...uncertainty is associated with both subjective and physiological measures of stress Two-thirds of adults responding to the 2018 Stress in America Survey (n=3,458) indicated significant levels of stress in a number of areas, including healthcare (American Psychological Association [APA], 2018). This reinforces a pattern that has been steady or increasing for years,across all demographic groups. Stress occurs when individuals are uncertain about how to ensure their own social, physical, or mental wellbeing (Peters, McEwen, & Friston, 2017). In fact, uncertainty is associated with both subjective and physiological measures of stress (De Berker et al., 2016). When a stressor is temporary or manageable, the stress response system is efficient and effective (McEwen, 2007). However, when stressors persist and uncertainty continues, the stress response can become maladaptive and lead to illness and disease (Hackney, 2006; Peters et al., 2017).

More than two decades of research have contributed to the knowledge that stress and adversity is associated with poor social, emotional, and physical outcomes later in life (see the seminal manuscript by Felitti et al., 1998). Specifically, childhood adversity or trauma is associated with increased risk of heart disease, diabetes, autoimmune disorders, and even premature mortality (Brown et al., 2009).

The healthcare system can be re-traumatizing for patients with trauma history Stress and trauma also affect behavior and engagement with services. The healthcare system can be re-traumatizing for patients with trauma history (Dubay, Burton, & Epstein, 2018).

When individuals feel threatened they rely on the parts of their brain aimed at survival, or the flight, fight, or freeze system (McEwen, 2007). As a result, the rational parts of the brain involved in memory, planning, decision making, and regulation become less important. In healthcare settings, this can impact the patient’s engagement with services and ability to adhere to treatment plans (Sansone, Bohinc, & Wiederman, 2014). Healthcare organizations are striving to incorporate this understanding into their own settings and practices, recognizing the potential for re-traumatization and its impact on care (Schulman & Menschner, 2018). They are turning to approaches like trauma-informed care (TIC) for guidance.

This article begins with an overview of TIC, and then discusses implications of a TIC framework in healthcare, generally, and then specifically as it relates to nursing practice. Nurses have ample opportunities to influence the experience of patients and colleagues and nursing is a critical field in which to introduce a trauma-informed approach. To assist in TIC implementation we will provide strategies for nurses to use in practice, followed by considerations for organizations and the workforce.

Trauma Informed Care

Since the 2001 report Crossing the Quality Chasm: A New Health System for the 21^st Century (Institute of Medicine, 2001), healthcare professionals have delivered patient-centered care as a way to improve engagement and quality (Levinson, Lesser, & Epstein, 2010). Inherent in this approach is an understanding that trusting, emotionally supportive, and collaborative relationships with patients can affect patient knowledge, decision-making, and adherence to care (Levinson et al., 2010). Trauma-informed care (TIC) is a patient-centered approach to healthcare that not only attends to these elements of quality, but also requires healthcare professionals to attune to the distinct experience of trauma survivors.

...TIC is conceptualized as a lens through which policy and practice are reviewed and revised to ensure settings and services are safe and welcoming for both patients and staff. Grounded in an understanding of the impact of trauma on patients and the workforce, TIC is conceptualized as a lens through which policy and practice are reviewed and revised to ensure settings and services are safe and welcoming for both patients and staff. As an example, a clinic may implement a more lenient appointment cancellation policy with the understanding that many patients have barriers preventing them from getting to appointments on time. Perhaps a clinic revises its intake protocol, noting that sensitive questions are best asked face to face. For the workforce, a trauma-informed workplace may include adequate supervision and support for self-care.

Healthcare professionals demonstrate TIC in interpersonal interactions when they provide direct and clear communication, empower patients and other staff, and work to create emotional safety for others. The Substance Abuse and Mental Health Administration (SAMHSA, 2014) offered the following principles for a trauma-informed approach:

• Safety (physical and emotional)
• Trustworthiness and transparency
• Empowerment, voice, choice
• Use of peer support
• Cultural, historical, and gender responsiveness

Supporters of a trauma-informed approach recognize the prevalence of trauma survivors within healthcare settings, and are aware that the service setting can also be a source of trauma (Reeves, 2015; SAMHSA, 2014). Whether a patient interaction with providers in a healthcare setting is directly or indirectly related to trauma they have experienced, the potential to be re-traumatized is high. “Understanding how trauma has affected patients’ lives and their interactions with and perceptions of the health care system is fundamental to structuring a healthcare system that responds to these patients’ needs and promotes better physical and mental health outcomes” (Dubay et al., 2018, p. 2).

