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ACEs Implications for Nurses, Nursing Education, and Nursing Practice

      Nurses, as the largest health profession, are ubiquitous. They practice everywhere—in hospitals, patient and family homes, churches, prisons, homeless shelters, long-term care facilities, ambulatory care settings, community health centers, schools, camps, prisons, and concert halls—most everywhere people are found. Nurses provide care across the continuum from preventive to end of life. Nurses provide care for people who are well, people who are dying, and people with any and all acute and chronic illnesses. Nurses care for individuals, families, communities, and populations through their direct care and advocacy roles. Thus, to prevent adverse childhood experiences (ACEs) and to reduce their negative effects, we must engage nurses as they “are already on the front lines in the battle against the negative effects of toxic stress.”
      • Kasef Z.
      Exposure to toxic stress in childhood linked to risky behavior and adult disease.
      If we are to engage nurses in the battle against the toxic stress associated with ACEs in patients and clients, it is essential to understand the scope of the problem among nurses, raise their understanding about how ACEs impact them, and assure they have the knowledge, skills, and attitudes (KSAs) to join the battle and lead the war to prevent and mitigate the impact of ACEs.
      Nurses are not exempt from having ACEs and suffering the consequences. Although there is little information about the prevalence of ACEs among nurses, we can assume that rates of ACEs are at least comparable to those in the general population. Some studies suggest that ACEs may be more common among nurses and other health care professionals than among the general population.
      • Li Y.
      • Cao F.
      • Liu F.
      Nursing students' post-traumatic growth, emotional intelligence and psychological resilience.
      • Reyome N.D.
      • Ward K.S.
      Self-reported history of childhood maltreatment and codependency in undergraduate nursing students.
      • Maunder R.G.
      • Peladeau N.
      • Savage D.
      • et al.
      The relevance of childhood adversity among health care workers and its relationship to adult life events, distress and impairment.
      Nurses (and other health care providers) who have experienced ACEs may, like their patients, experience physical, social, emotional, and behavioral sequelae. Nurses suffering from such health problems are less likely to be able to perform as effectively as their colleagues who have not experienced ACEs. Research suggests that nursing work, given its often stressful nature, exacerbates the stress of ACEs and that ACEs may negatively impact performance in the work setting.
      To fully participate in prevention and mitigation of adverse childhood events, nurses must play a major role with individuals, organizations, and communities as well as in the public policy arena to address the negative health and social outcomes associated with ACEs. The nurse's ability to be present in patient interactions and connect with them to form trusting, therapeutic relationships may be diminished. Without this trust, patients and families are less likely to disclose experiences that affect their health and well-being. This double jeopardy—nurses with ACEs caring for people with ACEs—makes it important for all nurses, especially those with ACEs and their teachers, colleagues, and supervisors—to learn about, assess, and intervene to support nurses so affected. When the nurse suffers the negative consequences of ACEs, decreased productivity, loss of time at work, and less than optimal performance are possible.
      To fulfill their professional role in health promotion for persons with ACEs, nurses must become aware of their exposure to ACEs and the potential impact of them on their health, well-being, and professional practice.
      • Healy D.
      • McSharry P.
      Promoting self awareness in undergraduate nursing students in relation to their health status and personal behaviours.
      This is the first step toward a healthier life and enhanced resiliency, and it should begin in basic nursing education programs and continue in graduate and continuing education. Nurse educators should study the prevalence of ACEs among nursing students to understand the prevalence in general and its occurrence among specific student groups to target self-awareness and interventions. Awareness of the prevalence of ACEs among students and practicing nurses should lead to the design of interventions targeted for this group and could help mitigate the negative individual and societal impact of ACEs on nurses. Faculty and employers should encourage self-assessment of their students and nurses and provide stress reduction programs.
      Although we do not know the extent of KSA deficits related to ACEs, the literature suggests that neither nursing nor continuing education has given a great deal of attention to this phenomenon.
      • Hornor G.
      Childhood trauma exposure and toxic stress: what the PNP needs to know.
      Nursing education and continuing education programs should include ACEs content in the curriculum to prepare nurses for ACEs awareness among their patients, as is being done with other health risks like falls, AIDS, and substance abuse. In addition, educators and employers should engage with researchers to identify and assess best practices in preventing and mitigating the impact of ACEs on children and adults. Interprofessional research that assesses providers' KSAs about ACEs would be helpful to identify areas for education and support to include in preprofessional and professional education.
      Nurses, in collaboration with patients and colleagues from other professions, should work to create care settings that support screening, anticipatory guidance, and thoughtful discussions of the elements of trauma to destigmatize the experience and support patients. Positive work environments can provide a safe place for both nurses and patients to discuss their stressors and receive support. The nurse's advocacy role should extend to the local, state, and national levels by supporting policies to prevent the adverse events that so profoundly affect the individual and the community. All nurses, but especially those practicing in community-based settings, can help raise awareness of ACEs and introduce public campaigns to reduce violence and traumatic events in the community. Working with police, churches, businesses, and others, the nurse can be instrumental in changing the culture of the community. Multiple efforts by multiple people in education, practice, and the community can raise awareness and start a movement to a less stressful society with fewer occurrences of adverse events in the home and community.

      Acknowledgment

      Financial disclosure: Publication of this article was supported by the Promoting Early and Lifelong Health: From the Challenge of Adverse Childhood Experiences (ACEs) to the Promise of Resilience and Achieving Child Wellbeing project, a partnership between the Child and Adolescent Health Measurement Initiative (CAHMI) and Academy-Health, with support from the Robert Wood Johnson Foundation (#72512).

      References

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        Nursing students' post-traumatic growth, emotional intelligence and psychological resilience.
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