Childhood Traumatic Experiences and Happiness of Nursing Students: A Mixed Methods Study

Abstract

The aim of this study was to examine the childhood trauma experiences and current happiness levels of nursing students. The quantitative part of the study was carried out with 349 student nurses and the qualitative part with 25 student nurses. An explanatory-sequential mixed methods design was used. Data were collected using Demographic Information Form, Childhood Trauma Questionnaire-Short Form, Oxford Happiness Questionnaire-Short Form and semi-structured Interview Form between November 2020 and September 2021. Quantitative data were analysed using descriptive statistics with the SAS 9.4 package program. Transcribed qualitative data were analysed using Braun and Clarke’s six stage thematic analysis approach, and this was performed with the MAXQDA 2020 package program. In the quantitative section, it was determined that as the participants’ childhood traumatic experiences increased, their happiness levels decreased. In the qualitative section six themes were formed (Childhood Trauma, Effects of Childhood Trauma, Coping with Childhood Trauma, Growing Up After Trauma, Perceptions of Future Parenting, Empowerment Through Nursing Education). It was determined that participants had various childhood traumatic experiences and mostly been exposed to emotional neglect. Some of the participants' childhood traumas continued to affect them in adulthood, and nursing education contributed to coping with trauma and raising awareness about it.

Keywords

childhood traumatic experiences happiness nursing students mixed methods

Introduction

Traumatic experiences in childhood can have lasting effects into adulthood. Traumatic experiences are short- or long-term encounters with unusual mental or physical stressors at any stage of life (WHO, 2004). Childhood trauma includes various negative life events experienced during the childhood period. These negative life events may be natural events, such as floods, earthquakes, hurricanes, and the death of a loved one, as well as human-caused events such as war, abuse, and terrorist acts (Baloğlu & Göv, 2019). When the psychosocial effects of childhood trauma experience (CTE) cannot be overcome and adequate support is not provided during this period, various psychopathologies may be seen which may continue to have negative effects into adulthood (Wu et al., 2018). The lasting effects of CTE may lead to mental problems such as personality disorders, depression (Kürtüncü et al., 2020), alcoholism, drug abuse (Felitti et al., 2019) and may negatively affect the individual’s levels of happiness (Diette et al., 2018), their personalities, work and relationships (Karakaş & Çingöl, 2021).

CTE is prevalent among nursing students and health professionals who look after patients (Girouard & Bailey, 2017). Trauma can have lasting effects, and these can also impact nursing students. Because nurses provide care to others, it is important that they recognize their own past traumatic experiences and how these may influence their interactions with patients and relationships with their team at work. Therefore, awareness of CTE, coping strategies, resilience, and psychosocial interventions should be included alongside nursing skills in basic nursing education.

Background

Childhood is one of the most vulnerable periods of life. Exposure to childhood trauma can be a traumatic experience for nursing students, as it is for society in general, affecting areas such as individuals’ career choices, patient care, interpersonal interactions, and feelings of happiness. Studies conducted with nursing students have observed that students have been traumatized by being exposed to physical, emotional, sexual abuse, and neglect during childhood (Baydemir et al., 2014; Dong et al., 202; Kürtüncü et al., 2020; Özçevik & Güneş, 2019). Male students in particular were found to be more frequently exposed to emotional and physical neglect and maltreatment, and CTE has been associated with the number of siblings, authoritarian (Baydemir et al., 2014) and indifferent parental attitudes, the parents' low educational level, a low income (Kürtüncü et al., 2020), psychiatric disorders in adulthood (Baydemir et al., 2014), and resilience (Dong et al., 2021).

Although there is limited information on the prevalence of CTE among nurses and nursing students, CTE may be more common than in the general population (Girouard & Bailey, 2017). The prevalence of CTE in nurses was found to be 33% (Maunder et al., 2010) as opposed to 18.6% in nursing students (Dong et al., 2021). In another study, the proportion of those with four or more adverse childhood experiences was 12.5–13.3% in the general population, but over 40% in nursing students (Clark & Aboueissa, 2021). Cognitive, emotional, and behavioural problems resulting from these experiences can negatively affect the quality of personal relationships and patient care (Karakaş & Çingöl, 2021). Gallop et al. (1995), found that nurses who were abused in childhood had higher levels of stress and that the abuse affected their professional lives. This experience was found to play a role in the decision to become a nurse in 10% of nurses who were exposed to childhood sexual abuse (Gallop et al., 1995).

According to Peplau (1952), the therapeutic relationship is at the heart of nursing and the nurse’s “therapeutic use of self” occupies an important place in the relationship between patient and nurse (Peplau, 1952). According to Travelbee (1971), the “therapeutic use of self” is the ability to consciously use a full awareness of one’s own personality to establish a relationship with the patient and to provide care (Travelbee, 1971). Nurses who do not understand themselves and are not self-aware may have difficulty communicating with patients. CTE can negatively impact nurse-patient interactions and impair the nurse’s ability to establish a trusting, therapeutic relationship (Girouard & Bailey, 2017). Nurses with CTE are less likely to perform well compared to their colleagues (Girouard & Bailey, 2017).

The fact that CTE lowers happiness levels (Diette et al., 2018) may also impact nurses' relationships with patients and the quality of care. Nurses' happiness levels have been found to have a positive impact on patient satisfaction (Tzeng & Ketefian, 2002). The literature has examined student nurses' happiness levels and concepts such as academic self-efficacy, resilience, departmental satisfaction (Kim & Yoon, 2021), self-esteem, social support, and self-efficacy (Kwon et al., 2018), but CTE has not been the focus. In addition, nurses play a role in preventing CTE and caring for people with CTE (Girouard & Bailey, 2017). Therefore, to help these individuals, nurses must be adequately skilled in coping with CTE and must be highly resilient in order to improve professional practice (Dong et al., 2021).

Gaining awareness about the effects of CTE is the first step in coping with these experiences. A quantitative approach alone is not sufficient to understand the unique childhood experiences and levels of happiness of individuals; clarifying these experiences using qualitative methods will provide a better understanding. In this way, light can be shed on the negative experiences of unhappy students, support programs can be planned to help these students heal, and advanced research can be conducted.

The Study

Aims

The aim of this research was to examine the CTE and happiness levels of nursing students using an explanatory-sequential approach, which is a type of mixed methods design.

Research Questions

The research questions related to the quantitative research section were: “Is there a relationship between the sociodemographic characteristics of the student nurses and the experience of childhood abuse?”; “Do the sociodemographic characteristics of the student nurses influence their levels of happiness?”, “Is there a relationship between the student nurses’ experience of childhood abuse and their levels of happiness?”

The research questions related to the qualitative section were: “What were the student nurses' experiences of childhood abuse?”, “What meaning do the student nurses place on childhood abuse?”, “What meaning do the student nurses attach to happiness?”

Design

This study was designed as a form of mixed methods research. Mixed-methods research allows for a better understanding of a problem, and expands and strengthens the results by combining quantitative and qualitative methods (Creswell & Clark, 2017). In the quantitative part, which was the first stage of the research, a descriptive and correlational design was used. In the second stage, a phenomenological approach, one of the qualitative research methods, was used. The aim was to provide a better understanding of the numerical results of traumatic experiences and happiness levels in the quantitative section, and then to determine the effects of nursing education on trauma and happiness in the second part.

Sample Size

The population of the quantitative part consisted of 916 students enrolled in the undergraduate Department of Nursing in a single university. The study was conducted at a state university in Turkey, near the capital, with students from all regions. Basic nursing education in Turkey lasts 4 years. The sample of the research was calculated as 300 participants with a 95% confidence interval and 5% error, and 349 participants were reached considering the probability of a 10% loss. The inclusion criteria for the quantitative section were being a student in the nursing department, being 18 years old or over, speaking Turkish, not currently experiencing an emotional crisis (such as grief, relationship breakdown, etc.), and agreeing to participate in the research.

The population of the qualitative section consisted of a number of the participants in the quantitative part. The sample was determined as 25 people using the maximum diversity sampling strategy. Maximum diversity was aimed by considering the sociodemographic characteristics, familial characteristics, parental attitudes, and scale scores of the participants. The students’ sociodemographic characteristics determined in the quantitative section were analysed and randomly selected to maximize diversity. However, since the perception of experiences differs from individual to individual, a mixed group was formed regardless of their scores from the Childhood Trauma Questionnaire-Short Form (CTQ-SF) and the Oxford Happiness Questionnaire-Short Form (OHQ-SF). The inclusion criteria for the qualitative research were having participated in the quantitative part of the research, agreeing to participate in the research, and speaking Turkish.

