Building an Evidence-Based Model to Integrate ACEs in Baccalaureate Nursing Education: A Proposed Literature Review

Friday, 22 February 2019

Agatha Muire, BA
Michele Solloway, PhD, MPA
Suzanne Carr, PhD, RN
Shirley Girouard, PhD, RN, FAAN
College of Nursing, SUNY Downstate College of Nursing, Brooklyn, NY, USA


It has been 20 years since CDC-Kaiser Permanente’s landmark study linked adverse childhood experiences (ACEs) to adult health risk factors and disease, and while the impact of ACEs has since been well studied and documented, the literature shows that – by and large – baccalaureate nursing education has not yet adapted curricula that includes knowledge, skills and attitudes (KSAs) related to the life-long impact of ACEs and the importance of prevention and mitigation.

Exposure to adverse childhood experiences, which includes both abuse (psychological, physical, or sexual) and household dysfunction (substance abuse, mental illness, domestic abuse against mother, or criminal behavior), has been shown to have a strong relationship to detrimental health consequences (Center for Disease Control and Prevention, 2016). Many ACEs are interrelated – so children may be exposed to several events or various categories of adverse experiences before turning eighteen. Negative health outcomes include top risk factors and diseases associated with leading causes of death in the United States, such as smoking, obesity, and drug abuse as well as chronic lung disease, cancer, ischemic heart disease, and skeletal fractures (Felitti et al., 1998).

Adverse childhood experiences are events occurring in childhood (< age 18) that produce severe, prolonged or chronic stress and include such events as abuse, neglect, household dysfunction and addiction, interpersonal and neighborhood violence, bullying, food & housing insecurity, and discrimination (Felitti et al., 1998). Adults with two or more ACEs are at increased risk for chronic disease, risk-taking behaviors, unhealthy lifestyles, addiction, social dysfunction, poor educational and economic attainment in adulthood, and early death (Hughes et al., 2017). There is also a dose response for ACEs: for example, the respondents who were exposed to more than four adverse ACEs were four to twelve times more likely to have health risks associated with alcoholism, drug abuse, depression, and attempts at suicide, when compared to those people who had no adverse childhood experiences (Felitti, et al., 1998). Moreover, exposure to adverse childhood experiences is common – the original 1998 study found over 50% of respondents experienced at least one ACE, and 13% of respondents reported three or more adverse exposures (Felitti et al., 1998).

ACEs are prevalent across gender, race, and income (Halfon et al., 2017), considered a major public health issue (Bethell et al., 2017), and linked to social determinants of health and health disparities (Arkin et al., 2013). Therefore, if nurses are to provide patient-centered care it is essential that they are aware of and address ACEs and its sequeli in their assessments, plans, interventions and evaluations of care. Staff need education and training to be able to meet these expectations.

Through direct care and advocacy, nurses represent the largest group of healthcare providers (Girouard & Bailey, 2017). However, the majority of baccalaureate nursing education curricula do not currently address the role ACEs play in affecting patient’s decisions regarding their health and the long-term consequences. Instead, nursing education surrounding ACEs has been topic specific, for example, focusing on abuse or neglect, the neuroscience of toxic stress, how to create enhanced resilience, and trauma-informed care (Gill et al., 2018) rather than the more complex phenomenon of ACEs.


Nurses need knowledge, skills, and awareness about ACEs and their impact on health behavior and disease in order to provide proper care and employ preventative methods. However, the literature suggests a dearth of information and awareness about ACEs in baccalaureate nursing programs. Despite calls for ACEs education for all health professional students, discussion of the systematic integration of ACEs knowledge across curricula for nurses remains absent in the literature.


The proposed literature review is aimed at identifying key knowledge, skills and attitudes about ACEs for nurses to effectively integrate prevention and mitigation into their practice. The key words of “Nursing Education”, “Adverse Childhood Experiences”, “ACEs”, “Nursing Curriculum” were searched using PubMed, PsycInfo, and Google Scholar. Additionally, several search questions were included: (1) What do nurses know about adverse childhood experiences? (2) What are nurses taught about adverse childhood experiences? and, (3) Are there curriculum for adverse childhood experience teaching? Additional terms resulting from these searches – “trauma-informed care”; “sexual abuse”; and, “childhood adversity and toxic stress – were identified. Explored themes included ACEs KSAs for nursing students, faculty and providers, efforts to integrate ACEs interprofessional education (IPE) into nursing curriculum; and the impact of nurses’ ACEs on practice.

Literature Review

A preliminary review of the literature provides an example of a program that integrated ACE education systemically throughout its curriculum – the Loewenberg College of Nursing in Memphis, Tennessee developed and implemented a model for incorporating ACEs into their baccalaureate nursing curriculum over the course of five semesters. The Loewenberg College of Nursing ACEs Curriculum Integration Model was developed by a team of faculty skilled in curriculum design and nursing education. They engaged with ACE specialists as consultants to develop the curriculum. The team worked together and identified twelve courses deemed well suited to incorporate teaching regarding ACEs. For example: in pathophysiology, students learn about brain architecture and effects of trauma and toxic stress on brain development; health assessment included skills to assess for ACEs (Gill et al., 2018). The students were taught about ACEs sequentially: in the first semester students learned awareness and prevention; subsequent semesters included KSAs about building resilience, implementing trauma informed care, and informing policy. An evaluation of the Loewenberg curriculum revealed that systematically integrating ACEs across the curriculum helped faculty to prepare students with the KSAs they needed to impact ACEs prevention, toxic stress reduction, trauma informed care, building resilience and informing health care policies (Gill et al., 2018).

Another study focused on integrating ACEs into an Associate Degree Nursing (ADN) program by providing a group with a four-hour interprofessional education seminar on ACEs. One objective was to examine student’s knowledge of ACEs. The study identified four themes regarding ACEs. First, students were surprised to learn of the connection between ACEs and health – one student noted “I had no idea about the problem or its detrimental impact” (Olsen & Warring, 2018). Second, students involved in the training discussed the need to provide individualized personal care in order to promote trust. Third, students identified a desire to learn more; and last, the nursing students identified the need for additional resources and community funding. Overall, the four-hour seminar provided the ADN students with some education on ACEs; however, the chosen teaching method of interprofessional education had only mixed results (Olsen & Warring, 2018).

Another study incorporated the principles and importance of trauma-informed care with a focus on ACEs through interprofessional education over the course of three training/discussion sessions. The study focused on healthcare students representing a variety of programs, including nursing, but also Doctor of Osteopathy, veterinary, pharmacy, physical therapy, dental medicine, physical therapy, and physician assistant students. As a result of the training, an additional 30% (an increase from 13.6% to 42%) of participants answered that they were “extremely likely administer and assess an ACE questionnaire for their patients (Strait & Bolman, 2017). This study showed promising results from a rather small amount of time-investment and is encouraging for educators and promising for health care practitioners.

Conclusion and Recommendations

While the concept of ACEs as a driver for health outcomes is not new, the integration of ACEs into baccalaureate nursing education largely continues to be lacking. The literature suggests that ACEs should be part of nursing education. Felitti et al. (1998) called for this incorporation, as have several authors since. As a result, and to build upon the work that has been completed by others, this project will assess current curriculum and conduct an in-depth literature review to identify best practices and develop an evidence-based education proposal for a curriculum that will equip graduates with the KSAs they need to prevent and care for patients who have had exposure to ACEs and are living with the long-term consequences of those event(s). Also, to build this curriculum, additional research is needed about student and faculty KSAs related to ACEs and their own life experiences. Additionally, reviews of current curricula are needed to assess what information is currently being taught regarding ACEs and their consequences.