Introduction

As nurses, we have been trained to perform ongoing assessments on patients with every encounter. Many patients have gone through traumatic events that often go undiscovered by the healthcare team.

A trauma informed care approach will help healthcare providers uncover past trauma. This will allow them to tailor a plan of care that helps alleviate patient suffering by decreasing overall stress and anxiety. When the healthcare team is aware of past trauma, they can avoid conversations and situations that could potentially re-traumatize the patient.

Trauma-Informed Care

Trauma is a human experience that can affect people from all different backgrounds and walks of life. There is no race, gender, sexual orientation, or social class that is immune to the far-reaching clutches of trauma. A traumatic event is an event that is marked by sexual violence, severe injury, and/or death. These events can be first-hand accounts where the people themselves were the victims of the event.

They can also be indirectly experienced by witnessing the event on another person. The event can also produce vicarious trauma when it happens to a close friend or loved one. No matter how traumatic an event was experienced, it can have severe and long-lasting effects (1).

Despite the rising accounts of traumatic events, trauma-informed care is an underused skill in the healthcare field. Those who support and use trauma-informed care understand that there is a large population of people seeking healthcare services who have had past traumatic experiences. They are also aware that just by seeking out care, they have the potential of being re-traumatized.

Empowering the patient to control their care through collaboration will help decrease the chances of re-traumatization.

There are six principles of trauma-informed care:

• Safety
• Trustworthiness and transparency
• Peer support
• Collaboration and mutual support
• Cultural and historical sensitivity
• Empowerment of voice and choice

Trauma-informed care runs parallel to ethics in the healthcare setting. It endeavors to ease the patient’s suffering by preventing re-traumatization and empowering them. (3)

Principles of Trauma-Informed Care

It is meaningful to explore each of the six principles of trauma-informed care

Safety

In trauma-informed care, safety pertains to the psychological and physical safety of the patient and their family throughout their encounter with the healthcare organization. The goal is to prevent any form of re-traumatization. This is accomplished by creating safe spaces, access to services, and engagement between the patient and the healthcare team.

One of the most significant aspects of safety in trauma-informed care is environmental. This demands that the healthcare teams create a welcoming and accommodating environment for all patients, regardless of their diverse backgrounds. We must understand that patients who have undergone traumatic events can be hypersensitive to their environmental safety.

The trauma-informed care plan must be individually tailored and include communication initiatives that promote the patient’s self-identity and how they would like to be addressed (1).

Trustworthiness and Transparency

Nursing has long been recognized as the nation’s most trusted profession. This has been accomplished through the intentional focus on patient advocacy. Nationwide policies and safety goals have promoted diversity, equity, and inclusion. Initiatives to ensure that the patient understands and agrees with their plan of care, such as using their preferred language in plain and clear terms, are an example of how nurses build that trust.

Using patient-centered care helps demonstrate transparency, a way nurses can further build trust. True transparency can be accomplished by encouraging patients to be involved in their care. We can ask patients if it is acceptable to document their experiences and even share our notes or computer screens to demonstrate our desire to be transparent.

Educating patients using the teach-back method also indicates our transparency as our knowledge becomes theirs (1).

Peer Support

Contrary to popular beliefs, the goal of peer support in trauma-informed care is not fixing the individual. Rather, the goal is to assist the individual to empower themselves by connecting them with supportive groups of peers that have similar experiences, culture, beliefs, and religion. Empowerment of the patient should be the goal of peer support. Traumatic stress is often accompanied by a re-traumatization cycle that can be interrupted and ultimately stopped through individual empowerment of the patient.

These peer support groups often contain members who themselves have survived traumatic events. To have the best probability of success, the patient should leave behind former friends who enable the re-traumatization cycle and gravitate to the peer support group members. This can leave the patient with further feelings of loss and grief. This has to be considered when developing the plan of care for the patient (1).

Identifying Past Trauma

Trauma-informed care does not mean that the care is tailored to a patient’s specific trauma, nor does it mean that the team endeavors to heal or even address past trauma. Instead, in simple terms, trauma-informed care recognizes that the patient has been through a traumatic ordeal and that the plan of care must take that trauma into account to care for the patient properly.