Data Collection

Quantitative Data Collection

The quantitative part of the research was conducted online due to the COVID-19 pandemic. An email with information about the quantitative and qualitative parts of the study was sent to the students to obtain their voluntary consent. The email informed the students that participation was not compulsory, that it had no impact on their academic results, and that they could leave the study if they wished. Students were given time to decide, and 5 days later the online survey form was emailed. A link to the survey was emailed to students who responded to the initial email. The sample was stratified by class, and the questionnaire was sent out until a sufficient number of participants was reached. For those who wished to participate in the qualitative portion of the study, a consent section was added to the form, and the qualitative portion was conducted with students who gave their consent. In the quantitative part of the research, the Demographic Information Form, the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Oxford Happiness Questionnaire-Short Form (OHQ-SF) were used as data collection tools.

Demographic Information Form: This form was created by the researchers after conducting a literature review. It consisted of 13 questions about sociodemographic information and characteristics that are considered to affect trauma experiences such as family environment, parental attitude, number of siblings and psychiatric illness of parents (Akpınar et al., 2019; Baydemir et al., 2014).

Childhood Trauma Questionnaire Short Form (CTQ-SF): This was developed by Bernstein et al. (2003) and the validity and reliability of its Turkish version was tested by Kaya (2014). The CTQ-SF is a measurement tool for retrospectively examining the history of neglect and abuse in childhood. It is a five-point Likert-type scale consisting of 28 items and five sub-dimensions. A higher score from the scale indicates a higher level of neglect and abuse in childhood. The scale is scored between 25 and 125 points. The Cronbach’s alpha internal consistency coefficient of the CTQ-SF is 0.77 (Kaya, 2014). In this study, the Cronbach’s alpha value of the CTQ-SF was found to be 0.81.

Oxford Happiness Questionnaire Short Form (OHQ-SF): This was developed by Hills and Argyle (2002) and the validity and reliability of its Turkish version was tested by Doğan and Çötok (2011). The OHQ-SF is a five-point Likert-type scale consisting of seven items and one dimension. The scale is scored between 7 and 35 points. A higher score from the scale indicates a higher level of happiness. The Cronbach’s alpha internal consistency coefficient of the scale is 0.74 (Doğan & Çötok, 2011). In this study, the Cronbach’s alpha value of the OHQ-SF was found to be 0.80.

Qualitative Data Collection

An invitation email was sent to the students who agreed to participate in the qualitative part of the survey. The students who responded to the mail were once again informed about the survey. The data were collected through in-depth interviews with the participants using a semi-structured interview form. The interviews were conducted via the Zoom application due to the pandemic. After the consent of the participants was obtained, the interviews were recorded and observation notes were kept during the interviews. The data collection process was concluded when the data saturation was reached and the data obtained became repetitive. Before starting the research, pilot interviews were conducted with two students and these interviews were not included in the research.

Semi-Structured Interview Form

A semi-structured Interview Form consisting of 16 questions was used to collect the qualitative data. The form was created in consultation with an expert with experience in qualitative research. This form discussed CTE, the experience of happiness, the individual’s perceptions of trauma and happiness, and their views about the effects of nursing education through open-ended questions (Annex-1).

Trustworthiness

In order to increase construct validity, the Interview Form was used and observation notes were taken. The interviews were conducted by one researcher who did not guide the participants during the interview but asked exploratory questions. In order to increase internal validity, the data obtained from the interviews were analysed by two researchers, and themes and sub-themes were created. After reaching consensus on the themes and sub-themes, expert opinion was obtained from two experts who were not involved in the research but had experience of qualitative research in the field of nursing. Intercoder consistency ratio (Kappa) analysis was then performed. After the necessary amendments were made to the codes, expert opinion was again obtained and the Kappa value calculated after the changes was found to be 1 (almost perfect agreement). In order to increase external validity, direct quotations from the statements of the participants were included in the study.

Ethical Considerations

The research was conducted in conformity with the principles of the Helsinki Declaration. Permission to perform the study was received from the Department of Nursing of the Faculty of Health Sciences of Kırşehir Ahi Evran University, and ethical approval was obtained from the Clinical Research Ethics Committee of Kırşehir Ahi Evran University (Date: September 22, 2020; No: 2020-13/101). The voluntary consent of the participants was obtained before starting both parts of the study.

Data Analysis

Quantitative Data Analysis

The trial version of SAS 9.4 package program was used for statistical analysis of the data obtained from the quantitative part of the research. Means and standard deviation were calculated as descriptive statistics for the quantitative variables of the study determined with measurement tools, and descriptive statistics were presented with numbers and percentages for qualitative variables. The conformity of the data to normal distribution was checked using the Shapiro-Wilk test. Since the data were not normally distributed, the Mann-Whitney U test and Kruskal-Wallis H test, which are non-parametric tests, were performed. The relationships between the sub-dimensions and the overall mean scores of the scales were calculated using the Spearman Correlation coefficient.

Qualitative Data Analysis

The researchers listened to audio recordings of the interviews, and all statements made by the participants were transcribed verbatim. 249 pages of transcriptions were obtained from the in-depth interviews. The transcriptions were read repeatedly by the researchers and coding was carried out using the trial version of MAXQDA 2020 program and analysed using Braun and Clarke’s six stage thematic analysis approach (Braun & Clarke, 2006). The researchers met to work on the codes until a consensus was reached. A total of 854 codes were obtained from the transcriptions. After the codes had been created, the thematic coding process was started, the codes were categorized by the researchers, and themes were created. The study was presented in accordance with consolidated criteria for reporting qualitative research (COREQ) for qualitative research (Tong et al., 2007).

Results

Quantitative Results

The majority of the participants were female, first-year students, had a nuclear family with an income equal to expenses, and described their family environment as peaceful (Table 1). The majority of the participants stated that their parents were their biological parents and were living, that their parents had an authoritarian attitude and maintained strict discipline. The students stated that they might partially apply their parents’ disciplinary methods to their own children in the future (Table 1). The variables of gender, income, psychiatric illness, family environment, parental attitude, and number of siblings had a statistically significant difference on the median scores for neglect and abuse (p < 0.05) (Table 1).

Table 1.

The Mean Scores of CTQ-SF and OHQ-SF by the Demographic Characteristics of the Participants.

