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Trauma-Informed Care
Trauma- Informed Care
Are We There Yet?
By Pam Greene, PhD, RNDirector, TNA Board
DO YOU PROVIDE TRAUMA-INFORMED CARE? When this question was posed to two dozen highly skilled, well-educated nurses from a variety of practice specialties, answers were unsurprisingly mixed.
Several nurses clearly understood what trauma-informed care (TIC) meant and described how TIC had been incorporated into their respective practices. Others assumed “trauma” was limited to caring for people with extreme physical injuries. Some nurses thought TIC related specifically to understanding and providing care to people with posttraumatic stress disorder. More than half of the nurses questioned indicated they had never heard of TIC and were not sure if they were using TIC in practice.
Integrated health care has been implemented slowly and inconsistently (Beeber, 2018), making it hard for nurses to even become familiar with TIC.
The first step toward implementing TIC universally is understanding what implementation involves and making good use of existing resources for implementation.
DEFINITIONS AND DESCRIPTIONS
Trauma can be defined in many ways. For the purpose of TIC implementation, trauma is an event or series of events that involve a direct or perceived threat of death, severe bodily harm, or psychological injury that the person finds deeply distressing at the time. Trauma can also be experienced by being a witness to trauma, such as when a child sees domestic violence. Trauma can occur at any point in the lifespan (Huckshorn & Lebel, 2013; TIC Resource Guide, 2017).
TIC is a form of care that takes the whole person into account. The framework incorporates the realization of how widespread trauma is, knowledge about
different kinds of trauma, and how trauma can manifest. The TIC-approach to healthcare is strengths-based and congruent with person-centered care: collaborative, supportive, and focused on helping the person reclaim control (Isobel & Delgado, 2017; National Center for TIC, 2015). TIC can be implemented in any healthcare setting.
BACKGROUND
In 1985, a doctor by the name of Vincent Felitti tried to get at the root cause of participants dropping out of a weightloss program when they were on a path to success. He ultimately found a link to 10 types of adverse childhood experi- ences, or traumas, now called ACEs (Stevens, 2012).
The ACEs screening tool shows that people with elevated ACE scores are more likely to have marital discord, autoimmune diseases, broken bones, cardiovascular disease, and cancer (Purkey, Patel & Phillips, 2018). Further research reveals the stress of severe, chronic childhood trauma—such as watching a parent hit their partner or being bullied repeatedly—causes a release of hormones that physically damages the developing child’s brain. These health outcomes affect how people with elevated ACE scores use human services systems throughout their lifespans.
PhDTo put it into perspective, from one year’s worth of confirmed cases of child abuse, an estimated $124 billion is spent on healthcare, special education, productivity loss, criminal justice, and welfare over the lifetime of those children (Stevens, 2012). Research with ACEs is ongoing and has launched more investigations into the manifestations of trauma across the lifespan and the impact of trauma on health. It is important to emphasize trauma can come in many forms and can occur at any age. No matter when it occurred, trauma can have a lasting effect. Epidemiological studies show an estimated 36 to 81 percent of the general population have experienced trauma (Huckshorn & Lebel, 2013). It is challenging to accurately determine the extent of trauma within the population if it is unassessed and allowed to remain invisible. Not all who experienced trauma will have the same manifestations.
PRINCIPLES OF TIC
TIC is not trauma-specific care. TIC does not heal trauma nor address trauma directly. However, all those who work in healthcare, from the receptionist and the nurse to allied health professionals and physicians, should understand and apply the principles of TIC as universal precautions (Purkey et al., 2018; Bruce et al., 2018).
The process of providing TIC begins with acknowledging the ongoing effects of trauma, validating its current relevance, and understanding how past experiences affect present functioning. External forces shape internal functioning and can trigger traumatic experiences. Past adverse experiences or trauma are often invisible in the present yet can invade the physical and emotional state, upsetting the allostatic balance, resulting in a range of illnesses or maladaptive coping: coping which once may have been adaptive (Purkey et al., 2018). For some people, that acknowledgement and the experience of being understood, perhaps for the first time, can be life-changing.