TIC in Healthcare

The healthcare system is populated by trauma survivors, both those providing and receiving care. The healthcare system is populated by trauma survivors, both those providing and receiving care. Among 1,784 patients participating in a Philadelphia health survey, 73% indicated they had experienced at least one adverse childhood experience (ACE) as described by Felitti et al. (1998), while an additional 14% reported trauma related to community violence, including racism (Cronholm et al., 2015). In another sample at a primary care setting in an urban area (n=509), 23% were shown to have post-traumatic stress disorder (PTSD). This rate was higher among those with other risk factors such as chronic pain, irritable bowel syndrome (IBS), and anxiety disorders (Liebschutz et al., 2007). Although the prevalence of work-related stress, such as vicarious trauma, secondary traumatic stress, and burnout, is not generally well understood among healthcare professions (van Mol, Kompanje, Benoit, Bakker, & Nijkamp, 2015), rates are known to be high among emergency department, oncology, pediatric, and hospice nurses (see Beck, 2011 for a review).

...patients who have experienced trauma are less likely to follow through with a medical provider’s instructions. Engagement in healthcare, for both patients and staff, is impacted by trauma (Marsac et al., 2016). For patients, the findings are mixed. Some research points to an increase in healthcare utilization among trauma survivors (Sansone et al., 2014), especially for emergency services (Walker et al., 1999); while other studies point to a lower use of preventive care and screening (Yanos, Czaja, & Widom, 2010). Sansone et al. (2014) noted childhood trauma is generally associated with increased utilization, but not adherence to treatment. Specifically, patients who have experienced trauma are less likely to follow through with a medical provider’s instructions. Engagement for staff is reflected in turnover and absenteeism. The turnover rate for nurses is significant, at times leading to worldwide shortages of these professionals, and impacting healthcare quality, cost, and effectiveness (Flinkman, Leino-Kilpi, & Salanterä, 2010).

Engagement for staff is reflected in turnover and absenteeism. In response, the medical field has called for trauma informed care (Machtinger, Cuca, Khanna, Rose, & Kimberg, 2015). Noting that the principles of TIC are congruent with the ethics of medicine and the expectation to “do no harm,” Kassam-Adams and Butler (2017) praised TIC for its focus on preventing re-traumatization. Raja, Hasnain, Hoersch, Gove-Yin, and Rajagopalan (2015) identified two ways medicine is able to focus on trauma in the provision of care. First, when necessary, trauma-specific care is provided; this type of care is aimed at reducing the impact of trauma and involves practices such as screening for ACEs and referring for mental health services and other care. Working with patients who have experienced trauma can have an impact on healthcare professionals, causing secondary traumatic stress or burnout (van Mol et al., 2015; see section titled Organizational Considerations and the Nursing Workforce). It is important when providing trauma-specific care to understand how one’s own history is impacting patient care, and to know the signs of vicarious traumatization.

...delivery of universal trauma precaution does not require knowing an individual’s trauma history, but can benefit all patients and staff.The second type of trauma-related care focuses on universal precaution. With a foundation of patient-centered care and communication, this type of care incorporates an understanding of the health implications of trauma. For example, healthcare professionals understand that maladaptive coping strategies may be related to a history of trauma, and they work with patients to identify alternative strategies. They provide education and advice in a non-judgmental, non-shaming manner that seeks to build trust and rapport. According to Raja et al. (2015), delivery of universal trauma precaution does not require knowing an individual’s trauma history, but can benefit all patients and staff.

Trauma-Informed Nursing Practice

For TIC to be thoroughly implemented and embodied by a healthcare system, policies, procedures, and culture need to be trauma-informed. This work requires multi-level commitment and can take substantial time and effort. There is value and utility in individual understanding of the principles of TIC and learning to apply them in all levels of nursing practice. Nurses who utilize a trauma-informed lens in practice can enhance job satisfaction, reduce risk for burnout, and improve patient experiences and outcomes (Schulman & Menschner, 2018).

Trauma-informed nursing practice requires cultivating nurses who are aware, sensitive, and responsive. Principles of TIC can be applied on a macro-level to systems of care and on a micro-level to nurses’ daily interactions with all patients. Trauma-informed nursing practice requires cultivating nurses who are aware, sensitive, and responsive. In alignment with the principles of safety, respect and trust, we suggest that nurses can begin to ask themselves, and their colleagues, three simple questions as a first step to applying a trauma-informed lens to their practice, as follows:

1. Safety: Does this cultivate a sense of safety?
2. Respect: Am I, and others, showing respect?
3. Trust: Does this build trust?