Demographic Characteristics	n	%	Physical Abuse	Sexual Abuse	Emotional Abuse	Physical Neglect	Emotional Neglect	CTQ-SF Total Score	OHQ-SF Total Score
Demographic Characteristics	n	%	Med (Min-Max)	Med (Min-Max)	Med (Min-Max)	Med (Min-Max)	Med (Min-Max)	Med (Min-Max)	Med (Min-Max)
Gender
Female	257	73.6	5 (5–22)	5 (5–25)	7 (5–22)	8 (5–22)	11 (5–20)	48 (38–98)	24 (10–35)
Male	92	26.4	5 (5–13)	5 (5–12)	6 (5–19)	9 (5–14)	11 (6–19)	48.5 (39–76)	24 (12–35)
Test statistic			Z = 2.976 p = 0.085	Z = 2.289 p = 0.130	Z = 3.614 p = 0.057	Z = 10.868 p = 0.001	Z = 0.568 p = 0.451	Z = 0.644 p = 0.422	Z = 0.115 p = 0.734
Class
First	98	28.1	5 (5–21)	5 (5–20)	7 (5–22)	8 (5–22)	11 (7–18)	47 (39–98)	24 (10–33)
Second	69	19.8	5 (5–16)	5 (5–13)	7 (5–18)	9 (5–15)	11 (5–17)	49 (38–72)	24 (15–35)
Third	88	25.2	5 (5–22)	5 (5–16)	7 (5–22)	8 (5–16)	11 (7–19)	47.5 (40–93)	26 (11–35)
Fourth	94	26.9	5 (5–13)	5 (5–25)	7 (5–19)	8 (5–15)	12 (5–20)	49 (39–73)	24 (10–32)
Test statistic			KW = 0.148 p = 0.985	KW = 0.642 p = 0.887	KW = 1.813 p = 0.612	H = 0.937 p = 0.816	KW = 1.837 p = 0.607	KW = 0.914 p = 0.822	KW = 5.050 p = 0.168
Income level
Income<Expenses¹	55	15.8	5 (5–21)	5 (5–16)	8 (5–21)	9 (5–22)	12 (8–20)	50 (39–98)	23 (11–31)
Income=Expenses²	231	66.2	5 (5–22)	5 (5–25)	7 (5–22)	8 (5–15)	11 (6–19)	48 (39–93)	24 (10–35)
Income>Expenses³	63	18	5 (5–10)	5 (5–21)	6 (5–18)	7 (5–15)	11 (5–15)	48 (38–73)	25 (10–31)
Test statistic			KW = 1.114 p = 0.573	KW = 3.292 p = 0.193	KW = 6.189 p = 0.045 1>2,3	KW = 6.862 p = 0.032 1>2,3	KW = 5.416 p = 0.067	KW = 6.481 p = 0.039 1>2,3	KW = 4.827 p = 0.090
Psychiatric disorder status
Yes	47	13.5	6 (5–22)	5 (5–15)	9 (5–22)	9 (5–16)	12 (5–19)	50 (39–93)	22 (10–35)
No	302	86.5	5 (5–20)	5 (5–25)	7 (5–21)	8 (5–22)	11 (5–20)	48 (38–98)	25 (10–35)
Test statistic			Z = 9.753 p = 0.002	Z = 5.992 p = 0.014	Z = 4.558 p = 0.033	Z = 5.302 p = 0.021	Z = 5.556 p = 0.018	Z = 5.817 p = 0.016	Z = 8.725 p = 0.003
Number of siblings
1–2¹	88	25.2	5 (5–20)	5 (5–20)	7 (5–19)	8 (5–15)	11 (5–19)	47 (39–87)	24 (12–35)
3²	122	35	5 (5–22)	5 (5–25)	6 (5–22)	8 (5–15)	10 (6–19)	47 (39–93)	25 (10–35)
4≤³	139	39.8	5 (5–21)	5 (5–21)	8 (5–21)	9 (5–22)	12 (5–20)	49 (38–98)	24 (11–35)
Test statistic			KW = 9.728 p = 0.008 3>1,2	KW = 2.356 p = 0.308	KW = 7.367 p = 0.025 3>1,2	KW = 11.130 p = 0.004 3>1,2	KW = 8.476 p = 0.014 3>1>2	KW = 11.357 p = 0.003 3>1,2	KW = 3.581 p = 0.167
Family environment
Peaceful¹	226	64.8	5 (5–20)	5 (5–25)	6 (5–18)	8 (5–14)	10 (5–19)	46 (38–87)	25.5 (10–35)
Indifferent²	14	4.1	7 (5–16)	5 (5–16)	12 (5–21)	10 (5–22)	15 (9–18)	55.5 (43–98)	23 (14–30)
Conflicted³	53	15.1	6 (5–22)	5 (5–15)	10 (5–22)	10 (5–15)	13 (8–19)	53 (39–93)	20 (10–31)
Boring⁴	27	7.7	5 (5–12)	5 (5–12)	9 (5–19)	9 (5–16)	13 (9–20)	49 (39–76)	20 (11–26)
Other⁵	29	8.3	5 (5–13)	5 (5–21)	9 (5–18)	9 (5–11)	12 (5–15)	49 (39–73)	23 (14–29)
Test statistic			KW = 22.161 p ≤ 0.0011 2>3>5,4>1	KW = 4.637 p = 0.327	KW = 79.663 p ≤ 0.001 2>3>4,5>1	KW = 33.141 p ≤ 0.001 2>3>4>5>1	KW = 71.337 p ≤ 0.001 2>4,3>5>1	KW = 42.167 p ≤ 0.001 2>3>4,5>1	KW = 65.495 p ≤ 0.001 1>3>2>4,5
Parental attitude
Authoritative¹	82	23.5	6 (5–22)	5 (5–16)	9 (5–22)	9 (5–22)	13 (7–19)	52 (39–98)	21 (10–30)
Permissive²	105	30.1	5 (5–13)	5 (5–21)	7 (5–18)	9 (5–14)	12 (5–19)	49 (39–73)	24 (12–35)
Democratic³	162	46.4	5 (5–20)	5 (5–25)	6 (5–19)	8 (5–15)	10 (5–20)	46 (38–87)	26 (11–35)
Test statistic			KW = 29.869 p ≤ 0.001 1>2>3	KW = 6.013 p = 0.049 1 > 2,3	KW = 54.829 p ≤ 0.001 1>2>3	KW = 14.582 p = 0.001 1>2>3	KW = 41.826 p ≤ 0.001 1>2>3	KW = 28.573 p ≤ 0.001 1>2>3	KW = 59.131 p ≤ 0.001 3>2>1
Status of using disciplinary methods of the parents in the future
Yes¹	101	28.9	5 (5–12)	5 (5–25)	5 (5–16)	7 (5–13)	9 (5–15)	46 (38–68)	27 (16–35)
Partly²	197	56.5	5 (5–21)	5 (5–21)	7 (5–19)	8 (5–15)	11 (5–19)	48 (39–87)	24 (10–33)
No³	51	14.6	6 (5–22)	5 (5–16)	12 (5–22)	10 (5–22)	14 (9–20)	55 (39–98)	21 (10–30)
Test statistic			KW = 29.999 p ≤ 0.001 3>2>1	KW = 4.324 p = 0.115	KW = 93.261 p ≤ 0.001 3>2>1	KW = 28.023 p ≤ 0.001 3>2>1	KW = 69.622 p ≤ 0.001 3>2>1	KW = 45.299 p ≤ 0.001 3>2>1	KW = 69.457 p ≤ 0.001 1>2>3

x^1,2,3,4,5: Groups that make a difference, Z: Mann-Whitney U Test, H=Kruskal Wallis H Test, p ≤ 0.05.

The variables of the participants who had an indifferent family environment, parents with authoritarian attitudes, and who stated that they would not apply their parent’s disciplinary methods in the future had a statistically significant difference on the median scores for neglect and abuse (p < 0.05) (Table 1). The variables of having an illiterate mother, an unemployed father, and parents with psychiatric disorders made a significant difference to the median scores for neglect and abuse (p < 0.05) (Table 2).

Table 2.

The Mean Scores of CTQ-SF and OHQ-SF by the Characteristics of the Participants’ Parents.

Characteristics of the Participants' Parents	n	%	Physical Abuse	Sexual Abuse	Emotional Abuse	Physical Neglect	Emotional Neglect	CTQ-SF Total Score	OHQ-SF Total Score
Characteristics of the Participants' Parents	n	%	Med (Min-Max)	Med (Min-Max)	Med (Min-Max)	Med (Min-Max)	Med (Min-Max)	Med (Min-Max)	Med (Min-Max)
Mother’s Education Status
Illiterate	40	11.5	5 (5–21)	5 (5–21)	7 (5–18)	9.5 (5–16)	11 (8–17)	50 (39–84)	24.5 (11–35)
Primary school	183	52.4	5 (5–20)	5 (5–25)	7 (5–21)	8 (5–22)	11 (5–20)	48 (38–98)	24 (10–35)
Secondary school	52	14.9	5 (5–13)	5 (5–11)	7 (5–19)	8 (5–15)	12 (8–18)	48 (40–72)	23.5 (12–33)
High school	51	14.6	5 (5–22)	5 (5–16)	6 (5–22)	8 (5–12)	11 (8–19)	47 (39–93)	25 (11–33)
Undergraduate and postgraduate	23	6.6	5 (5–10)	5 (5–7)	7 (5–18)	8 (5–15)	11 (5–14)	49 (39–58)	25 (15–35)
Test statistic			KW = 2992 p = 0.559	KW = 7622 p = 0.106	KW = 0.799 p = 0.939	KW = 13,751 p = 0.008 1 > 3.4>2.5	KW = 1894 p = 0.755	KW = 3927 p = 0.416	KW = 1408 p = 0.843
Mother’s occupation
Housewife	313	89.7	5 (5–22)	5 (5–25)	7 (5–22)	8 (5–22)	11 (5–20)	48 (38–98)	24 (10–35)
Public servant	19	5.4	6 (5–10)	5 (5–7)	8 (5–18)	8 (5–15)	11 (8–14)	49 (39–58)	25 (15–33)
Worker	11	3.2	5 (5–13)	5 (5–9)	5 (5–15)	8 (5–10)	10 (9–14)	47 (41–59)	23 (15–33)
Tradesman/Farmer	6	1.7	7 (5–12)	5 (5–9)	9 (5–15)	10 (5–13)	11 (9–19)	48.5 (47–67)	22.5 (19–26)
Test statistic			KW = 7066 p = 0.070	KW = 1089 p = 0.780	KW = 2658 p = 0.447	KW = 3794 p = 0.285	KW = 1615 p = 0.656	KW = 2526 p = 0.471	KW = 1585 p = 0.663
Mother’s psychiatric disorder
No psychiatric disorder¹	320	91.7	5 (5–20)	5 (5–21)	7 (5–20)	8 (5–16)	11 (5–20)	47.5 (38–87)	24 (10–35)
Anxiety disorders²	16	4.6	6 (5–22)	5 (5–16)	9 (5–22)	9 (6–15)	12 (9–19)	52.5 (45–93)	23 (18–31)
Emotion and mood disorders³	13	3.7	7 (5–21)	5 (5–25)	10 (5–22)	8 (5–22)	12 (9–18)	51 (42–98)	23 (14–29)
Test statistic			KW = 15,692 p = 0.000	KW = 5926 p = 0.052	KW = 12,017 p = 0.002	KW = 5139 p = 0.077	KW = 6541 p = 0.038	KW = 15,798 p = 0.000	KW = 2705 p = 0.259
Father’s education status
Illiterate	6	1.7	6 (5–21)	5.5 (5–21)	8 (5–18)	9 (7–13)	10 (9–12)	49.5 (45–84)	25.5 (10–32)
Primary school	135	38.7	5 (5–20)	5 (5–25)	7 (5–21)	8 (5–22)	11 (7–19)	48 (39–98)	24 (11–35)
Secondary school	61	17.5	5 (5–13)	5 (5–11)	7 (5–17)	9 (5–14)	11 (6–19)	49 (38–70)	24 (14–33)
High school	80	22.9	5 (5–13)	5 (5–15)	7 (5–22)	9 (5–15)	11 (5–18)	48.5 (39–76)	25 (14–35)
Undergraduate and postgraduate	67	19.2	5 (5–22)	5 (5–16)	8 (5–22)	8 (5–12)	11 (5–20)	47 (39–93)	25 (10–35)
Test statistic			KW = 3968 p = 0.410	KW = 6207 p = 0.184	KW = 0.961 p = 0.916	KW = 4318 p = 0.365	KW = 2058 p = 0.725	KW = 2795 p = 0.593	KW = 2091 p = 0.719
Father’s occupation
Unemployed¹	22	6.3	5 (5–16)	5 (5–12)	8 (5–20)	10 (5–16)	12 (8–18)	50.5 (42–76)	21 (11–31)
Public servant²	64	18.3	5 (5–12)	5 (5–16)	8 (5–22)	8 (5–15)	11 (8–18)	47.5 (39–67)	23.5 (10–35)
Worker³	95	27.2	5 (5–22)	5 (5–25)	8 (5–22)	8 (5–22)	11 (6–19)	49 (39–98)	25 (12–33)
Tradesman/Farmer⁴	172	48.2	5 (5–13)	5 (5–21)	7 (5–18)	8 (5–15)	11 (5–20)	47.5 (38–73)	24 (10–35)
Test statistic			KW = 8892 p = 0.031 1 > 2,4,3	KW = 5624 p = 0.131	KW = 3705 p = 0.295	KW = 5700 p = 0.127	KW = 4695 p = 0.196	KW = 5543 p = 0.136	KW = 7015 p = 0.071
Father’s psychiatric disorder
No psychiatric disorder¹	333	95.4	5 (5–21)	5 (5–25)	7 (5–21)	8 (5–22)	11 (5–20)	48 (38–98)	24 (10–35)
Anxiety disorders²	10	2.9	6 (5–13)	5 (5–8)	9 (5–22)	8.5 (5–11)	11 (8–14)	50.5 (44–65)	23.5 (15–30)
Emotion and mood disorders³	6	1.7	6.5 (5–22)	6.5 (5–15)	9.5 (5–22)	9.5 (5–12)	11.5 (10–19)	51 (39–93)	24 (16–29)
Test statistic			KW = 4424 p = 0.109	KW = 6664 p = 0.0363>2.1	KW = 5770 p = 0.056	KW = 1247 p = 0.536	KW = 1255 p = 0.534	KW = 2263 p = 0.323	KW = 0.045 p = 0.978

