1) Post-traumatic stress

PTS was measured using the PCL-5, which was developed by Weathers et al. [24] and revised by Weathers et al. [25] according to the revised PTSD definition in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) and translated into Korean by Kim et al. [26]. The Korean version of the PCL-5 (PCL-5-K) comprises 20 items, each scored from 0 (not at all) to 4 (extremely high). The score indicates the severity of symptoms caused by stress-related traumatic events during the last month. Possible scores range from 0 to 80, with higher scores indicating more severe PTSD symptoms [26]. Cronbach’s alpha for the PCL-5-K was .97 among Korean veterans of the Vietnam War [26] and .89 in this study.

2) Depression

Depression was assessed using the Center for Epidemiologic Studies Depression Scale (CES-D) developed by Radloff [27] and translated into Korean by Chon & Rhee [28]. The Korean version of the CES-D comprises 20 items rated on a 4-point Likert scale (0 = rarely or none of the time, 1 = some or a little of the time, 2 = occasionally or a moderate amount of the time, 3 = most or all of the time) according to how respondents felt during the last week. Possible scores range from 0 to 60, with higher scores indicating higher levels of depression [27]. Cronbach’s alpha for the Korean CES-D was .89 among Korean adults [28] and .78 in this study.

3) Health-promoting behaviors

Health-promoting behaviors were measured using the Health Promoting Lifestyle Profile-II (HPLP-II) developed by Walker et al. [29] and translated into Korean by Yun & Kim [30]. The Korean version of the HPLP-II comprises 52 items rated on a 4-point Likert scale (1 = never, 2 = sometimes, 3 = often, and 4 = routinely). Possible scores ranged from 52 to 208, with higher scores indicating higher levels of health-promoting behaviors. Cronbach’s alpha for the Korean HPLP-II was .91 among Korean adult women [30] and .92 in this study.

4) Self-esteem

Self-esteem was assessed using the Rosenberg Self-Esteem Scale (RSES) developed by Rosenberg [31] and translated into Korean by Bae et al. [32]. The Korean version of the RSES (K-RSES) comprises 10 items rated on a 4-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree). Possible scores range from 10 to 40, with higher scores indicating higher self-esteem. Cronbach’s alpha for the K-RSES was .90 among Korean adults [32] and in this study.

5) General and clinical characteristics

General and clinical characteristics included age, religion, marital status, education, employment, monthly income, exercise, medication, and physical disease. Smoking status was assigned as either “past smoker or nonsmoker” or “current smoker.” Drinking status was assigned as either “past drinker or nondrinker” or “current drinker.”

1) Development process

The caring program development process is as follows: First, needs assessment interviews were conducted with stakeholders at the self-sufficiency support center. The stakeholders included two activists who understood the purpose of the study and provided written informed consent before the interviews. Each had more than ten years of practical experience working with women who had experienced trauma, had a well-developed understanding of the needs of women who had experienced sexual trauma, and could confidently communicate their opinions. After analyzing the content of the interviews, six themes concerning the needs of women who had experienced trauma emerged: (1) self-understanding, (2) negative emotion conversion, (3) self-esteem improvement, (4) irregular sleep habit improvement, (5) somatic symptom control, and (6) health-promoting activities. These needs were considered during the development of the program.

Second, the program type and method were determined based on a literature review. Both individual and group interventions have been used for women who have experienced trauma, particularly those with PTS. In the context of group interventions, it can be difficult for women to disclose wounds caused by various traumatic events in front of multiple group participants. Individual interventions have the advantage in that participants can proceed at their own pace without being influenced by the progress of others. As each individual experiences different degrees of PTS, this approach allows for adjustment of the time and duration of the intervention according to symptom severity [18]. This program was structured according to recommendations in the literature as a one-on-one intervention conducted over six sessions [7, 18], with each session lasting between 60 and 120 minutes [18].

Finally, the outline, protocol, and worksheets of the initially developed program were reviewed and modified by experts, including six nurses employed at mental health centers, one mental health professor, and two stakeholders from the support center. The evaluation resulted in an average of 3.5 points on a 4-point Likert scale (1 = not at all appropriate, 2 = not appropriate, 3 = appropriate, and 4 = very appropriate) and a content validity index of 83.3%, indicating a high degree of validity and appropriateness. Expert feedback was used to modify the program. Modifications were made to (1) make the terms in the worksheet easier to understand; (2) include additional content on drug use, drinking, and smoking risks; (3) provide activities rather than explanations to enhance participants’ interest and concentration; (4) provide homework for each session to maintain continuity between sessions; (5) include music to stimulate the autonomic nervous system at the beginning and end of each session and during breathing meditation; and (6) provide space and time for participants to remember three pleasurable or happy experiences during the weekly session.

2) Caring program for health promotion

The caring program consisted of six individual intervention sessions per week for six weeks. Each session averaged 60~120 minutes. All sessions began with muscle relaxation activities with relaxing background music. The participants shared three experiences for which they were grateful. Each session provided homework assignments with content that could be applied in daily life or used to organize thoughts.

This study used Swanson’s caring theory to develop a health promotion program for women who have experienced trauma (Figure 1). Swanson’s caring theory outlines five caring processes: maintaining beliefs, knowing, being with, doing for, and enabling [21]. This program included the following concepts: understanding the self, sharing traumatic events and negative emotions, reframing the meaning of traumatic events, identifying thoughts and physical and emotional responses, developing health-promoting activities, and maintaining a positive attitude during the process of change (Table 1).

Figure 1
Conceptual framework used in this study based on Swanson’s caring theory.