Based on many years of nursing experience and several years of implementing TIC in medical settings, we have come to understand how nuanced and impactful TIC is on patient and staff experience. We have outlined several practical tips to apply TIC principles to nursing practice. These suggestions help nurse to incorporate a trauma-informed lens into their nursing practice. We would like to acknowledge many nurses already incorporating these approaches in their work; however, we have outlined how and why they are considered trauma-informed for those who may not yet know.

Introduce Yourself and Your Role in Every Patient Interaction
They [Patients] may recognize you, but may not remember your role. Introductions are important even if you think that the patient already knows you and your role. Patients often interact with many medical team members during their care. They [Patients] may recognize you, but may not remember your role. This may lead to confusion and misunderstanding. When a patient understands who you are and your role in their care, they can feel empowered to be more actively engaged in their own care. An example of this strategy might be: “I know we have met before and I wanted to remind you that I’m Hannah, your Maternity RN and I work with your primary care provider.”

Use Open and Non-Threatening Body Positioning
It is important to have awareness of your body position when working with patients. Open body language conveys trust and a sense of value. Trauma survivors often feel powerless and trapped. This can trigger past experiences of inability to escape or lacking control. Using non-threatening body positioning helps prevent the threat detection areas of the brain from taking over, which helps patients stay regulated.

Both nurse and patient should have access to the exit so that neither feels trapped.A trauma-informed approach to body position includes attempting to have your body on the same level as the patient, often sitting at or below the patient. It could also include raising a hospital bed in order for the nurse and the patient to be on the same level, reducing the likelihood of creating a perceived power differential through positioning. Additionally, it is important to think about where you and the patient are positioned in the room in relation to the door or exit. Both nurse and patient should have access to the exit so that neither feels trapped.

Provide Anticipatory Guidance
Verbalize what the patient can expect during a visit or procedure or what paperwork will cover. For example, frame the visit flow and/or the course of care (e.g., laboratory tests today, several visits in the next month, ultrasound in two months). Knowing what to expect can reassure patients even if it is something that may cause discomfort. Past trauma has often been associated with surprises and may have been unpredictable. Often trauma survivors will expect the worst if left to their imagination.

Past trauma has often been associated with surprises and may have been unpredictable. Anticipatory guidance may be used to prepare patients for invasive procedures, such as a vaginal ultrasound or a thoracentesis. When working in an inpatient setting, anticipatory guidance for patients may include sharing the time of team rounds, or when he or she might expect to see the doctor or a different nurse. Knowing details such as who will be part of their care, what they can expect of their day, or the hours of the cafeteria can give patients a sense of control during a hospitalization. Knowing what to expect reduces the opportunity for surprises and activation. It also helps patients feel more empowered in the care planning process with their care team. One example of anticipatory guidance might be: “The dressing on your wound needs to be changed and your skin cleaned every morning and evening. I will do the dressing change with you this morning, and you can expect your night shift nurse to do your evening change.”

Ask Before Touching
For many trauma survivors, inappropriate or unpleasant touch was part of a traumatic experience. Touch, even when appropriate and necessary for providing care, can easily activate a fight, flight, or freeze response. Nurses are often required to touch patients, sometimes in sensitive areas. This may include helping patients sit up in bed, applying their hospital identification band, listening to their lungs, or examining a wound. Any touch can be interpreted as unwanted or threatening and it is important to ask permission to touch someone and obtain verbal consent before doing so. Touch may be activating for a patient and may bring up difficult feelings or memories. This may lead to increased anxiety and activation of the stress response which can result in disruptive behaviors and even lead to the patient dissociating. Asking permission before you touch patients gives them a choice and empowers them to have control over their body and physical space.

Touch may be activating for a patient and may bring up difficult feelings or memories. For routine tasks that may be performed multiple times during a hospitalization, we recommend asking every time you perform the task. For example, even if you have measured a patient’s blood pressure several times already that day, it is important to ask permission again, every time you are going to touch him or her. You might say: “I’m going to need to listen to your lungs. Is it ok if I put my hand on your shoulder?” or “I am going to place my stethoscope here. It may feel a bit cold.”

Protect Patient Privacy
Patients may not feel empowered or safe asking others to step out. When caring for patients there are often others in the room in addition to yourself and the patient. Family members and other members of the medical team may be present when you care for a patient. It is important to protect patient privacy and ensure safety by making sure that the patient desires that the people present hear about his or her care. It is crucial that nurses do not put the responsibility on the patient to ask others to leave. Patients may not feel empowered or safe asking others to step out. As part of nurse role to protect patient safety, it is the responsibility of the nurse to ask the patient (in private) who they would like present during care.