x^1,2,3: Groups that make a difference Z: Mann-Whitney U Test, H = Kruskal Wallis H Test, p ≤ 0.05.

The participants' total CTQ-SF mean score was found to be 50.01 ± 8.48, while the emotional neglect mean scores were found to be higher; the total OHQ-SF mean score was found to be 23.90 ± 4.77 (Table 3). A weak and significant negative correlation was found between the CSQ-SF and OHQ-SF scores (Table 4).

Table 3.

The Scores of CTQ-SF and OHQ-SF of the Participants.

	Min-Max	X ± sd
Physical abuse	5–22	6.23 ± 2.44
Sexual abuse	5–25	5.83 ± 2.50
Emotional abuse	5–22	8.13 ± 3.68
Physical neglect	5–22	8.20 ± 2.50
Emotional neglect	5–20	11.37 ± 2.55
CTQ-SF total score	38–98	50.01 ± 8.48
OHQ-SF total score	10–35	23.90 ± 4.77

Table 4.

The Relationship between CTQ-SF and OHQ-SF.

	Physical Abuse	Sexual Abuse	Emotional Abuse	Physical Neglect	Emotional Neglect	CTQ-SF Total Score	OHQ-SF Total Score
Physical abuse	—
Sexual abuse	0.506^***	—
Emotional abuse	0.593^***	0.399^***	—
Physical neglect	0.355^***	0.158^**	0.432^***	—
Emotional neglect	0.367^***	0.153^**	0.610^***	0.491^***	—
CTQ-SF total score	0.786^***	0.637^***	0.812^***	0.644^***	0.630^***	—
OHQ-SF total score	−0.257^***	−0.075	−0.480^***	−0.288^***	−0.497^***	−0.350^***	—

p < 0.005^*, p < 0.01^**, p < 0.001^***.

Qualitative Results

25 people participated in this part of the research and their sociodemographic characteristics are given in Table 5. Six themes and 17 sub-themes were obtained from the interviews (Table 6).

Table 5.

Demographic Characteristics of Qualitative Section Participants (N = 25).

Participants	Gender	Age	Income Level	Family Structure	Number of Siblings	Parental Attitude	CTQ-SF Total Score	OHQ-SF Total Score
P-1	Female	21	Income>Expenses	Extended	10	Permissive	67	25
P-2	Female	20	Income<Expenses	Extended	3	Authoritative	40	17
P-3	Male	18	Income=Expenses	Extended	3	Authoritative	56	20
P-4	Female	22	Income>Expenses	Broken	2	Democratic	45	26
P-5	Female	19	Income>Expenses	Broken	2	Authoritative	39	6
P-6	Female	19	Income=Expenses	Extended	3	Permissive	55	11
P-7	Female	22	Income<Expenses	Nuclear	9	Authoritative	62	17
P-8	Female	19	Income<Expenses	Nuclear	5	Authoritative	93	14
P-9	Male	22	Income=Expenses	Extended	8	Permissive	40	13
P-10	Female	19	Income<Expenses	Nuclear	2	Permissive	33	23
P-11	Female	21	Income=Expenses	Nuclear	3	Authoritative	55	11
P-12	Female	24	Income=Expenses	Nuclear	1	Authoritative	40	19
P-13	Male	23	Income<Expenses	Nuclear	1	Authoritative	57	19
P-14	Female	21	Income<Expenses	Nuclear	3	Authoritative	69	21
P-15	Male	20	Income=Expenses	Nuclear	8	Democratic	44	17
P-16	Female	21	Income=Expenses	Extended	7	Authoritative	52	24
P-17	Female	21	Income=Expenses	Nuclear	1	Democratic	41	26
P-18	Male	19	Income=Expenses	Nuclear	1	Democratic	52	24
P-19	Female	19	Income=Expenses	Nuclear	-	Democratic	77	24
P-20	Female	20	Income=Expenses	Extended	4	Permissive	42	21
P-21	Female	21	Income=Expenses	Nuclear	1	Democratic	53	22
P-22	Female	22	Income=Expenses	Extended	2	Authoritative	58	26
P-23	Male	21	Income<Expenses	Extended	6	Permissive	44	25
P-24	Female	21	Income=Expenses	Broken	2	Permissive	58	26
P-25	Female	21	Income<Expenses	Nuclear	6	Authoritative	60	15

Table 6.

Thematic framework.

Theme	Sub-Theme
1. Childhood trauma	1.1 emotional abuse and neglect
	1.2 physical abuse and neglect
	1.3 sexual abuse
	1.4 other trauma
2. Effects of childhood trauma	2.1 reactions to childhood trauma
	2.2 hiding the trauma due to fear of stigmatization
	2.3 consequences of childhood trauma
3. Coping with childhood trauma	3.1 striving to be perfect to be loved
	3.2 making sense of childhood trauma later
	3.3 coping methods
4. Growing up after trauma	4.1 lasting effects of trauma
4. Growing up after trauma	4.2 post-traumatic growth
5. Future self-parenting perception	5.1 positive experiences and reflection on parenting perception
	5.2 negative experiences and reflection on parenting perception
	5.3 fear of parenting
6. Empowerment through nursing education	6.1 choosing nursing and re-interpreting the trauma from a nurse’s point of view
6. Empowerment through nursing education	6.2 healing through nursing

Theme 1. Childhood Trauma

Participants were asked to create metaphors for their traumatic experiences in childhood. Participants often compared childhood trauma to darkness and rain (Figure 1):

“I would liken it to a swamp, because a swamp draws in all the dirt. When something happens, I am in that swamp, I sink entirely and it covers me up. I move on as if nothing happened, but what I buried inside me remains there.” (P-8)

“I can liken it to the painting The Scream. I scream, I cry, but no one hears it on the outside, just like in that painting” (P-17)

Figure 1.

The metaphors of childhood traumatic experiences.