The second step in TIC is recognizing the need for physical and emotional safety. This may be more challenging than initially imagined. The environment for care must be clean, soothing and uncluttered with attention to seating arrangements in waiting areas and even signage. Consistency and predictability are necessary, especially in anticipating and explaining procedures. Trust, respect, and acceptance are always vital to establishing and maintaining therapeutic interpersonal relationships.
In TIC, the care provider must understand the sensitivity trauma survivors have for nuances in the environment and in interpersonal interactions. Since trauma-related issues may not have been identified in every person that enters a care environment, it is important to intentionally integrate TIC as part of the process
of providing person-centered care for all people. Nurses already build trust and use the strategies above, but when demands increase, even the best healthcare providers can become task-focused and rushed, unintentionally falling short of what is needed to promote TIC.
Giving control and choice to the patient and building a collaborative alliance with them is the third step (Purkey et al., 2018). The fourth step focuses on helping patients build skills and believing in patients’ strength and resilience, and the incorporation of culture and ethnicity is the fifth step.
INTERVENTIONS AND RESOURCES
Of the evidence-based models for TIC, many are trauma specific or designed for a specific age group. The resources provided below are intended as a starting point to provide additional information. Try to find a model that aligns with the population you serve and the type of care provided.
Trauma-Informed Care Resources Guide (2017) is from Crisis Prevention Intervention. Adapted from SAMHSA’s Roadmap to Seclusion and Restraint-Free Mental Health Services (2006), this guide describes types of trauma and addresses secondary trauma along with compassion fatigue, both of which can be common for nurses. A de-escalation preferences form is also included with tips on preventing re-traumatization, especially when the initial trauma occurred in a healthcare setting. For instance, if a child had to be physically restrained for an injection and experienced this as trauma, he or she may experience negative reactions when future injections are indicated. Understanding past experiences helps with developing an individualized approach through collaborative planning and considering another form of the medication to mitigate a recurrence of trauma. Visit www.crisisprevention.com/Resources/ to download the ebook.D-E-F Protocol for Trauma-Informed Pediatric Care (2018) is part of an overall healthcare toolbox aimed at helping children and families cope with illness and injury. There are links to additional resources including a free one-hour continuing education course for nurses. Visit healthcaretoolbox.org to learn more.Trauma-Informed Approach and Trauma Specific Interventions provides bulleted information about TIC principles and approaches with descriptions of eight models of care. There are links to each of those models. This resource is provided by SAMHSA. Visit samhsa.gov/nctic to find resources.
ARE WE THERE YET?
How would you answer if asked: Do you provide Trauma-Informed Care? Now, if not before, you have a little bit of an idea of what is being asked. TIC tends to be more common in behavioral health treatment facilities. As a nation, we have a long way to go to incorporate TIC into all care. As nurses, we can leverage our position with patients, families, healthcare organizations, and communities to partner and make trauma-informed care universal. i
REFERENCES
Beeber, L. (2018). Somebody help! Journal of the American Psychiatric Nurses Association, 24(1) 87-88 doi: 101.1177/1078390317746332.
Bruce, M.M., Kassam-Adams, N., Rogers, M., Anderson, K., Sluys, K.P., & Richmond, T.S. (2018). Trauma provider’s knowledge, views, and practice of trauma-informed care. Journal of Trauma Nursing.
Huckshorn, K., & Lebel, J. (2013). Trauma-informed care In Yeager, et al. (Eds) Modern community mental health: An interdisciplinary approach (pp. 62- 83). Oxford, UK:Oxford University Press.
Isobel, S., & Delgado, C. (2017). Safe and collaborative communication skills: A step towards mental health nurses implementing trauma informed care. Archives of Psychiatric Nursing, 32, 291-296.
National Center Trauma Informed Care (2015). Trauma-informed approach and trauma-specific interventions. Accessed: https://www.samhsa.gov/ nctic/trauma-interventions
Purkey, E., Patel, R., & Phillips, S.P. (2018). Traumainformed care: Better for everyone. Canadian Family Physician, 64, 170-173.
Stevens, J. E. (2012). ACE study, child abuse, child trauma, chronic disease, neurobiology comments. Daily Archives: October 3,2012, Accessed: https:// acestoohigh.com/2012/10/03/