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Table 1
Outline of the Caring Program for Health Promotion in Women Who Have Experienced Trauma

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First, in the “maintaining beliefs” stage, trust between the participant and nurse is essential [21]. Women who have experienced trauma may incorrectly recall events. These responses may cause discomfort [33]. However, trauma survivors experience relief in knowing that a diagnosis exists and that although they are psychologically or spiritually wounded, they can heal [34]. Swanson emphasized that nurses should help patients maintain self-esteem and hope while remaining respectful [21]. Session 1 focused on understanding oneself. The participants received detailed guidance on the purpose and content of the program to help them recognize the significance of their trauma. Additionally, Session 1 emphasized the autonomy of participation in the program and specified the necessary rules that would be followed as the program progressed. Participants took time to understand themselves by monitoring their current status, which was assessed using questionnaires on PTS, depression, health-promoting behaviors, and self-esteem. The researcher focused on women who had experienced trauma and physical and mental health problems consequent to the trauma. The researcher shared their status of PTS, depression, health-promoting behaviors, and self-esteem.

Second, in the “knowing” stage, the nurse attempts to understand the meaning of an event in the participant’s life [21]. Traumatic events can negatively affect maintenance of emotional control [35]. However, this is a natural reaction, and trauma survivors require time to learn how to manage previous traumatic events [34]. Swanson indicated that nurses should avoid making assumptions about participants and should focus on their care [21]. In this study, Session 2 focused on sharing traumatic events and negative emotions. The participants recalled their personal background and history by drawing a timeline from birth to the present. They addressed traumatic events on a timeline by focusing on facts, names, and other information. When a participant recalled a traumatic event, relaxation therapy was administered to stop or reduce PTS symptoms such as intrusive memories, avoidance, hyperarousal, flashbacks, and negative changes in thought and mood [2]. Session 2 emphasized the ways to identify and cope with negative emotions arising from traumatic events. The participants then wrote a letter to themselves (by writing or drawing), and as homework, they gave themselves a small gift (doll, pencil, or hairpin). The researcher focused on avoiding prejudice, spending time with the participants, and paying close attention to them. The goal was to find clues regarding things that could cause problems, carefully analyze them, comprehend their experiences and emotions, and attentively listen to and understand their verbal and nonverbal expressions, such as eye contact and body language. The researcher communicated awareness of physical, mental, social, and cultural effects by considering traumatic events from a new perspective.

Third, in the “being with” stage, nurses shared meaning, feelings, and experiences with the participants to communicate their emotional presence [21]. Trauma survivors may react sensitively, experience amplified fear, and experience pain when faced with triggering events that they have previously avoided revisiting [34]. Swanson stressed that nurses should communicate clearly with participants and not overburden them [21]. In this study, Session 3 highlighted the reframing of the meaning of traumatic events. Participants identified their strengths and weaknesses and considered their shortcomings from different perspectives. This led them to examine trauma from different perspectives. Session 3 provided methods for creating and strengthening positive emotions. Participants focused on the present, and their feelings of stability were evaluated. In addition, participants shared what they felt grateful for. They focused on themselves by focusing on their inner selves. They use their strengths to formulate future goals for internal growth. The researcher actively listened to the participants with a positive attitude and provided feedback to ensure a clear understanding of what was being said, while showing empathy and compassion. They discussed participants’ strengths and emphasized that trauma was not a participant’s fault, with an empathetic attitude and without criticism.

Fourth, in the “doing for” stage, nurses provide care to participants [21]. Women who have experienced trauma may worry or feel nervous about everything or may have recurrent intrusive memories, which can lead to physical changes such as increased muscle tension, blood pressure, and nausea [2]. The fourth stage identified thoughts and physical and emotional responses elicited. Swanson emphasized that nurses should help participants maintain their well-being by protecting and caring for them and enabling them to set their own goals [21]. This formed the focus of Session 4 of this study. The participants identified the physical symptoms they experienced when recalling their traumatic events. They practiced breathing meditation to control physical symptoms by relaxing with music and sharing thoughts, feelings, emotions, and specific physical sensations [36]. The participants were also informed about the potential side effects and the caution required when taking psychiatric drugs. The researcher provided a safe environment for objective examination of the participants’ traumatic events through breathing meditation.

Fifth, in the “enabling” stage, nurses enable participants to change their daily lives and solve problems on their own when they encounter new events [21]. In this study, Session 5 focused on developing health-promoting activities. The following health-promoting behaviors were explained: proper eating and sleeping habits and physical and social activities. Additionally, participants examined their current nutrition, sleep, and physical and social activity practices. While sharing their health behaviors, participants set specific goals by selecting the health behaviors that needed to be changed. Swanson emphasizes that nurses should provide participants with new information and support [21]. The researcher recognized participants’ anticipated needs, proposed alternatives for problem solving, received feedback, and assisted in developing a plan for health-promoting activities.

Finally, in the “well-being” stage, nurses should promote participant’s well-being by helping them recognize reality and facilitate activities while being together physically and emotionally and maintaining basic human trust [21]. By increasing their inner strength during the recovery process, trauma survivors can develop a more positive self-image, engage in meaningful activities, focus on a new life, and embrace their vulnerable selves [37]. In this study, Session 6 emphasized the maintenance of a positive attitude during the process of change. Participants shared their actions to change their health behaviors and feelings. They identified other strengths that they possessed but had never been previously recognized. This session focused on how to control emotions and maintain the previously identified health-promoting activities by applying these strengths. The researcher assisted the participants in discovering changes in their lives and in providing health guidance.