Sub-theme I: Emotional Abuse and Neglect

Some of participants had experienced emotional abuse and neglect in childhood, including being yelled at, scolded, insulted, belittled, neglected, disliked, and treated differently from their siblings:

“There was no room for error in our family. Not even for a very small mistake…For example, if I accidently spilled salt on the table, I would be yelled at, scolded, and insulted.” (P-13)

“My father only cares about his own life and doesn't care about anyone else. Therefore, it felt like a part of me was always missing. I was never complete. The void my father created has never been filled.” (P-3)

“Because of the culture and the traditional family structure, we did not grow up with a lot of love from our mother and father; I feel the lack of this. I wish they had grown up in a loving family.” (P-24)

Sub-theme II: Physical Abuse and Neglect

This sub-theme included the statements of participants who had experienced physical abuse, violence, and neglect:

“I had a fight with my friend when I was a kid. When my father found out about this, he beat me very badly instead of giving me advice; I remember my nose bleeding and then I passed out.” (P-3)

“When my mom and dad got into a fight, I would pull my dad away from my mom as much as I could to somewhere else and then lock the door. I remember that I kept sharp tools such as scissors and knives in secret places in the house, so that my father could not find them.” (P-17).

“My mother used to send us to Qur'an lessons. Sometimes I wouldn't go so that I could play with my friend. Then she would take a slipper and beat me.” (P-9)

Sub-theme III: Sexual Abuse

This sub-theme included the experiences of the participants who were exposed to sexual abuse during their childhood. Participants who were sexually abused by a family member stated that the abuse was repetitive:

“We were playing in the pool with my aunt's husband. I was a kid; my breasts were just starting to grow. I felt him squeezing them. He squeezed them pretty tightly and it hurt a lot. I was so scared…Another day, when everyone was together, I went to the toilet. When I came out, he forced me into a corner and did the same thing again.” (P-19) (Her voice trembles and she cries).

Some participants reported being sexually abused by an adult other than family members:

“He was a man I didn't know...He was a tradesman, it happened in his shop. He hugged and touched me but I did not understand what is happening because I was child.. I was so embarrassed.” (P-1)

Sub-theme IV: Other Trauma

This sub-theme included experiences such as loss of a parent, war and migration, having to work at an early age, and taking on the role of a parent. These experiences were not included in the scope of neglect and abuse but were considered as negative life events:

“My mother's death and my father marrying someone else…was a complete disappointment. I wasn't aware of many things at the time, but the worst thing I remember is my mother's death.” (P-10)

“The gunshots, the bombs, the corpses we saw, the blood…A missile hit our house, one corner of the house was destroyed, I can't tell you the fear I had there.” (P-23)

“I had a difficult childhood. I started working when my feet could reach the brakes of the tractor, that is, when I was 5–6 years old. I didn't even have time to play hide-and-seek, blindfold, or those kinds of games with my friends because of work.” (P-13)

Theme 2. Effects of Childhood Trauma

There are three sub-themes under this theme: “reactions to childhood trauma”, “hiding the trauma due to fear of stigmatization” and “consequences of childhood trauma” (Table 6).

Sub-theme I: Reactions to Childhood Trauma

The participants' reactions to traumatic experiences were crying, feeling bad, longing for their mother, feeling of hate, and poor communication skills:

“When I was being sexually harassed…I cried all night long. I had a tendency to cry out of nowhere.” (P-8)

“When my father started using violence, I was afraid at first. After getting over that fear, I felt hatred and anger. My hatred was suppressing my sadness.” (P-17)

Sub-theme II: Hiding the Trauma due to Fear of Stigmatization

The participants hid their trauma due to being a foreigner, having a parent with an alcohol problem, and fearing the family’s reaction to sexual harassment:

“My family wouldn't believe my cousin was sexually harassing me. They thought that my cousin wouldn't do it and said to me that I had misunderstood it. That's why I always hid it.” (P-8)

“When I went out, I felt like everybody knew my father was an alcoholic. I thought everyone was looking at me in a bad way.” (P-17)

“When I say I’m Syrian, they look at me in a bad way. They say you're a coward, you left your homeland, why didn't you fight…That's why I don't tell anyone that I’m Syrian at first.” (P-23)

Sub-theme III: Consequences of Childhood Trauma

The participants felt sad, angry, lonely, exhausted, lacked self-confidence and had problems adapting as a result of trauma:

“I didn't grow up as a confident kid. I got used to being quiet. If I’d been a child who expressed their thoughts about a situation that upset me when I was younger, I wouldn't be like this now. I still keep quiet just like when I was a kid.” (K-12)

“I was criticized so much as a child that I have little patience for being criticized now. I just tell the other person that they are right, but I’m so passive-aggressive. I am very angry inside.” (K-22)

Theme 3. Coping with Childhood Trauma

There are three sub-themes under this theme: “striving to be perfect to be loved”, “making sense of childhood trauma later” and “coping methods” (Table 6).

Sub-theme I: Striving to Be Perfect to Be Loved

The participants thought that they would be loved by their parents if they were perfect, if they tried to not upset their parents, and if they put their families before themselves:

“When I was a child, I didn’t think I should play games, because I had to be perfect. When I kept quiet and didn't play, people called me a very mature and quiet child. I used to think that I had to conform to that maturity.” (P-1)

“After my sister's death, my strong mother disappeared and was replaced by a person who needed to be loved. At that time, I felt like I had to help my family. I’d prepare breakfast in the morning, tidy up around the house and then leave. It was hard, but I couldn't get rid of that sense of responsibility because I thought my family expected that from me.” (P-1)

Sub-theme II: Making Sense of Childhood Trauma Later

The participants tried to make sense of their childhood trauma as they got older, and they felt bad, sad, angry, and a sense of being “incomplete” during this process:

“I was treated for enuresis as a child and was told it was psychological. I didn't think about the reason at the time, but now as I study nursing, I realize that I knew then that my stepmother was not my real mother. Now I understand that this realization caused enuresis.” (P-6)

“I couldn't understand that the sexual abuse I was exposed to in my childhood was a bad thing. But as I got older, I realized it. When I started to make sense of it, I felt very bad, I started to resent it. I wish it had never happened.” (P-19) (Cries).

Sub-theme III: Coping Methods

The participants used coping methods such as normalizing, avoiding the problem, giving up, reasoning, and self-deception:

“I’ve had to deal with sexual harassment and similar incidents…because sexual harassment is unfortunately a part of life now. You experience it in childhood and young adulthood as well. It's almost inevitable when you're a woman.” (P-1)

“My father always beat me. When I was in the third grade, he beat me badly in public. I learned a lesson there. From then on, I tried to approach everything in a normal way, whether it was beating or a joyful occasion.” (P-3)

“The person who abused me when I was a child was our neighbour's son. Our families were visiting each other. After he assaulted me, I did not go to their place again. I tried to cope like this by running away.” (P-16)

“My parents hitting me is also for my own good. They were like this because of the way they were raised; one learns to be a parent from the way one is raised.” (P-9)

Theme 4. Growing Up After Trauma

There are two sub-themes under this theme: “lasting effects of trauma” and “post-traumatic growth” (Table 6).

Sub-theme I: Lasting effects of trauma

Trauma had effects on the participants such as forgetfulness, withdrawal, loss of confidence, crying, and rumination in adulthood:

“I don't want to remember my childhood and I get angry when I do. When I think about my childhood, I immediately feel sad and hurt.” (P-17) (Cries).

“My mother and father never showed me love. When I was little, I needed someone to trust. Since I didn’t have love and trust, I look for happiness in other things, in friends. That's why I'm living an unhappy life right now, unfortunately.” (P-9)

“When I see scenes of sexual abuse on TV, I feel so bad and I almost cry.” (P-19) (Her voice trembles).

Sub-theme II: Post-traumatic growth

Some participants experienced post-traumatic psychological growth and empowerment:

“You may think, ‘This is the worst thing that could happen to me,’ but then something worse happens. It’s always good not to give up and to respond by being stubborn. This is how I have overcome the worst things that happened to me. I say, ‘Tomorrow the sun will rise again, everything will be alright.’” (P-23)

“There are good aspects of starting to work at an early age; it made me more mature and gave me strength in life.” (P-13)

Theme 5. Perceptions of Future Parenting

There are three sub-themes under this theme: “positive experiences and perceptions of parenting”, “negative experiences and perceptions of parenting” and “fear of parenting” (Table 6).

Sub-theme I: Positive experiences and perceptions of parenting

Some participants stated that they liked that their parents respected them, that problems could be solved by talking, and that they had been shown love and care in their childhoods:

“In the future, I want to be like my mother and father, because I think I was raised well. They did their best. I would like to do the same for my child.” (P-18)

The participants were asked to create metaphors by comparing their happy childhood experiences to something (Figure 2). They often compared happiness to the sun:

“Happiness is like the sun because the sun eliminates the darkness. After a long time, it begins to rise from the deepest point of darkness.” (P-23)

Figure 2.

The Metaphors of Happiness.

