What is Trauma Informed Care?
When you first hear the term “trauma informed care” it may sound like we’re talking about caring for patients who are in the trauma ICU. But it’s actually a much deeper topic and affects so many more patients than you may realize.
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Trauma informed care is an approach to practice that strives to understand how past traumas affect why our patients do (or don’t do) what is needed in order to manage their health optimally. This concept of trauma informed care is gaining traction and being extensively studied in healthcare, education and public health.
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines it in this way: “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.” So when we look at trauma through that lens, it’s easy to see how it can affect so many of our patients…maybe even ourselves.
Trauma informed care enables us, as health care practitioners, to support our patients who have experienced trauma in whatever form that takes for them. We do this through the interventions we provide, and how we evaluate why an intervention did or did not produce the desired outcome. It also plays a significant role in how and what we teach our patients. In short, providing trauma informed care brings the whole patient fully into their treatment plan and we cannot have patient-centered care without it.
Why is trauma informed care essential?
Exposure to trauma is actually more prevalent than one might first assume. Surveys routinely show that more than half the respondents report trauma in their past history. Traumatic experiences and the chronic stress they cause affects the HPA axis, limbic system, and neurotransmitter dysregulation. Altogether, this is a significant amount of strain on the body which can lead to physical manifestations. Individuals who have experienced trauma are more likely to suffer serious consequence including:
- Heart disease
- Substance abuse
- Social isolation
- Shorter life expectancy
Additionally, trauma can affect a patient’s ability to get routine and preventive care. Many times these patients are labeled “noncompliant,” and instead of recognizing the trauma, addressing the barriers that it creates, and providing true patient-centered care, these patients often get lost in the healthcare system. The result is they often avoid seeking care or abandon treatment prematurely. Not only does this increase healthcare costs, it has a direct correlation with poorer outcomes.
How can we screen for past trauma?
A key element to successfully screening for past trauma and implementing trauma informed care is to foster an environment based on trust so the patient feels safe sharing their experiences.
One tool used for screening adults for past trauma is The Stressful Life Events Screening Questionnaire (SLE), which is a 20-question tool assessing exposure to traumatic events. It asks about the individual’s experience with things like natural disasters, man-made disasters such as a plane crash, life-threatening illnesses, death of someone close to them, and being a victim of violence.
Another tool is the Trauma Assessment for Adults (TAA) which is a 17-item assessment tool that asks the individual about potentially traumatic events using a yes/no format. This tool asks about the same general traumatic situations as the SLE but also specifically mentions military combat or war zone experience.
The New Jersey Division of Mental Health and Addiction Services suggests introducing the screening tool in a way that fosters an environment of safety and trust. The script they provide is:
“It is common for people to have experienced stressful and upsetting events. Even if those events happened to you a long time ago, those events can still affect how a person thinks and feels today. Things that happen to us can affect how we react to other people and situations many years later.
People who have experienced a traumatic event, a series of traumatic events, or certain kinds of stress over time can have different needs than people who have not. Because of this, it is helpful for us to be aware of your past experiences, and the way in which those events may still affect you. This questionnaire asks about many different types of stressful life events.
We would like you to answer the following questions on your own to see if any of these things have happened to you. These kinds of events can be frightening or distressing to almost everyone. I am here to help if you have any questions, or need assistance with completing this questionnaire, and I will stay with you afterward if you would like.”
What does trauma informed care entail?
Some key tenements of a trauma informed healthcare system are:
- Acknowledge the widespread impact of trauma.
- Recognize the signs and symptoms of trauma in patients and their families (also in staff).
- Individuals (and those who support them) are involved in the planning, implementation and evaluation of the treatment plan.
- Staff speak respectfully and in a non-judgmental way when inquiring about past trauma
- Recognize the impact of all types of trauma and that the weight of that trauma is what the patient states it is – this can include being a victim of violence to witnessing a natural disaster.
- Recognize that trauma can be acute and ongoing.
- Providing care and services in a way that does not re-victimize the individual.
Additionally, Substance Abuse and Mental Health Services Administration (SAMHSA) has identified six key principles of a trauma-informed approach to healthcare in their resource “Guiding Principles of Trauma-Informed Care”. These principles are:
- Safety – Ensure patients, families and staff always feel physically and psychologically safe
- Trustworthiness and transparency – Decisions are made with transparency with the goal of building and maintaining trust.
- Peer support – Individuals with shared experiences are integrated into the organization as a way to establish safety, garner a sense of hope and build trust.
- Collaboration – The organization recognizes the role each individual can play and places an importance on the development of partnerships.
- Empowerment – Recognize and build on patient and staff strengths, which includes a core belief in the power of resiliency and the ability to heal from trauma.