The patient’s reaction and compliance may be affected by their past trauma. Past trauma needs to be identified and acknowledged. Past trauma can affect all aspects of a patient’s life. Identifying and acknowledging the trauma and how the patients then needed coping mechanisms may have become detrimental to their health is essential for the overall well-being of the patient.

Through the identification of past trauma, the team can take the opportunity to ensure that the patient does not feel responsible for the life-altering trauma and understands that the trauma was not their fault. Identifying the trauma can lead to the revelation that there is a connection between past trauma and the patient’s current coping and functioning; this can change their overall perspective, thus changing their lives (4).

Collaboration and Mutual Support

Collaboration and mutual support demand that the entire healthcare team see the patient as both an equal partner and an expert in their own personal experiences. The patient should be allowed to identify and prioritize their goals, and then the healthcare team can work with the patient to develop a plan of care with these goals at the forefront.

Collaboration takes longer than the traditional healthcare “do as I say” method. It helps in the trust-building process, and when done properly, it helps the patient succeed, as the goals have come from them. This can also interrupt the re-traumatization cycle. It also increases the probability that the patient will be compliant with the plan of care and any after-care appointments and follow-ups (1,4).

Cultural and Historical Sensitivity

Cultural and historical sensitivity surrounds the patient’s entire identity. This encompasses aspects such as race, gender, age, and more, as well as life experiences and relationships down to the base familial associations.

It also includes beliefs, core values, and experiences in open spaces. When seeking healthcare, no matter the reason, all aspects of the patient’s identity are brought to the facility and laid before the healthcare team (1).

Empowerment of Voice and Choice

As discussed earlier in the peer support principle, empowerment is paramount in trauma-informed care. Empowerment of voice and choice is perhaps the chief cornerstone of all the other trauma-informed care principles. Trauma-informed care empowers patients by making them feel heard and letting them know their voices are essential for their well-being.

Though the healthcare team may not always agree, trauma-informed care also enforces the concept that the patient’s choices are to be respected. Through the trauma-informed care journey, the patient develops their ability to navigate the healthcare setting and becomes familiar with the language of the medical community.

This further empowers the patient, as they can understand the plan of care and become an active participant in that plan, as they were involved in both the planning and implementation. Further, trauma-informed care creates a safe and supportive environment where the patient is allowed to grow and mature in their knowledge and understanding of themselves and their health (1).

Effects of Traumatic Stress

Traumatic stress has been shown to increase chronic illness, mental health issues, and early death. When left alone, traumatic stress can morph into enduring stress. Some forms of enduring stress include:

• Chronic stress – this happens when trauma is continuous over a long period.
• Toxic stress – this is found in children who experience long-standing and/or frequent trauma such as emotional and physical abuse, neglect, and exposure to violence.

Traumatic stress can alter multiple brain processes, including the neurologic, immunologic, endocrinologic, metabolic, inflammatory, and autonomic processes. The long-lasting effects depend on which phase of brain development the patient is in when the trauma occurs.

Repeated trauma can cause a hormonal cascade, which can result in the allostatic load phenomenon. This phenomenon distorts the everyday stress-mediating processes.

Traumatic stress often leads to self-destructive behavior. Drug and alcohol use/addiction, violence, and risky behavior often follow those who have had traumatic stress events. There is a fear among traumatic stress victims that they may be judged for their choices and lifestyle (1).

Adverse Childhood Experiences

Nearly 40% of people have been exposed to adverse childhood experiences. Of course, adverse childhood experiences harm the overall health and well-being of the child; they also have a potentially significant impact on the physical and mental health of the person as they transition into adulthood.

Adverse childhood experiences and childhood trauma have been shown to leave the patient with an increased risk for developing the leading causes of death and disability. These conditions include heart disease, stroke, cancer, and depression with suicidal ideation. Also, childhood trauma can lead to symptoms of chronic headache and pain as an adult (2).

As most childhood trauma is perpetrated by someone known and close to the child, such as a parent, relative, or close family friend, the child is often left with an altered expectation of interpersonal relationships. This may lead to severe insecurity and distrust, where negative personal perception, especially about others, may develop.

