Experience Of Traumatic Stress Research Articles

The Invisible Face of Social Work Field Education: Secondary Traumatic Stress Experiences of BSW Students

The Invisible Face of Social Work Field Education: Secondary Traumatic Stress Experiences of BSW Students

Fear of Flying, Stress and Epileptic-Like Symptoms.

Intense fear of flying, called aviophobia, is a highly prevalent psychological phenomenon, afflicting (in some estimates) up to 40% of the population of industrialized countries and although aviophobia is a highly prevalent mental health problem, published studies about its epidemiology and treatment are rare. In this study, including 61 participants (28 males and 33 females; mean age 26.85) engaged in business related travels in the last two years, we assessed relationships of fear of flying problems with symptoms of stress also reflecting childhood traumatic stress experiences and its influences on brain sensitization and epileptic-like symptoms. In this assessment we also studied fear of flying symptoms and work related psychological problems described as burnout. The results show that the participants who manifest higher levels of stress symptoms have higher levels of aviophobic experiences. Stress symptoms measured by TSC-40 manifested significant correlations with aviophobic experiences measured by Flight Anxiety Modality Questionnaire (FAS) (Spearman R=0.46, p<0.01). Other correlations were found between FAS and Limbic System Checklist (LSCL-33) (Spearman R=0.39, p<0.01) and FAS and Burnout Measure (BM) (Spearman R=0.30, p<0.01). The results of this study indicate that the experience of fear of flying is related to past and recent stressful events and also to levels of work related problems described and experienced as burnout.

Persecution as stigma-driven trauma: Social determinants, stigma, and violence in asylum seekers in the United States

ObjectiveExisting literature documents high rates of experienced violence in asylum seekers. Despite this high prevalence, experiences of traumatic stress are neither necessary nor sufficient grounds for claiming asylum, without documented experiences of persecution. The aim of the current study is to better understand the role of co-occurring pre-migratory social determinants, stigma, and trauma on the experiences of persecution among asylum seekers in the United States. MethodWe conducted a retrospective file review of legal declarations submitted by 25 asylum seekers who participated in forensic mental health evaluations at a pro-bono asylum clinic. We coded de-identified data for co-occurring events of trauma, social determinants of health, and components of “discrimination” from the legal definition of persecution - conceptualizing persecution as stigma-driven infliction of violence. Data was analyzed using a tiered deductive and inductive reflexive thematic analysis. ResultsFindings suggest pre-migratory social determinants included demographics, neighborhood, economic, environmental, and social and cultural level disparities across various grounds for seeking asylum, and experiences of stigma were associated with the specific acts of violence and harm. ConclusionsOur findings - specific to asylum seekers who have obtained legal representation and completed applications for asylum in the United States - describe the co-occurrence of social determinants, stigma and traumatic experiences among asylum seekers. To our knowledge, this study is the first of its kind to bridge the existing legal framework of asylum to a psychological construct incorporating trauma, stigma, and social determinants of health, lending support for the conceptualization of persecution as stigma-driven trauma.

Prosocial Behaviour Towards Victims of Road Accidents: Examining Personality, Gender and Traumatic Experience

As Ebonyi State develops into a city with the attendant population growth and increasing motor traffic, the category of residents that can form part of the road safety network should be of great concern. The study investigated the strengths of personality, gender and traumatic experience as predictors of prosocial behaviour among motorists in Abakaliki, Ebonyi State. One hundred and ninety-nine (199) road users in Abakaliki, Ebonyi State, participated in the study. Participants were randomly drawn using a convenient sampling technique in a cross-sectional survey design. The Big-Five Personality Inventory, the Trauma History Questionnaire (THQ), and the Self-Report Altruism Scale were used for data collection. Data analysis using the multiple regression analysis revealed that some dimensions of personality (extraversion, agreeableness, conscientiousness, and openness to experience) were positively related to prosocial behaviour; gender was not significantly associated with prosocial behaviour and traumatic stress experience especially and positively predicted prosocial behaviour. The study observed that personality trait is the most significant predictor of prosocial behaviour toward road accident victims. Based on the theory of empathic altruism, we recommend aggressive and widespread education on road safety measures for all ages and establishing a civilian road safety network to complement the efforts of FRSC in Ebonyi State.

