The Importance of Trauma-Informed Care in Nursing
Healthcare providers are trained to recognize how the social determinants of health can impact a patient's well-being. They help connect factors like a patient's housing situation or employment status to their overall picture of health.
Trauma-informed care examines a patient's health picture even closer. For instance, did they experience a past trauma that led to a substance use disorder?
We discuss how nurses can incorporate trauma-informed care (TIC) to create a healing environment and improve patient outcomes. Explore tips on how you can use TIC in your practice as a nurse.
What Is Trauma-Informed Care?
Trauma-informed care is a human-centered approach to patient care. By recognizing a patient's past and present trauma, healthcare providers can create an individual plan of care for patients.
The Trauma-Informed Care Implementation Resource Center defines trauma as something that "results from exposure to an incident or series of events that are emotionally disturbing or life-threatening with lasting adverse effects on the individual's functioning and mental, physical, social, emotional, and/or spiritual well-being."
Experiences that cause trauma may include abuse, neglect, sudden loss of a loved one, poverty, racism, or oppression. Trauma-informed care redirects the focus from "what is wrong with you?" to "what happened to you?" This approach leads to a more trusting, collaborative relationship between patients and providers.
Catherine Uram, MD, is an integrative medicine provider, Reiki master, and author. She says, "Trauma-informed care is compassionate care. Engaging in compassionate care allows us to connect with our patients in their humanity, offering them solace, comfort, hope, and many times, reinstating their sense of dignity."
By incorporating the principles of TIC, nurses can approach mental healthcare differently.
The Six Principles
Healthcare facilities can become trauma-informed organizations by adopting strategies based on evidence-based research. An organization will need to take foundational steps like creating a culture of safety and wellness to embody the values of TIC.
The Trauma-Informed Care Implementation Resource Center establishes six core principles of trauma-informed care:
Caregivers create an environment that allows patients to feel physically and emotionally safe in their care.
Trustworthiness and transparency
When caregivers are straightforward about health information with patients, they build a trusting relationship.
Trauma survivors support one another through shared experiences. This may involve including individuals with past trauma in the organization.
Patients are active participants in their care. To achieve this, healthcare providers eliminate the patient-provider power dynamic. This allows patients to feel included, heard, and supported.
Patients' strengths are acknowledged and leveraged, which is shown to improve resilience.
Humility and responsiveness
Healthcare providers should be aware of gender biases and stereotypes.
Ralph Klotzbaugh is an assistant professor for the School of Nursing at Duquesne University. His research interests relate to the role of nursing in the equitable healthcare of lesbian, gay, bisexual, and transgender populations.
"Trauma-informed care goes a long way in attempting to understand a patient's life experiences," he says, "and in the case of trauma, unpleasant experience(s) that can impact a patient's understanding of the healthcare they receive, and the plan related to that care."
Klotzbaugh states that "for patients who identify as LGBTQ+, it is important to understand how they might experience trauma through societal stigma that in turn can become internalized."
How to Identify Past Trauma in Patients
Trauma can occur at any time in a patient's life. A person who experienced an adverse childhood event (ACE) such as abuse or neglect is at risk for developing health issues as an adult. Applying the principles of trauma-informed care helps providers connect these issues.
Emily Weber, chief nursing officer at Children's Memorial Hermann Hospital in Houston, says, "Adverse childhood events have impacts on life-long mental and physical health. Therefore, it is essential that we understand how trauma impacts the body, brain, behaviors, and beliefs of our patients."
She continues, "This is especially important in caring for children because complex trauma impacts the development of the brain and stress response systems."
According to one 2018 study, ACEs can be linked to illnesses in adulthood such as mental health challenges, substance use disorder, heart or lung disease, and cancer.
As a nurse, identifying a patient's past or present trauma can inform your care. Depending on the clinical setting, nurses may be trained to recognize the signs that a patient has experienced trauma. Practice settings like the emergency department may use tools like the trauma screening questionnaire to identify trauma.
Lindsay Nelson, MPA, is an expert trauma-informed care activist, coach, and trainer. She specializes in sexual and reproductive rights and advocates for TIC in the clinical setting.
Nelson shares her recommendations for identifying past trauma in patients. She says to look for signs like:
- Abnormal speech patterns, such as quick, nervous rambling or speaking very loudly or very quietly
- Excessive or sudden moaning, screaming, or crying
- Muscle tensing, tightly clenched eyes, or flinching to touch
- Disassociating, such as a distant stare
How Trauma-Informed Care Reduces Patient Retraumatization
Hospital admissions are stressful and anxiety-inducing for most patients. If a patient has experienced trauma in the past, being in the hospital can cause a reaction called retraumatization.
The American Psychological Association defines retraumatization as "one's reaction to a traumatic exposure that is colored, intensified, amplified, or shaped by one's reactions and adaptational style to previous traumatic experiences."
Betty Long, RN, MHA, is the president, CEO, and founder of Guardian Nurses Healthcare Advocates and a nationally recognized expert and speaker on patient advocacy. She explains how important trauma-informed care is in today's healthcare climate:
"Today's post-COVID healthcare environment is fraught with staffing shortages resulting in negatively impacting patients' experiences. And that is true for ALL patients, not just those who have experienced previous trauma."
Not only could a poor experience lead to retraumatization, but it could prevent patients from seeking care in the future. With the following tips, nurses can incorporate TIC strategies to prevent retraumatization and promote healing.
6 Tips for Nurses Caring for Patients With Past Trauma
Understanding the value of trauma-informed care is the first step. Below are strategies nurses can take into practice.
1. Assume Every Patient Has Experienced Trauma
Nelson says it's safest for nurses to approach each patient assuming they may have experienced trauma. Observe for nonverbal cues or listen for hints in conversation.
