Introduction

.. . highlights, TIC is an approach that has been considered extremely important for providing effective nursing care in mental health.

Exploratory research with a mixed methods design by Hall et al. (2016), we can determine providing trauma informed care in nursing is considered extremely important to avoid re-traumatising a patient during their care in hospital. Hall et al. (2016) focussed on

Patient history and whanau context:

Sara a twenty-five-year-old New Zealand European female who is currently thirty-four weeks pregnant, well known to the mental health services. Her admission to inpatient ward was three months ago, following strong suicidal ideations to end her life, in context of feeling low about her unplanned pregnancy and an uncertainty about whether she wants to be pregnant or not. Sara has a diagnosis of borderline personality disorder, has a history of periods of extreme emotional dysregulation, history of suicide attempts and stockpiling her medications. At the age of twelve, she was placed in foster care after experiencing emotional and physical abuse from her father, who struggled with substance dependence. During her time at foster homes, Sara lost all faith in child protective services due to her social workers not believing her about being sexually abused her by her foster parent. She later got diagnosed post-traumatic stress disorder. Sara’s early life experiences around trauma includes emotional abuse during her childhood, moving from foster home to foster home, moving schools, witnessing domestic violence.  Sara has a high history of substance use since the age of fourteen, these experiences were intensified by substance use in adulthood, socio economic hardship, contributing to symptoms of depression, suicide attempts and confusion around her pregnancy.

Despite these hardships, Sara remained connected to her best friend and flat. Sara currently lives with her flatmate, Lana, who is her main support and provided a sense of stability. Lana had noticed a recent drop in Sara’s mood, along with her pregnancy, neglecting herself, substance abuse, withdrawing from activities of daily living, social isolation and was able to recognise these as Sara’s early warning signs. Lana contacted services after discovering Sara stockpiled her medication in preparation for an overdose to end her life. Sara was placed under the Mental Health Act because she declined to be admitted into the hospital for additional treatment and assessment, became agitated and attempted to leave to end her life. She was required a restraint to come into hospital. Sara resented Lana for putting her in the hospital, which strained their relationship.

Trauma History and Manifestation:

The term trauma informed care starts with looking at an individual’s experiences and their family’s experiences before blaming what appears to be wrong  (Te Pou, 2024)

Sara’s trauma history is deeply linked with her current mental health presentation, as Smith & Pollak 2020 found chronic and intense stress in early life, also known as early child adversity (ACEs), childhood trauma, or early life stress, such as mistreatment, abandonment and poverty affecting a child’s growing outcomes. ACEs is known to have long term effects on behaviour, mental development and controlling her emotions, which have been observed in Sara’s ability to trust others, maintaining relationships and her frequent outburst of unstable emotions leading to suicide attempt.  Sara’s trauma manifests in several ways.

Present a person you have worked with in your clinical practice and provide an overview of their history and broader whānau context. Explore the persons history of trauma using the evidence and literature as it relates to their current mental health presentation. This should include consideration of how their history of trauma is currently manifesting and how it might impact their social, physical, spiritual, psychological and relational health. Consider the implications for the therapeutic nursing relationship.

Critically analyse the service response to the persons trauma history, including the nurse’s role in providing trauma-informed care

Demonstrates an understanding of the relevance of early life adversity and trauma in relation to the persons current presentation.

Considers the social, environmental, and cultural context of the person and whānau life experiences

Critically analyses the therapeutic nursing relationship and examines the service and nurses’ role in providing a trauma informed response.

To adapt the assignment for **inpatient nursing** in **specialist mental health services**, you’ll need to focus specifically on the context of working within a **specialized mental health unit**, such as an inpatient psychiatric ward or a crisis intervention unit.

The principles of **trauma-informed care** and **culturally safe practices** will still be central to your analysis, but now you’ll frame it within the unique environment of inpatient mental health services. Below is a modified breakdown of the assignment with the inpatient context in mind.

Introduction (300-400 words) **

Introduce the Person: **

Briefly introduce the patient you worked with Provide details such as their age, presenting mental health issues, and why they were admitted to the inpatient facility.

