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  1. Heavey, Elizabeth PhD, RN, CNM

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CESARINE* SAT QUIETLY, hunched in a chair in the waiting room, her gaze cast downward. She walked into the exam area without resistance, appearing resigned. She stared at the floor without looking at me or acknowledging my presence.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

It was the first time I'd met this patient, who was being seen in a busy public clinic. Communicating through a qualified medical interpreter, I introduced myself and asked her if she understood why she was in the clinic today. Staring at her hands, she said she'd gotten a disease from the men who'd raped her in her native country.


I sat down nearby but didn't block the door. I told her I was a nurse-midwife, and I wanted to help her as much as I could. "Cesarine, if all you want to do today is see what the clinic is like and then go home, that's fine. I'm glad you're here and I think I can help you, but sometimes this is overwhelming when you've had such a difficult experience. I want you to be comfortable here with us. We're going to take our time, and I'll ask you what you want to do next."


Cesarine appeared to relax a little. I continued, "Would you like to keep talking, or would you rather stop for today?"


Cesarine looked up for the first time, seeming a bit surprised. She quietly indicated she wanted to keep talking.


I smiled and said, "Good. It's okay to stop whenever you want, even if it's just to take a break. Does that sound okay?" She nodded her head, and we began to talk.


Casualties of war

Cesarine had immigrated to the United States after surviving rape and torture by the military and civilian forces fighting in her country of origin. More and more, sexual violence is being used as an explicit war tactic. Women live in fear of not only dying or becoming disabled, but being ostracized by their community.


In some parts of the world, the terror involves the fear that loved ones, including children, will be forcibly recruited into murderous militia forces or will "disappear" forever. Almost half of those forcibly displaced by violence are adolescents and children with limited means of providing for and protecting themselves.1


Before World War II, most wartime injuries and deaths involved military personnel. During and after World War II, noncombatants, including many women and children, were injured and killed at alarming rates, largely in conflicts or wars within their own country.2 Globally, violence is now one of the leading causes of death for those ages 15 to 44.3 Many refugees who've been exposed to violence and can relocate to the United States are resettled into low-income neighborhoods, where they may experience more violence and discrimination. The displacement, immigration, and acculturation experienced can further social exclusion and economic adversity, necessitating long-term community-based responses.4


Impact of posttraumatic stress disorder

These exposures may result in posttraumatic stress disorder (PTSD), a trauma- and stressor-related disorder that involves reexperiencing the traumatic event, trying to avoid triggers, having negative cognitions and mood, and experiencing hyperarousal signs and symptoms, over which the affected individual has very little control.5 In regions with high levels of violence, population rates of PTSD are estimated to be from 30% to 80% or sometimes even higher.6,7 Refugees from violent areas are more likely to experience PTSD than returning combat veterans and are 10 times as likely to experience PTSD compared with the general population.6,8


A traumatic event involving an assault on a child or woman is more likely than one on a man to result in PTSD and may result in long-term debilitating consequences.5,9 PTSD not only affects the mental health of the individual, but also impacts his or her physical well-being. (See Health risksassociated with PTSD.) Exposure to trauma and acute stress increases inflammation, immune system dysfunction, and disturbances in corticoadrenal steroid production, resulting in premature aging.10


The presence of PTSD impacts health-related behaviors and the ability to access healthcare. People with PTSD are more likely to smoke and less likely to be physically active, and report higher levels of medication nonadherence, sometimes due to forgetfulness. They're more likely to experience depression and low income, both of which exacerbate these issues.11 Refugees who aren't diagnosed with PTSD but have a history of trauma or exposure to political violence also report higher levels of distress and are more likely to suffer from chronic medical illnesses while being less likely to use mental health services.4 Women traumatized by violence are more likely to develop disorders such as heart disease and sexually transmitted infections.12,13


Further complicating the situation is the increased likelihood that women exposed to trauma will avoid preventive services, such as Pap smears, clinical breast exams, and early prenatal care, for fear of repeated traumatization.14