Ketamine alleviates fear memory and spatial cognition deficits in a PTSD rat model via the BDNF signaling pathway of the hippocampus and amygdala

BackgroundPost-traumatic stress disorder (PTSD) is associated with traumatic stress experiences. This condition can be accompanied by learning and cognitive deficits. Studies have demonstrated that ketamine can rapidly and significantly alleviate symptoms in patients with chronic PTSD. Nonetheless, the effects of ketamine on neurocognitive impairment and its mechanism of action in PTSD remain unclear. MethodsIn this study, different concentrations of ketamine (5, 10, 15, and 20 mg/kg, i.p.) were evaluated in rat models of single prolonged stress and electrophonic shock (SPS&S). Expression levels of brain-derived neurotrophic factor (BDNF) and post-synaptic density-95 (PSD-95) in the hippocampus (HIP) and amygdala (AMG) were determined by Western blot analysis and immunohistochemistry. ResultsThe data showed that rats subjected to SPS&S exhibited significant PTSD-like cognitive impairment. The effect of ketamine on SPS&S-induced neurocognitive function showed a U-shaped dose effect in rats. A single administration of ketamine at a dosage of 10–15 mg/kg resulted in significant changes in behavioral outcomes. These manifestations of improvement in cognitive function and molecular changes were reversed at high doses (15–20 mg/kg). ConclusionOverall, ketamine reversed SPS&S-induced fear and spatial memory impairment and the down-regulation of BDNF and BDNF-related PSD-95 signaling in the HIP and AMG. A dose equal to 15 mg/kg rapidly reversed the behavioral and molecular changes and promoted the amelioration of cognitive dysfunction. The enhanced association of BDNF signaling with PSD-95 effects could be involved in the therapeutic efficiency of ketamine for PTSD.

PERSPECTIVES ON THE SUBJECT MODEL OF MENTAL TRAUMA AND POST-TRAUMATIC STRESS DISORDER

The article presents the perspectives of considering psychological trauma and related disorders, in particular post-traumatic stress disorder (PTSD), through the concept of subjectness - the subjectness model of psychological trauma. Psychic trauma is defined as an area of the self with a critical devaluation of subjectness. The concepts of subjectness are briefly reviewed, and three main aspects are highlighted: synthesizing, activity, and cognitive. The synthesizing function (aspect) of subjectivity is responsible for the formation of a holistic image of oneself, the world, and relationships - the more holistically an individual perceives the world and oneself, including one's life narrative in the form of a holistic autobiographical time, the higher the level of one's subjectivity. The cognitive function corresponds to the transfer of the sensory level of information to the abstract level and the creation, construction, and restructuring of mental models of the world by setting and solving problems. The synthesizing and cognitive function can be compared to such a concept as mentalization. The activity function corresponds to the individual's sense of himself as a free author of his life and ability to act in sense of a personal form of behavior in which he independently chooses goals and ways of achieving them, and/or an act of moral self-determination in which he asserts himself as a person. The activity function can be compared to such a concept as agency. It is shown that the critical devaluation of the synthesizing function of subjectness can describe the phenomenon of post-traumatic split personality, the devaluation of the activity function of subjectivity – a group of avoidance symptoms in PTSD and post-traumatic negative self-concept, the devaluation of the cognitive function – the inability to integrate the experience of traumatic stress and its existence in a dissociated sensory form. Examples of the author's models of post-traumatic splitting, devaluation of mentalization and formation of a negative self-concept through the formation of a complex of learned helplessness are presented. The concept of subjectness can be convenient for describing mental trauma because, on the one hand, it is holistic and humanistic. On the other hand, it allows working with individual functions of subjectness.

Change in the Learning Motivations and Attention Orientations of Students in the Pre- and Post-COVID-19 Periods: A Longitudinal Study

The purpose of this research is the longitudinal examination of the change in learning motivation (LM) and attention level (AL) of students continuing formal education at secondary school in the pre-pandemic period (PreP), in the pandemic period (PP) during the process of online education, and in the post-pandemic period (PostP) during the new school year of face-to-face education. The data for the research was collected through the Persona 360 software, which is used to support guidance and psychological counseling services in K-12 and follows the development of students. It is known that the students’ psycho-social and educational developments are followed at school by the psychological counselors. The data for the research was collected through the Persona 360 school guidance software used for this purpose from 1,183 students continuing education in 9th and 10th grades at private and state schools in Azerbaijan and Turkey. Within the longitudinal research model, the data was collected three years in a row by the Burdon Attention Test, Learning Motivation Scale, and Temperament-Enneagram 9-Factor Personality Test (MEM-9). The analyses were performed using SPSS 23.0/Windows software pack and ANOVA, two-way ANOVA, and MANOVA tests. Pursuant to the findings obtained, it was found that the students’ learning motivations and attention levels changed negatively in the COVID-19 period for the three different time frames. The findings were discussed in the context of temperament and traumatic stress experiences affecting the students’ learning motivations and attention levels.