Nurses should avoid forcing a patient to discuss details about their trauma. Instead, ask leading questions to allow the patient to open up on their terms.
2. Anticipate Retraumatization
Always let the patient know they're in control of their body. Ask permission before touching a patient and try to find out about any triggers.
You can incorporate TIC in the pediatric setting by assuming hospitalization will be traumatic for the child. How can you make the child's experience as comfortable as possible while allowing them to feel in control? Consider how your care will impact the child's future so they avoid experiencing retraumatization later in life. Take advantage of resources like the child's parents or guardians or a child life therapist during invasive procedures.
3. Respect Boundaries and Privacy
When nurses respect patients' boundaries and privacy, it allows them to maintain bodily autonomy during a hospitalization. For instance, always be mindful to knock before entering a room or step out during private conversations. Remember to ask permission before touching a patient or lifting their gown during an assessment.
4. Use Therapeutic Communication
When supporting a patient who's experienced trauma, speak with a calm, steady voice and take pauses so the patient can ask questions. Maintain soft eye contact that shows you're engaged in the conversation while taking appropriate gaze breaks.
"By forming connections and providing a safe environment, nurses can help provide the nurturing care that will help them heal," says Weber.
Consider phrasing questions in a way that allows patients to feel in control. Long recommends nurses "listen generously." Instead of listening to respond, listen to understand.
Long also notes the value of overcommunicating with patients who've experienced trauma. This may mean spending extra time explaining procedures or confirming the patient's preferences.
Nurses may also overcommunicate during patient education. When teaching your patient about items like follow-up care or discharge instructions, allow them plenty of opportunities to ask questions. You can also print extra copies of health material and include any loved ones at the bedside in teaching.
5. Empower Patients to Be in Charge
As you establish a rapport with your patient, create an environment that allows them to feel in control of their care. For example, instead of saying, "I'm going to do this," Nelson suggests asking, "May I do this?"
Nelson also discusses the importance of validating a patient's decision to come in for care. Many survivors avoid healthcare to prevent retraumatization, so acknowledge their courage by saying something like, "I'm so glad you came in today so we can help you take care of yourself."
6. Keep the Patient Informed Throughout Procedures
For a trauma survivor, feelings of helplessness and anticipating pain can cause retraumatization during a bedside procedure. Here are a few tips for incorporating TIC during a procedure.
― Before a procedure
Explain what you or the provider will be doing and why. Carefully explain all the steps that will be involved during the procedure and how long it'll take. At this time, you'll want to find out if any touch or position will be triggering for the patient. This will help you and any other providers avoid retraumatizing the patient.
― During the procedure
As the nurse, your role is to serve as a go-between for patients and providers throughout bedside procedures. Ask the patient their preference on updates throughout the procedure. You may ask something like, "Do you want to know what's next, or would you rather us tell you after we're finished?".If a potentially painful part is coming up, explain to the patient the sensations they may feel so they're not triggered by any surprises. You may need to report patient reactions to the provider, such as the need for breaks or better pain control. Offer support by holding the patient's hand or communicating what's going on throughout the procedure.
― After a procedure
Following an invasive procedure, ask the patient if they want time alone or your support. You can guide the patient in deep breathing exercises as they recover and return to a relaxed state.This is a good time to ask the patient how they felt about the procedure and answer any questions they have. Remember to follow-up as often as needed.
For trauma-informed care to be effective, everyone in a healthcare facility needs to be on board, from clerical staff to advanced care providers. Nurses typically spend the most time with patients, so it's especially important for them to understand the value of TIC.
"TIC is important for all professionals in healthcare, but as the frontline workers, assistants, and coordinators of various providers, nurses are the MOST important and can make the biggest impact in TIC with patients," says Nelson.
Meet Our Contributors
Catherine Uram, MD
Catherine Uram specializes in integrative medicine. Uram has served as an instructor for the Dr. Andrew Weil Center for Integrative Medicine and a Reiki master teacher through the International Center for Reiki Training. She is an expert editor and contributor to the Reader's Digest digital health publication and a consultant to Veterans Affairs, among others. Her work can be seen in major spirituality publications such as The Light of Consciousness: Journal for Spiritual Awakening.
Lindsay Nelson, MPA
Lindsay Nelson is an expert trauma-informed care international activist/coach/trainer with a specialty in sexual and reproductive rights. Nelson took her education in human services and public administration, work experiences in public service, and personal experience of rape, domestic violence, and medical retraumatizations to launch Repro Empowerment Services to change the culture of trauma-informed care in healthcare settings.
Betty Long, RN, MHA
Betty Long, RN, MHA, is the president/CEO and founder of Guardian Nurses Healthcare Advocates and a nationally recognized expert and speaker on patient advocacy. As a registered nurse since 1986, she has experience in clinical, management, and consulting capacities. In addition, she has a long history of healthcare advocacy with special expertise in critical care, long-term care, and geriatric care management.
Emily Weber, DNP, RN, CPN, NEA-BC
Emily Weber is the chief nursing officer and operations at Children's Memorial Hermann Hospital in Houston. Children's is a designated level IV maternal care facility and level IV NICU, which offers the highest level of comprehensive care for women and premature, sick, and critically ill newborns. In her role, she is responsible for advancing nursing practice, operational performance, and ensuring compliance with the highest professional standards of patient care.
Ralph Klotzbaugh, Ph.D., RN, FNP-BC
Ralph Klotzbaugh is an assistant professor for the School of Nursing at Duquesne University. Klotzbaugh's research interests relate to the role of nursing in the equitable healthcare of lesbian, gay, bisexual, and transgender populations. More specifically, his research focuses on the intersection of sexual and gender minorities within a rural context. His research has been featured in major scholarly nursing journals.
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