Wide-ranging effects of rape

Women who've experienced rape and war-related sexual violence are more likely to develop PTSD than any other crime victims.7 (See Health problems associated with sexual violence.) In many cultures, women may be unwilling to report their experience of sexual violence because losing virginity before marriage, regardless of the circumstances, can make others consider them unfit for marriage. The loss of social stature after sexual violation can lead to a future of subsistence living, involving either begging or working in the sex trade.15 The immediate trauma associated with sexual violence is frequently also followed by other long-term consequences, such as unwanted pregnancies, death of the victim's infants who have no further source of nourishment, psychological distress, sexual dysfunction, infertility, cervical cancer, altered self-image, and further cultural rejection.16


Exposure to highly traumatic events can lead to changes in thought and behavior patterns, either immediately or long afterward. "Flashbacks" may occur after exposure to triggers or may not be related to any apparent cause. Victims may experience intrusive thoughts that disturb or frighten them.


Nursing challenges

Nurses should be alert to common triggers that may be experienced in a healthcare setting, such as a scent in an exam room; the act of disrobing; and the presence of equipment such as speculums, retractors, or biopsy equipment. Locked facilities and security may be reassuring to some patients, frightening to others.


Anniversary dates or certain times of the year are particularly difficult for many survivors of violence. People coping with PTSD develop significant avoidance behaviors to help control their memories and intrusive thoughts.


During acute episodes of distress, the patient may display hyperarousal behavior, which may include a pounding and rapid heart rate, racing thoughts, hypervigilance, profuse diaphoresis, hyperventilation, nausea, and extreme anxiety. It may become difficult for patients to concentrate or even maintain awareness and presence in their current physical environment and condition.5,17


Patients with PTSD may instinctively sit with their back to the wall facing the door or right next to a door to feel they have an escape route. Even with these accommodations, patients may continuously scan the room and have difficulty concentrating on what's actually happening.


Understanding coping mechanisms

Disassociation is a coping mechanism that may be evident in patients experiencing crisis levels of stress. War-related trauma is associated with what some cultures call spirit possession. In this, the patient experiences an altered state of consciousness with impairments in functional indicators beyond those experienced with PTSD, with no memory of the experience afterwards.17


In the United States, this type of response to extreme trauma is also seen and classified as a variant of dissociative identity disorders. These are very difficult for patients and providers to manage. In some war-torn areas of the world, up to 18% of the population experiences this very debilitating condition, which leads to both physical and reproductive health impairments. It's also associated with frequent trauma-related nightmares.17


Trauma exposure can lead to mood changes, which may be extreme; anxiety or depression may become the baseline emotional state for extended periods. Eating, sleeping, and activity schedules can be easily disrupted, with some patients going days without being able to rest or eat appropriately. Fear of recurrence of the event or even the fear of reexperiencing the memories and flashbacks to the event may lead to isolation, provoking feelings of claustrophobia, agoraphobia, self-injurious coping behavior, or even suicidal ideation. With appropriate support, many patients can recover but others, particularly those with a history of extreme or multiple traumas, may have little or no symptom resolution.1,5


Who fares best?

Not all patients with a history of trauma develop mental health issues. Research clearly shows that those with a limited history of trauma, significant familial and community support, and the presence of positive coping mechanisms with protective cultural factors fare better than those without these traits.1


A higher educational level also clearly has a protective effect for refugees' mental health after exposure to trauma or violence. Education may empower refugees to prepare and survive trauma and violence or protect them through enhanced social status, resources, and benefits once they arrive in the United States.14


Communication issues

Nurses are in a key position to facilitate the elimination of communication barriers, to note and respond to verbal and nonverbal communication cues, and to ensure that the information given is in a format the patient can understand. For patients for whom English is a second language, having a medical interpreter available before the patient is even brought into the exam room is extremely helpful. Clear and compassionate communication is critical to optimizing nursing and medical care. Patients who can normally function without an interpreter may need one in these circumstances because the stress induced by the visit itself may negatively affect language fluency.15


Others may be reluctant to have an interpreter present because of confidentiality concerns. Nurses should ask patients if they'd like a medical interpreter in the room or would prefer one who's available remotely, such as by phone, video, or Internet connection.18


Overcoming patients' fears

For patients like Cesarine, even coming into a clinic for care can be very difficult. The experience may be enough to induce frightening psychological responses. You may find a patient in your healthcare facility who isn't prepared psychologically or physically to participate in an exam or her own care. Whenever possible, provide extra time for these patients to establish a safe and trusting relationship.