Example: “The individual I worked with during my clinical placement was a 28-year-old man who had been admitted to the inpatient psychiatric unit following a suicide attempt and severe depressive episodes, with underlying complex trauma issues.”

Purpose of the Assignment: **   Outline that the paper will critically analyze the patient’s trauma history, its impact on their mental health, and how this history influences their interactions and experience within the **inpatient setting**. You will also discuss the role of inpatient nursing in providing **trauma-informed care**.

 **Overview of Structure: **

Provide an overview of the structure, such as the exploration of trauma, its impact on the patient’s health, the implications for the **therapeutic nursing relationship**, and a critical analysis of the **service response** in the inpatient environment.

Overview of the Person’s History and Broader Whānau Context (600-700 words)

Personal History and Background in the Inpatient Context: **  Detail the person’s background, including any traumatic events they may have experienced, especially within the context of their *admission to inpatient care**. Discuss how these events may have led to hospitalization and how their **mental health presentation** is linked to trauma.

Example: “The individual’s trauma history includes severe emotional abuse during childhood and witnessing domestic violence. These experiences were exacerbated by substance abuse in adulthood, which contributed to his current depressive symptoms and suicide attempt that led to his inpatient admission.”

Sara a twenty-five-year-old New Zealand European female, currently thirty-four weeks pregnant, well known to the mental health services. Her admission to inpatient ward was three months ago, following strong suicidal ideations to end her life, in context of feeling low about her unplanned pregnancy and an uncertainty about whether she wants to be pregnant or not. Sara has a diagnosis of borderline personality disorder (BPD), post-traumatic stress disorder (PTSD), has a history of periods of extreme emotional dysregulation, history of suicide attempts and stockpiling her medications. At the age of twelve, she was placed in foster care after experiencing emotional and physical abuse from her father, who struggled with substance dependence. During her time at foster homes, Sara lost all faith in child protective services due to her social workers not believing her about being sexually abused her by her foster parent. She later got diagnosed post-traumatic stress disorder.

Whānau Context and Cultural Factors: Describe how the individual’s **family dynamics** and **cultural background** have shaped their mental health and how these factors influence their response to inpatient care

Sara grew up in a fragmented family dynamic, with an absent mother and abusive father, moving between foster homes. Experiencing such trauma of being perpetrated at a young age and having no one believe her, made it difficult for Sara to navigate a hospital setting, struggling with forming a trusting relationship with nurses, interacting with members of Multidisciplinary team to feel safe or open.

Sara unable to cooperate, discuss how she is feeling leading to becoming dysregulated and aggressive. Sara’s early life experiences around trauma includes emotional abuse during her childhood, moving from foster home to foster home, moving schools, witnessing domestic violence.  Sara has a high history of substance use since the age of fourteen, these experiences were intensified by substance use in adulthood, socio economic hardship, contributing to symptoms of depression, suicide attempts and confusion around her pregnancy.

An example social factor would be an absence of secure relationships during her young years. Liming et al. (2021), highlights the outward effects, showing children like Sara who has experienced trauma known as ACE’s by being moved foster to foster home were more inclined to face instability manifesting in unsafe behaviours and other health challenges. Additionally, showing how an unpredictable home has long term effects on child’s development and emotional survival tools as they grow older.

Innamorati et al. (2025) explains an adult’s mood can be influenced by barriers they have gone through as a young child, like insecure attachment. Making it hard for this adult to process, comprehend and recognise their internal feelings and reactions.

Alternatively, Dye, 2018 study shows the internal changes, biological and neurological impacts of abuse and abandonment. Functional disruptions to the brain affect memory, making it difficult process information presenting as a challenge, affecting trauma patients like Sara’s ability to act and think effectively. Both studies collectively highlight a relationship growing up in an unstable environment and how the surroundings can lead to have lasting effects on the neurological alterations. This can involve Sara’s ability to regulate her external responses and reframing from negative thoughts, affecting her internal mental responses. This may lead to facing challenges in future in building trust, regulating emotions, self-esteem issues.

Literature Support:**   Draw from literature to explain the importance of understanding the **family and cultural context** in inpatient mental health care, especially when considering how **trauma impacts mental health**.