- Cultural, historical and gender issues – Moving beyond biases and stereotypes based on ethnicity, sexual orientation, religion, geography, age, etc…) and recognizing the impact of historical trauma
How can we provide trauma informed care?
In addition to fostering an environment of safety and trust with your patient, some examples of trauma informed care are:
- Explaining what you are doing when working with patients in language that is easy to understand – this creates an environment of transparency and trust.
- Letting the patient know you are going to touch them before beginning your assessment or intervention, especially if it involves removing clothes or touching genitals or breasts. Say, “I’m going to lift your blouse so I can better hear your lungs.” You can take this a step further if you know you are working with someone for whom this may be difficult and say,”‘If at any time you are uncomfortable, please let me know and I’ll stop the assessment.”
- Explain the reason behind sensitive questions that are asked and ensure the patient their privacy is always protected.
- Understanding that a patient had a traumatic experience with a male figure, so assigning this patient only female nurses to avoid revictimization.
- Practicing cultural humility, which seeks to understand a culture rather than making assumptions.
- Being aware of your body language so as to not convey an intimidating or aggressive demeanor.
- Greet patients and families warmly and with sincerity. Ask about preferred names and pronouns.
- Collaborate with patients on their plan of care. Ask open ended questions to verify understanding and seek solutions.
There’s so much more to this topic. If you’d like to explore further, some helpful links are below:
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Aces Aware. (n.d.). Trauma Informed Care. Aces Aware. https://www.acesaware.org/ace-fundamentals/principles-of-trauma-informed-care/#
Aces Aware. (2020). ACE Screening Clinical Workflows, ACEs and Toxic Stress Risk Assessment Algorithm, and ACE-Associated Health Conditions: For Pediatrics and Adults. Aces Aware. https://www.acesaware.org/wp-content/uploads/2019/12/ACE-Clinical-Workflows-Algorithms-and-ACE-Associated-Health-Conditions.pdf
Alameda County. (n.d.). Assessment Tools | Alameda County Trauma Informed Care. https://alamedacountytraumainformedcare.org/caregivers-and-providers/assessment-tools/
Centers for Disease Control and Prevention. (n.d.). What are Adverse Childhood Experiences? Centers for Disease Control and Prevention. https://www.cdc.gov/violenceprevention/aces/fastfact.html
Chapa. (n.d.). Trauma Informed Care: ACOG April 2021. https://podcasts.apple.com/us/podcast/trauma-informed-care-acog-april-2021/id1412385746?i=1000515996230
Health Care Toolbox. (n.d.). Tools You Can Use: Screening | Patient Centered Care and Trauma Informed Care for Pediatric Patients. https://www.healthcaretoolbox.org/tools-you-can-use-screening-2
National Library of Medicine. (2014). Screening and Assessment. In Trauma-Informed Care in Behavioral Health Services. Substance Abuse and Mental Health Services Administration (US). https://www.ncbi.nlm.nih.gov/books/NBK207188/
Nurse Family Partnership. (n.d.). Nurse-Family Partnership: About Us. Nurse-Family Partnership. https://www.nursefamilypartnership.org/about/
Oral, R., Ramirez, M., Coohey, C., Nakada, S., Walz, A., Kuntz, A., Benoit, J., & Peek-Asa, C. (2016). Adverse childhood experiences and trauma informed care: The future of health care. Pediatric Research, 79(1), 227–233. https://doi.org/10.1038/pr.2015.197
Racine, N., Killam, T., & Madigan, S. (2020). Trauma-Informed Care as a Universal Precaution: Beyond the Adverse Childhood Experiences Questionnaire. JAMA Pediatrics, 174(1), 5. https://doi.org/10.1001/jamapediatrics.2019.3866
State of New Jersey. (n.d.). Department of Human Services | DMHAS Trauma Informed Care. https://www.nj.gov/humanservices/dmhas/initiatives/trauma/
Substance Abuse and Mental Health Services Administration. (n.d.). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. 27.
Substance Abuse and Mental Health Services Administration. (2014). Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. : Substance Abuse and Mental Health Services Administration. https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4816.pdf
Trauma-Informed Care Implementation Resource Center. (2021). Trauma Informed Care Implementation Resource Center. What Is Trauma Informed Care? https://www.traumainformedcare.chcs.org/
Wright, T. (n.d.). Trauma-Informed Care. https://podcasts.apple.com/us/podcast/trauma-informed-care/id1444985511?i=1000426942389
Youth.gov. (n.d.). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach | Youth.gov. https://youth.gov/feature-article/samhsas-concept-trauma-and-guidance-trauma-informed-approach