Patients with a history of trauma may respond better to having multiple visits for more complex needs or procedures. Scheduling multiple visits with the healthcare provider breaks the process down into smaller steps that may be more manageable for the patient.


The patient should be fully clothed for the initial patient contact, and meet with clinicians in a private location that's ideally not an exam room. The patient's consent to discuss her health concerns as well as for any subsequent exams should be obtained. If the patient can't participate in an exam on the first visit, it should be deferred until she's more comfortable. It may take multiple visits to obtain a full health history and perform a complete physical assessment. During this time, the healthcare provider is building rapport and a trusting relationship with the patient.


Step by step

When I met Cesarine, she needed a colposcopy. In her case, several cervical biopsies would be needed as well. This is an invasive and uncomfortable procedure for many women, let alone someone with a traumatic history.


We didn't do the procedure the first day she came in; instead, we talked and she shared her history. I reinforced that I saw her as incredibly resilient and strong and was glad she'd come to the clinic. I explained the procedure and reinforced her control over how we'd proceed. She hadn't gone to any of her previous appointments because of her fear. I could see she'd become more comfortable with me and the clinic as I walked her out to schedule our next appointment, which I assured her would be with me so she wouldn't have to start the process all over again with a new provider.


Continuity and comfort

With patients like Cesarine, continuity of care is critical. A familiar environment where the patient works with the same nurses and provider can make a significant difference in the patient's comfort level and ability to participate in her care.


Traditional gender roles may also impact when treatment is sought and what's shared or disclosed during a visit. Some refugees may be willing to see healthcare providers from only their own ethnic background or of only one gender.15 Many female refugees are more likely to seek care for their children or spouse than for themselves.19


In later conversations, Cesarine disclosed she was reluctant to seek care because of her fear of being victimized again and her belief that after the rape, her own life had no value. Women who are raped in her country don't typically report it because the legal system blames the victim, who may be raped again by the police if she tries to seek justice. Cesarine had no reason to believe that things would be any different in the United States; she was prepared for us to continue to blame or harm her as well.


Stopping the cycle

Another challenging aspect of caring for patients with a history of trauma is the unfortunate reality that the cycle of violence is frequently perpetuated.6 Nurses must screen all patients with a history of violence for current violence concerns, either as a perpetrator or a victim. Asking appropriate open-ended questions lets patients from various cultural backgrounds express themselves using the culturally appropriate verbal framework.


For example, nurses may lead into a safety question with a comment like this: "In this country, it's against the law for someone including a spouse to hit or physically hurt you. Are you ever concerned that someone will hurt you? How so?"


If a concern for violence is identified, specifically ask about coercive sexual practices. In many cultures, a married woman doesn't have the right to say no to sexual contact with her husband regardless of the circumstances.20


Ask about children in the home being exposed to violence. Frame the question appropriately; for example, "In this country, we have support and protection available for women with children who are experiencing violence. Children can be protected from violence and can legally remain with a nonviolent parent even if that parent is a woman." In many areas of the world, women don't have any legal custody rights, so clinicians should establish the existence of some legal gender equity in this country before expecting a mother to report violence against her children. Although many women are reluctant to report abuse or will minimize it, they may be more willing to disclose the violence that their children experience if they feel they can protect them. In many cultures, women's roles in maintaining the family's integrity may preclude reporting any abuse because this could cause the family's disintegration and result in the woman being shunned and stigmatized.20


Screening for further violence

Because those who've experienced violence may perpetuate it on others, ask patients about this risk in a nonjudgmental way. For example, say, "Some people who've been hurt find themselves hurting others when they become frustrated or upset. Have you ever felt this way? If so, what's happened?"