Exploring the Person’s History of Trauma (700-800 words);

Detailed Trauma History and Mental Health Impact:**   In an inpatient setting, trauma history may manifest differently due to the **intense environment**. Focus on how the patient’s trauma history led to the **need for inpatient care**, and describe how they presented during their hospitalization (e.g., extreme emotional distress, suicidal thoughts, flashbacks).Example: “The trauma history significantly impacted his ability to regulate emotions, which led to a suicide attempt and acute symptoms of **depression**, **anxiety**, and **dissociation**, necessitating hospitalization.”

(Stuart, 2013) highlights an early sign for inpatient hospitalization is the need to prevent of harm to herself or others. In Sara’s case, the decision by made by the admitting doctor, was made to prevent harm to Sara and her unborn baby. Furthermore, admission to hospital is meant to alleviate her impaired mental state, letting Sara to get care at less restrictive setting (Stuart, 2013). Early in Sara’s admission she had instances of severe emotional dysregulation in an inpatient environment, having intense suicidal thoughts, flashbacks impacting her ability to regulate emotions. During this time, she damaged hospital property and threatened staff by throwing butter knives at staff but as her admission progressed to the third month she has been settled on the ward.

– **Evidence from Literature on Trauma and Mental Health:**

Use evidence-based literature to support the relationship between **trauma** and **mental health disorders**, particularly in the inpatient context. Discuss how **trauma-related disorders** (e.g., PTSD, complex PTSD) often present in **acute care settings**

– Example: “Studies suggest that patients in inpatient settings with a trauma history are at increased risk of **retraumatization** by the very nature of the hospital environment, which often lacks appropriate trauma-informed strategies (Moulding et al., 2014).”

– **Manifestation of Trauma in Inpatient Care:**

Address how the trauma **manifests in the inpatient unit**. This could include behaviors such as withdrawal, anger, aggression, or difficulty following hospital protocols due to the trauma triggers within the unit’s environment.

– Example: “The hospital environment often triggered intense **hypervigilance** and **dissociation**, as the patient struggled with trusting authority figures and felt threatened by the lack of privacy and control.”

Impact of Trauma on Social, Physical, Spiritual, Psychological, and Relational Health (700-800 words)

social Health in an Inpatient Setting:   Discuss how the patient’s trauma influences their ability to engage socially within the inpatient setting. For instance, trauma survivors may avoid interaction with other patients or staff, which could affect their **rehabilitation** and **social reintegration** after discharge.

example: “Due to a history of abandonment and betrayal, the patient was highly suspicious of other patients and staff, making it difficult for them to engage in group therapies or build any sense of community within the unit.”

Physical Health and Trauma’s Manifestation: Explain how the physical symptoms of trauma may be present or exacerbated in the inpatient setting. Inpatient care often deals with **somatic complaints** like sleep disturbances, appetite changes, and substance withdrawal. These physical manifestations should be connected to trauma.

  Example: The patient’s chronic pain, which had no clear physical cause, seemed to be an expression of their unresolved trauma, a phenomenon frequently seen in individuals with complex PTSD.”

Spiritual Health and Trauma Consider the **spiritual** impact of trauma, particularly in inpatient settings where patients are often at their lowest and may experience spiritual crises. This is important for **culturally safe care** in mental health services.

Example: “While initially disconnected from spirituality, the individual later expressed a desire to reconnect with their cultural roots, seeking guidance from a spiritual leader during their inpatient stay.”

-Psychological Health and Trauma in Inpatient Care: The inpatient setting can be both a supportive and triggering environment for someone with a trauma history. Discuss the psychological toll of being in the inpatient unit, including the potential effects of **hospitalization** on **self-esteem** and **mental well-being

Example: “Being confined in an institutional setting was a constant reminder of powerlessness, which exacerbated the patient’s feelings of **worthlessness** and led to an increase in depressive episodes during hospitalization.”

-Relational Health in the Inpatient Context:

Inpatient care can affect how the patient forms relationships with **nurses, peers, and therapists**. Explain how trauma history influences their ability to trust and engage with those providing care. Example: “The patient’s previous traumatic experiences with authority figures led them to reject the therapeutic relationships, often pushing away staff members who attempted to provide support.”