MicroRNA expression profiles of stress susceptibility and resilience in the prelimbic and infralimbic cortex of rats after single prolonged stress.

The experience of traumatic stress can engender lasting memories associated with the trauma, often resulting in post-traumatic stress disorder (PTSD). However, only a minority of individuals develop PTSD symptoms upon exposure. The neurobiological mechanisms underlying the pathology of PTSD are poorly understood. Utilizing a rat model of PTSD, the Single Prolonged Stress (SPS) paradigm, we were able to differentiate between resilient and susceptible individuals. Fourteen days after the SPS exposure, we conducted the behavioral analyses using Elevated Plus Maze (EPM) and Open Field (OF) tests to identify male rats as trauma resilient or susceptible. We focused on the microRNA (miRNA) profiles of the infralimbic (IL) and prelimbic (PL) cortical regions, known to be crucial in regulating the stress response. Our investigation of stressed rats exposed to the SPS procedure yielded divergent response, and differential expression microRNAs (DEmiRs) analysis indicated significant differences in the IL and PL transcriptional response. In the IL cortex, the GO analysis revealed enriched GO terms in the resilient versus control comparison, specifically related to mitogen-activated protein kinase and MAP kinase signaling pathways for their molecular functions as well as cytosol and nucleoplasm for the biological process. In the susceptible versus resilient comparison, the changes in molecular functions were only manifested in the functions of regulation of transcription involved in the G1/S transition of the mitotic cell cycle and skeletal muscle satellite cell activation. However, no enriched GO terms were found in the susceptible versus control comparison. In the PL cortex, results indicated that the DEmiRs were enriched exclusively in the cellular component level of the endoplasmic reticulum lumen in the comparison between resilient and control rats. Overall, our study utilized an animal model of PTSD to investigate the potential correlation between stress-induced behavioral dysfunction and variations in miRNA expression. The aforementioned discoveries have the potential to pave the way for novel therapeutic approaches for PTSD, which could involve the targeted regulation of transcriptome expression.

Traumatic stress symptoms in family caregivers of patients with acute leukaemia: protocol for a multisite mixed methods, longitudinal, observational study

IntroductionThe diagnosis, progression or recurrence of cancer is often highly traumatic for family caregivers (FCs), but systematic assessments of distress and approaches for its prevention and treatment are lacking. Acute...

When Teaching Hurts: Exploring the Secondary Traumatic Stress Experiences of Early-Career SBAE Teachers

Sources of satisfaction, stress, and burnout are all-too-familiar to school-based agricultural education (SBAE) teachers. Yet, the current literature related to SBAE stress has not addressed the overwhelming existence of trauma in our greater society. Teacher wellbeing can be compromised when students share their own adversities and traumatic experiences, thus producing secondary traumatic stress (STS). To lay a foundation for inquiry, we used the Professional Quality of Life (ProQOL) survey and scale to quantify and draw attention to STS. In this study, we found early-career SBAE teachers (n = 49) in Oregon experienced moderate levels of STS along with STS being a significant positive predictor of burnout. Given our findings, we urge scholars and practitioners to recognize the implications student trauma has on the lives of teachers. Students carry invisible wounds to the SBAE classroom, which inextricably transfers to the teachers caring for them. Secondary exposure to trauma is salient to the experiences of teachers. Left unattended to, STS could result in severe implications for the individual as well as the profession.

Traumatic stress experienced by Japanese midwives and its relation to burnout and work engagement.