In an outpatient setting this might be accomplished by bringing the individual patient back to a room and asking whom they would like present for the visit. If patients do not feel safe with those who accompany them, this allows them to continue the visit alone. In an inpatient setting, visitors should be asked to leave the room to allow opportunity to speak with patients directly about whom they would permit to hear health information before discussing any information or care plan.

Provide Clear and Consistent Messaging About Services and Roles
Trust is built when patients experience care providers who are forthright and honest. Consistent messaging and transparency are important to foster realistic expectations. Dependability, reliability, and consistency are important when working with trauma survivors because trauma is often unexpected or unpredictable. Trust is built when patients experience care providers who are forthright and honest. We recommend that nurses are clear about what can and cannot be done. Providing consistency from the nurse team about such information as expectations and/or hospital rules can help patients feel secure and decrease opportunities for unmet expectations that might lead to activation and disruptive behavior. Transparency about limits of one’s role or what can be done in the context of a visit will decrease opportunities for confusion and activation or dysregulation.

Use Plain Language and Teach Back
We recommend avoiding medical jargon and using clear, simple language. We recommend avoiding medical jargon and using clear, simple language. When using medical language, explain what you are talking about with simple non-medical words. When patients are feeling activated (i.e., using their fight, flight, or freeze system), information processing and learning parts of the brain do not function optimally and it is hard to remember new information. When providing education, information, or instructions, break the information you share into small chunks and check for understanding. Using clear language and teach back empowers patients with knowledge and understanding about their care. An example of this recommendation might be: After demonstrating how to test blood glucose at home, for a patient newly diagnosed with diabetes, have the patient demonstrate and explain how and when they will perform the test.

Practice Universal Precaution
With universal precaution, TIC is provided to patients regardless of a trauma history, and in many cases, this is not known. Although many providers advocate for ACE screening as part of routine care (see Purewal, et al., 2016 as an example for screening children and youth in pediatric settings), this practice is not without concerns, including the potential negative effects for patients (Finkelhor, 2018). Unless a trauma-focused intervention is needed to ameliorate the impact of trauma, many TIC experts propose universal precaution rather than direct screening (Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005). Using universal precaution encourages a trauma-informed system of care and nursing practice instead of relying on screening or trauma disclosures. Using these practical tips listed above, nurses can begin to implement the universal precaution approach in their daily practice.

...many TIC experts propose universal precaution rather than direct screening The universal precaution approach is well known and widely used in nursing mitigate exposure to bloodborne pathogens (e.g., applying gloves before preforming a procedure in which one could be exposed to blood). In this case, it is not necessary to know if a patient has a bloodborne illness. Gloves are applied because it is possible for blood to carry disease and gloves reduce risk of the spread of bloodborne illnesses for nurses and patients. Just like the gloves, we apply TIC principles to our practice, regardless of trauma disclosure, because we want to reduce the risk of re-traumatization.

Organizational Considerations and the Nursing Workforce

Although the patient experience is important, this work often begins with an examination of how principles of TIC are applied to the workforce. Nurses can begin to use TIC principles to recognize opportunities for activation and re-traumatization in themselves and their colleagues. This awareness can require the examination of policies and procedures that inform personnel management, clinical practice, and workplace culture. The following are tips for organizations and systems for addressing TIC in the workforce.

Recognize Exposure to Trauma
The nursing workforce is at significant risk for secondary trauma, also referred to as vicarious traumaHealthcare settings can be inherently stressful environments. The nursing workforce is at significant risk for secondary trauma, also referred to as vicarious trauma (Beck, 2011). There are opportunities for improvement in medical settings to address nurse exposure to traumatic events and secondary trauma (Bell, Kulkarni, & Dalton, 2003). The first step in this work is to recognize and normalize the routine exposure by nurses to difficult, scary, and traumatic events. With training, nurses can develop common language for trauma exposure and can support each other by recognizing when this happens.

Reduce Opportunities for Activation
Nurse Managers and Chief Nursing Officers may wish to consider how they might support their nursing staff to reduce opportunities for activation on the job and establish practices that support a nurse once activation has occurred. When nurses and their leadership share a common language and understanding about trauma and activation, it can be helpful to lead staff through an exercise where together they identify circumstances in their work when they feel most activated. These “hot spots” can then be evaluated and addressed to create a more safe and supportive work environment.