People who develop physical symptoms of past childhood trauma are often unable to adjust and move on post-trauma. On the other hand, those who can form positive relationships tend to have fewer physical symptoms and are more likely to have adjusted to childhood trauma. Childhood trauma can have long-reaching effects on the ability of the adult to form positive relationships and have normal responses to stressful situations (2).

Trauma-Informed Approach

The trauma-informed approach was born out of the research on adverse childhood experiences. The study showed that the more adverse childhood experiences that took place in the patient’s life, the more it affected their mental and physical health, even leading to early death.

A trauma-informed approach begins at the organizational level, where the culture must adapt to prevent re-traumatization. A few aspects need to be incorporated into the organization’s training to accomplish the needed changes.

The organization must wear trauma glasses and view the healthcare team through the trauma lens. There is a direct correlation between trauma and mental health; this needs to be acknowledged, accepted, and considered as part of the care plan.

For the trauma-informed approach to be practical, the organization must realize that trauma expands beyond Post Traumatic Stress Disorder (PTSD). Instead, trauma incorporates a multitude of differing issues that can include mental, emotional, physical, and other trauma sources.

The healthcare professional assessing the patient should be trained to recognize the signs of trauma and, if disclosed, respond appropriately in the moment. Training needs to be done with all front-line staff whom the patient may confide in.

The healthcare team should be aware of resources available in the community and be able to refer the patient to those organizations. The treatment should be as trauma-specific as possible so that the patient can connect in a meaningful way with this new support system. The organization should partner with these support groups to ensure an easy transition from the institution to the community.

The team should also prioritize the principles of trauma-informed care. For instance, to promote trustworthiness and transparency, the team could limit the number of healthcare providers asking the patient to repeat the story of their traumatic experience. Turning to more collaborative communication and relationships between the team and the patient, allowing the patient to be actively involved in their care plan, also promotes the trauma-informed care principles.

Promoting safety within the organization for both the patient and the healthcare team also helps to change the culture to a trauma-informed approach. Trauma survivors could be approached and asked to help design, implement, and evaluate the trauma-informed approach. What better way to get to know your community resources than to actively partner with them to help meet the needs of the organization’s patients?

It needs to be recognized that not all patients who show similar symptoms to those of past trauma have gone through a traumatic event. There is no cookie-cutter care plan, and all patients must be appropriately assessed to determine their plan of care (6).

Impact of Trauma-Informed Care

The impact of trauma-informed care on the patient and the healthcare system cannot be overstated. By understanding that many of the patients who seek out healthcare services have undergone a traumatic event and tailoring the assessment accordingly, an organization can minimize the occurrence of re-traumatization.

When we understand how trauma has affected our patients’ lives, how they perceive the healthcare system, and what their previous experiences within that system have been like, steps can be taken to ensure better outcomes within this population (1).

Nursing Implications

In order for trauma-informed care to be properly accepted and used in the healthcare setting, the culture must be transformed to be trauma-informed. Nurses are with the patient around the clock, and nurses have the ability to touch patients’ lives in the most impactful way.

Here are a few considerations that pertain to the healthcare team, but when used by nurses, can transform the patient’s environment into a true trauma-informed care setting.

Introductions

Even if the nurse believes that the patient knows who they are, the nurse needs to reintroduce themselves with every interaction. The patient generally has many different healthcare team members entering their space throughout their stay. Team members tend to meld into one anonymous face to the patient; the nurse, by introducing and reintroducing themselves and their role to the patient, will not only foster an understanding of who does what, but they will empower the patient to be engaged and involved in their plan of care.

Body Language

Body language is essential when caring for any patient. When caring for a patient who has experienced trauma, this becomes even more impactful. Open body language sets the stage for trust.

Trauma survivors may often feel a sense of being trapped or confined, which may lead to an overall sense of powerlessness. Unintentional threatening body language magnifies these feelings and could bring on a re-traumatization episode. By contrast, non-threatening body language decreases the trauma center, leaving the patient calm and non-triggered.

Trauma-informed care body language includes being at the patient’s level; committing to sit or raising the bed so that both the patient and the nurse are at the same level. Knowing the environment and de-escalating trauma by the nurse positioning themselves properly in relation to the patient and the door, allowing for both to access so that the patient does not feel confined.