Sub-theme II: Negative experiences and perceptions of parenting

This sub-theme included the negative parenting attitudes and punishment experienced by the participants, and their thoughts about their own future parenting:

“Because I went to work alone as a little child, sometimes I couldn't keep up with the work. When I couldn't keep up, my father would punish me with anger, insults, and beatings.” (P-13)

“My mom used to put hot pepper in our mouths when we had a lot of fights. But it was no use. When she would leave, we would keep on fighting. That punishment did not teach us a lesson.” (P-17)

“When I was little, I was terrified that I would be punished. If I was even a little late to come back home, I would be punished because I was a girl.” (P-14)

Sub-theme III: Fear of parenting

The participants feared becoming a parent after the traumatic experiences:

“I don't want to be a parent in the future. With all the children in the world, there is no need for new ones. Maybe this is because I’m exhausted from all these years that I had to be a parent to my own family.” (P-1)

Theme 6. Empowerment through Nursing Education

There are two sub-themes under this theme: “choosing nursing and re-interpreting the trauma from a nurse’s point of view” and “healing through nursing” (Table 6).

Sub-theme I: Choosing nursing and re-interpreting the trauma from a nurse’s point of view

This sub-theme included findings about re-interpreting childhood experiences through nursing education:

“Nursing education made it easier for me to understand the problems I had in childhood. I couldn't understand them before, but now I can understand them more easily.” (P-17)

“Nursing education and the paediatric nursing class made me realize the wrong things that are traditionally done to babies. If I hadn’t received this education, I would do the wrong things my mother did. But after nursing education, I have learned how to take care of a child.” (P-12)

“In particular, the child health, child mental health, and psychiatric nursing courses made a great contribution. I learned that the child also has mental health needs, that the childhood period affects adulthood a lot, and that it’s necessary to care about children's thoughts.” (P-4)

Sub-theme II: Healing through nursing

This sub-theme included findings related to the impact of nursing on childhood trauma and happiness:

“Nursing is a special concept, a special profession. Due to the nature of the profession, you start to care about yourself and it’s made me feel like I’m an important person. I say I was quiet as a child, but now I can speak up because I care about myself. I’m an important person, I deal with people, I treat them, I give them medicine, I relieve their pain; I’m in their prayers. This is why nursing education makes people feel valuable.” (P-12)

“Nursing has made me think more positively and have a more positive outlook on life. Even though I am psychologically worn out, it makes me think that there are better days to come.” (P-14)

Discussion

The aim of this mixed methods research was to examine happiness and CTE, which are significant issues child health, among nursing students, who will themselves inevitably affect many lives in the future. The participants had most frequently been subjected to emotional neglect in childhood. Studies have shown that emotional neglect is a common childhood problem (Dong et al., 2021; Kürtüncü et al., 2020). How parenting is approached depends on culture, religion, traditions and customs, and corporal punishment is sometimes socially accepted and deemed necessary to discipline a child (Elghossain et al., 2019). The individuals in the present study who had been exposed to emotional and physical abuse in childhood had experience behaviours similar to those in the literature (Correia et al., 2019). Some participants stated that they were beaten by their parents because they did not want to attend religious lessons, while others stated that they did not receive love as a result of cultural traditions. These experiences are striking examples of the impact of culture, religion, and customs on child-rearing. The physical and emotional abuse and neglect experienced by the participants clearly depended on the culture they grew up in, where violence was seen as a viable discipline tool. This situation is normalized through its acceptance by a majority of society, and those exposed to habitual violence pass this on to following generations.

The study found a significant negative correlation between childhood trauma and happiness levels. This finding is consistent with other findings in the literature (Diette et al., 2018; Oshio et al., 2013). The experience of childhood trauma makes it difficult to achieve happiness in adulthood. Happiness is a multifaceted and subjective concept. It is influenced by many factors, from the sociodemographic characteristics of the individual to their attitudes toward life (Diette et al., 2018); one of these is factors is CTE.

When CTE was examined by gender, the male students had been exposed to more physical neglect in childhood. Similarly, studies have reported that physical neglect was a common form of CTE, and that men were more exposed to it at a higher level (Üstüner Top & Çam, 2021). In the qualitative part of the study, the female participants stated that they were exposed to more pressure within the family compared to their brothers, that cultural tradition increased the pressure, and that gender inequality took precedence over education. This difference may be because men typically avoid reporting negligence, and that women express their feelings and experiences more easily than men. Today, as a result of patriarchal family structures, gender inequality is an ongoing problem that affects all areas of life (Aslan & Demirci, 2019). Studies have shown that women face more pressure in their childhood and are sometimes unable to continue their education (Aslan & Demirci, 2019). The oppressive upbringing of women and the deprivation of education lead them to engage in similar behaviours when they become mothers, thus perpetuating the cycle of trauma in their children. The current study found that students with an illiterate mother were more likely to experience physical neglect during childhood. The literature has reported that students whose parents have low education levels are more traumatized in childhood (Akpınar et al., 2019). In order to raise children who are both physically and mentally healthy, women themselves must first be healthy and educated. A parent with a low education level may be incompetent in child-rearing and child health, have difficulty in establishing healthy communication, and exhibit behaviors that harm the child (Kürtüncü et al., 2020).

When CTE was examined in terms of the employment status of parents, the students who had an unemployed father were found to have suffered more physical abuse in their childhood. It has been reported that there is no significant relationship between the profession of the parents and CTE (Taşar et al., 2018). An unemployed father may spend more time with the child at home, and there may be economic difficulties, and a harsher parental attitude due to the stress of being unemployed. The participants with a low income were more traumatized in their childhood, and they had been particularly exposed to physical neglect and emotional abuse. Studies have shown that those with a low income are more likely to have suffered neglect and abuse in their childhood (Kürtüncü et al., 2020; Üstüner Top & Çam, 2021). A low socioeconomic level is a risk factor for trauma in terms of how it affects family dynamics, increases stress, limits opportunities, and leads to familial needs not being adequately met (Özçevik & Güneş, 2019). Economic issues may also result in children starting to work at an early age. As a matter of fact, in the qualitative part of the research, some participants stated that starting work at a young age due to having a large family and financial need was traumatic for them. They also stated that their educational needs could not be met by their parents. The study found that participants with four or more siblings were more traumatized during childhood, and they had experienced more physical and emotional abuse. The literature has demonstrated that having a high number of siblings increases CTE (Kürtüncü et al., 2020). The increase in the number of children in the family may result in trauma by leading to increased familial needs, economic problems and care burden, and decreased time and attention allocated to each child. In support of this finding, the participants stated that taking on the parenting role for their parents and siblings was a traumatic experience.

Participants who had indifferent and authoritarian parents were more traumatized in childhood. Those who were brought up with an authoritarian parenting attitude were also more unhappy. Studies have revealed that individuals with indifferent (Kürtüncü et al., 2020) and authoritarian parents (Baydemir et al., 2014) are more traumatized in childhood and that happiness increases with democratic parenting attitudes (Mohammadi & Firoozi, 2016). The participants who stated that they would not use their parents’ disciplinary methods when they become parents were more traumatized and unhappy in childhood. This finding indicates that parental attitudes may affect children’s future feelings. In this respect, in the qualitative part, the participants who were raised with positive attitudes and enjoyed happier experiences had a more positive perception of parenting. Participants who were brought up with negative attitudes by their parents and who had experiences of punishment stated that they would not use their parents' methods with their children in the future. Similarly, in a study conducted with mothers who were traumatized in childhood, the mothers wanted to be better than their own parents and learned from negative childhood experiences (Woods et al., 2018). Although it is a common view that child maltreatment and parental attitudes are passed down from generation to generation (Woods et al., 2018), the participants in the current study who were exposed to the negative attitudes of their parents had an opposite view. This situation may have been caused by the fact that nursing has adopted a humanist philosophy, and that there are various courses in the fields of child health and mental health in the nursing curriculum. In the interviews, the participants who were traumatized in their childhood stated that they did not want to become parents and they were afraid of doing so. The participants who were afraid of becoming a parent were worried about projecting their stress onto their children. Another study also found that individuals were afraid of becoming a parent after their own experiences of trauma (Mert & Aksoy, 2018).

In addition to the fear of becoming a parent, those who were traumatized in childhood had more psychiatric disorders and had lower levels of happiness. Studies have revealed that individuals with psychiatric disorders had experienced more trauma in childhood (Üstüner Top & Çam, 2021; Wu et al., 2018) and that psychiatric disorders were found to have a negative correlation with happiness (Burns & Crisp, 2022). When psychiatric disorders cannot be managed, they can reduce the number of positive emotions felt by the individual and lead them to feel unhappy. In the qualitative part, the participants stated that they coped with traumatic experiences through normalizing them, avoiding them, suppressing their emotions, keeping busy, and rationalization. Similarly, participants in other studies coped by avoidance, suppressing their emotions, normalizing (Freer et al., 2010) and finding other pursuits (Perry & Cuellar, 2021). On the other hand, the participants who were not sufficiently loved and cared for by their parents in their childhood stated that they thought their parents would love them if they were perfect. For this reason, they made an effort to be perfect during their childhood, tried not to upset their parents, and put the needs of their family members before their own needs. Children have a tendency to seek the reasons for negative events in themselves and to feel guilty about these events. In this context, it is a natural consequence of the way children think that they find themselves responsible for traumatic incidents, and think that they will be loved if they are perfect.

