Middle Range Theory of Nurses’ Psychological Trauma

Contributor: Karen J. Foli
September 3, 2019

Author – Karen J. Foli, PhD, RN, FAAN

First published – 2019

Middle Range Theory of Nurses’ Psychological Trauma

Major Concepts

Types of Nurses’ Psychological Traumas:

  • vicarious/secondary trauma
  • historical trauma
  • workplace violence
  • system/medically induced trauma
  • insufficient resource trauma
  • second-victim trauma
  • trauma from disasters

Psychological traumas:

  • Humankind psychological trauma (acute, chronic, complex, developmental, and neglect)
  • Nurse-specific psychological trauma
  • Nurse-patient-specific psychological trauma

Factors affecting how trauma is processed w/ neurobiological changes: Genetic/biological, familial, psychological, cultural, spiritual, and environmental facets

The impact of trauma: Event, experience, effects

Avoidable and unavoidable traumas

  • Individual-level (humankind)
  • Professional-level (nursing practice)
  • Organizational/system-level (healthcare facilities)

Allostatic load: chronic exposure to repeated stress with resulting neural and neuroendocrine responses

Mitigators and Buffers (examples):

  • Individual resiliency
  • Posttraumatic growth
  • Trauma-informed care (nurse and patient)
  • System/organizational recognition and praxis

Negative outcomes related to psychological trauma (examples)

  • Staff turnover
  • Leave nursing
  • Mental health issues (e.g., depression, anxiety, posttraumatic stress disorder, secondary traumatic stress, and substance use
Theoretical Statements

Statement One:
The traumas may be nurse-focused (i.e., nurse-specific) or patient-focused (i.e., nurse-patient specific), which may overlap. For example, when a medical error occurs, there may be second-victim trauma to the nurse and medically-induced trauma to the patient.  These psychological forces are differentiated from the traumas facing humankind, such as acute, chronic, complex, and developmental traumas.

Statement Two:
Each individual perceives trauma in a unique way because the events, experiences, and the effects of the traumatic event(s) are exclusive to the person. Nurses’ genetic/biological, familial, psychological, cultural, spiritual, and environmental facets influence how traumatic events are processed.

Statement Three:
Select nurse-specific traumas are threaded into the work of the nurse and may be unavoidable at the individual level. These include vicarious/secondary trauma and patients’ medically-induced traumas. Other traumas, including workplace violence and insufficient resource trauma, may be mitigated or prevented by the environments produced by systems and organizations. System forces create environments that increase or decrease the risk for nurse-specific traumas.

Statement Four:
Nurse-specific traumas stimulate neurobiological changes in the nurse and if not lessened, may create an allostatic load, leading to negative outcomes. Nurses’ decreased physical and mental health (e.g., depression, anxiety, and substance use), unsafe patient care lacking in quality, and leaving organizations and the profession are examples of negative outcomes.

Statement Five:
Resiliency and posttraumatic growth act as buffers and outcomes to nurse-specific psychological traumas. Positive and negative individual outcomes are possible, and both may simultaneously be present.

Statement Six:
Trauma-informed self-care may lessen the impact of individual nurse-specific traumas. Similarly, trauma-informed patient care may lessen the impact of nurse-patient-specific traumas. System and organizational strategies designed to provide safe working conditions and sufficient resources, which add to individual resources and praxis, may reduce the impact of nurse-specific psychological traumas.

Primary Source(s)

Foli, K. J., & Thompson, J. R. (2019). The influence of psychological trauma in nursing. Indianapolis, Indiana: Sigma.  2019 Book of the Year – awarded first place in the Nursing Education/Continuing Education/Professional Development category and first place in the Psychiatric and Mental Health Nursing category.

Foli, K. J. (2019). Nurses’ trauma: “They leave me lying awake at night.” E-poster. American Academy of Nurses 2019: Transforming Health, Driving Policy Conference, Washington, DC, October 24-26, 2019

McEwen, B. S. (2005). Stressed or stressed out: what is the difference?. Journal of Psychiatry & Neuroscience : JPN, 30(5), 315–318.

Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). SAMHSA’s concept of trauma and guidance for a trauma-informed approach. HHS Publication No. (SMA) 14-4884. Rockville, MD: Author.

Karen J. Foli ( 1959 – )

Dr. Foli is a fellow in the American Academy of Nursing (AAN) in recognition for her work with adoption and kinship families. Her research is bound together by the theme of care rendered through the lens of psychological trauma. With this thread, she has received funding from the National Institute of Food and Agriculture (trauma-informed parenting for kinship parents), the National Council of State Boards of Nursing: Center for Regulatory Excellence (relationships between trauma and substance use in nurses), and private foundations (exploring parental postadoption depression). Dr. Foli’s work has uncovered adoptive parents’ trajectories of depressive symptoms prior to and after placement of a child. As a nurse theorist, Dr. Foli conceptualized and disseminated a middle-range theory of parental postadoption depression, a theory now being used by other nurse researchers.

She is author or coauthor of five, well-received, health-related books. One of these, Nursing Care of Adoption and Kinship Families: A Clinical Guide for Advanced Practice Nurses, received the American Psychiatric Nurses Association (APNA) Award for Media in 2018. Her most recent book, The Influence of Psychological Trauma in Nursing, co-authored by John R. Thompson, MD (Sigma, 2019), is intended to build resiliency and post-traumatic growth in student and new nurses who face considerable firsthand and secondary trauma.

Dr. Foli is also the recipient of numerous research and teaching awards, including the Charles B. Murphy Outstanding Undergraduate Teaching Award from Purdue University, which is the highest award bestowed for undergraduate teaching at the university. For her work as an educator, Dr. Foli was inducted into the Purdue University Book of Great Teachers in 2018. She also received the Sigma Theta Tau Honorary Society of Nursing, Delta Omicron Chapter Award for Outstanding Mentoring in 2017.

Currently, Dr. Foli is an Associate Professor and the Director of the PhD Program at Purdue University, School of Nursing, West Lafayette, Indiana. She received her nursing degrees from Indiana State University and Indiana University School of Nursing, Indianapolis, and her PhD in Communications Research from the University of Illinois, Urbana/Champaign.