder, L., Sullivan, K., & Copeland-Linder, N. (2008). Adolescent resilience: Lessons for primary care. Journal for Nurse Practitioners, 4(7), 535-543. Stillerman, A. (2018). Childhood adversity & lifelong health: From research to action, The Journal of Family Practice, 67 (11), 690-699.Ungar, M. (2006). Nurturing hidden resilience in at-risk youth in different cultures. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 15(2), 53-58. Wen, F. K., Miller-Cribbs, J. E., Coon, K. A., Jelley, M. J., & Foulks-Rodriguez, K. A. (2017). A simulation and video-based training program to address adverse childhood experiences. The International Journal of Psychiatry in Medicine, 52(3), 255-264. Williamson, L. F., & Kautz, D. D. (2018). Trauma-informed care is the best clinical practice in rehabilitation nursing. Rehabilitation Nursing, 43(2), 73-80. doi: 10.1002/rnj.311Wright, E. M., Matthai, M. T., & Warren, N. (2017). Methods for alleviating stress and increasing resilience in the midwifery community: A Scoping review of the literature. Journal of Midwifery & Women’s Health, 62(6), 737-745. HYPERLINK "" \t "10.1111/jmwh.12651" \o "" & RESILIENCE COMPETENCIES FOR PMHNP NURSING EDUCATIONThe Undergraduate and Graduate Competencies for Trauma & Resilience for Nursing Education are foundational for the following PMHNP Competencies.DomainCompetency K/S/A*ContentSelf Resilience1) Maintain a high degree of self-awareness through engaging in self-reflective practices by seeking ongoing consultation, supervision and/or individual psychotherapy.K, S, AVicarious trauma,exercise,mindfulness,breath work,internal resources,spirituality1a) Understand how one’s own history, values, and vulnerabilities impact trauma treatment.K, ATransference countertransference;traumatic re-enactment1b) Implement ongoing self-care plan to enhance one’s own resilience.K, SSelf-inventory and measurement tools. (Tactics for Coping with Stress Inventory)Resilience2) Teach patients self-regulation skills such as Dialectical Behavior Therapy, Grounding, Somatic Skills, and Mindfulness to enhance resilience. K, SCommunity Resilience Model (CRM); CBT, ACT, DBT, Compassion Cultivation Training, Foundations of Wellbeing Program (Hanson)2a) Examine the individual, family, and community barriers to resilience.SInternal and external resources. (Maslow, Social Determinants of Health, Self-Efficacy, Vulnerability)Knowledge3) Demonstrate knowledge of the current literature on trauma and critically evaluate research on the science and theory of trauma treatment.KProcess/outcome research;Polyvagal theory, Attachment theory, Adaptive Information Processing 3a) Synthesize advanced neurobiology of stress and trauma response to inform effective and accurate clinical interventions. KTrauma Resilience Model; mind-body connection; 3b) Analyze the effects of early attachment dysfunction on the development of complex trauma.KAttachment theory, (Siegel) chronic-relational trauma (Howell) 3c) Analyze the role of memory in symptom presentation and treatment targets.KImplicit/explicit memory;types of memory and trauma3d) Explain the importance of a phase-oriented approach in trauma therapy. KTheory of Structural Dissociation,stabilization, processing, integration3e) Recognize the role of trans-generational trauma on health.KRachel Yehuda, epigenetics3f) Articulate professional roles and responsibilities in disaster response plans including providing psychological first aid and crisis intervention to victims of disaster and first responders.Leadership, Crisis intervention, psychological first aidAssessment4) Demonstrate the ability to tailor a comprehensive trauma assessment based on patient’s history, attachment style, dissociation, avoidance, triggers, current resources, and skills.SACE: DES (Adolescent and Adult); PCL. TSI; IES, DDIS, MDI, CAPS, CDC, TESI-C, LEC-5, Trauma timeline, primary, secondary, tertiary dissociation, window of tolerance4a) Develop a trans-generational trauma genogram.K, SEpigenetics, trauma and resilience genogram4b) Order appropriate laboratory studies to screen for medical complications due to trauma.K, SCBC, CMP, TSH, T3, T4, CRP, IgG, IgA, Cortisol, HbA1C, HCG, HIV, Folate, B12, Vit D, 4c) Order diagnostic tests to screen for neurocognitive dysfunction related to trauma.K, SBrain: CT, MRI4d) Recognize signs and symptoms of dissociation.K, SInappropriate behavior, slow response, eyes fixed, body still, attention drifting off, falling asleep inappropriately; recognize differences between splitting (idealization/devaluation) and splitting (self-states/multiplicity)Diagnosis5) Diagnose trauma related disorders and co-occurring psychiatric disorders.KDSM 55a) Develop differential diagnoses in trauma and stressor related disordersKDSM 5; i.e. DID/DDNOS and BPD w/imitative DID or Factitious