The purpose of this study was to: (1) clarify the traumatic stress experienced by Japanese midwives using the Traumatic Stress Scale for Midwives (TSSM); (2) identify the traumatic stress experience with the highest frequency and greatest impact; and (3) clarify the relationship of the frequency and impact of the traumatic stress experience with burnout and work engagement. A quantitative exploratory study was conducted using a self-administered questionnaire. The target midwives were those employed in hospitals, clinics, and midwifery centers throughout Japan. TSSM item 7 "Disregarded oneself when providing care" showed the highest average frequency score (1.70, SD=0.8). TSSM item 2 "Experience of intrauterine fetal death" showed the highest average impact score (2.84, SD=1.2). There was a significant difference in the average scores of frequency and impact of traumatic stress by current workplace, marital status, and living with family members. There was no significant difference in the average scores of frequency and impact of traumatic stress by midwife educational background. The frequency and impact of traumatic stress showed a positive correlation with burnout, but a negative correlation with work engagement. TSSM is a valid measure to determine traumatic stress. It correlated with burnout and work engagement. TSSM may be used to prevent turnover. Additional research to understand traumatic stress is needed.

Childhood Trauma and Psychosocial Stress Affect Treatment Outcome in Patients With Psoriasis Starting a New Treatment Episode.

ObjectiveTraumatic childhood experiences and psychosocial stress may predispose the evolvement of somatic diseases. Psoriasis is a multifactorial chronic inflammatory skin disease that often associates with current and past stress. Both may entail pathological alterations in major stress axes and a balance shift in the level of T helper type 1 (Th1) and 2 (Th2) cytokines, affecting the development and course of psoriasis. Until now, it is unclear whether traumatic stress experiences during the childhood or current stress are more frequent in psoriatic compared to skin-healthy individuals, and if they interact with treatment outcome.MethodIn a prospective cohort study, the impact of acute and early childhood stress on the course of dermatological treatment were studied in patients with moderate to severe psoriasis (PSO). Patients were examined before (T1) and about 3 months after (T2) the beginning of a new treatment episode. Assessments included clinical outcomes (Psoriasis Area and Severity Index—PASI, Structured Clinical Interview SCID-I) and patient-reported outcomes (PRO) (Childhood Trauma Questionnaire-CTQ, Perceived Stress Scale-PSS, itching/scratching, Dermatology Life Quality Index-DLQI, Hospital Anxiety and Depression Scale, Body Surface Area, Self-Administered PASI).ResultsN = 83 PSO patients (median age 53.7, IQR 37.8, 62.5) and n = 66 skin-healthy control subjects (HC) (median age 51.5, IQR 33.3, 59.2) participated. PSO had higher CTQ physical neglect than HC, as well as higher PRO levels. The positive impact of improved skin on the skin-related quality of life was moderated by the perceived stress. Acute stress at T1 had a positive effect both on the skin severity and the skin-related quality of life. CTQ total closely interacted with baseline psoriasis severity, and was associated with higher improvement from T1 to T2.ConclusionOne might tentatively conclude, that chronic psychosocial stressors like childhood maltreatment may predispose the manifestation of psoriasis. The latter may be amplified by acute psychological stressors. In addition, the present evidence suggests that systemic therapies work well in PSO, with childhood trauma and acute psychosocial stress. Both should therefore be routinely assessed and addressed in PSO.

I have to hold it together: Trauma in law enforcement couples

AbstractObjectiveGrounded in secondary traumatic stress theory, this study explored the impact of work‐related traumatic stress on law enforcement couples.BackgroundStudies exploring the impact of traumatic stress on law enforcement couples are limited. Such studies suggest that when traumatic stress impacts law enforcement professionals, their spouses often experience secondary traumatic stress and serve in a supportive role after trauma exposure.MethodSemistructured dyadic interviews were conducted with law enforcement couples (N = seven couples, 14 participants) using transcendental phenomenology.ResultsThree themes emerged within the data that captured the essence of law enforcement couples' experiences of traumatic stress: (a) the stressful nature of the law enforcement profession, (b) the impact of work‐related traumatic stress on the couple relationship, and (c) protective factors and resilient coping characteristics.ConclusionThe impact of work‐related traumatic stress manifested in couple's communication, role responsibilities and parenting, and commitment to the relationship and the profession. The impact of work‐related traumatic events differed for the law enforcement professional and their spouse based on the type of traumatic event. Overall, work‐related traumatic stress led couples to engage in a meaning‐making process and activation of resilient couple coping characteristics.ImplicationsGiven the significant impact that work‐related traumatic stress has on the law enforcement couple dyad, couple and family therapy services are needed for law enforcement professionals and their spouses. Couple and family therapists, family researchers, and other professionals working to promote healthy couple and family relationships should inquire about how couples adapt to traumatic stress and reinforce use of resilient coping characteristics.