Some participants who were traumatized in their childhood experienced distrust towards their surroundings, introversion, social isolation, obsession, posttraumatic reactions, and rumination in adulthood. Trauma originating from the family has lasting effects. Other studies have also found that participants experienced rumination (Forde & Duvvury, 2020) and social isolation (Mert & Aksoy, 2018).

Participants in the current study whose mothers had a psychiatric disorder were more traumatized in childhood. In particular, those whose mothers had mood disorders were more exposed to physical and emotional abuse. In the literature, having parents with psychopathological features was stated as a risk factor for CTE (Felitti et al., 2019). This is due to the effects of the mental disorder, neglect of self-care and child care, and deterioration in emotions, thoughts, perceptions, and impulse control.

Another aspect of the study is that some participants in the qualitative part of the study who reported their childhood sexual abuse there had not reported it in the quantitative part. This is an advantage of mixed methods research. The perpetrators of sexual abuse in these cases were family members or someone they knew. The abuse by family members had occurred repeatedly. Similar to the current study, another study reported that the perpetrators of child sexual abuse were from the environment and family and that the abuse was repetitive (Correia et al., 2019). It can be argued that when an abuser has constant access to the child due to being in their immediate environment, and can spend a prolonged length of time with them, then this leads the abuse to be repeated. The participants were not able understand sexual abuse when they were children, but they attributed meaning to it as they got older. Research has shown that participants were not able to make sense of sexual abuse in childhood, and only started to understand it as they got older (Forde & Duvvury, 2021). This stems from the cognitive abilities of the child at the age when that the sexual abuse occurs, and a lack of knowledge about good and bad touching.

The qualitative part of the study, which complemented the quantitative part, determined that the participants were also traumatized due to experiences of parental loss, chronic illness, war, and starting to working at an early age, as well as from neglect and abuse. Although it is common to examine CTE within the scope of neglect and abuse, negative life events can also cause trauma. The participants stated that their lives had changed after the loss of a parent, that the surviving parent tried to help the child get over the loss, and that they were traumatized due to this loss. Similarly, children have reported in other studies that when they saw their parents sick, they felt sad (Faugli et al., 2020), felt incomplete due to the loss of a parent, and that the surviving parent assumed the role of the deceased partner (Köseoglu & Yıldız, 2018). Some participants, who had witnessed the war in their country and had to migrate to Turkey, stated that they were traumatized by this experience. While witnessing the images of war and leaving one’s home and country is a traumatic experience in itself, poor living conditions, early start to working life, and stigmatization after immigrating to Turkey also caused trauma. In a study conducted with refugee children, children stated that they had been exposed to emotional and physical violence and excluded by their peers at school (Ersoy & Turan, 2019).

In the qualitative part, the participants talked about reassessing their trauma from a nursing perspective and healing their traumatized psyches through nursing. They stated that they were empowered through nursing education, that the knowledge they had learned made them happy, and that they used the power of nursing education to heal their own wounds, even if they had been traumatized as a child. Nursing is a profession that combines science, philosophy and art; it focuses on human care, and it is inevitable that positive effects will be observed when this concept is present (Alligood, 2017). The strength and spiritual satisfaction the participants gained in nursing helped them to heal from their negative experiences, and providing care to patients increased their positive feelings.

The study found that after taking some courses, the participants recognized their own childhood trauma and used the information they had learnt to manage them. The nursing curriculum includes courses such as psychiatric nursing, pediatric nursing, child mental health, and stress management. These courses in the nursing curriculum may have effects on students, allowing them to draw conclusions about themselves, which indirectly leads to the occurrence of healing. Previous studies have reported that self-awareness and communication techniques courses in nursing curriculum improved communication and stress management skills (Demir & Ercan, 2019), assertiveness, and self-esteem (Ünal, 2012). A child and women’s rights course helped develop positive attitudes toward gender roles and reporting child abuse (Turan, 2022), and the pediatric nursing course raised awareness of child abuse (Turan & Söyünmez, 2022). Courses in the nursing curriculum help students develop coping strategies, learn about mental health, and monitor and improve their own mental health. In addition, the fact that the information acquired in nursing education can be used in other individuals' daily lives can make people in the student’s social circle want to receive information from them, making them feel valuable. All these factors enhance individuals' self-confidence, contribute to personal and social development, and reinforce positive experiences.

Limitations and Suggestions for Future Studies

This study has some limitations. The self-report nature of the research data and the retrospective evaluations of childhood may have been affected by the students’ level of recall. Due to the qualitative part of the research, the results are limited to the individuals participating in the research. This study was conducted at only one university and for only one nursing education program. We recommend a multi-centre study using the same method. The study found that some courses in the nursing curriculum and enjoying providing patient care had a healing effect. However, further research is needed to determine the impact of nursing education on students' personal development and self-confidence, as well as on their professional development. To determine the impact of nursing education on CTE, it is recommended that longitudinal studies be conducted throughout undergraduate education. We recommend that experimental studies be conducted on the coping skills and psychological problems of students with CTE. In this study, the participants described only the positive effects of their nursing education experience, because the research was carried out on a voluntary basis. Some of students responded positively to the emailed invitation, but when called by the researcher they refused to participate in the research in order not to have to remember their traumatic experiences. The fact that some students did not want to participate in the research and that voluntary interviews were conducted resulted in only positive feedback.

For students who cannot benefit from nursing education and feel exhausted because of their CTE, it may be beneficial to conduct CTE screenings and to expand trauma and psychological support units in schools.

Conclusion

This mixed methods research, found that CTE may occur in many situations other than typical experiences of neglect and abuse, that it is related to gender, parental attitude, education, economic level and mental health, and that it affects the level of happiness in adulthood. Given that nursing students are the nurses of the future and the necessity of therapeutic use of self in patient-nurse relationship, that CTE influences patient care and having awareness of CTE is important. The nursing curriculum is indirectly effective in teaching this. The nursing education curriculum contains information about trauma and the nursing approach to trauma-exposed patients. However, there is no course in the nursing curriculum that directly addresses the trauma of nursing students. The nursing students made inferences about their own CTEs from the information given in the course on trauma, trauma-related disorders, and nursing care. It can therefore be said that the nursing education indirectly provided self-awareness about their own CTE. Some of the students were able to better adjust to these experiences by gaining an awareness of their CTE and developing coping skills through their nursing education. However, it cannot be said that all the nursing students with traumatic experiences were affected positively by nursing education at the same level. This is indicated by the fact that some students did not agree to participate in the research because they did not want to remember their CTE. It was thus impossible to shed light on the experiences of students who could not cope with their trauma. CTE should be studied in nursing schools, psychosocial support should be offered to students who need support, and training should be organized to increase nurses’ satisfaction and develop coping methods through appropriate courses that are integrated into the nursing curriculum.

Supplemental Material

Supplemental Material - Childhood Traumatic Experiences and Happiness of Nursing Students: A Mixed Methods Study

Supplemental Material for Childhood Traumatic Experiences and Happiness of Nursing Students: A Mixed Methods StudySupplemental Material by Selin Söyünmez, and Hilal Seki öz in Child Maltreatment

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Selin Söyünmez

Supplemental Material

Supplemental material for this article is available online.

References

Akpınar

R. B.

Küçükoğlu

Apay

S. E.

Karaca

Balcı

(2019). Childhood abuse experences, gender perceptions, violence tendencies and violenit situations of university students. Atatürk University Journal of Faculty of Letters, 19(62), 409–430.

Alligood

M. R.

(2017). Nursing theorists and their work-e-book. Elsevier Health Sciences.

Aslan

Demirci

Ç.

(2019). Gender inequality and domestic violence interaction: A qualitative research on university students. Business & Management Studies: An International Journal, 7(5), 3027–3046. https://doi.org/10.15295/bmij.v7i5.1382

Baloğlu

Göv

(2019). Psikososyal önleyici destek programı. Retrieved March 2020, from http://orgm.meb.gov.tr/psikososyaldijitaldestek/pdf/psikososyalonleyicikitab.pdf

Baydemir

Acıkgoz

Derince

Kaya

Ongun

Kok

(2014). The effect of childhood trauma life on self-esteem in school of health students in a province of Western Turkey. Life Science Journal, 11(11), 749–758. https://doi.org/10.7537/marslsj111114.137

Bernstein

D. P.

Stein

J. A.

Newcomb

M. D.

Walker

Pogge

Ahluvalia

Stokes

Handelsman

Medrano

Desmond

Zule

(2003). Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse & Neglect, 27(2), 169–190. https://doi.org/10.1016/S0145-2134(02)00541-0

Braun

Clarke

(2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101.

Burns

R. A.

Crisp

D. A.

(2022). Prioritizing happiness has important implications for mental health, but perhaps only if you already are happy. Applied Research in Quality of Life, 17(1), 375–390. https://doi.org/10.1007/s11482-020-09891-6

Clark

C. S.

Aboueissa

A. E. M.

(2021). Nursing students’ adverse childhood experience scores: A national survey. International Journal of Nursing Education Scholarship, 18(1).