Anticipatory Guidance

Past trauma may have been unpredictable or an outright surprise. Verbally telling patients what will be expected during their stay will reassure them, even if the procedure or test may cause pain. Sharing who will be part of their care during their stay will also set them at ease. Knowing and understanding the expectation further empowers the patient to be involved in their plan of care.

When known, expectation decreases feelings of surprise, which could bring them back to the time of trauma.

Permission

Touch can have an incredible impact on the patient who has experienced past trauma. Unwanted or inappropriate touch quite likely may have been a part of their traumatic experience. It can activate those traumatic memories and activate the re-traumatization cycle. Touch is also inevitable when it comes to the nurse/patient relationship.

The nurse can control when the touch occurs. Touch should always be preceded by the nurse explaining what they are going to do and asking for the patient’s permission to touch them. Asking permission puts the ball in the patient’s court and empowers them, as they are now given a choice and are in control of their body and space.

Permission to touch the patient should never be assumed; permission should be asked whenever the nurse needs to feel the patient.

Protect

In many cases, patients who have experienced trauma experienced it at the hands of someone they know. The patient will often not be alone in their room; family and friends are often present. Patient advocacy has always been the primary role of the nurse.

As part of advocating for the patient, the nurse should protect the patient’s privacy and safety. Asking those in the room to leave before discussing the patient’s plan of care is a way to protect both privacy and protection. The patient may not feel safe asking visitors to leave their room, especially if they may have been involved in the prior traumatic episode.

By asking visitors to leave, the nurse gives control back to the patient. In private, the nurse can ask who the patient is comfortable with remaining in the room. Once again, the patient is empowered.

Clear and Consistent

Realistic expectations are understood when given in clear and consistent language. This will also foster trust, especially if the entire healthcare team is on the same page, vocalizing the same message, and is consistent. Using language that the patient understands is also paramount. Avoiding medical terminology and acronyms also builds trust as the patient knows that the nurse has made it their priority that the patient understands their plan of care.

Universal Precaution

Finally, trauma-informed care needs to be a universal precaution regardless of whether the patient’s past trauma history is known or not. By treating all patients as if they had experienced past trauma, those who have will be more apt to share the experience.

Also, nurses will be less likely to start the re-traumatization cycle by inadvertently triggering an episode. It will help treat the patient without relying on them to disclose something they may not yet feel comfortable sharing. (3)

Resources

It is not easy to become a center that practices trauma-informed care; it does not happen overnight. Trauma-informed care is an intentional shift in culture at the facility and/or system level. Trauma-informed training should be implemented, and the staff must understand the “why” behind the training to buy in.

Trauma-informed care not only empowers the patient and prevents re-traumatization, but it can also help staff who have undergone past traumatic experiences once a facility adopts this culture. This culture should be at the forefront of both staff and leadership’s minds. Staff meetings, unit huddles, and any other opportunity where leadership actively communicates with staff should incorporate the messaging of trauma-informed care.

Facilities should actively hire a trauma-informed workforce. The interview panel should include people from various racial and cultural backgrounds. Questions pertaining to trauma-informed care can and should be asked to identify skills and traits that will promote this culture.

Environmental factors that can help create a trauma-informed culture include keeping doors and common areas well-lit, low noise levels, and decorating regions with warm, cozy colors. (5)

Below are some websites that can be visited to help kickstart the culture of trauma-informed care: 

• https://TraumaInformedCare.chcs.org 
• https://www.creatingpresence.net/ 
• https://www.chcs.org/resource/key-ingredients-for-successful-trauma-informed-care-implementation/ 
• https://store.samhsa.gov/product/SAMHSA-s-Concept-of-Trauma-and-Guidance-for-a-Trauma-Informed-Approach/SMA14-4884 

(5) 

Conclusion

Though not a new concept, trauma-informed care is essential to help patients who have had traumatic experiences navigate through the healthcare system. Trauma-informed care empowers patients to control their care in collaboration with the healthcare team. Ultimately, the goal of trauma-informed care is to prevent re-traumatization of the patient at the hands of the healthcare team.

When patients arrive at the facility, their trauma background is unknown. The nurse’s responsibility is to use trauma-informed care to assess the patient and create trust so that they will disclose the trauma. Once this information is available, the team will be able to work together with the patient to prevent further trauma and achieve positive outcomes.