Create Systems for Addressing Trauma Exposure
Healthcare settings need to create a mechanism/venue to address trauma exposure as part of nurses’ work. Healthcare settings need to create a mechanism/venue to address work-related trauma exposure. One recommendation is to create policies and practices to offer and encourage help for staff. This includes making the employee assistance program available and accessible; offering daily stress reduction opportunities (e.g., sufficient staffing to support breaks for nurses with removal from a stimulating environment and time to meet biologic needs); and recognizing the need for support or a break to reset the nervous system.

Evaluate Policies and Leadership Practices
When nursing leadership and staff begin to examine systems, policies, and procedures, there often is a need for systems level change and application of trauma-informed principles in leadership and policies. This can be challenging and difficult work. Often, systems and culture have foundational ideologies that directly conflict with TIC principles. Nursing culture has long had strong hierarchical power dynamics. Self-sacrifice may be seen as necessary to be a “good nurse,” and breaks are not valued.

Often, systems and culture have foundational ideologies that directly conflict with TIC principles. While nursing culture is changing, structures are often lacking to support self-care during a shift. Many hospital cultures use the buddy system to implement breaks for nurses; this results in insufficient break time for nurses on the floor. Cultural practices like the buddy system de-incentivize nurses to take breaks from stressful situations or meet their own biologic needs because they may feel they are compromising patient care or burdening colleagues.

Summary

Our knowledge is growing about providing TIC to patients, and how doing so first requires those providing the care to have a trauma-informed workplace. It is important that nursing leaders and educators consider the first step as addressing the workforce. If staff feel safe, respected, and empowered, they will likely more easily provide trauma-informed care for patients.

Implementation of TIC is much like putting on an oxygen mask in an airplane. You must first put on your mask before assisting others. Implementation of TIC is much like putting on an oxygen mask in an airplane. You must first put on your mask before assisting others. If nurses do not care for themselves, they will not be able to properly care for patients. We must advocate for systems change at all levels to promote a trauma-informed workplace in order to provide the best patient care.

While systems level changes take time, nurses can begin now to implement the tips outlined above to work toward a more trauma-informed practice. These simple, yet powerful, behaviors can begin to transform both the patient and nurse experience, ensuring safe and empowering interactions for all.

Authors

Joan Fleishman, PsyD
Email: fleishma@ohsu.edu

Dr. Fleishman completed a Doctorate in Clinical Psychology (PsyD) at Pacific University School of Professional Psychology in 2012 and went on to complete a fellowship in Primary Care Psychology at University of Massachusetts Medical School Department of Community and Family Medicine in 2014. She is the Behavioral Health Clinical Director for Oregon Health & Science University Department of Family Medicine, leading the expansion of behavioral health services across six primary care clinics. Dr. Fleishman has focused her work on integrating behavioral health services into primary care. She has partnered with regional leaders in trauma-informed care to implement TIC across her clinical system. She has lead the strategic planning, program development, clinician training, and workflow implementation for the widespread use of TIC principles in clinic practice in healthcare settings.

Hannah Kamsky, BSN, RN, CCCTM
Email: kamsky@ohsu.edu

Hannah Kamsky completed a BA in Spanish and Cross-Cultural Studies at Beloit College in 2009. She then spent 5 years working in research, including exploring the impact of health insurance status on individual health within the Medicaid population (with Providence Health and Services) as well as clinical trials in contraception (with the Women’s Health Research Unit at Oregon Health & Science University). Hannah earned a BSN at Oregon Health & Science University in 2015. She worked on the trauma unit at Oregon Health & Science University, a level 1 trauma facility for the region. Since 2016, Hannah has worked as a maternity nurse for Family Medicine at Richmond and in program development with Project Nurture. Hannah’s work with Project Nurture focuses on trauma-informed care delivery as well as systems improvement for pregnant people with substance use disorders.

Stephanie Sundborg, PhD
Email: ssund2@pdx.edu

Stephanie Sundborg is Director of Research and Evaluation for Trauma Informed Oregon, a statewide collaborative funded by the Addictions and Mental Health Division of Oregon Health Authority, and housed at the Regional Research Institute (RRI) at Portland State University. Since 2014, Dr. Sundborg has been working with Trauma Informed Oregon to provide training, consultation, and research related to trauma and trauma-informed care. In particular, she focuses on the implementation of TIC in systems, including healthcare, and the impact trauma has on service utilization and satisfaction. Dr. Sundborg holds a Master’s of Science in Cognitive Neuroscience (focused on attention and memory), and a PhD from Portland State University in Social Work Research, focused on commitment to TIC.