As with any other patient, use appropriate nursing assessment and judgment to identify physical, psychological, and emotional signs of abuse. Follow-up should involve reporting as necessary, according to facility policy and state law.


Providing support

Identifying risks for violence early on may enable us to interject familial support and prevent further escalation. Involving appropriate resources such as social workers, psychologists, and child protective services may provide enough support to help a patient develop better coping mechanisms or may provide protection for the children in the home should the situation escalate. Violence assessments should be done regularly because patients and their environments can change quickly. Also, as patients become more comfortable in the healthcare environment, they're more likely to disclose current violence concerns.13


Ensure that the patient with a history of trauma has access to appropriate psychological treatment. If you're working with a recent refugee with a history of trauma, she may already be established with a care agency and have services in place. For patients who aren't connected with support agencies, making these referrals may facilitate regular and preventive care.


Caring for oneself

Nurses should also be aware that having regular interactions with traumatized patients can affect all healthcare personnel. Vicarious trauma, when those who care for victims of trauma are significantly affected by hearing and interacting with the victims, is a real concern for healthcare personnel. Being aware of one's own responses and limitations is essential when working with these patients. Having a way to "debrief" after these encounters helps nurses maintain their own health and longevity in the field.21 (For more information, see Preventing vicarious traumaand burnout.)


On the path to health

I'm happy to say that we could collect the cervical specimens we needed to ensure Cesarine received the follow-up care she needed. When she left my office the day of the procedure, she took my hand and thanked me. "You are kind," she said. "You take care of me. I see you again?" I said yes, she'd see me again and between the two of us, we'd help her to be well. For nurses, that's what it's all about.


Health risks associated with PTSD10,11

PTSD is a major risk factor for these problems:


* cardiovascular disorders


* digestive disorders


* musculoskeletal disorders


* respiratory disorders


* cancer


* infectious diseases


* unintended injuries


* suicide, homicide, and drug overdose.



Health problems associated with sexual violence16

Victims of sexual violence may have these health issues:


* genitourinary disorders, including urinary difficulties and subsequent infections


* anal sphincter damage


* rectal and vaginal fistulae


* genital and bodily disfigurement, including necrosis of breast tissue resulting in an inability to breastfeed


* chronic pain involving the pelvic region that makes it difficult to sit or stand for extended periods


* sexually transmitted infections, including HIV/AIDS.



Preventing vicarious trauma and burnout22

Use these tips when caring for patients who have a history of trauma.


* Share the load. Although consistency of care providers should be maintained for these high-need patients, distribute them among several care teams so the burden isn't overwhelming for any one care provider.


* Provide adequate time for visits. These patients will need more time. Overscheduled healthcare personnel can't provide the care needed, and their stress levels will go up when they try to "catch up" after seeing these patients.


* Maintain as balanced a lifestyle as possible. Try to balance work and play. Exercise, adequate rest, and breaks from the intensity of work are all critical. Use vacation time wisely and rejuvenate as much as possible. Seek and follow through with preventive healthcare for yourself and your family. Take breaks whenever you can throughout the day, and get away from the office or your unit even if it's just to go to the bathroom or step outside for a few minutes.


* Be aware of your own stress level and responses. Regularly assess your own feelings and consider outside counseling or support as needed. Meet regularly with friends and develop a strong social network. Maintain a spiritual practice that resonates with you. Recognize when your own experiences are impacting your interactions with your patients. Give yourself the same break you'd give a patient who needed it. Sometimes we take better care of our patients than of ourselves.





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World Health Organization. Risks to mental health: an overview of vulnerabilities and risk factors. 2012. http://www.who.int/mental_health/mhgap/risks_to_mental_health_EN_27_08_12.pdf.


* The patient's name has been changed to protect her privacy. [Context Link]