Therapeutic Nursing Relationship (600-700 words)**

Nurse-Patient Trust in Inpatient Care: Building **trust** in an inpatient setting is crucial for patients with a trauma history. Discuss how you, as the nurse, worked to establish a trusting, empathetic relationship while ensuring **trauma-informed care** was at the forefront of your practice.

– Example: “I focused on establishing trust by being consistent, clear in communication, and respecting boundaries, which was important for reducing anxiety and creating a sense of safety.”

Inpatient Care Challenges and Implications:Reflect on the challenges of working with trauma survivors in a **high-stress inpatient environment** and how the physical and emotional demands of the setting influenced the therapeutic relationship.

– Example: “The chaotic nature of the inpatient unit made it difficult at times to provide the patient with the consistent emotional support they required, and the constant supervision triggered a heightened sense of **hypervigilance**.”

–Cultural Safety in the Therapeutic Relationship:  Discuss how **cultural safety** was integrated into your nursing practice in the inpatient unit, particularly for Māori or other culturally diverse individuals. This is vital in creating a **culturally safe environment**.

Example: “Incorporating cultural support by connecting the patient with a **culturally appropriate** advocate helped foster trust and made the care plan more responsive to their specific needs.”

Critical Analysis of the Service Response to Trauma (600-700 words)**

Service Response in the Inpatient Unit:

Critically analyze the service’s response to trauma in the **inpatient context**. This might include evaluating the **trauma-informed practices** employed by the multidisciplinary team.

– Example: “While the inpatient unit provided some trauma-informed care strategies, such as de-escalation techniques, there was a lack of focus on **cultural sensitivity** and tailored interventions for individuals from diverse cultural backgrounds.”

– **Trauma-Informed Care in the Inpatient Setting:**

Discuss the service’s ability to integrate **trauma-informed care principles** into the inpatient unit, including **environmental safety**, **trust**, and the **emotional security** of the patient.

– Example: “While the service provided some trauma-informed approaches, the physical setting (e.g., lack of privacy, high noise levels) was often re-traumatizing, and more could have been done to create a truly **safe space** for the individual.

 Conclusion (300-400 words)**

Summary of Key Findings:

Summarize the main findings from your analysis, emphasizing the importance of **trauma-informed care** in inpatient psychiatric settings.Reflection on Nursing Practice:** eflect on how your nursing practice was shaped by this experience

References

De Aquino Ferreira, L. F., Queiroz Pereira, F. H., Neri Benevides, A. M. L., & Aguiar Melo, M. C. (2018). Borderline personality disorder and sexual abuse: A systematic review. Psychiatry Research, 262(262), 70–77. https://doi.org/10.1016/j.psychres.2018.01.043

Dye, H. (2018). The impact and long-term effects of childhood trauma. Journal of Human Behavior in the Social Environment, 28(3), 381–392. https://doi.org/10.1080/10911359.2018.1435328

Goddard, A. (2021). Adverse childhood experiences and trauma-informed care. Journal of Pediatric Health Care, 35(2), 145–155. https://doi.org/10.1016/j.pedhc.2020.09.001

Gradus, J. L., & Galea, S. (2022). Reconsidering the definition of trauma. The Lancet Psychiatry, 9(8), 608–609. https://doi.org/10.1016/s2215-0366(22)00196-1

Hall, A., McKenna, B., Dearie, V., Maguire, T., Charleston, R., & Furness, T. (2016). Educating emergency department nurses about trauma informed care for people presenting with mental health crisis: a pilot study. BMC Nursing, 15(1). https://link-springer-com.ezproxy.otago.ac.nz/article/10.1186/s12912-016-0141-y. https://doi.org/10.1186/s12912-016-0141-y

Liming, K. W., Akin, B., & Brook, J. (2021). Adverse childhood experiences and foster care placement stability. Pediatrics, 148(6). https://doi.org/10.1542/peds.2021-052700

Smith, K. E., & Pollak, S. D. (2020). Early life stress and development: potential mechanisms for adverse outcomes. Journal of Neurodevelopmental Disorders, 12(1). https://doi.org/10.1186/s11689-020-09337-y

World Health Organization. (2022, June 17). Mental Health. World Health Organization; World Health Organization. https://www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response