Are You Trauma Informed?

Vickye Hayter

Trauma is a major public health concern with significant impact to patients and providers. Failure to understand and address the impact of traumatic events has detrimental effects on health and well-being. In the United States, nearly 90% of adults have experienced some type of traumatic event at least once in their lives¹³, and globally almost 31% have been exposed to four or more traumatic events⁴. The five most prevalent event types reported are witnessing death or severe injury, the unexpected death of a loved one, being mugged, being in a life-threatening automobile accident, and experiencing a life-threatening illness or injury. Multiple exposures to traumatic events—directly or vicariously—increase the risk of developing post-traumatic stress disorder (PTSD) and other negative health outcomes^{8, 18}.

As a result of trauma research over the past few decades, a trauma-informed approach to care has emerged as a priority in public health and various sectors of human services^{5, 7, 11, 16}. Despite the growing awareness of the relationship between trauma and health, as well as emerging research on the benefits of implementing trauma-informed care (TIC), it is unclear to what extent healthcare organizations and providers have adapted this approach to providing care. TIC is most often defined as a multi-dimensional, multi-sectoral approach that includes public awareness, provider training, prevention, early identification, and treatment strategies to caring for individuals and communities who have experienced traumatic events. Trauma in the context of TIC refers to psychological trauma, which typically includes experiences that cause intense reactions and lasting effects¹⁹.

Traditionally, the biomedical model is the most pervasive approach to care services in the healthcare disciplines^{3, 16, 22}. This model aligns most often with nurses' clinical mental view of trauma which is associated with sudden life-threatening physical injury rather than psychological distress¹⁰. Whereas the biomedical model focuses mostly on biological/physiological factors, it overlooks the impact of detrimental psychological, environmental, and social traumatic experiences on health outcomes. While nursing practice has been established on theoretical concepts which support a holistic view of the patient, nurses' perceptions and approach to care from a trauma-informed lens are not well studied. Additionally, little is known regarding factors that may influence their implementation of this new care model.

Being trauma-informed is necessary to render quality patient care and prevent retraumatizing patients, particularly minorities who are at greater risk for trauma exposure. Currently, no standards exist specifying how organizations and providers are to implement trauma-informed care—leaving them to figure out what being "trauma-informed" really means. Implementation domains inherent in most TIC frameworks include screening, collaboration, workforce development (I.e., training, governance, and policy), prevention (of re-traumatization and secondary traumatic stress), cultural sensitivity, program monitoring, and evaluation.

The Substance Abuse and Mental Health Services Administration (SAMHSA)’s framework asserts that in order to achieve the most optimal health outcomes, trauma must be addressed in a safe and sensitive way—in all health settings¹⁹. Being trauma-informed is not only necessary for providers, but entire organizations. SAMHSA's framework indicates trauma-informed organizations "respond by fully integrating knowledge about trauma into policies, procedures, and practices, and seek to actively resist retraumatization.” Essential components of TIC practices include awareness and assessment of the signs and symptoms of traumatic stress (exhibited by patients and providers), cultural responsiveness, therapeutic provider communication, and use of appropriate trauma-informed interventions.

Integral to prominent TIC models, such as SAMHSA and National Child Traumatic Stress Network (NCTSN), is the importance of addressing secondary traumatic stress (STS), which is the "emotional duress that results when an individual hears about the firsthand trauma experiences of another"²⁰. A research report of TIC initiatives found that none of the organizations reviewed explicitly referenced addressing staff's trauma histories or experiences of secondary traumatic stress (STS) in their trauma-informed definitions, despite experts' acknowledgment of this important aspect of TIC¹⁴.

Although emerging TIC frameworks recognize the impact of adverse experiences on individual health outcomes and patients' experiences with the healthcare system, limited research has been conducted on the impact of nurses' work-related traumatic experiences on their practice of TIC. Examining factors associated with nurses' practices of TIC is critical, considering the added stress and trauma associated with the COVID-19 pandemic.

Trauma exposure is higher for certain groups, such as medical professionals, first responders, military personnel, women, and racial/ethnic minorities^{4, 12, 23}. Nurses are exposed to trauma directly and indirectly through work-related and non-work-related experiences. Direct trauma exposure is when an event happens directly to the nurse, such as being hit by a patient. Indirect trauma exposure is when the nurse learns of or witnesses an event such as providing emergency care for a pediatric patient with a gunshot injury. Both are examples of work-related trauma exposure. Non-work-related trauma exposure are events that happen to the nurse directly or indirectly external to the nurse's job.

Nurses' constant exposure to trauma increases their risk for developing PTSD, compassion fatigue, and burnout through vicarious exposure^{2, 6, 15, 17}. PTSD and traumatic stress have long been recognized in populations who have experienced war, abuse, interpersonal violence, maltreatment, disaster, and displacement, among other traumatic events. However, the advent of the pandemic has spurred a surge in research exploring the impact and outcomes of trauma exposure among healthcare providers. Because of the "nature of job" it is expected that nurses will encounter work-related trauma exposure. However, the impact of repeated trauma exposure without adequate resources and support may be detrimental. Nurses often feel a grave responsibility to protect or minimize patient suffering but may feel helpless when system-related factors hinder their ability to best care for patients and themselves. Staff turnover, leaving the profession, and mental health and substance use issues are some of the negative outcomes of unaddressed traumatic stress experienced by nurses^{1, 10}.

Foli's theory regarding nurses' psychological trauma (2019) offers a new perspective for examining the impact of nurses' work-related trauma on their ability to provide care. The theory underscores the role organizations play in acting as barriers or mitigators of nurses' experience of traumatic stress on the job. Organizations can affect positive or negative outcomes for nurses and, ultimately, patients. Foli and Thompson (2019) translated SAMHSA's six principles into recommended TIC guidelines for nurses¹⁰. The authors indicate organizations have a responsibility to provide staff, as well as patients, with physical and psychological safety. Constant exposure to potentially traumatic events without sufficient support and resources from employers can contribute to traumatic stress, jeopardizing nurses' personal and professional well-being²¹. Nurses' Psychological Trauma theory extends the scope beyond individual-level nurse resiliency to organizational culpabilities and strategies to provide a trauma-informed environment for nurses⁹. Unraveling the intricacies of providing care in a multifaceted environment with frequent exposure to trauma is essential to the sustainability of our healthcare system.

References

¹The impact of traumatic events on emergency room nurses: Findings from a questionnaire survey

²Perceived barriers to flexible sigmoidoscopy screening for colorectal cancer among UK ethnic minority groups: a qualitative study

³Understanding human adaptation to traumatic stress exposure: Beyond the medical model.

⁴The epidemiology of traumatic event exposure worldwide: results from the World Mental Health Survey Consortium

⁵Trauma-Informed Family Practices: Toward Integrated and Evidence-Based Approaches

⁶Prevalence of Secondary Traumatic Stress Among Emergency Nurses

⁷Child Welfare, Juvenile Justice, Mental Health, and Education Providers' Conceptualizations of Trauma-Informed Practice

⁸Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study

⁹A Middle-Range Theory of Nurses' Psychological Trauma

¹⁰The influence of psychological trauma in nursing. (1st ED.). Sigma Theta Tau International.

¹¹A Critical Look At Trauma-Informed Care Among Agencies and Systems Serving Maltreated Youth and Their Families