10.

Correia

C. M.

Gomes

N. P.

Diniz

N. M. F.

Andrade

I. C. S. D.

Romano

C. M. C.

Rodrigues

G. R. S.

(2019). Child and adolescent violence: Oral story of women who attempted suicide. Revista Brasileira de Enfermagem, 72(6), 1450–1456. https://doi.org/10.1590/0034-7167-2017-0814

11.

Creswell

J. W.

Clark

V. L. P.

(2017). Designing and conducting mixed methods research. Sage publications.

12.

Demir

Ercan

(2019). The effect of a self-awareness and communication techniques course on the communication skills and ways of coping with stress of nursing students: An interventional study in Ankara, Turkey. J Pak Med Assoc, 69(5), 659–665.

13.

Diette

T. M.

Goldsmith

A. H.

Hamilton

Darity

(2018). Adult happiness and prior traumatic victimization in and out of the household. Review of Economics of the Household, 16(2), 275–295. https://doi.org/10.1007/s11150-016-9334-0

14.

Doğan

Çötok

N. A.

(2011). Adaptation of the short form of the Oxford happiness questionnaire into Turkish: A validity and reliability study. Turkish Psychological Counseling and Guidance Journal, 4(36), 165–170.

15.

Dong

(2021). Relationship of childhood trauma, psychological resilience, and family resilience among undergraduate nursing students: A cross‐sectional study. Perspectives in Psychiatric Care, 57(2), 852–859. https://doi.org/10.1111/ppc.12626

16.

Elghossain

Bott

Akik

Ghattas

Obermeyer

C. M.

(2019). Prevalence of key forms of violence against adolescents in the arab region: A systematic review. Journal of Adolescent Health, 64(1), 8–19. https://doi.org/10.1016/j.jadohealth.2018.08.016

17.

Ersoy

A. F.

Turan

(2019). Social exclusion and gangs in asylum seeker and immigrant students. Third Sector Social Economic Review, 54(2), 828–840. https://doi.org/10.15659/3.sektor-sosyal-ekonomi.19.05.1103

18.

Faugli

Kufås

Haukland

Kallander

E. K.

Ruud

Weimand

B. M.

(2020). ‘I have cried a lot’: A qualitative study on children experiencing severe parental illness. Scandinavian Journal of Caring Sciences, 35(4), 1196–1206. https://doi.org/10.1111/scs.12938

19.

Felitti

V. J.

Anda

R. F.

Nordenberg

Williamson

D. F.

Spitz

A. M.

Edwards

Koss

M. P.

Marks

J. S.

(2019). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) study. American Journal of Preventive Medicine, 56(6), 774–786. https://doi.org/10.1016/j.amepre.2019.04.001

20.

Forde

Duvvury

(2020). Survivor‐led relational psychotherapy and embodied trauma: A qualitative inquiry. Counselling and Psychotherapy Research, 21(3), 633–643. https://doi.org/10.1002/capr.12355

21.

Freer

B. D.

Whitt-Woosley

Sprang

(2010). Narrative coherence and the trauma experience: An exploratory mixed-method analysis. Violence and Victims, 25(6), 742–754. https://doi.org/10.1891/0886-6708.25.6.742

22.

Gallop

McKeever

Toner

Lancee

Lueck

(1995). The impact of childhood sexual abuse on the psychological well-being and practice of nurses. Archives of Psychiatric Nursing, 9(3), 137–145.

23.

Girouard

Bailey

(2017). ACEs implications for nurses, nursing education, and nursing practice. Academic Pediatrics, 17(7), S16–S17.

24.

Hills

Argyle

(2002). The Oxford happiness questionnaire: A compact scale for the measurement of psychological well-being. Personality and Individual Differences, 33(7), 1073–1082. https://doi.org/10.1016/S0191-8869(01)00213-6

25.

Karakaş

Çingöl

(2021). The relationship of childhood trauma experiences with cognitive distortions and sense of coherence in nursing students. Perspectives in Psychiatric Care, 58(4), 1546–1553. https://doi.org/10.1111/ppc.12962

26.

Kaya

(2014). The adaptation of the brief screening version of childhood trauma Questionnaire into Turkish [unpublished master thesis]. Muğla Sıtkı Koçman University.

27.

Kim

G. S.

Yoon

Y. J.

(2021). The influence of academic self-efficacy, self-resilience, and department satisfaction on subjective happiness of nursing students. Journal of Convergence for Information Technology, 11(1), 244–253.

28.

Köseoglu

S. A.

Yıldız

(2018). Life experiences of single-parent children. HAYEF: Journal of Education, 15(2), 80-99. https://doi.org/10.26650/hayef.2018.15.2.0009

29.

Kürtüncü

Yıldız

Kurt

(2020). The effect of childhood traumatization on close relationships of first year university students. Journal of Higher Education & Science, 10(1), 103–113. https://doi.org/10.5961/jhes.2020.372

30.

Kwon

Y. C.

Jeong

C. Y.

Seo

Y. S.

(2018). Validation of a path model for subjective happiness of nursing students. Journal of Digital Convergence, 16(1), 197–206.

31.

Maunder

R. G.

Peladeau

Savage

Lancee

W. J.

(2010). The prevalence of childhood adversity among healthcare workers and its relationship to adult life events, distress and impairment. Child Abuse & Neglect, 34(2), 114–123.

32.

Mert

Aksoy

S. D.

(2018). Working with women in Turkey exposed to childhood sexual abuse. Public Health Nursing, 35(6), 517–525. https://doi.org/10.1111/phn.12547

33.

Mohammadi

Firoozi

(2016). The relationship between parenting styles and happiness with the mediating role of emotional intelligence. International Journal of Medical Research & Health Sciences, 5(9), 667–673.

34.

Oshio

Umeda

Kawakami

(2013). Childhood adversity and adulthood subjective well-being: Evidence from Japan. Journal of Happiness Studies, 14(3), 843–860. https://doi.org/10.1007/s10902-012-9358-y

35.

Özçevik

Güneş

Ö. D.

(2019). Nursing students' childhood trauma according to some sociodemographic characteristics. Journal of Public Health Nursing, 1(1), 28–42.

36.

Peplau

H. E.

(1952). Interpersonal relations in nursing. New York: Putnam.

37.

Perry

Cuellar

M. J.

(2021). Coping methods used by college undergraduate and graduate students while experiencing childhood adversities and traumas. Journal of Child & Adolescent Trauma, 15(2), 451–459. https://doi.org/10.1007/s40653-021-00371-z

38.

Taşar

M. A.

Özcan

Ç.

Saç

R. Ü.

(2018). The evaluation of childhood traumatic experiences in a low-income district. Medical Journal of Bakırköy, 14(2), 198–203. https://doi.org/10.5350/BTDMJB.20170328120808

39.

Tong

Sainsbury

Craig

(2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. Int. J. Qual. Health Care, 19(6), 349–357. https://doi.org/10.1093/intqhc/mzm042

40.

Travelbee

(1971). Interpersonal aspects of nursing (2nd ed.). Philadelphia: F. A. Davis.

41.

Turan

F. D.

(2022). Effects of a structured online educational program course on nursing students' attitudes toward gender roles and women and children's violence abuse reports: A quasi-experimental evaluation. Nurse Education Today, 108, 105191.

42.

Turan

F. D.

Söyünmez

(2022). Perceptions of third and fourth year nursing students enrolled in a pediatric nursing course regarding the concept of child abuse: A metaphorical study. Nurse Education Today, 113, 105359.

43.

Tzeng

H. M.

Ketefian

(2002). The relationship between nurses' job satisfaction and inpatient satisfaction: An exploratory study in a taiwan teaching hospital. Journal of Nursing Care Quality, 16(2), 39–49.

44.

Ünal

(2012). Evaluating the effect of self-awareness and communication techniques on nurses’ assertiveness and self-esteem. Contemporary Nurse, 43(1), 90–98.

45.

Üstüner Top

Çam

H. H.

(2021). Childhood maltreatment among university students in Turkey: Prevalence, demographic factors, and health-related quality of life consequences. Psychology, Health & Medicine, 26(5), 543–554. https://doi.org/10.1080/13548506.2020.1768274

46.

WHO (2004). Guidelines for essential trauma care: World health organization. Retrieved February 05, 2021, from www.who.int/violence_injury_prevention/publications/services/en/guidelines_traumacare.pdf

47.

Woods-Jaeger

B. A.

Cho

Sexton

C. C.

Slagel

Goggin

(2018). Promoting resilience: Breaking the intergenerational cycle of adverse childhood experiences. Health Education & Behavior, 45(5), 772–780. https://doi.org/10.1177/1090198117752785

48.

Chi

Lin

(2018). Child maltreatment and adult depressive symptoms: Roles of self-compassion and gratitude. Child Abuse & Neglect, 80, 62–69. https://doi.org/10.1016/j.chiabu.2018.03.013

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.01 MB