MSN Course Insight: The Three "E’s" of Trauma Every Nurse Practitioner Should Know
In your nursing career, you’re almost certain to encounter patients who have experienced trauma. This is doubly true if you’re a psych nurse. But what should you do if you have a patient who appears to be dealing with the effects of trauma?
According to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), before you can properly treat patients who’ve experienced trauma, you need to know how to identify those patients. Fortunately, SAMHSA has a method for making such identifications. Known as The Three “E’s” of Trauma, which appears in SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach,1 the identification method is used by psychologists, mental health counselors, psych RNs, and other healthcare providers, such as physicians and nurse practitioners. In fact, The Three “E’s” is considered the go-to way to define and identify trauma and is routinely studied, including in Walden University’s Master of Science in Nursing (MSN) degree course, Psychotherapy With Individuals.
As taken directly from SAMHSA’s guidelines, The Three “E’s” are:
Events and circumstances may include the actual or extreme threat of physical or psychological harm (i.e., natural disasters, violence, etc.) or severe, life-threatening neglect for a child that imperils healthy development. These events and circumstances may occur as a single occurrence or repeatedly over time. This element of SAMHSA’s concept of trauma is represented in the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which requires all conditions classified as “trauma and stressor-related disorders” to include exposure to a traumatic or stressful event as a diagnostic criterion.
The individual’s experience of these events or circumstances helps to determine whether it is a traumatic event. A particular event may be experienced as traumatic for one individual and not for another (e.g., a child removed from an abusive home experiences this differently than their sibling; one refugee may experience fleeing one’s country differently from another refugee; one military veteran may experience deployment to a war zone as traumatic while another veteran is not similarly affected). How the individual labels, assigns meaning to, and is disrupted physically and psychologically by an event will contribute to whether or not it is experienced as traumatic. Traumatic events by their very nature set up a power differential where one entity (whether an individual, an event, or a force of nature) has power over another. They elicit a profound question of “why me?” The individual’s experience of these events or circumstances is shaped in the context of this powerlessness and questioning. Feelings of humiliation, guilt, shame, betrayal, or silencing often shape the experience of the event. When a person experiences physical or sexual abuse, it is often accompanied by a sense of humiliation, which can lead the person to feel as though they are bad or dirty, leading to a sense of self blame, shame and guilt. In cases of war or natural disasters, those who survived the traumatic event may blame themselves for surviving when others did not. Abuse by a trusted caregiver frequently gives rise to feelings of betrayal, shattering a person’s trust and leaving them feeling alone. Often, abuse of children and domestic violence are accompanied by threats that lead to silencing and fear of reaching out for help.
How the event is experienced may be linked to a range of factors including the individual’s cultural beliefs (e.g., the subjugation of women and the experience of domestic violence), availability of social supports (e.g., whether isolated or embedded in a supportive family or community structure), or to the developmental stage of the individual (i.e., an individual may understand and experience events differently at age five, fifteen, or fifty).
The long-lasting adverse effects of the event are a critical component of trauma. These adverse effects may occur immediately or may have a delayed onset. The duration of the effects can be short to long term. In some situations, the individual may not recognize the connection between the traumatic events and the effects. Examples of adverse effects include an individual’s inability to cope with the normal stresses and strains of daily living; to trust and benefit from relationships; to manage cognitive processes, such as memory, attention, thinking; to regulate behavior; or to control the expression of emotions. In addition to these more visible effects, there may be an altering of one’s neurobiological make-up and ongoing health and well-being. Advances in neuroscience and an increased understanding of the interaction of neurobiological and environmental factors have documented the effects of such threatening events. Traumatic effects, which may range from hyper-vigilance or a constant state of arousal, to numbing or avoidance, can eventually wear a person down, physically, mentally, and emotionally. Survivors of trauma have also highlighted the impact of these events on spiritual beliefs and the capacity to make meaning of these experiences.
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