Disorder or iatrogenic DID5b) Recognize the effect of trauma in the development of other psychiatric disorders and mental health problems.K, SACE; Behavioral, somatic, cognitive, emotional indices such as hearing voices, re-enactments, pain, flashbacks, etc.Interventions6) Conduct evidence-based psychotherapy for trauma and co-occurring conditions. K, SEMDR, CPT, TF-CBT, SE (somatic experiencing) sensorimotor psychotherapy, SI (somatic intervention), psychodynamic.6a) Identify and manage relational paradigms of dependence and avoidance (e.g. pull to rescue and caretake, reject, collude with, and/or violate boundaries) that are activated between the nurse and the trauma victim.K, SBoundaries, informed consent, confidentiality, role overlap, termination6b) Apply developmental models in working with traumatized children.K, SErikson, family systems, attachment theory, polyvagal theory, theory of structural dissociation6c) Track signs of arousal/hypoarousal and implement advanced stabilization techniques.K, SGrounding, body-awareness, progressive relaxation, meditation, visualization.6d) Prescribe medication to target trauma-related and comorbid symptoms.K, Ssertraline, paroxetine, prazosin6e) Demonstrate the ability to modulate pace of trauma treatment based on patient response and assess for indicators of improvement or worsening of symptoms.K, SPhases of trauma treatment6f) Provide consultation to health care providers and patients following potentially traumatic medical illness and procedures, and other traumatic events.SSupervision, consultation,6g) Apply treatment modalities specific to the type of trauma.K, SDebriefing; behavioral techniques, stabilization, processingEvaluation7) Evaluate treatment progress and attainment of patient’s identified goals.SChanges in rating scale scores (PTGI, LES, patient satisfaction. narrative report).Ethics/Culture/Policy8) Engage in political advocacy to effect change for vulnerable populations who are victims of trauma.SState Nurse Practice Act, Scope and Standards of Nursing,APNA, ISPN, ANA, ISTSS, ISSTD, Local, State, Federal Policy related to trauma care. 8a) Provide expertise to advance policy for traumatized populations.SMandated reporters, least restrictive practice, ACE, state policies,relationship between health care providers and law enforcement, APNA Scope & Standards of Practice for Psychiatric-Mental Health Nursing8b) Implement health care system delivery change toward trauma informed care.K, SPhases of change for TIC, components if TIC (SAMSHA)*Knowledge/Skills/AttitudeFaculty ResourcesAdler-Tapia, R. (2012). Child Psychotherapy: Integrating Developmental Theory Into Clinical Practice. N.Y.: Springer Pub. Co.American Psychiatric Association (2013). DSM5: Diagnostic and statistical manual of mental disorders (5th ed., Text Revision). Washington, DC: passion Cultivation Training, Stanford Medicine The Center for Compassion and Altruism Research and Education, Retrieved from Fischer, J. (2017). Healing the fragmented selves of trauma survivors: Overcoming internal self-alienation, N.Y.: Routledge.Grabbe, L. & Miller-Karas, E. (2018). The Trauma Resiliency Model: A “bottoms-up” intervention for trauma psychotherapy. Journal of the American Psychiatric Nurses Association, Vol. 24(1) 76–84. DttOpsI://1d0o.i.1o1rg7/71/01.1017873/19007381397073415717345313 Hari, J. (2018). Uncovering the real causes of depression-and the unexpected solutions. N.Y.: Bloomsbury Pub.Hanson, R. Foundations of Wellbeing Program. Retrieved from , J. (1997). Trauma & recovery. N.Y.: Perseus Books.Howell, E. (2011). Understanding and treating dissociation identity disorder: A relational approach. N.Y.: Routledge.Miller-Karas, E. (2015). Building resilience to trauma, N.Y.: Routledge.National Centre of Excellence for Complex Trauma (2018). The truth of memory & the memory of truth: Different types of memory and the significance for trauma, Blue Knot Foundation.Porges, S. (2004) Neuroception: A subconsciour system for detecting threats and safety, Zero to Three, 19-24, Permissions@Shapiro, F. (2018). Eye Movement Desensitization and Reprocessing (EMDR) Therapy, 3rd edition, N.Y.: Guilford Press.Steele, K., Boon, S., van der Hart, O. (2017). Treating trauma-related dissociation: A practical integrative approach. N.Y.: W.W. Norton & Co.Steele, K, van der Hart, O., & Nijenhuis, E. (2005). Phase-oriented Treatment of Structural Dissociation in Complex Traumatization: Overcoming Trauma-related Phobias, Journal of Trauma & Dissociation, vol. 6 (3). 11-53. Stien, P. & Kendall, J. (2004). Psychological Trauma and the Developing Brain. Binghampton, N.Y.: The Hawthorn Press.Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse. 2nd edition. N.Y.: Springer Pub. ................
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