A Trauma-Informed Approach to Youth Suicide Prevention and Intervention

ABSTRACT Suicide, suicidal behaviors, and self-harm are major public health problems among youth and can often co-occur with traumatic stress experiences and related symptoms. Given this interrelation, it is important that suicide prevention and intervention practices take a trauma-informed approach to reflect the complex, intertwined relation of traumatic stress symptoms and suicidal thoughts/behaviors. To that end, we summarize key steps in a proposed trauma-informed approach to suicide prevention and illustrate this approach with examples of how to clinically apply suggested components for youth who are suicidal and have been exposed to traumatic events.

Stress and pathophysiological mechanisms for the development of psychosomatic disease

According to the biopsychosocial model, disease is the dysfunctional resultant of various fields of human function (biological, psychological, behavioral, socioeconomic). This article deals with the psycho-biological field of Psychosomatic research, namely, the effect of stress on the body. The human organism, in the prospect of evolution, has developed biological mechanisms for maintaining its homeostasis (ομοιόσταση), in its interchange with the stressor stimuli. This process is called allostasis. The response to mild - short-term stress induces activation of the hypothalamic - pituitary - adrenal axis, the sympathetic system and the immune system; a process that proves beneficial to the body. On the contrary, exposure to traumatic or chronic stress, with subsequent overactivation of the body's allostatic mechanisms, wears out its homeostatic ability and initiates pathophysiological mechanisms that pave the way for the development of physical and mental illness. The above procedure is called allostatic load or, in its most severe form, allostatic overload. More specifically, the experience of traumatic stress, either in childhood or in adulthood, induces dysregulation of neuroendocrine pathways in the Central Neural System (CNS), as well as immune dysfunction, and is associated with more frequent development of psychiatric and medical pathology, in a dose-dependent way. On the other hand, exposure to chronic repetitive stress induces neurobiological lesions at the level of the CNS, which undermine the body's very ability to respond to stress. At the same time, chronic stress has been associated with increased morbidity from major medical disorders, such as diabetes mellitus, obesity, metabolic syndrome and cardiovascular disease, through a variety of pathophysiological pathways. Finally, chronic stress causes dysfunction of the body's immuno-protective mechanisms, while at a cellular level, it induces oxidative stress and cellular apoptosis. However, regardless of the quantity and quality of the stressor stimuli, it has also emerged that the individual's personal characteristics judge the vulnerability to stress, too. Psychiatrists must insist on the scientific documentation of the biopsychosocial model, so that they can raise awareness amongst the medical community, aiming at a holistic care of the patients.

Cultural Scripts of Traumatic Stress: Outline, Illustrations, and Research Opportunities.

As clinical-psychological scientists and practitioners increasingly work with diverse populations of traumatized people, it becomes increasingly important to attend to cultural models that influence the ways in which people understand and describe their responses to trauma. This paper focuses on potential uses of the concept of cultural script in this domain. Originally described by cognitive psychologists in the 1980s, scripts refer to specific behavioral and experiential sequences of elements such as thoughts, memories, attention patterns, bodily sensations, sleep abnormalities, emotions and affective expressions, motivation, coping attempts, and ritualized behaviors that are relevant to posttraumatic adjustment. We differentiate between experiences of traumatic stress that are scripted (e.g., cultural explanations are available) versus unscripted. Further characteristics such as script tracks, the effect of script interruptions, and contextual fit of scripts with other cultural models are also described. We consider examples of traumatic stress associated with war and organized, sexualized violence from “Western” and “non-Western” world regions. The concluding part of this review describes a number of possibilities for methodological approaches to assessment of cultural scripts. Capturing central elements of the script(s) of trauma would aid psychological researchers and clinicians in understanding the experiences of trauma in cultural context, which could ultimately lead to better clinical service opportunities worldwide.

Empowering Through Embodied Awareness: Evaluation of a Peer-Facilitated Trauma-Informed Mindfulness Curriculum in a Woman’s Prison

The cumulative effects of trauma, violence, and substance abuse both define women’s pathways into the correctional system and contribute to their unique needs within it. This research offers a case study of the implementation of a gender-responsive, trauma-informed integrated mindfulness program within a women’s prison. Applying a yoga-based psycho-educational approach, the manualized curriculum was presented in a 16-session, closed-group format with peer-facilitation and pre- and postprogramming assessments. Overall, outcomes of this study were promising. Program participants demonstrated improvements in the use of healthy coping skills, experience of traumatic stress, symptoms of anxiety and depression, self-compassion, sense of connection, ability to relate to others, emotional awareness, and self-regulation.

How are pain and traumatic stress symptoms related in acute whiplash-associated disorders? An investigation of the role of pain-related fear in a daily diary study.

Comorbidity of pain and posttraumatic stress disorder is well recognized, but the reason for this association is unclear. This study investigated the direction of the relationship between pain and traumatic stress and the role that pain-related fear plays, for patients with acute whiplash-associated disorder. Participants (n = 99) used an electronic diary to record hourly ratings of pain, traumatic stress, and fear of pain (FOP) symptoms over a day. Relationships between pain, traumatic stress, and pain-related fear symptoms were investigated through multilevel models including variables lagged by 1 hour. Traumatic stress was associated with previous pain, even after controlling for previous traumatic stress and current pain; current pain was not associated with previous traumatic stress. The relationship between traumatic stress and previous pain became negligible after controlling for FOP, except for traumatic stress symptoms of hyperarousal that were driven directly by pain. Overall, these results support a pain primacy model, and suggest that pain-related fear is important in the maintenance and development of comorbid pain and traumatic stress symptoms. They also confirm that traumatic stress symptoms of hyperarousal are central in this relationship. Differences between this study and others that reported mutual maintenance can be understood in terms of different stages of whiplash-associated disorder and different intervals between repeated measurements. Traumatic stress may affect pain over longer time intervals than measured in this study. Future research could explore how relationships between traumatic stress symptoms, pain, and FOP change over time, and whether previous experiences of traumatic stress influence these relationships.

The ethanolic extract of Aralia continentalis ameliorates cognitive deficits via modifications of BDNF expression and anti-inflammatory effects in a rat model of post-traumatic stress disorder

BackgroundPost-traumatic stress disorder (PTSD) is a disease associated with that the experience of traumatic stress. The traumatic experience results in the development of a prolonged stress response that causes impaired memory function and increased inflammation in the hippocampus. Currently, antidepressants are the only approved therapy for PTSD. However, the efficacy of antidepressants in the treatment of PTSD is marginal. The ethanol extract of Aralia continentalis (AC) is traditionally used in oriental medicine, and has been showed to possess pharmacological properties, including anti-inflammatory, anti-cancer, anti-atherosclerotic, and anti-diabetic effects. Nevertheless, the effects of AC on cognitive memory and its mechanism of action in PTSD remain unclear. Given the necessity of further treatment options for PTSD, we investigated the effect of AC on the spatial cognitive impairment caused by single prolonged stress (SPS) in a rat model of PTSD.MethodsMale rats were treated with various intraperitoneal (i.p.) doses of AC for 21 consecutive days after inducing chronic stress with the SPS procedure.ResultsCognitive impairment caused by SPS were inhibited after treatment with 100 mg/kg AC, as measured by the Morris water maze test and an object recognition test. Additionally, AC treatment significantly alleviated memory-related decreases in brain-derived neurotrophic factor (BDNF) mRNA and protein levels in the hippocampus. Our results suggest that AC significantly inhibited the cognitive deficits caused by SPS via increased expression of pro-inflammatory cytokines, including tumor necrosis factor-α and interleukin-6, in the rat brain.ConclusionsAC reversed the behavioral impairments and inflammation triggered by SPS-derived traumatic stress and should be further evaluated as a potential therapeutic drug for PTSD.

Secondary traumatic stress experiences of nurses caring for cancer patients.

The aim of this study was to explore secondary traumatic stress experiences of nurses caring for cancer patients. A qualitative descriptive approach was taken in the study. The team conducted semi-structured in-depth interviews with 13 oncology nurses. We evaluated the responses collected using content analysis. Three distinct themes emerged from the interviews: cycle of desperation, coping, and change. Based on the results obtained, it is suggested that programs containing cognitive restructuring techniques be developed; peer support groups may enable senior nurses to guide inexperienced nurses.